Ciaran S Phibbs
Professor (Research) of Pediatrics (Neonatology) and, by courtesy, of Health Policy
Pediatrics - Neonatal and Developmental Medicine
Academic Appointments
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Professor (Research), Pediatrics - Neonatal and Developmental Medicine
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Professor (Research) (By courtesy), Health Policy
Administrative Appointments
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Associate Director, VA HSR&D Health Economics Resource Center (1999 - 2003)
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Associate Director, VA Women's Health Evaluation Initiative (2009 - Present)
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Associate Director, VA Geriatrics and Extended Care Data and Analysis Center (2012 - Present)
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Associate Director, VA HSR&D Health Economics Resource Center (2017 - 2021)
Professional Education
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PhD, University of California, San Diego, Economics (1987)
2024-25 Courses
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Independent Studies (5)
- Directed Reading in Pediatrics
PEDS 299 (Aut, Win, Spr, Sum) - Early Clinical Experience
PEDS 280 (Aut, Win, Spr, Sum) - Graduate Research
PEDS 399 (Aut, Win, Spr, Sum) - Medical Scholars Research
PEDS 370 (Aut, Win, Spr, Sum) - Undergraduate Directed Reading/Research
PEDS 199 (Aut, Win, Spr, Sum)
- Directed Reading in Pediatrics
All Publications
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The Impact of Hospital Delivery Volumes of Newborns Born Very Preterm on Mortality and Morbidity.
The Journal of pediatrics
2024: 114323
Abstract
To examine if the annual patient volume of infants born very preterm (VPT, gestational age <32 weeks) at a hospital is associated with neonatal mortality and morbidity.We performed an observational, secondary data analysis using a 20-year panel of birth certificates linked to hospital discharge abstracts, including transfers in California, Michigan, Missouri, Oregon, Pennsylvania, and South Carolina from 1996 through 2015. The study included all in-hospital VPT deliveries (N=208,261). Study outcomes were in-hospital mortality or serious morbidity (intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, or bronchopulmonary dysplasia), attributed to the hospital of birth. Poisson regression models estimated the risk-adjusted relative risk (RR) for mortality and serious morbidity across different patient volume categories within a given hospital using hospital fixed effects.The risk of mortality and serious morbidity for VPT infants increased as the number of infants born VPT at a hospital decreased. Compared with VPT delivery volumes >100 infants per year, the risk of mortality increased when a given hospital had VPT delivery volumes < 60 per year, ranging from a RR of 1.13 (95% C.I. 1.02-1.25) for volumes between 50 to 59 to 1.39 (1.19-1.62) for VPT volumes <10, and the risk of mortality or serious morbidity increased when a given hospital had VPT volumes <100, ranging from a RR of 1.05 (1.02-1.08) for volumes between 90 to 99 and 1.27 (1.19-1.36) for VPT volumes <10.These results suggest that, for VPT infants, the risk of both mortality and mortality or serious morbidity is increased as the VPT volume within a given hospital declines.
View details for DOI 10.1016/j.jpeds.2024.114323
View details for PubMedID 39304118
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Assessing the Infant Effects of Severe Maternal.
The Journal of pediatrics
2024: 114230
View details for DOI 10.1016/j.jpeds.2024.114230
View details for PubMedID 39142561
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Acute hospitalizations and outcomes in Veterans Affairs Hospitals 2011 to 2017.
Medicine
2024; 103 (30): e38934
Abstract
Hospitals within the Veterans Affairs (VA) health care system exhibited growing use of observation care. It is unknown how this affected VA hospital performance since observation care is not included in acute inpatient measures. To examine changes in VA hospitalization outcomes and whether it was affected by shifting acute inpatient care to observation care. Longitudinal analysis of 986,355 acute hospitalizations and observation stays in 11 states 2011 to 2017. We estimated temporal changes in 30-day mortality, 30-day readmissions, costs, and length of stay (LOS) for all hospitalizations and 6 conditions in adjusted models. Changes in mortality and readmissions were compared including and excluding observation care. A 9% drop in acute hospitalizations was offset by a 157% increase in observation stays 2011 to 2017. A 30-day mortality decreased but readmissions did not when observation stays were included (all P < .05). Mean costs increased modestly; mean LOS was unchanged. There were differences by condition. VA hospital mortality decreased; there was no change in readmissions.
View details for DOI 10.1097/MD.0000000000038934
View details for PubMedID 39058822
View details for PubMedCentralID PMC11272369
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Life-sustaining treatment decisions and family evaluations of end-of-life care for Veteran decedents in Department of Veterans Affairs nursing homes.
Journal of the American Geriatrics Society
2024
Abstract
Modeled after the Physician Orders for Life Sustaining Treatment program, the Veterans Health Administration (VA) implemented the Life-Sustaining Treatment (LST) Decisions Initiative to improve end-of-life outcomes by standardizing LST preference documentation for seriously ill Veterans. This study examined the associations between LST documentation and family evaluation of care in the final month of life for Veterans in VA nursing homes.Retrospective, cross-sectional analysis of data for decedents in VA nursing homes between July 1, 2018 and January 31, 2020 (N = 14,575). Regression modeling generated odds for key end-of-life outcomes and family ratings of care quality.LST preferences were documented for 12,928 (89%) of VA nursing home decedents. Contrary to our hypothesis, neither receipt of wanted medications and medical treatment (adjusted odds ratio [OR]: 0.85, 95% confidence interval [CI] 0.63, 1.16) nor ratings of overall care in the last month of life (adjusted OR: 0.96, 95% CI 0.76, 1.22) differed significantly between those with and without completed LST templates in adjusted analyses.Among Community Living Center (CLC) decedents, 89% had documented LST preferences. No significant differences were observed in family ratings of care between Veterans with and without documentation of LST preferences. Interventions aimed at improving family ratings of end-of-life care quality in CLCs should not target LST documentation in isolation of other factors associated with higher family ratings of end-of-life care quality.
View details for DOI 10.1111/jgs.19050
View details for PubMedID 38970392
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Who's in the NICU? A population-level analysis.
Journal of perinatology : official journal of the California Perinatal Association
2024
Abstract
To understand the characteristics of infants admitted to US NICUs.2006-2014 linked birth certificate and hospital discharge data for potentially viable deliveries in Pennsylvania and South Carolina were used. NICU admissions were identified using revenue codes. NICU-admitted infants were categorized by gestational age (GA), birthweight, and condition severity (for GA 35+ weeks). We also assessed total patient days and trends over time.12% of infants were admitted to a NICU; 13.6% were GA < 32 weeks (45.3% of total days); 36.1% were GA 32-36 weeks (31.2% of total days); and 50.4% were GA 37+ weeks (23.5% of total days). 20% of admissions were for infants with GA 35+ weeks and mild conditions. Admissions increased numerically from 11.2% (2006) to 13.0% (2014), with increases among infants 35+ weeks.Most NICU admissions are for infants 35+ weeks GA, many with mild conditions who may be accommodated in well-baby units.
View details for DOI 10.1038/s41372-024-02039-6
View details for PubMedID 38944662
View details for PubMedCentralID 7303809
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Racial and Ethnic Disparities in Severe Maternal Morbidity from Pregnancy through 1-year Postpartum.
American journal of obstetrics & gynecology MFM
2024: 101412
Abstract
Previous studies examining racial and ethnic disparities in severe maternal morbidity (SMM) have mainly focused on intrapartum hospitalization. There is limited information regarding the racial and ethnic distribution of SMM occurring in the antepartum and postpartum periods, including SMM occurring beyond the traditional 6 weeks postpartum period.To examine the racial and ethnic distribution of SMM during antepartum, intrapartum, and postpartum hospitalizations through 1-year postpartum, overall and stratified by maternal sociodemographic factors, and to estimate the percent increase in SMM by race and ethnicity and maternal sociodemographic factors within each racial and ethnic group after accounting for both antepartum and postpartum SMM through 1-year postpartum rather than just SMM occurring during the intrapartum hospitalization.We conducted a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008-2020. We examined the distribution of non-transfusion SMM and total SMM per 10,000 cases during antepartum, intrapartum, and postpartum hospitalizations through 365 days postpartum by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. We subsequently examined "SMM cases added" by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. The "SMM cases added" represent cases among unique individuals that are identified by considering the antepartum and postpartum periods but that would be missed if only the intrapartum hospitalization cases were included.Among 2,584,206 birthing individuals, a total of 37,112 (1.4%) individuals experienced non-transfusion SMM and 64,661 (2.5%) experienced any SMM during antepartum, intrapartum, and/or postpartum hospitalization. Black individuals had the highest rate of antepartum, intrapartum, and postpartum non-transfusion and total SMM followed by American Indian individuals. Asian individuals had the lowest rate of non-transfusion and total SMM during antepartum and postpartum hospitalizations while White individuals had the lowest rate of non-transfusion and total SMM during the intrapartum hospitalization. Black individuals were 1.9 times more likely to experience non-transfusion SMM during the intrapartum hospitalization than White individuals, which increased to 2.8 times during the antepartum period and to 2.5 times during the postpartum period. Asian and Hispanic individuals were less likely to experience SMM in the postpartum period than White individuals. Including antepartum and postpartum hospitalizations resulted in disproportionately more cases among Black and American Indian individuals than among White, Hispanic, and Asian individuals. The additional cases were also more likely to occur among individuals with lower educational levels and individuals on government insurance.Racial disparities in SMM are underreported in estimates that focus on the intrapartum hospitalization. Additionally, individuals with low socio-economic status bear the greatest burden of SMM occurring during the antepartum and postpartum periods. Approaches that focus on mitigating SMM during the intrapartum period only do not address the full spectrum of health disparities.
View details for DOI 10.1016/j.ajogmf.2024.101412
View details for PubMedID 38908797
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Severe Maternal Morbidity from Pregnancy through 1-year Postpartum.
American journal of obstetrics & gynecology MFM
2024: 101385
Abstract
Few recent studies have examined the rate of severe maternal morbidity (SMM) occurring during the antenatal and/or the postpartum period through 42 days postpartum. However, little is known about the rate of SMM occurring beyond 42 days postpartum.To examine the distribution of SMM and its indicators during antenatal, delivery, and postpartum hospitalizations through 365 days postpartum, and to estimate the increase in SMM rate and its indicators after accounting for antenatal and postpartum SMM through 365 days postpartum.We conducted a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008-2020. We examined the distribution of SMM, non-transfusion SMM, and SMM indicators during antenatal, delivery, and postpartum hospitalizations through 365 days postpartum. We subsequently examined "SMM cases added," which represent cases among unique individuals that are included by considering the antenatal and postpartum periods but that would be missed if only the delivery hospitalization cases were included.A total of 64,661 (2.5%) individuals experienced SMM while 37,112 (1.4%) individuals experienced non-transfusion SMM during antenatal, delivery, and/or postpartum hospitalization. A total of 31% of SMM cases were added after accounting for SMM occurring during the antenatal or postpartum hospitalization through 365 days postpartum while 49% of non-transfusion SMM cases were added after accounting for non-transfusion SMM occurring during the antenatal or postpartum periods. SMM occurring between 43 and 365 days postpartum contributed to 12% of all SMM cases while non-transfusion SMM occurring between 43 and 365 days postpartum contributed to 19% of all non-transfusion SMM cases.We showed that a total of 31% of SMM and 49% of non-transfusion SMM cases were added after accounting for SMM occurring during the antenatal or postpartum hospitalization through 365 days postpartum. Our findings highlight the importance of expanding the SMM definition beyond the delivery hospitalization to better capture the full period of increased risk, identify contributing factors, and design strategies to mitigate this risk. Only then, can we improve outcomes for mothers and subsequently the quality of life of their infants.
View details for DOI 10.1016/j.ajogmf.2024.101385
View details for PubMedID 38768903
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Lower comorbidity scores and severity levels in Veterans Health Administration hospitals: a cross-sectional study.
BMC health services research
2024; 24 (1): 601
Abstract
Previous studies found that documentation of comorbidities differed when Veterans received care within versus outside Veterans Health Administration (VHA). Changes to medical center funding, increased attention to performance reporting, and expansion of Clinical Documentation Improvement programs, however, may have caused coding in VHA to change.Using repeated cross-sectional data, we compared Elixhauser-van Walraven scores and Medicare Severity Diagnosis Related Group (DRG) severity levels for Veterans' admissions across settings and payers over time, utilizing a linkage of VHA and all-payer discharge data for 2012-2017 in seven US states. To minimize selection bias, we analyzed records for Veterans admitted to both VHA and non-VHA hospitals in the same year. Using generalized linear models, we adjusted for patient and hospital characteristics.Following adjustment, VHA admissions consistently had the lowest predicted mean comorbidity scores (4.44 (95% CI 4.34-4.55)) and lowest probability of using the most severe DRG (22.1% (95% CI 21.4%-22.8%)). In contrast, Medicare-covered admissions had the highest predicted mean comorbidity score (5.71 (95% CI 5.56-5.85)) and highest probability of using the top DRG (35.3% (95% CI 34.2%-36.4%)).More effective strategies may be needed to improve VHA documentation, and current risk-adjusted comparisons should account for differences in coding intensity.
View details for DOI 10.1186/s12913-024-11063-3
View details for PubMedID 38714970
View details for PubMedCentralID PMC11077812
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Evaluating feedback reports to support documentation of veterans' care preferences in home based primary care.
BMC geriatrics
2024; 24 (1): 389
Abstract
BACKGROUND: To evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented.METHODS: We distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation.RESULTS: LST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports.CONCLUSIONS: Feedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.
View details for DOI 10.1186/s12877-024-04999-y
View details for PubMedID 38693502
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Lower Oral Anticoagulant Prescribing for Atrial Fibrillation in Women compared to Men.
The American journal of cardiology
2024
View details for DOI 10.1016/j.amjcard.2024.03.023
View details for PubMedID 38548010
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Behavioral weight management use in the Veterans Health Administration: Sociodemographic and health correlates.
Eating behaviors
2024; 53: 101864
Abstract
Over 40 % of United States Veterans Health Administration (VHA) primary care patients have obesity. Few patients use VHA's flagship weight management program, MOVE! and there is little information on other behavioral weight management program use.The national United States cohort included over 1.5 million primary care patients with obesity, age 18-79, based on VHA administrative data. Gender stratified multivariable logistic regression identified correlates of weight management use in the year after a patient's first primary care appointment (alpha of 0.05). Weight management use was defined as MOVE! or nutrition clinic visits.The cohort included 121,235 women and 1,521,547 men with 13 % and 7 % using weight management, respectively. Point estimates for specific correlates of use were similar between women and men, and across programs. Black patients were more likely to use weight management than White patients. Several physical and mental health diagnoses were also associated with increased use, such as sleep apnea and eating disorders. Age and distance from VHA were negatively associated with weight management use.When assessing multiple types of weight management visits, weight management care in VHA appears to be used more often by some populations at higher risk for obesity. Other groups may need additional outreach, such as those living far from VHA. Future work should focus on outreach and prevention efforts to increase overall use rates. This work could also examine the benefits of tailoring care for populations in greatest need.
View details for DOI 10.1016/j.eatbeh.2024.101864
View details for PubMedID 38489933
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The impact of volume and neonatal level of care on outcomes of moderate and late preterm infants.
Journal of perinatology : official journal of the California Perinatal Association
2024
Abstract
Evaluate the relationship of neonatal unit level of care (LOC) and volume with mortality or morbidity in moderate-late preterm (MLP) (32-36 weeks' gestation) infants.Retrospective cohort study of 650,865 inborn MLP infants in 4976 hospitals-years using 2003-2015 linked administrative data from 4 states. Exposure was combined neonatal LOC and MLP annual volume. The primary outcome was death or morbidity (respiratory distress syndrome, severe intraventricular hemorrhage, necrotizing enterocolitis, sepsis, infection, pneumothorax, extreme length of stay) with components as secondary outcomes. Poisson regression models adjusted for patient characteristics with a random effect for unit were used.In adjusted models, high-volume level 2 units had a lower risk of the primary outcome compared to low-volume level 3 units (aIRR 0.90 [95% CI 0.83-0.98] vs. aIRR 1.13 [95% CI 1.03-1.24], p < 0.001) CONCLUSION: MLP infants had improved outcomes in high-volume level 2 units compared to low-volume level 3 units in adjusted analysis.
View details for DOI 10.1038/s41372-024-01901-x
View details for PubMedID 38413758
View details for PubMedCentralID 4544710
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Validity of Birth Certificate Data Compared With Hospital Discharge Data in Reporting Maternal Morbidity and Disparities.
Obstetrics and gynecology
2024
Abstract
A growing number of studies are using birth certificate data, despite data-quality concerns, to study maternal morbidity and associated disparities. We examined whether conclusions about the incidence of maternal morbidity, including Black-White disparities, differ between birth certificate data and hospitalization data. Using linked birth certificate and hospitalization data from California and Michigan for 2018 (N=543,469), we found that maternal morbidity measures using birth certificate data alone are substantially underreported and have poor validity. Furthermore, the degree of underreporting in birth certificate data differs between Black and White individuals and results in erroneous inferences about disparities. Overall, Black-White disparities were more modest in the birth certificate data compared with the hospitalization data. Birth certificate data alone are inadequate for studies of maternal morbidity and associated racial disparities.
View details for DOI 10.1097/AOG.0000000000005497
View details for PubMedID 38176017
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Perinatal mental health and pregnancy-associated mortality: opportunities for change.
Archives of women's mental health
2024
Abstract
Perinatal mental health conditions have been associated with adverse pregnancy outcomes, including maternal death. This quality improvement project analyzed pregnancy-associated death among veterans with mental health conditions in order to identify opportunities to improve healthcare and reduce maternal deaths. Pregnancy-associated deaths among veterans using Veterans Health Administration (VHA) maternity care benefits between fiscal year 2011 and 2020 were identified from national VHA databases. Deaths among individuals with active mental health conditions underwent individual chart review using a standardized abstraction template adapted from the Centers for Disease Control and Prevention (CDC). Thirty-two pregnancy-associated deaths were identified among 39,720 paid deliveries with 81% (n = 26) occurring among individuals with an active perinatal mental health condition. In the perinatal mental health cohort, most deaths (n = 16, 62%) occurred in the late postpartum period and 42% (n = 11) were due to suicide, homicide, or overdose. Opportunities to improve care included addressing (1) racial disparities, (2) mental health effects of perinatal loss, (3) late postpartum vulnerability, (4) lack of psychotropic medication continuity, (5) mental health conditions in intimate partners, (6) child custody loss, (7) lack of patient education or stigmatizing patient education, and (8) missed opportunities for addressing reproductive health concerns in mental health contexts. Pregnancy-associated deaths related to active perinatal mental health conditions can be reduced. Mental healthcare clinicians, clinical teams, and healthcare systems have opportunities to improve care for individuals with perinatal mental health conditions.
View details for DOI 10.1007/s00737-023-01404-2
View details for PubMedID 38172275
View details for PubMedCentralID 8399218
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In Reply.
Obstetrics and gynecology
2024; 143 (1): e18-e19
View details for DOI 10.1097/AOG.0000000000005457
View details for PubMedID 38096558
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Improving the Maternity Care Safety Net: Establishing Maternal Mortality Surveillance for Non-Obstetric Providers and Institutions.
International journal of environmental research and public health
2023; 21 (1)
Abstract
The siloed nature of maternity care has been noted as a system-level factor negatively impacting maternal outcomes. Veterans Health Administration (VA) provides multi-specialty healthcare before, during, and after pregnancy but purchases obstetric care from community providers. VA providers may be unaware of perinatal complications, while community-based maternity care providers may be unaware of upstream factors affecting the pregnancy. To optimize maternal outcomes, the VA has initiated a system-level surveillance and review process designed to improve non-obstetric care for veterans experiencing a pregnancy. This quality improvement project aimed to describe the VA-based maternal mortality review process and to report maternal mortality (pregnancy-related death up to 42 days postpartum) and pregnancy-associated mortality (death from any cause up to 1 year postpartum) among veterans who use VA maternity care benefits. Pregnancies and pregnancy-associated deaths between fiscal year (FY) 2011-2020 were identified from national VA databases. All deaths underwent individual chart review and abstraction that focused on multi-specialty care received at the VA in the year prior to pregnancy until the time of death. Thirty-two pregnancy-associated deaths were confirmed among 39,720 pregnancies (PAMR = 80.6 per 100,000 live births). Fifty percent of deaths occurred among individuals who had experienced adverse social determinants of health. Mental health conditions affected 81%. Half (n = 16, 50%) of all deaths occurred in the late postpartum period (43-365 days postpartum) after maternity care had ended. More than half of these late postpartum deaths (n = 9, 56.2%) were related to suicide, homicide, or overdose. Integration of care delivered during the perinatal period (pregnancy through postpartum) from primary, mental health, emergency, and specialty care providers may be enhanced through a system-based approach to pregnancy-associated death surveillance and review. This quality improvement project has implications for all healthcare settings where coordination between obstetric and non-obstetric providers is needed.
View details for DOI 10.3390/ijerph21010037
View details for PubMedID 38248502
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Better performance for right-skewed data using an alternative gamma model.
BMC medical research methodology
2023; 23 (1): 298
Abstract
The Maximum Likelihood Estimator (MLE) for parameters of the gamma distribution is commonly used to estimate models of right-skewed variables such as costs, hospital length of stay, and appointment wait times in Economics and Healthcare research. The common specification for this estimator assumes the variance is proportional to the square of the mean, which underlies estimation and specification tests. We present a specification in which the variance is directly proportional to the mean.We used simulation experiments to investigate finite sample results, and we used United States Department of Veterans Affairs (VA) healthcare cost data as an empirical example comparing the fit and predictive ability of the models.Simulation showed the MLE based on a correctly specified alternative has less parameter bias, lower standard errors, and less skewness in distribution than a misspecified standard model. The application to VA healthcare cost data showed the alternative specification can have better R square, smaller root mean squared error, and smaller mean residuals within deciles of predicted values.The alternative gamma specification can be a useful alternative to the standard specification for estimating models of right-skewed continuous variables.
View details for DOI 10.1186/s12874-023-02113-1
View details for PubMedID 38102539
View details for PubMedCentralID 7183716
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Outcomes of Veterans Treated in Veterans Affairs Hospitals vs Non-Veterans Affairs Hospitals.
JAMA network open
2023; 6 (12): e2345898
Abstract
Many veterans enrolled in the Veterans Affairs (VA) health care system have access to non-VA care through insurance and VA-purchased community care. Prior comparisons of VA and non-VA hospital outcomes have been limited to subpopulations.To compare outcomes for 6 acute conditions in VA and non-VA hospitals for younger and older veterans using VA and all-payer discharge data.This cohort study used a repeated cross-sectional analysis of hospitalization records for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), gastrointestinal (GI) hemorrhage, heart failure (HF), pneumonia, and stroke. Participants included VA enrollees from 11 states at VA and non-VA hospitals from 2012 to 2017. Analysis was conducted from July 1, 2022, to October 18, 2023.Treatment in VA or non-VA hospital.Thirty-day mortality, 30-day readmission, length of stay (LOS), and costs. Average treatment outcomes of VA hospitals were estimated using inverse probability weighted regression adjustment to account for selection into hospitals. Models were stratified by veterans' age (aged less than 65 years and aged 65 years and older).There was a total of 593 578 hospitalizations and 414 861 patients with mean (SD) age 75 (12) years, 405 602 males (98%), 442 297 hospitalizations of non-Hispanic White individuals (75%) and 73 155 hospitalizations of non-Hispanic Black individuals (12%) overall. VA hospitalizations had a lower probability of 30-day mortality for HF (age ≥65 years, -0.02 [95% CI, -0.03 to -0.01]) and stroke (age <65 years, -0.03 [95% CI, -0.05 to -0.02]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.03]). VA hospitalizations had a lower probability of 30-day readmission for CABG (age <65 years, -0.04 [95% CI, -0.06 to -0.01]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.02]), GI hemorrhage (age <65 years, -0.04 [95% CI, -0.06 to -0.03]), HF (age <65 years, -0.05 [95% CI, -0.07 to -0.03]), pneumonia (age <65 years, -0.04 [95% CI, -0.06 to -0.03]; age ≥65 years, -0.03 [95% CI, -0.04 to -0.02]), and stroke (age <65 years, -0.11 [95% CI, -0.13 to -0.09]; age ≥65 years, -0.13 [95% CI, -0.16 to -0.10]) but higher probability of readmission for AMI (age <65 years, 0.04 [95% CI, 0.01 to 0.06]). VA hospitalizations had a longer mean LOS and higher costs for all conditions, except AMI and stroke in younger patients.In this cohort study of veterans, VA hospitalizations had lower mortality for HF and stroke and lower readmissions, longer LOS, and higher costs for most conditions compared with non-VA hospitalizations with differences by condition and age group. There were tradeoffs between better outcomes and higher resource use in VA hospitals for some conditions.
View details for DOI 10.1001/jamanetworkopen.2023.45898
View details for PubMedID 38039003
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Differences in use of Veterans Health Administration and non-Veterans Health Administration hospitals by rural and urban Veterans after access expansions.
The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association
2023
Abstract
To examine changes in rural and urban Veterans' utilization of acute inpatient care in Veterans Health Administration (VHA) and non-VHA hospitals following access expansion from the Veterans Choice Act, which expanded eligibility for VHA-paid community hospitalization.Using repeated cross-sectional data of VHA enrollees' hospitalizations in 9 states (AZ, CA, CT, FL, LA, MA, NY, PA, and SC) between 2012 and 2017, we compared rural and urban Veterans' probability of admission in VHA and non-VHA hospitals by payer over time for elective and nonelective hospitalizations using multinomial logistic regression to adjust for patient-level sociodemographic features. We also used generalized linear models to compare rural and urban Veterans' travel distances to hospitals.Over time, the probability of VHA-paid community hospitalization increased more for rural Veterans than urban Veterans. For elective inpatient care, rural Veterans' probability of VHA-paid admission increased from 2.9% (95% CI 2.6%-3.2%) in 2012 to 6.5% (95% CI 5.8%-7.1%) in 2017. These changes were associated with a temporal trend that preceded and continued after the implementation of the Veterans Choice Act. Overall travel distances to hospitalizations were similar over time; however, the mean distance traveled decreased from 39.2 miles (95% CI 35.1-43.3) in 2012 to 32.3 miles (95% CI 30.2-34.4) in 2017 for rural Veterans receiving elective inpatient care in VHA-paid hospitals.Despite limited access to rural hospitals, these data demonstrate an increase in rural Veterans' use of non-VHA hospitals for acute inpatient care and a small reduction in distance traveled to elective inpatient services.
View details for DOI 10.1111/jrh.12812
View details for PubMedID 38036456
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An exploratory analysis of factors associated with spontaneous preterm birth among pregnant veterans with post-traumatic stress disorder.
Women's health issues : official publication of the Jacobs Institute of Women's Health
2023; 33 (2): 191-198
Abstract
Pregnant veterans with post-traumatic stress disorder (PTSD) are at increased risk for spontaneous preterm birth, yet the underlying reasons are unclear. We examined factors associated with spontaneous preterm birth among pregnant veterans with active PTSD.This was an observational study of births from administrative databases reimbursed by the Veterans Health Association (VA) between 2005 and 2015. Singleton livebirths among veterans with active PTSD within 12 months prior to childbirth were included. The primary outcome was spontaneous preterm birth. Maternal demographics, psychiatric history, and pregnancy complications were evaluated as exposures. Covariates significant on bivariate analysis, as well as age and race/ethnicity as a social construct, were included in multivariable logistic regression to identify factors associated with spontaneous preterm birth. Additional analyses stratified significant covariates by the presence of active concurrent depression and explored interactions between antidepressant use and preeclampsia.Of 3,242 eligible births to veterans with active PTSD, 249 (7.7%) were spontaneous preterm births. The majority of veterans with active PTSD (79.1%) received some type of mental health treatment, and active concurrent depression was prevalent (61.4%). Preeclampsia/eclampsia (adjusted odds ratio [aOR] 3.30, 95% confidence interval [CI] 1.67-6.54) and ≥6 antidepressant medication dispensations within 12 months prior to childbirth (aOR 1.89, 95% CI 1.29-2.77) were associated with spontaneous preterm birth. No evidence of interaction was seen between antidepressant use and preeclampsia on spontaneous preterm birth (p=0.39). Findings were similar when stratified by active concurrent depression.Among veterans with active PTSD, preeclampsia/eclampsia and ≥6 antidepressant dispensations were associated with spontaneous preterm birth. While the results do not imply that people should discontinue needed antidepressants during pregnancy in veterans with PTSD, research into these factors might inform preterm birth prevention strategies for this high-risk population.
View details for DOI 10.1016/j.whi.2022.09.005
View details for PubMedID 37576490
View details for PubMedCentralID PMC10421070
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Hospital and Patient Factors Affecting Veterans' Hospital Choice.
Medical care research and review : MCRR
2023: 10775587231194681
Abstract
Veterans enrolled in the Veterans Affairs (VA) health care system gained greater access to non-VA care beginning in 2014. We examined hospital and Veteran characteristics associated with hospital choice. We conducted a longitudinal study of elective hospitalizations 2011 to 2017 in 11 states and modeled patients' choice of VA hospital, large non-VA hospital, or small non-VA hospital in conditional logit models. Patients had higher odds of choosing a hospital with an academic affiliation, better patient experience rating, location closer to them, and a more common hospital type. Patients who were male, racial/ethnic minorities, had higher VA enrollment priority, and had a mental health comorbidity were more likely than other patients to choose a VA hospital than a non-VA hospital. Our findings suggest that patients respond to certain hospital attributes. VA hospitals may need to maintain or achieve high levels of quality and patient experience to attract or retain patients in the future.
View details for DOI 10.1177/10775587231194681
View details for PubMedID 37679963
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Chronic Hypertension in Pregnancy and Racial-Ethnic Disparities in Complications.
Obstetrics and gynecology
2023
Abstract
To evaluate whether there are individual- and population-level associations between chronic hypertension and pregnancy complications, and to assess differences across seven racial-ethnic groups.This population-based study used linked vital statistics and hospitalization discharge data from all live and stillbirths in California (2008-2018), Michigan (2008-2020), Oregon (2008-2020), Pennsylvania (2008-2014), and South Carolina (2008-2020). We used multivariable log-binomial regression models to estimate risk ratios (RRs) and population attributable risk (PAR) percentages with 95% CIs for associations between chronic hypertension and several obstetric and neonatal outcomes, selected based on prior evidence and pathologic pathways. We adjusted models for demographic factors (race and ethnicity, payment method, educational attainment), age, body mass index, obstetric history, delivery year, and state, and conducted analyses stratified across seven racial-ethnic groups.The study included 7,955,713 pregnancies, of which 168,972 (2.1%) were complicated by chronic hypertension. Chronic hypertension was associated with several adverse obstetric and neonatal outcomes, with the largest adjusted PAR percentages observed for preeclampsia with severe features or eclampsia (22.4; 95% CI 22.2-22.6), acute renal failure (13.6; 95% CI 12.6-14.6), and pulmonary edema (10.7; 95% CI 8.9-12.6). Estimated RRs overall were similar across racial-ethnic groups, but PAR percentages varied. The adjusted PAR percentages (95% CI) for severe maternal morbidity-a widely used composite of acute severe events-for people who were American Indian or Alaska Native, Asian, Black, Latino, Native Hawaiian or Other Pacific Islander, White, and Multiracial or Other were 5.0 (1.1-8.8), 3.7 (3.0-4.3), 9.0 (8.2-9.8), 3.9 (3.6-4.3), 11.6 (6.4-16.5), 3.2 (2.9-3.5), and 5.5 (4.2-6.9), respectively.Chronic hypertension accounts for a substantial fraction of obstetric and neonatal morbidity and contributes to higher complication rates, particularly for people who are Black or Native Hawaiian or Other Pacific Islander.
View details for DOI 10.1097/AOG.0000000000005342
View details for PubMedID 37678888
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Perinatal Care Measures Are Incomplete If They Do Not Assess The Birth Parent-Infant Dyad As A Whole.
Health affairs (Project Hope)
2023; 42 (9): 1266-1274
Abstract
Measures of perinatal care quality and outcomes often focus on either the birth parent or the infant. We used linked vital statistics and hospital discharge data to describe a dyadic measure (including both the birth parent and the infant) for perinatal care during the birth hospitalization. In this five-state cohort of 2010-18 births, 21.6 percent of birth parent-infant dyads experienced at least one complication, and 9.6 percent experienced a severe complication. Severe infant complications were eight times more prevalent than severe birth parent complications. Among birth parents with a severe complication, the co-occurrence of a severe infant complication ranged from 2 percent to 51 percent, whereas among infants with a severe complication, the co-occurrence of a severe birth parent complication was rare, ranging from 0.04 percent to 5 percent. These data suggest that measures, clinical interventions, public reporting, and policies focused on either the birth parent or the infant are incomplete in their assessment of a healthy dyad. Thus, clinicians, administrators, and policy makers should evaluate dyadic measures, incentivize positive outcomes for both patients (parent and infant), and create policies that support the health of the dyad.
View details for DOI 10.1377/hlthaff.2023.00398
View details for PubMedID 37669487
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Association between stillbirth and severe maternal morbidity.
American journal of obstetrics and gynecology
2023
Abstract
Severe maternal morbidity (SMM) has been increasing in the past few decades. Few studies have examined the risk of SMM among individuals experiencing a stillbirth versus a live birth.To examine the prevalence and risk of SMM among individuals with stillbirth versus individuals with live birth deliveries during delivery hospitalization as a primary outcome and during postpartum period as a secondary outcome.We conducted a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from California (2008-2018), Michigan (2008-2020), Missouri (2008-2014), Pennsylvania (2008-2014), and South Carolina (2008-2020). We used relative risk regression analysis to examine the crude and adjusted relative risk (aRR) of SMM along with 95% confidence intervals (CI) among individuals with stillbirth versus live birth deliveries, adjusting for birth year, state of residence, maternal sociodemographic characteristics, and an obstetric comorbidity index.Of the 8,694,912 deliveries, 35,012 (0.40%) were stillbirth. Compared to individuals with a live birth delivery, those with a stillbirth were more likely to be non-Hispanic Black (20.5% versus 10.8%), on Medicaid (52.0% versus 46.5%), have pregnancy complications including preexisting diabetes (4.3% versus 1.1%), preexisting hypertension (6.2% versus 2.3%), and preeclampsia (8.4% versus 4.4%), have multiple gestations (6.2% versus 1.6%), and reside in South Carolina (11.6% versus 7.4%). During the delivery hospitalization, the prevalence of SMM for stillbirth versus live birth deliveries was 791 versus 154 cases per 10,000 deliveries, while the prevalence for non-transfusion SMM was 502 versus 68 cases per 10,000 deliveries. The crude RR for SMM was 5.1 (95% CI 4.9-5.3) while the aRR was 1.6 (95% CI 1.5-1.8). For non-transfusion SMM, the crude RR was 7.4 (95% CI 7.0-7.7) while the aRR was 2.0 (95% CI 1.8-2.3) among stillbirth compared with live birth deliveries. This risk was not only elevated among individuals with stillbirth during the delivery hospitalization but also through one year postpartum (SMM aRR: 1.3; 95% CI 1.1-1.4; non-transfusion SMM aRR: 1.2; 95% CI 1.1-1.3).Stillbirth was found to be an important contributor to SMM.
View details for DOI 10.1016/j.ajog.2023.08.029
View details for PubMedID 37659745
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Association of Sickle Cell Disease With Racial Disparities and Severe Maternal Morbidities in Black Individuals.
JAMA pediatrics
2023
Abstract
Little is known about the association between sickle cell disease (SCD) and severe maternal morbidity (SMM).To examine the association of SCD with racial disparities in SMM and with SMM among Black individuals.This cohort study was a retrospective population-based investigation of individuals with and without SCD in 5 states (California [2008-2018], Michigan [2008-2020], Missouri [2008-2014], Pennsylvania [2008-2014], and South Carolina [2008-2020]) delivering a fetal death or live birth. Data were analyzed between July and December 2022.Sickle cell disease identified during the delivery admission by using International Classification of Diseases, Ninth Revision and Tenth Revision codes.The primary outcomes were SMM including and excluding blood transfusions during the delivery hospitalization. Modified Poisson regression was used to estimate risk ratios (RRs) adjusted for birth year, state, insurance type, education, maternal age, Adequacy of Prenatal Care Utilization Index, and obstetric comorbidity index.From a sample of 8 693 616 patients (mean [SD] age, 28.5 [6.1] years), 956 951 were Black individuals (11.0%), of whom 3586 (0.37%) had SCD. Black individuals with SCD vs Black individuals without SCD were more likely to have Medicaid insurance (70.2% vs 64.6%), to have a cesarean delivery (44.6% vs 34.0%), and to reside in South Carolina (25.2% vs 21.5%). Sickle cell disease accounted for 8.9% and for 14.3% of the Black-White disparity in SMM and nontransfusion SMM, respectively. Among Black individuals, SCD complicated 0.37% of the pregnancies but contributed to 4.3% of the SMM cases and to 6.9% of the nontransfusion SMM cases. Among Black individuals with SCD compared with those without, the crude RRs of SMM and nontransfusion SMM during the delivery hospitalization were 11.9 (95% CI, 11.3-12.5) and 19.8 (95% CI, 18.5-21.2), respectively, while the adjusted RRs were 3.8 (95% CI, 3.3-4.5) and 6.5 (95% CI, 5.3-8.0), respectively. The SMM indicators that incurred the highest adjusted RRs included air and thrombotic embolism (4.8; 95% CI, 2.9-7.8), puerperal cerebrovascular disorders (4.7; 95% CI, 3.0-7.4), and blood transfusion (3.7; 95% CI, 3.2-4.3).In this retrospective cohort study, SCD was found to be an important contributor to racial disparities in SMM and was associated with an elevated risk of SMM among Black individuals. Efforts from the research community, policy makers, and funding agencies are needed to advance care among individuals with SCD.
View details for DOI 10.1001/jamapediatrics.2023.1580
View details for PubMedID 37273202
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Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals.
JAMA health forum
2023; 4 (6): e232110
Abstract
Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts.To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients.This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023.Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties.The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity.Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients.In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.
View details for DOI 10.1001/jamahealthforum.2023.2110
View details for PubMedID 37354537
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Physical Fitness in Relationship to Depression and Post-Traumatic Stress Disorder During Pregnancy Among U.S. Army Soldiers.
Journal of women's health (2002)
2023
Abstract
Background: Depression and post-traumatic stress disorder (PTSD) are prevalent in pregnancy, especially among military members. These conditions can lead to adverse birth outcomes, yet, there's a paucity of evidence for prevention strategies. Optimizing physical fitness is one understudied potential intervention. We explored associations between prepregnancy physical fitness and antenatal depression and PTSD in soldiers. Materials and Methods: This was a retrospective cohort study of active-duty U.S. Army soldiers with live births between 2011 and 2014, identified with diagnosis codes from inpatient and outpatient care. The exposure was each individual's mean Army physical fitness score from 10 to 24 months before childbirth. The primary outcome was a composite of active depression or PTSD during pregnancy, defined using the presence of a code within 10 months before childbirth. Demographic variables were compared across four quartiles of fitness scores. Multivariable logistic regression models were conducted adjusting for potential confounders selected a priori. A stratified analysis was conducted for depression and PTSD separately. Results: Among 4,583 eligible live births, 352 (7.7%) had active depression or PTSD during pregnancy. Soldiers with the highest fitness scores (Quartile 4) were less likely to have active depression or PTSD in pregnancy (Quartile 4 vs. Quartile 1 adjusted odds ratio 0.55, 95% confidence interval 0.39-0.79). Findings were similar in stratified analyses. Conclusion: In this cohort, the odds of active depression or PTSD during pregnancy were significantly reduced among soldiers with higher prepregnancy fitness scores. Optimizing physical fitness may be a useful tool to reduce mental health burden on pregnancy.
View details for DOI 10.1089/jwh.2022.0538
View details for PubMedID 37196157
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Trends in Resources for Neonatal Intensive Care at Delivery Hospitals for Infants Born Younger Than 30 Weeks' Gestation, 2009-2020.
JAMA network open
2023; 6 (5): e2312107
Abstract
In an ideal regionalized system, all infants born very preterm would be delivered at a large tertiary hospital capable of providing all necessary care.To examine whether the distribution of extremely preterm births changed between 2009 and 2020 based on neonatal intensive care resources at the delivery hospital.This retrospective cohort study was conducted at 822 Vermont Oxford Network (VON) centers in the US between 2009 and 2020. Participants included infants born at 22 to 29 weeks' gestation, delivered at or transferred to centers participating in the VON. Data were analyzed from February to December 2022.Hospital of birth at 22 to 29 weeks' gestation.Birthplace neonatal intensive care unit (NICU) level was classified as A, restriction on assisted ventilation or no surgery; B, major surgery; or C, cardiac surgery requiring bypass. Level B centers were further divided into low-volume (<50 inborn infants at 22 to 29 weeks' gestation per year) and high-volume (≥50 inborn infants at 22 to 29 weeks' gestation per year) centers. High-volume level B and level C centers were combined, resulting in 3 distinct NICU categories: level A, low-volume B, and high-volume B and C NICUs. The main outcome was the change in the percentage of births at hospitals with level A, low-volume B, and high-volume B or C NICUs overall and by US Census region.A total of 357 181 infants (mean [SD] gestational age, 26.4 [2.1] weeks; 188 761 [52.9%] male) were included in the analysis. Across regions, the Pacific (20 239 births [38.3%]) had the lowest while the South Atlantic (48 348 births [62.7%]) had the highest percentage of births at a hospital with a high-volume B- or C-level NICU. Births at hospitals with A-level NICUs increased by 5.6% (95% CI, 4.3% to 7.0%), and births at low-volume B-level NICUs increased by 3.6% (95% CI, 2.1% to 5.0%), while births at hospitals with high-volume B- or C-level NICUs decreased by 9.2% (95% CI, -10.3% to -8.1%). By 2020, less than half of the births for infants at 22 to 29 weeks' gestation occurred at hospitals with high-volume B- or C-level NICUs. Most US Census regions followed the nationwide trends; for example, births at hospitals with high-volume B- or C-level NICUs decreased by 10.9% [95% CI, -14.0% to -7.8%) in the East North Central region and by 21.1% (95% CI, -24.0% to -18.2%) in the West South Central region.This retrospective cohort study identified concerning deregionalization trends in birthplace hospital level of care for infants born at 22 to 29 weeks' gestation. These findings should serve to encourage policy makers to identify and enforce strategies to ensure that infants at the highest risk of adverse outcomes are born at the hospitals where they have the best chances to attain optimal outcomes.
View details for DOI 10.1001/jamanetworkopen.2023.12107
View details for PubMedID 37145593
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Correction: Visual process maps to support implementation efforts: a case example.
Implementation science communications
2023; 4 (1): 29
View details for DOI 10.1186/s43058-023-00414-6
View details for PubMedID 36941699
View details for PubMedCentralID PMC10026513
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Racial/Ethnic Disparities in Costs, Length of Stay, and Severity of Severe Maternal Morbidity.
American journal of obstetrics & gynecology MFM
2023: 100917
Abstract
BACKGROUND: In contrast to other high-resource countries, the US has experienced increases in the rates of severe maternal morbidity. The US also has pronounced racial/ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people.OBJECTIVE(S): The objective of this study was to examine if the racial/ethnic disparities in severe maternal morbidity extended beyond the rates of these complications to include disparities in maternal costs and lengths of stay, which could indicate differences in the case severity.STUDY DESIGN: This study used California's linkage of birth certificates to inpatient maternal and infant discharge data for 2009-2011. Of the 1.5 million linked records, 250,000 were excluded due to incomplete data, for a final sample of 1,262,862. Cost-to-charge ratios were used to estimate costs from charges (including readmissions) after adjusting for inflation to December 2017. Mean diagnostic-related group-specific reimbursement was used to estimate physician payments. We used the Centers for Disease Control and Prevention definition of severe maternal morbidity, including readmissions up to 42 days postpartum. Adjusted Poisson regression models estimated the differential risk of severe maternal morbidity for each racial/ethnic group, compared with the non-Hispanic White group. Generalized linear models estimated the associations of race/ethnicity with costs and length of stay.RESULTS: Asian/Pacific Islander, Non-Hispanic Black, Hispanic, and Other race/ethnicity patients all had higher rates of severe maternal morbidity than non-Hispanic White patients. The largest disparity was between non-Hispanic White and non-Hispanic Black patients, with unadjusted overall rates of severe maternal morbidity of 1.34% and 2.62%, respectively (adjusted risk ratio 1.61, p<0.001). Among patients with severe maternal morbidity, the adjusted regression estimates showed that non-Hispanic Black patients had 23% (p<0.001) higher costs (marginal effect $5,023) and 24% (p<0.001) longer hospital stays (marginal effect 1.4 days) compared to non-Hispanic White patients. These effects changed when cases where a blood transfusion was the only indication of severe maternal morbidity were excluded, with 29% higher costs (p<0.001) and 15% longer length of stay (p<0.001). For other racial/ethnic groups, the increases in costs and length of stay were smaller than those observed for non-Hispanic Black patients, and many were not significant different from non-Hispanic White patients. Hispanic patients had higher rates of severe maternal morbidity than non-Hispanic White patients but significantly lower costs and length of stay.CONCLUSION(S): There were racial/ethnic differences in the costs and length of stay among patients with severe maternal morbidity across the groupings that we examined. The differences were especially large for non-Hispanic Black patients compared with non-Hispanic White patients. Non-Hispanic Black patients experienced twice the rate of severe maternal morbidity; additionally, the higher relative costs and longer lengths of stay for non-Hispanic Black patients with severe maternal morbidity supports greater case severity in that population. These findings suggest that efforts to address racial/ethnic inequities in maternal health need to consider differences in case severity in addition to the differences in the rates of severe maternal morbidity and that these differences in case severity merit additional investigation.
View details for DOI 10.1016/j.ajogmf.2023.100917
View details for PubMedID 36882126
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An Exploratory Analysis of Factors Associated With Spontaneous Preterm Birth Among Pregnant Veterans With Post-Traumatic Stress Disorder
WOMENS HEALTH ISSUES
2023; 33 (2): 191-198
View details for DOI 10.1016/j.whi.2022.09.005
View details for Web of Science ID 000990469400001
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Associations between physical fitness, depression, and PTSD during pregnancy among US Army soldiers
MOSBY-ELSEVIER. 2023: S121
View details for Web of Science ID 000909337400167
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Impact of psychiatric conditions on the risk of severe maternal morbidity in veterans
MOSBY-ELSEVIER. 2023: S457-S458
View details for Web of Science ID 000909337401261
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IMPROVING PROGNOSTIC NEONATAL EARLY WARNING SCORES IN LOW-RESOURCE SETTINGS: A FOLLOW-UP RETROSPECTIVE CASE-CONTROL STUDY IN ADDIS ABABA, ETHIOPIA
LIPPINCOTT WILLIAMS & WILKINS. 2022
View details for Web of Science ID 001002238300168
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Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care.
Military medicine
2022
Abstract
INTRODUCTION: A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk care fragmentation. Postpartum transitions in care are known to be especially tenuous, with low rates of primary care reengagement. The objective of this study is to better understand this transition from the perspectives of the VA care teams.MATERIALS AND METHODS: Eight semi-structured qualitative interviews with VA team members who work in maternity care were conducted at a single VA center's regional network. Interviews explored the transition from maternity care to primary care to understand the care team's perspective at three levels: patient, clinician, and systems. Rapid qualitative analysis was used to identify emergent themes.RESULTS: Participants identified facilitators and opportunities for improvement in the postpartum transition of care. Patient-clinician trust is a key facilitator in the transition from maternity to primary care for veterans, and the breadth of VA services emerged as a key system-level facilitator to success. Interviewees also highlighted opportunities for improvement, including more trauma-informed practices for nonbinary veterans, increased care coordination between VA and community staff, and the need for training in postpartum health with an emphasis on health equity for primary care clinicians.CONCLUSIONS: The Department of Veterans Affairs Healthcare System care team perspectives may inform practice changes to support the transition from maternity to primary care for veterans. To move toward health equity, a system-level approach to policy and programming is necessary to reduce barriers to primary care reengagement. This study was limited in terms of sample size, and future research should explore veteran perspectives on VA postpartum care transitions.
View details for DOI 10.1093/milmed/usac275
View details for PubMedID 36151892
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Hospital variation in extremely preterm birth.
Journal of perinatology : official journal of the California Perinatal Association
2022
Abstract
Given that regionalization of extremely preterm births (EPTBs) is associated with improved infant outcomes, we assessed between-hospital variation in EPTB stratified by hospital level of neonatal care, and determined the proportion of variance explained by differences in maternal and hospital factors.We assessed 7,046,253 births in California from 1997 to 2011, using hospital discharge, birth, and death certificate data. We estimated the association between maternal and hospital factors and EPTB using multivariable regression, calculated hospital-specific EPTB frequencies, and estimated between-hospital variances and median odds ratios, stratified by hospital level of care.Hospital frequencies of EPTB ranged from 0% to 2.5%. Between-hospital EPTB frequencies varied substantially, despite stratifying by hospital level of care and accounting for confounding factors.Our results demonstrate differences in EPTBs among hospitals with level 1 and 2 neonatal care, an area to target for future research and quality improvement.
View details for DOI 10.1038/s41372-022-01505-3
View details for PubMedID 36104499
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Gynecologist Supply Deserts Across the VA and in the Community.
Journal of general internal medicine
2022
Abstract
The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care.Compare gynecologist supply in veterans' county of residence versus at their VA site.We identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called "local") of veterans' VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were "inadequate-supply" counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences.All women veteran FY2017 VA primary care users nationally.Availability of a VA gynecologist within 50 miles of a veteran's VA homesite; county-level "inadequate-supply" of gynecologists.Among 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women's clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist.Most veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA's critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity.
View details for DOI 10.1007/s11606-022-07591-5
View details for PubMedID 36042097
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Successful Discharge of Short Stay Veterans from VA Community Living Centers.
Journal of aging & social policy
2022: 1-17
Abstract
The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007-2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed the patient and facility rates of successful discharge to the community (SDC) of these short-stay Veterans. We found large variation in inter- as well as intra- facility SDC rates across the rehabilitation and skilled nursing short-stay cohorts. We discuss how our results can help guide VHA policy directed at delivering high-quality short-stay CLC care for Veterans.
View details for DOI 10.1080/08959420.2022.2111169
View details for PubMedID 35959862
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Health Care Access Expansions and Use of Veterans Affairs and Other Hospitals by Veterans
JAMA HEALTH FORUM
2022; 3 (6): e221409
Abstract
This cohort study examines changes in the use of Veterans Affairs (VA) and non-VA hospitals by VA enrollees and mortality associated with these policies.
View details for DOI 10.1001/jamahealthforum.2022.1409
View details for Web of Science ID 000837641700003
View details for PubMedID 35977247
View details for PubMedCentralID PMC9187948
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A data-driven health index for neonatal morbidities.
iScience
2022; 25 (4): 104143
Abstract
Whereas prematurity is a major cause of neonatal mortality, morbidity, and lifelong impairment, the degree of prematurity is usually defined by the gestational age (GA) at delivery rather than by neonatal morbidity. Here we propose a multi-task deep neural network model that simultaneously predicts twelve neonatal morbidities, as the basis for a new data-driven approach to define prematurity. Maternal demographics, medical history, obstetrical complications, and prenatal fetal findings were obtained from linked birth certificates and maternal/infant hospitalization records for 11,594,786 livebirths in California from 1991 to 2012. Overall, our model outperformed traditional models to assess prematurity which are based on GA and/or birthweight (area under the precision-recall curve was 0.326 for our model, 0.229 for GA, and 0.156 for small for GA). These findings highlight the potential of using machine learning techniques to predict multiple prematurity phenotypes and inform clinical decisions to prevent, diagnose and treat neonatal morbidities.
View details for DOI 10.1016/j.isci.2022.104143
View details for PubMedID 35402862
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Evaluating implementation strategies to support documentation of veterans' care preferences.
Health services research
2022
Abstract
OBJECTIVE: To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented.DATA SOURCES: Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020.STUDY DESIGN: In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites.DATA COLLECTION METHODS: Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation.PRINCIPAL FINDINGS: LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate -2.38, standard error 0.72).CONCLUSIONS: Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites. The large increases in completion rates are likely due to the well-planned national roll-out of the LSTDI. This finding suggests that when dissemination and support for widespread implementation are present and system-mandated, significant enhancements in the adoption of evidence-based practices may require more intensive support.
View details for DOI 10.1111/1475-6773.13958
View details for PubMedID 35261022
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The effect of severe maternal morbidity on infant costs and lengths of stay.
Journal of perinatology : official journal of the California Perinatal Association
2022
Abstract
OBJECTIVE: To examine the association between severe maternal morbidity (SMM) and infant health using the additional infant costs and length of stay (LOS) as markers of added clinical complexity.STUDY DESIGN: Secondary data analysis using California linked birth certificate-patient discharge data for 2009-2011 (N=1,260,457). Regression models were used to estimate the association between SMM and infant costs and LOS.RESULTS: The 16,687 SMM-exposed infants experienced a $6550 (33%) increase in costs and a 0.7 (18%) day increase in LOS. Preterm infants had ($11,258 (18%) added costs and 1.3 days (8.1%) longer LOS) than term infants ($2539 (38%) added costs and 0.5 days (22%) longer LOS).CONCLUSIONS: SMM was associated with increased infant costs and LOS, suggesting that SMM may have adverse health effects for infants, including term infants. The relatively larger effect on costs indicates an increase in treatment intensity (clinical severity) greater than additional LOS.
View details for DOI 10.1038/s41372-022-01343-3
View details for PubMedID 35184145
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Timeliness and Adequacy of Prenatal Care Among Department of Veterans Affairs-Enrolled Veterans: The First Step May Be the Biggest Hurdle.
Women's health issues : official publication of the Jacobs Institute of Women's Health
1800
Abstract
INTRODUCTION: Little is known about access to and use of prenatal care by veterans using U.S. Department of Veterans Affairs (VA) maternity benefits. We compared the timeliness and adequacy of prenatal care by veteran status and payor.STUDY DESIGN: We used VA clinical and admistrative data linked with California vital statistics patient discharge data to identify all births to VA-enrolled veterans and non-veterans between 2000 and 2012. Births were categorized based on veteran status and payor (non-veterans with Medicaid, non-veterans with private insurance, VA-enrolled veterans using VA maternity care benefits, and VA-enrolled veterans with other payor). Outcomes were timeliness of prenatal care (initiation before the end of the first trimester) and adequacy of prenatal care as measured by the Kotelchuck Index (inadequate, intermediate, adequate). Covariates included demographic, health, and pregnancy characteristics. We used generalized linear models and multinomial logistic regression to analyze the association of veteran status and payor with timeliness of prenatal care and adequacy of prenatal care, respectively.RESULTS: We identified 6,196,432 births among VA-enrolled veterans (n=17,495) and non-veterans (n=6,178,937). Non-veterans using Medicaid had the lowest percentage of timely prenatal care (78.1%; n=2,240,326), followed by VA-enrolled veterans using VA maternity care benefits (82.8%; n=1,248). VA-enrolled veterans using VA maternity care benefits were the most likely to receive adequate prenatal care (92.0%; n=1,365). Results remained consistent after adjustment.CONCLUSIONS: This study provides key baseline data regarding access to and use of prenatal care by veterans using VA maternity benefits. Longitudinal studies including more recent data are needed to understand the impact of changing VA policy.
View details for DOI 10.1016/j.whi.2021.12.008
View details for PubMedID 35074265
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Understanding the relative contributions of prematurity and congenital anomalies to neonatal mortality
JOURNAL OF PERINATOLOGY
2022
Abstract
To examine the relative contributions of preterm delivery and congenital anomalies to neonatal mortality.Retrospective analysis of 2009-2011 linked birth cohort-hospital discharge files for California, Missouri, Pennsylvania and South Carolina. Deaths were classified by gestational age and three definitions of congenital anomaly: any ICD-9 code for an anomaly, any anomaly with a significant mortality risk, and anomalies recorded on the death certificate.In total, 59% of the deaths had an ICD-9 code for an anomaly, only 43% had a potentially fatal anomaly, and only 34% had a death certificate anomaly. Preterm infants (<37 weeks GA) accounted for 80% of deaths; those preterm infants without a potentially fatal anomaly diagnosis comprised 53% of all neonatal deaths. The share of preterm deaths with a potentially fatal anomaly decreases with GA.Congenital anomalies are responsible for about 40% of neonatal deaths while preterm without anomalies are responsible for over 50%.
View details for DOI 10.1038/s41372-021-01298-x
View details for Web of Science ID 000742795700001
View details for PubMedID 35034095
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A Comprehensive Analysis of the Costs of Severe Maternal Morbidity.
Women's health issues : official publication of the Jacobs Institute of Women's Health
1800
Abstract
INTRODUCTION: The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases.METHODS: California linked birth certificate-patient discharge data for 2009 through 2011 (n=1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS.RESULTS: Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME], $3,550) and a 33% increase in LOS (ME 0.9days). These increased to 70% (ME $5,806) and 46% (ME 1.3days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7days]).CONCLUSIONS: Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.
View details for DOI 10.1016/j.whi.2021.12.006
View details for PubMedID 35031196
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Evaluating Care in Safety Net Hospitals: Clinical Outcomes and NICU Quality of Care in California.
The Journal of pediatrics
2021
Abstract
OBJECTIVES: To examine the characteristics of safety net (sn) and non-safety net neonatal intensive care units (NICUs) in California and whether the site of care is associated with clinical outcomes.STUDY DESIGN: This population-based retrospective cohort study of 34 snNICUs and 104 non-snNICUs included 22,081 infants born between 2014-2018 with birth weights of 401-1500g or gestational ages of 22-29 weeks. Quality of care as measured by Baby-MONITOR score and rates of survival without major morbidity were compared between snNICUs and non-snNICUs.RESULTS: Black and Hispanic infants were disproportionately cared for in snNICUs, where care and outcomes varied widely. We found no significant differences in Baby-MONITOR scores (snNICUs: z-score (SD) = -0.31 (1.3); non-snNICUs: 0.03 (1.1), P = 0.1). Among individual components, infants in snNICUs exhibited lower rates of human milk nutrition at discharge (-0.64 (1.0) vs. 0.27 (0.9)), lower rates of no healthcare associated infection (-0.27 (1.1) vs. 0.14 (0.9)) and higher rates of no hypothermia on admission (0.39 (0.7) vs. -0.25 (1.1)). We found small but significant differences in survival without major morbidity (Adjusted rate = 65.9% (63.9-67.9) for snNICUs vs. 68.3% (67.0-69.6) for non-snNICUs, p=0.02) and in some of its components; snNICUS had higher rates of necrotizing enterocolitis (3.8% (3.4-4.3) vs. 3.1% (2.8-3.4)) and mortality (7.1% (6.5-7.7) vs. 6.6% (6.2-7.0)).CONCLUSIONS: Safety net NICUs achieved similar performance to non-snNICUs in quality of care, except for small but significant differences in any human milk at discharge, infection, hypothermia, necrotizing enterocolitis, and mortality.
View details for DOI 10.1016/j.jpeds.2021.12.003
View details for PubMedID 34890584
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Birth Volume and Geographic Distribution of US Hospitals With Obstetric Services From 2010 to 2018.
JAMA network open
2021; 4 (10): e2125373
Abstract
Importance: Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care.Objective: To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume.Design, Setting, and Participants: This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare & Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021.Exposure: Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births.Main Outcomes and Measures: Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area.Results: The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas.Conclusions and Relevance: In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.
View details for DOI 10.1001/jamanetworkopen.2021.25373
View details for PubMedID 34623408
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The Effect of Data Aggregation on Estimations of Nurse Staffing and Patient Outcomes.
Health services research
2021
Abstract
OBJECTIVE: To examine how estimates of the association between nurse staffing and patient length of stay (LOS) change with data aggregation over varying time periods and settings, and statistical controls for unobserved heterogeneity.DATA SOURCES/STUDY SETTING: Longitudinal secondary data from October, 2002 through September, 2006 for 215 ICUs and 438 general acute care units at 143 facilities in the Veterans Affairs health care system.RESEARCH DESIGN: This retrospective observational study used unit-level panel data to analyze the association between nurse staffing and LOS. This association was measured over both a month-long and a year-long period, with and without fixed effects.DATA COLLECTION: We used VA administrative data to obtain patient data on severity of illness and LOS, as well as labor hours and wages for each unit by month.PRINCIPAL FINDINGS: Overall, shorter length of stay was associated with higher nurse staffing hours and lower proportions of hours provided by LPNs, unlicensed personnel, and contract staff. Estimates of the association between nurse staffing and LOS changed in magnitude when aggregating data over years instead of months, in different settings, and when controlling for unobserved heterogeneity.CONCLUSIONS: Estimating the association between nurse staffing and LOS is contingent on time period of analysis and specific methodology. In future studies, researchers should be aware of these differences when exploring nurse staffing and patient outcomes.
View details for DOI 10.1111/1475-6773.13866
View details for PubMedID 34378181
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Postpartum Transition of Care: Racial/Ethnic Gaps in Veterans' Re-Engagement in VA Primary Care after Pregnancy.
Women's health issues : official publication of the Jacobs Institute of Women's Health
2021
Abstract
INTRODUCTION: Pregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be exacerbated by differential postpartum care. This study explores variation in postpartum re-engagement in U.S. Department of Veteran Affairs health care system (VA) primary care to identify potential racial/ethnic inequities in this care transition.METHODS: We conducted a complete case analysis of the 2005-2014 national VA birth cohort (n=18,414), and subcohorts of veterans with GDM (n=1,253), and hypertensive disorders of pregnancy (HDP; n=2,052) using VA-reimbursed discharge claims and outpatient data. Outcomes included incidence of any VA primary care visit in the postpartum year; in age-adjusted logistic regression, we explored race/ethnicity as a primary predictor.RESULTS: In the year after a VA-covered birth, the proportion of veterans with one or more primary care visit was 53.8% overall, and slightly higher in the GDM (56.0%) and HDP (57.4%) subcohorts. In adjusted models, the odds of VA primary care follow-up were significantly lower for Black/African American (odds ratio, 0.87; 95% confidence interval, 0.81-0.93), Asian (odds ratio, 0.76; 95% confidence interval, 0.61-0.95), and Hawaiian/other Pacific Islander (odds ratio, 0.73; 95% confidence interval, 0.55-0.96) veterans, compared with White veterans. Among the subcohorts with GDM or HDP, there were no significant associations between primary care and race/ethnicity.CONCLUSIONS: One-half of veterans re-engage in VA primary care after childbirth, with significant racial differences in this care transition. Re-engagement for those with the common pregnancy complications of HDP and GDM is only slightly higher, and less than 60%. The potential for innovations like VA maternity care coordinators to address such gaps merits attention.
View details for DOI 10.1016/j.whi.2021.06.003
View details for PubMedID 34229932
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Association of Costs and Days at Home With Transfer Hospital in Home.
JAMA network open
2021; 4 (6): e2114920
Abstract
Importance: New Centers for Medicare & Medicaid Services waivers created a payment mechanism for hospital at home services. Although it is well established that direct admission to hospital at home from the community as a substitute for hospital care provides superior outcomes and lower cost, the effectiveness of transfer hospital at home-that is, completing hospitalization at home-is unclear.Objective: To evaluate the outcomes of the transfer component of a Veterans Affairs (VA) Hospital in Home program (T-HIH), taking advantage of natural geographical limitations in a program's service area.Design, Setting, and Participants: In this quality improvement study, T-HIH was offered to veterans residing in Philadelphia, Pennsylvania, and their outcomes were compared with those of propensity-matched veterans residing in adjacent Camden, New Jersey, who were admitted to the VA hospital from 2012 to 2018. Data analysis was performed from October 2019 to May 2020.Intervention: Enrollment in the T-HIH program.Main Outcomes and Measures: The main outcomes were hospital length of stay, 30-day and 90-day readmissions, VA direct costs, combined VA and Medicare costs, mortality, 90-day nursing home use, and days at home after hospital discharge. An intent-to-treat analysis of cost and utilization was performed.Results: A total of 405 veterans (mean [SD] age, 66.7 [0.83] years; 399 men [98.5%]) with medically complex conditions, primarily congestive heart failure and chronic obstructive pulmonary disease exacerbations (mean [SD] hierarchical condition categories score, 3.54 [0.16]), were enrolled. Ten participants could not be matched, so analyses were performed for 395 veterans (all of whom were men), 98 in the T-HIH group and 297 in the control group. For patients in the T-HIH group compared with the control group, length of stay was 20% lower (6.1 vs 7.7 days; difference, 1.6 days; 95% CI, -3.77 to 0.61 days), VA costs were 20% lower (-$5910; 95% CI, -$13 049 to $1229), combined VA and Medicare costs were 22% lower (-$7002; 95% CI, -$14 314 to $309), readmission rates were similar (23.7% vs 23.0%), the numbers of nursing home days were significantly fewer (0.92 vs 7.45 days; difference, -6.5 days; 95% CI, -12.1 to -0.96 days; P=.02), and the number of days at home was 18% higher (81.4 vs 68.8 days; difference, 12.6 days; 95% CI, 3.12 to 22.08 days; P=.01).Conclusions and Relevance: In this study, T-HIH was significantly associated with increased days at home and less nursing home use but was not associated with increased health care system costs.
View details for DOI 10.1001/jamanetworkopen.2021.14920
View details for PubMedID 34185069
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Quantifying the variation in neonatal transport referral patterns using network analysis.
Journal of perinatology : official journal of the California Perinatal Association
2021
Abstract
OBJECTIVE: Regionalized care reduces neonatal morbidity and mortality. This study evaluated the association of patient characteristics with quantitative differences in neonatal transport networks.STUDY DESIGN: We retrospectively analyzed prospectively collected data for infants <28 days of age acutely transported within California from 2008 to 2012. We generated graphs representing bidirectional transfers between hospitals, stratified by patient attribute, and compared standard network analysis metrics.RESULT: We analyzed 34,708 acute transfers, representing 1594 unique transfer routes between 271 hospitals. Density, centralization, efficiency, and modularity differed significantly among networks drawn based on different infant attributes. Compared to term infants and to those transported for medical reasons, network metrics identify greater degrees of regionalization for preterm and surgical patients (more centralized and less dense, respectively [p<0.001]).CONCLUSION: Neonatal interhospital transport networks differ by patient attributes as reflected by differences in network metrics, suggesting that regionalization should be considered in the context of a multidimensional system.
View details for DOI 10.1038/s41372-021-01091-w
View details for PubMedID 34035453
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VA Home-Based Primary Care Interdisciplinary Team Structure Varies with Veterans' Needs, Aligns with PACE Regulation.
Journal of the American Geriatrics Society
2021
Abstract
BACKGROUND: Interdisciplinary team (IDT) care is central to home-based primary care (HBPC) of frail elders. Traditionally, all HBPC disciplines managed a patient (Full IDT), a costly approach to maintain. The recent PACE (Program of All-inclusive Care for the Elderly) regulation provides for a flexible approach of annual assessments from a core team with involvement of additional disciplines dependent upon patient needs (Core+). Current Department of Veterans Affairs (VA) HBPC guidance specifies Full IDTs care for medically-complex and functionally-impaired Veterans similar to PACE participants. We evaluated whether VA HBPC has adopted the flexible structure of the PACE regulation, aligned to Veteran needs.DESIGN: Cross-sectional analysis.SETTING: All 139 VA HBPC programs administered across 379 sites.PARTICIPANTS: 55,173 Veterans enrolled in HBPC during fiscal year 2018.MEASUREMENTS: Patients' HBPC physician, nurse, psychologist/psychiatrist, social worker, therapist, dietitian, and pharmacist visits were grouped into interdisciplinary team types. Patient frailty was classified using VA HNHR v2 (High-Need High-Risk version 2, a measure of high, medium, and low risk of long-term institutionalization). Medical complexity was measured by clusters of impairment in the JEN frailty index (JFI). JFI clusters were validated by VA's Nosos measure to project cost and Care Assessment Need (CAN) measure of hospitalization and mortality risk.RESULTS: HBPC provided Full IDT care to 21%, Core+ care to 54%, and Home Health+ (HHA+) care (skilled home health services plus additional disciplines, without primary care) to 16% of Veterans. Team type was associated with medical complexity (X2 2863.5 [66 df], p<0.0001). High-risk Veterans (72% of sample) were more likely to receive Full IDT care (X2 62.9, 1 df), p<0.0001), while low-risk Veterans (28%) were more likely to receive HHA+ care (X2 314.8, 1 df, p<0.0001).CONCLUSION: There is a strong association between HBPC team patterns and patient frailty, indicating tailoring of care to match Veteran needs. This article is protected by copyright. All rights reserved.
View details for DOI 10.1111/jgs.17174
View details for PubMedID 33834504
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Access to risk-appropriate hospital care and disparities in neonatal outcomes in racial/ethnic groups and rural-urban populations.
Seminars in perinatology
2021: 151409
Abstract
Variations in infant and neonatal mortality continue to persist in the United States and in other countries based on both socio-demographic characteristics, such as race and ethnicity, and geographic location. One potential driver of these differences is variations in access to risk-appropriate delivery care. The purpose of this article is to present theimportance of delivery hospitals on neonatal outcomes, discuss variation in access to these hospitals for high-risk infants and their mothers, and to provide insight into drivers for differences in access to high-quality perinatal care using the available literature.This review also illustrates the lack of information on a number of topics that are crucial to the development of evidence-based interventions to improve access to appropriate delivery hospital services and thus optimize the outcomes of high-risk mothers and their newborns.
View details for DOI 10.1016/j.semperi.2021.151409
View details for PubMedID 33931237
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Clinical factors associated with spontaneous preterm birth in women with active post-traumatic stress disorder
MOSBY-ELSEVIER. 2021: S100
View details for Web of Science ID 000621547400147
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SHORT-TERM AND LONG-TERM EDUCATIONAL OUTCOMES OF INFANTS BORN MODERATELY AND LATE PRETERM.
The Journal of pediatrics
2021
Abstract
To assess the relationship of moderate and late preterm birth (32-36 6/7 weeks) to long-term educational outcomes.We hypothesized that moderate and late preterm birth would be associated with adverse outcomes in elementary school. To test this, we linked vital statistics-patient discharge data from the Office of Statewide Health Planning and Development including birth outcomes, to the school year 2015-2016 administrative data of a large, urban school district (N = 72,316). We compared the relative risk of moderate and late preterm and term infants for later adverse neurocognitive and behavioral outcomes in kindergarten through 12th grade.After adjusting for socioeconomic status, compared with term birth, moderate and late preterm birth was associated with increased risk of low performance in mathematics and English language arts, chronic absenteeism, and suspension. These risks emerged in kindergarten through second grade and remained in grades 3-5, but appeared to wash out in later grades, with the exception of suspension which remained through grades 9-12.Confirming our hypothesis, moderate and late preterm birth was associated with adverse educational outcomes in late elementary school, indicating that it is a significant risk factor that school districts could leverage when targeting early intervention. Future studies will need to test these relations in geographically and socioeconomically diverse school districts, include a wider variety of outcomes, and consider how early interventions moderate associations between birth outcomes and educational outcomes.
View details for DOI 10.1016/j.jpeds.2020.12.070
View details for PubMedID 33412166
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Visual process maps to support implementation efforts: a case example.
Implementation science communications
2020; 1 (1): 105
Abstract
BACKGROUND: Process mapping is often used in quality improvement work to examine current processes and workflow and to identify areas to intervene to improve quality. Our objective in this paper is to describe process maps as a visual means of understanding modifiable behaviors and activities, in this case example to ensure that goals of care conversations are part of admitting a veteran in long-term care settings.METHODS: We completed site visits to 6 VA nursing homes and reviewed their current admission processes. We conducted interviews to document behaviors and activities that occur when a veteran is referred to a long-term care setting, during admission, and during mandatory VA reassessments. We created visualizations of the data using process mapping approaches. Process maps for each site were created to document the admission activities for each VA nursing home and were reviewed by the research team to identify consistencies across sites and to identify potential opportunities for implementing goals of care conversations.RESULTS: We identified five consistent behaviors that take place when a veteran is referred and admitted in long-term care. These behaviors are assessing, discussing, decision-making, documenting, and re-assessing.CONCLUSIONS: Based on the process maps, it seems feasible that the LST note and order template could be completed along with other routine assessment processes. However, this will require more robust multi-disciplinary collaboration among both prescribing and non-prescribing health care providers. Completing the LST template during the current admission process would increase the likelihood that the template is completed in a timely manner, potentially alleviate the perceived time burden, and help with the provision of veteran-centered care.
View details for DOI 10.1186/s43058-020-00094-6
View details for PubMedID 33292818
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Predictors of Basal Cell Carcinoma and Implications for Follow-Up in High-Risk Patients in the Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) Trial.
Journal of cutaneous medicine and surgery
2020: 1203475420945230
View details for DOI 10.1177/1203475420945230
View details for PubMedID 32880186
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Hospital variation in admissions to neonatal intensive care units by diagnosis severity and category.
Journal of perinatology : official journal of the California Perinatal Association
2020
Abstract
OBJECTIVE: To examine interhospital variation in admissions to neonatal intensive care units (NICU) and reasons for the variation.STUDY DESIGN: 2010-2012 linked birth certificate and hospital discharge data from 35 hospitals in California on live births at 35-42 weeks gestation and ≥1500g birth weight were used. Hospital variation in NICU admission rates was assessed by coefficient of variation. Patient/hospital characteristics associated with NICU admissions were identified by multivariable regression.RESULTS: Among 276,489 newborns, 6.3% were admitted to NICU with 34.5% of them having mild diagnoses. There was high interhospital variation in overall risk-adjusted rate of NICU admission (coefficient of variation=26.2) and NICU admission rates for mild diagnoses (coefficient of variation: 46.4-74.0), but lower variation for moderate/severe diagnoses (coefficient of variation: 8.8-14.1). Births at hospitals with more NICU beds had a higher likelihood of NICU admission.CONCLUSION: Interhospital variation in NICU admissions is mostly driven by admissions for mild diagnoses, suggesting potential overuse.
View details for DOI 10.1038/s41372-020-00775-z
View details for PubMedID 32801351
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Differences in body mass index based on self-reported versus measured data from women veterans.
Obesity science & practice
2020; 6 (4): 434-438
Abstract
The objective was to compare differences in body mass index (BMI) calculated with self-reported versus clinically measured pre-conception data from women veterans in California.Veterans Health Administration (VHA) and California state birth certificate data were used to develop a cohort of women who gave birth from 2007-2012 and had VHA data available to calculate BMI (N = 1,326 mothers, 1,473 births). Weighted Kappa statistics assessed concordance between self-reported and measured BMI. A linear mixed-effects model with maximum likelihood estimation, adjusted for mother as a random effect, assessed correlates of differences in BMI.Mean BMI was in the overweight range based on self-reported (26.2 kg/m2, SD: 5.2) and measured (26.8 kg/m2, SD: 5.2) data. Weighted Kappa statistics indicated good agreement between self-reported and measured BMI (0.73, 95% CI: 0.70, 0.76). Compared to the normal weight group, groups with overweight or obesity were significantly more likely to have lower BMIs when calculated using self-reported versus measured heights and weights, in unadjusted and adjusted models. The finding was pronounced for class 3 obesity, which was associated with a BMI underestimation of 6.4 kg/m2.Epidemiologic research that guides the clinical care of pregnant women should account for potential under-estimation of BMI in heavier women, and perform direct measurement where feasible.
View details for DOI 10.1002/osp4.421
View details for PubMedID 32874677
View details for PubMedCentralID PMC7448139
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Racial/Ethnic Disparities in Costs, Length of Stay, and Severity of Severe Maternal Morbidity
WILEY. 2020: 144
View details for Web of Science ID 000618786100211
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Differences in body mass index based on self-reported versus measured data from women veterans
OBESITY SCIENCE & PRACTICE
2020
View details for DOI 10.1002/osp4.421
View details for Web of Science ID 000538652200001
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The changing landscape of perinatal regionalization.
Seminars in perinatology
2020: 151241
Abstract
Regionalization, which emphasizes matching patient needs with the capabilities of the hospital in which care is provided, has long been a recommended approach to reducing neonatal morbidity and mortality. Over the past decade, research methods surrounding the measurement and evaluation of such programs have improved, thus strengthening arguments for implementation of these strategies. However, regionalization policies vary widely across regions and between countries, with potential impacts on neonatal outcomes as well as costs of care. It is important to account for geographic and other regional differences when determining the feasibility of regionalization for a specific region, as certain areas and populations may need particular consideration in order for regionalization policies to be successful.
View details for DOI 10.1016/j.semperi.2020.151241
View details for PubMedID 32248957
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Multilevel social factors and NICU quality of care in California.
Journal of perinatology : official journal of the California Perinatal Association
2020
Abstract
OBJECTIVE: Our objective was to incorporate social and built environment factors into a compendium of multilevel factors among a cohort of very low birth weight infants to understand their contributions to inequities in NICU quality of care and support providers and NICUs in addressing these inequitiesvia development of a health equity dashboard.STUDY DESIGN: We examined bivariate associations between NICU patient pool and NICU catchment area characteristics and NICU quality of care with data from a cohort of 15,901 infants from 119 NICUs in California, born 2008-2011.RESULT: NICUs with higher proportion of minority racial/ethnic patients and lower SES patients had lower quality scores. NICUs with catchment areas of lower SES, higher composition of minority residents, and more household crowding had lower quality scores.CONCLUSION: Multilevel social factors impact quality of care in the NICU. Their incorporation into a health equity dashboard can inform providers of their patients' potential resource needs.
View details for DOI 10.1038/s41372-020-0647-8
View details for PubMedID 32157221
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Population Improvement Bias Observed in Estimates of the Impact of Antenatal Steroids to Outcomes in Preterm Birth.
The Journal of pediatrics
2020
Abstract
To examine the hypothesis that increasing rates and differential uptake of antenatal steroids (would bias estimation of impact of ANS on neonatal death and severe (grade III-IV) intraventricular hemorrhage (IVH).The study population included infants born between 24 to 28 weeks gestational age in the California Perinatal Quality Care Collaborative. Outcomes were in-hospital mortality and severe IVH. Mixed multivariable logistic regression models estimated the effect of ANS exposure, one model accounting for individual risk factors as fixed effects, and a second model incorporating a predicted probability factor estimating overall risk status for each time period.The study cohort included 28,252 infants. ANS exposure increased from 80.1% in 2005 to 90.3% in 2016, severe IVH decreased from 14.5% to 9.0%, and mortality decreased from 12.8% to 9.1%. When stratified by group, 3-year observed outcomes improved significantly in infants exposed to ANS (12.5% to 8.6% for IVH, 11.5% to 8.8% for death), but not in those not exposed (20.7% to 19.1% and 16.6% to 15.5%, respectively). Women not receiving ANS had higher risk profile (such as no prenatal care) and higher predicted probability for severe IVH and mortality. Both outcomes exhibited little change (P > .05) over time for the group without ANS. In contrast, in women receiving ANS, observed and adjusted rates for both outcomes decreased (p < 0.0001).As the population's proportion of ANS use increased, the observed positive effect of ANS also increased. This apparent increase may be designated as the "population improvement bias."
View details for DOI 10.1016/j.jpeds.2020.11.067
View details for PubMedID 33275981
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Evaluating the Role of Past Clinical Information on Risk Adjustment.
Medical care
2019
Abstract
OBJECTIVE: The objective of this study was to evaluate whether incorporating historical clinical information beyond 1 year improves risk adjustment.DATA SOURCES: Administrative data from the Department of Veterans Affairs and Medicare (for veterans concurrently enrolled in Medicare) for fiscal years (FYs) 2011-2015.STUDY DESIGN: We regressed total annual costs on Medicare hierarchical condition category indicators and risk scores for FY 2015 in both a concurrent and a prospective model using 5-fold cross-validation. Regressions were repeated incorporating clinical information from FY 2011 to 2015. Model fit was appraised using R and mean squared predictive error (MSPE).DATA COLLECTION: All veterans affairs users (n=3,254,783) with diagnostic information FY 2011-2015.PRINCIPAL FINDINGS: In a concurrent model, adding additional years of historical clinical information (FY 2011-2014) did not result in substantive gains in fit (R from 0.671 to 0.673) or predictive capability (MSPE from 1956 to 1950). In a prospective model, adding additional years of historical clinical information also did not result in substantive gains in fit (R from 0.334 to 0.344) or predictive capability (MSPE from 3988 to 3940).CONCLUSION: Incorporating historical clinical information yielded no material gain in risk adjustment fit.
View details for DOI 10.1097/MLR.0000000000001236
View details for PubMedID 31688567
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Racial and Ethnic Differences Over Time in Outcomes of Infants Born Less Than 30 Weeks' Gestation.
Pediatrics
2019
Abstract
OBJECTIVES: To examine changes in care practices over time by race and ethnicity and whether the decrease in hospital mortality and severe morbidities has benefited infants of minority over infants of white mothers.METHODS: Infants 22 to 29 weeks' gestation born between January 2006 and December 2017 at a Vermont Oxford Network center in the United States were studied. We examined mortality and morbidity rate differences and 95% confidence intervals for African American and Hispanic versus white infants by birth year. We tested temporal differences in mortality and morbidity rates between white and African American or Hispanic infants using a likelihood ratio test on nested binomial regression models.RESULTS: Disparities for certain care practices such as antenatal corticosteroids and for some in-hospital outcomes have narrowed over time for minority infants. Compared with white infants, African American infants had a faster decline for mortality, hypothermia, necrotizing enterocolitis, and late-onset sepsis, whereas Hispanic infants had a faster decline for mortality, respiratory distress syndrome, and pneumothorax. Other morbidities showed a constant rate difference between African American and Hispanic versus white infants over time. Despite the improvements, outcomes including hypothermia, mortality, necrotizing enterocolitis, late-onset sepsis, and severe intraventricular hemorrhage remained elevated by the end of the study period, especially among African American infants.CONCLUSIONS: Racial and ethnic disparities in vital care practices and certain outcomes have decreased. That the quality deficit among minority infants occurred for several care practice measures and potentially modifiable outcomes suggests a critical role for quality improvement initiatives tailored for minority-serving hospitals.
View details for DOI 10.1542/peds.2019-1106
View details for PubMedID 31405887
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The disproportionate cost of operation and congenital anomalies in infancy
MOSBY-ELSEVIER. 2019: 1234–42
View details for DOI 10.1016/j.surg.2018.12.022
View details for Web of Science ID 000472984500028
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The disproportionate cost of operation and congenital anomalies ininfancy.
Surgery
2019
Abstract
BACKGROUND: Congenital anomalies are the leading cause of infant death and pediatric hospitalization, but existing estimates of the associated costs of health care are either cross-sectional surveys or economic projections. We sought to determine the percent of total hospital health care expenditures attributable to major anomalies requiring surgery within the first year of life.METHODS: Utilizing comprehensive California statewide data from 2008 to 2012, cohorts of infants undergoing major surgery, with birth defects and with surgical anomalies, were constructed alongside a referent group of newborns with no anomalies or operations. Cost-to-charge and physician fee ratios were used to estimate hospital and professional costs, respectively. For each cohort, costs were broken down according to admission, birth episode, and first year of life, with additional stratifications by birth weight, gestational age, and organ system.RESULTS: In total, 68,126 of 2,205,070 infants (3.1%) underwent major surgery (n= 32,614) or had a diagnosis of a severe congenital anomaly (n= 57,793). These accounted for $7.7 billion of the $18.9 billion (40.7%) of the total health care costs/expenditures of the first-year-of-life hospitalizations, $7.0 billion (48.6%) of the costs for infants with comparatively long birth episodes, and $5.2 billion (54.7%) of the total neonatal intensive care unit admission costs. Infants with surgical anomalies (n= 21,264) totaled $4.1 billion (21.7%) at $80,872 per infant. Cardiovascular and gastrointestinal diseases accounted for most admission costs secondary to major surgery or congenital anomalies.CONCLUSION: In a population-based cohort of infant births compared with other critically ill neonates, surgical congenital anomalies are disproportionately costly within the United States health care system. The care of these infants, half of whom are covered by Medi-Cal or Medicaid, stands as a particular focus in an age of reform of health care payments.
View details for PubMedID 31056199
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Racial Segregation and Inequality in the Neonatal Intensive Care Unit for Very Low-Birth-Weight and Very Preterm Infants
JAMA PEDIATRICS
2019; 173 (5): 455–61
View details for DOI 10.1001/jamapediatrics.2019.0241
View details for Web of Science ID 000467505200013
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Racial Segregation and Inequality in the Neonatal Intensive Care Unit for Very Low-Birth-Weight and Very Preterm Infants.
JAMA pediatrics
2019
Abstract
Importance: Racial and ethnic minorities receive lower-quality health care than white non-Hispanic individuals in the United States. Where minority infants receive care and the role that may play in the quality of care received is unclear.Objective: To determine the extent of segregation and inequality of care of very low-birth-weight and very preterm infants across neonatal intensive care units (NICUs) in the United States.Design, Setting, and Participants: This cohort study of 743 NICUs in the Vermont Oxford Network included 117 982 black, Hispanic, Asian, and white infants born at 401 g to 1500 g or 22 to 29 weeks' gestation from January 2014 to December 2016. Analysis began January 2018.Main Outcomes and Measures: The NICU segregation index and NICU inequality index were calculated at the hospital level as the Gini coefficients associated with the Lorenz curves for black, Hispanic, and Asian infants compared with white infants, with NICUs ranked by proportion of white infants for the NICU segregation index and by composite Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research) score for the NICU inequality index.Results: Infants (36 359 black [31%], 21 808 Hispanic [18%], 5920 Asian [5%], and 53 895 white [46%]) were segregated among the 743 NICUs by race and ethnicity (NICU segregation index: black: 0.50 [95% CI, 0.46-0.53], Hispanic: 0.58 [95% CI, 0.54-0.61], and Asian: 0.45 [95% CI, 0.40-0.50]). Compared with white infants, black infants were concentrated at NICUs with lower-quality scores, and Hispanic and Asian infants were concentrated at NICUs with higher-quality scores (NICU inequality index: black: 0.07 [95% CI, 0.02-0.13], Hispanic: -0.10 [95% CI, -0.17 to -0.04], and Asian: -0.26 [95% CI, -0.32 to -0.19]). There was marked variation among the census regions in weighted mean NICU quality scores (range: -0.69 to 0.85). Region of residence explained the observed inequality for Hispanic infants but not for black or Asian infants.Conclusions and Relevance: Black, Hispanic, and Asian infants were segregated across NICUs, reflecting the racial segregation of minority populations in the United States. There were large differences between geographic regions in NICU quality. After accounting for these differences, compared with white infants, Asian infants received care at higher-quality NICUs and black infants, at lower-quality NICUs. Explaining these patterns will require understanding the effects of sociodemographic factors and public policies on hospital quality, access, and choice for minority women and their infants.
View details for PubMedID 30907924
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Veterans' Reliance on VA Care by Type of Service and Distance to VA for Nonelderly VA-Medicaid Dual Enrollees
MEDICAL CARE
2019; 57 (3): 225–29
View details for DOI 10.1097/MLR.0000000000001066
View details for Web of Science ID 000459157900010
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Veterans' Reliance on VA Care by Type of Service and Distance to VA for Nonelderly VA-Medicaid Dual Enrollees.
Medical care
2019
Abstract
BACKGROUND: Not much is known about nonelderly veterans and their reliance on care from the Veterans Affairs (VA) health care system when they have access to non-VA care.OBJECTIVES: To estimate VA reliance for nonelderly veterans enrolled in VA and Medicaid.RESEARCH DESIGN: Retrospective, longitudinal analysis of Medicaid claims data and VA administrative data to compare patients' utilization of VA and Medicaid services 12 months before and for up to 12 months after Medicaid enrollment began.SUBJECTS: Nonelderly veterans (below 65y) receiving VA care and newly enrolled in Medicaid, calendar years 2006-2010 (N=19,890).MEASURES: VA reliance (proportion of care received in VA) for major categories of outpatient and inpatient care.RESULTS: Patients used VA outpatient care at similar levels after enrolling in Medicaid with the exceptions of emergency department (ED) and obstetrics/gynecology care, which decreased. VA inpatient utilization was similar after Medicaid enrollment for most types of care. VA-adjusted outpatient reliance was highest for mental health care (0.99) and lowest for ED care (0.02). VA-adjusted inpatient reliance was highest for respiratory (0.80) and cancer stays (0.80) and lowest for musculoskeletal stays (0.20). Associations between VA reliance and distance to VA providers varied by type of care.CONCLUSIONS: Veterans dually enrolled in Medicaid received most of their outpatient care from the VA except ED, obstetrics/gynecology, and dental care. Patients received most of their inpatient care from Medicaid except mental health, respiratory, and cancer care. Sensitivity to travel distance to VA providers explained some of these differences.
View details for PubMedID 30676354
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Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit.
Health services research
2019
Abstract
To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes.Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276 054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs).Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression.We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients.An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality.Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.
View details for DOI 10.1111/1475-6773.13249
View details for PubMedID 31869865
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Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California, 2009-2011
JOURNAL OF PEDIATRICS
2019; 204: 118-+
View details for DOI 10.1016/j.jpeds.2018.08.041
View details for Web of Science ID 000453785200023
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Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data
HEALTH SERVICES RESEARCH
2018; 53: 5260–84
View details for DOI 10.1111/1475-6773.13041
View details for Web of Science ID 000450256200008
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The Impact of Medicaid Enrollment on Veterans Health Administration Enrollees' Behavioral Health Services Use
HEALTH SERVICES RESEARCH
2018; 53: 5238–59
View details for DOI 10.1111/1475-6773.13062
View details for Web of Science ID 000450256200007
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Attributable Cost of Dementia: Demonstrating Pitfalls of Ignoring Multiple Health Care System Utilization
HEALTH SERVICES RESEARCH
2018; 53: 5331–51
Abstract
To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data.VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013.Analyses were conducted with VHA data alone and with combined VHA and Medicare data. Dementia was identified from a VHA sanctioned list of ICD-9 diagnoses. Attributable cost of dementia was estimated using recycled predictions.Veterans age 65 and older who used VHA and were enrolled in Traditional Medicare in FY 2013 (1.9 million).VHA records indicated the prevalence of dementia in FY 2013 was 4.8 percent while combined VHA and Medicare data indicated the prevalence was 7.4 percent. Attributable cost of dementia to VHA was, on average, $10,950 per veteran per year (pvpy) using VHA alone and $6,662 pvpy using combined VHA and Medicare data. Combined VHA and Medicare attributable cost of dementia was $11,285 pvpy. Utilization attributed to dementia using VHA data alone was lower for long-term institutionalization and higher for supportive care services than indicated in combined VHA and Medicare data.Better planning for clinical and cost-efficient care requires VHA and Medicare to share data for veterans with dementia and likely more generally.
View details for PubMedID 30246404
View details for PubMedCentralID PMC6235812
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Validation of the JEN frailty index in the National Long-Term Care Survey community population: identifying functionally impaired older adults from claims data.
BMC health services research
2018; 18 (1): 908
Abstract
BACKGROUND: Use of a claims-based index to identify persons with physical function impairment and at risk for long-term institutionalization would facilitate population health and comparative effectiveness research. The JEN Frailty Index [JFI] is comprised of diagnosis domains representing impairments and multimorbid clusters with high long-term institutionalization [LTI] risk. We test the index's discrimination of activities-of-daily-living [ADL] dependency and 1-year LTI and mortality in a nationally representative sample of over 12,000 Medicare beneficiaries, and compare long-term community survival stratified by ADL and JFI.METHODS: 2004U.S. National Long-Term Care Survey data were linked to Medicare, Minimum Data Set, Veterans Health Administration files and vital statistics. ADL dependencies, JFI score, age and sex were measured at baseline survey. ADL and JFI groups were cross-tabulated generating likelihood ratios and classification statistics. Logistic regression compared discrimination (areas under receiver operating characteristic curves), multivariable calibration and accuracy of the JFI and, separately, ADLs, in predicting 1-year outcomes. Hall-Wellner bands facilitated contrasts of JFI- and ADL-stratified 5-year community survival.RESULTS: Likelihood ratios rose evenly across JFI risk categories. Areas under the curves of functional dependency at ≥3 and≥2 for JFI, age and sex models were 0.807 [95% c.i.: 0.795, 0.819] and 0.812 [0.801, 0.822], respectively. The area under the LTI curve for JFI and age (0.781 [0.747, 0.815]) discriminated less well than the ADL-based model (0.829 [0.799, 0.860]). Community survival separated by JFI strata was comparable to ADL strata.CONCLUSIONS: The JEN Frailty Index with demographic covariates is a valid claims-based measure of concurrent activities-of-daily-living impairments and future long-term institutionalization risk in older populations lacking functional information.
View details for PubMedID 30497450
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Validation of the JEN frailty index in the National Long-Term Care Survey community population: identifying functionally impaired older adults from claims data
BMC HEALTH SERVICES RESEARCH
2018; 18
View details for DOI 10.1186/s12913-018-3689-2
View details for Web of Science ID 000451694600007
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The Impact of Medicaid Enrollment onVeterans Health Administration Enrollees' Behavioral Health Services Use.
Health services research
2018
Abstract
OBJECTIVE: To examine Veterans Health Administration (VA) enrollees' use of VA services for treatment of behavioral health conditions (BHCs) after gaining Medicaid, and if VA reliance varies by complexity of BHCs.DATA SOURCES/STUDY SETTING: VA and Medicaid Analytic eXtract utilization data from 31 states, 2006-2010.STUDY DESIGN: A retrospective, longitudinal study of Veterans enrolled in VA care in the year before and year after enrollment in Medicaid among 7,249 nonelderly Veterans with serious mental illness (SMI), substance use disorder (SUD), posttraumatic stress disorder (PTSD), depression, or other BHCs.DATA COLLECTION/EXTRACTION METHODS: Utilization and VA reliance (proportion of care received at VA) for BH outpatient and inpatient services in unadjusted and adjusted analyses.PRINCIPAL FINDINGS: In adjusted analyses, we found that overall Veterans did not significantly change their use of VA outpatient BH services after Medicaid enrollment. In beta-binomial models predicting VA BH outpatient reliance, veterans with SMI (IRR=1.38, p<.05), PTSD (IRR=1.62, p<.01), and depression (IRR=1.36, p<.05) had higher reliance than veterans with other BHCs after Medicaid enrollment.CONCLUSIONS: While veterans did not change the amount of VA outpatient BH services they used after enrolling in Medicaid, the proportion of care they received through VA or Medicaid varied by BHC.
View details for PubMedID 30298566
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Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California, 2009-2011.
The Journal of pediatrics
2018
Abstract
OBJECTIVE: To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight.STUDY DESIGN: We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean diagnosis related group-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1 265 212.RESULTS: The mean maternal costs for all in-hospital deliveries was $8204, increasing to $13 154 for late preterm (32-36 weeks) and $22 702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6389: $2433 for term infants, $22 102 for late preterm, $223 931 for very preterm infants, and $317 982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants, these shares were 1.0% and 36.5%, and 0.4% and 20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization.CONCLUSIONS: Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs and these costs have increased over time.
View details for PubMedID 30297293
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Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data.
Health services research
2018
Abstract
OBJECTIVE: To describe variation in payer and outcomes in Veterans' births.DATA/SETTING: Secondary data analyses of deliveries in California, 2000-2012.STUDY DESIGN: We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.METHODS: We anonymously linked VA administrative data for all female VA enrollees with California birth records.PRINCIPAL FINDINGS: From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).CONCLUSIONS: VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.
View details for PubMedID 30198185
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Effect of Repetitive Transcranial Magnetic Stimulation on Treatment-Resistant Major Depression in US Veterans A Randomized Clinical Trial
JAMA PSYCHIATRY
2018; 75 (9): 884–93
Abstract
Treatment-resistant major depression (TRMD) in veterans is a major clinical challenge given the high risk for suicidality in these patients. Repetitive transcranial magnetic stimulation (rTMS) offers the potential for a novel treatment modality for these veterans.To determine the efficacy of rTMS in the treatment of TRMD in veterans.A double-blind, sham-controlled randomized clinical trial was conducted from September 1, 2012, to December 31, 2016, in 9 Veterans Affairs medical centers. A total of 164 veterans with TRD participated.Participants were randomized to either left prefrontal rTMS treatment (10 Hz, 120% motor threshold, 4000 pulses/session) or to sham (control) rTMS treatment for up to 30 treatment sessions.The primary dependent measure of the intention-to-treat analysis was remission rate (Hamilton Rating Scale for Depression score ≤10, indicating that depression is in remission and not a clinically significant burden), and secondary analyses were conducted on other indices of posttraumatic stress disorder, depression, hopelessness, suicidality, and quality of life.The 164 participants had a mean (SD) age of 55.2 (12.4) years, 132 (80.5%) were men, and 126 (76.8%) were of white race. Of these, 81 were randomized to receive active rTMS and 83 to receive sham. For the primary analysis of remission, there was no significant effect of treatment (odds ratio, 1.16; 95% CI, 0.59-2.26; P = .67). At the end of the acute treatment phase, 33 of 81 (40.7%) of those in the active treatment group achieved remission of depressive symptoms compared with 31 of 83 (37.4%) of those in the sham treatment group. Overall, 64 of 164 (39.0%) of the participants achieved remission.A total of 39.0% of the veterans who participated in this trial experienced clinically significant improvement resulting in remission of depressive symptoms; however, there was no evidence of difference in remission rates between the active and sham treatments. These findings may reflect the importance of close clinical surveillance, rigorous monitoring of concomitant medication, and regular interaction with clinic staff in bringing about significant improvement in this treatment-resistant population.ClinicalTrials.gov Identifier: NCT01191333.
View details for PubMedID 29955803
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Impact of topical fluorouracil cream on costs of treating keratinocyte carcinoma (nonmelanoma skin cancer) and actinic keratosis
JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
2018; 79 (3): 501-+
Abstract
It is unknown whether treatment costs for keratinocyte carcinoma (KC) and actinic keratosis (AK) can be lowered by spending more on chemoprevention.To examine the impact of 1-course treatment with topical fluorouracil (5-FU) on the face and ears on KC and AK treatment costs over 3 years.The Veterans Affairs Keratinocyte Carcinoma Chemoprevention trial compared the efficacy of topical 5-FU 5% with that of vehicle control cream for reducing KC risk. Trial data and administrative data on costs and utilization were analyzed to measure postrandomization encounters and treatment costs for KC and AK care. Adjusted models were used to test for statistically significant differences between treatment arms for number of treatment encounters and costs.One year after randomization, the control arm had a higher mean number of treatment encounters for squamous cell carcinoma (0.04) than the intervention arm (0.01) (P < .01). At 1 year, the intervention arm had lower treatment and dermatologic costs: $2106 (standard deviation, $2079) compared with $2444 (standard deviation, $2716) for the control patients (P = .02). After 3 years, the intervention arm incurred a cost of $771 less per patient.Care not provided or paid for by the Department of Veterans Affairs was not included. Results may not be generalizable to other payers.We found significant cost savings for patients treated with 5-FU.
View details for PubMedID 29505863
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Hospice Care of Veterans in Medicare Advantage and Traditional Medicare: A Risk-Adjusted Analysis
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
2018; 66 (8): 1508–14
Abstract
To compare the quality of end-of-life care in Medicare Advantage (MA) and traditional Medicare (TM), specifically, receipt and length of hospice care.Retrospective analysis of administrative data.Hospice care.Veterans dually enrolled in the Veterans Health Administration (VHA) and MA or TM who died between 2008 and 2013 (N = 1,515,441).Outcomes studied included use and duration of hospice care. Use of a VHA-enrolled population allowed for risk adjustment that is otherwise challenging when studying MA.Adjusted analyses revealed that MA beneficiaries were more likely to receive hospice than TM beneficiaries; results corroborate published non-risk-adjusted analyses. MA beneficiaries had shorter hospice duration; this is an opposite direction of effect than non-risk-adjusted analyses. Results were robust to multiple sensitivity analyses limiting the cohort to individuals in MA and TM who had equal opportunity for their comorbidities to be captured. Removing risk adjustment resulted in results that mirrored those in the existing published literature.Our work provides two important insights regarding MA that are important to consider as enrollment in this insurance mechanism grows. First, MA beneficiaries received poorer-quality end-of-life care than TM beneficiaries, as ascertained by exposure to hospice. Second, any comparisons made between MA and TM require proper risk adjustment to obtain correct directions of effect. We encourage the Centers for Medicare & Medicaid Services to make comorbidity data specific to MA enrollees available to researchers for these purposes.
View details for PubMedID 30091240
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Evaluation of the Cincinnati Veterans Affairs Medical Center Hospital-in-Home Program
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
2018; 66 (7): 1392–98
Abstract
To examine hospital readmissions, costs, mortality, and nursing home admissions of veterans who received Hospital-in-Home (HIH) services.Retrospective cohort study.Cincinnati Veterans Affairs Medical Center (VAMC).Study cohort included veterans who received HIH services as an alternative to inpatient care between October 1, 2012, and November 30, 2015, and non-HIH veterans who were hospitalized for similar conditions in the Cincinnati VAMC during the same period. We identified 138 veterans who used HIH services and 694 non-HIH veterans.HIH veterans received hospital-equivalent care at home. Non-HIH veterans received traditional inpatient services in the Cincinnati VAMC.Total costs of care for treating an acute episode (HIH services vs inpatient) and likelihood of hospital readmission, death, or nursing home admission within 30 days of discharge from HIH services or hospitalization.Average per person costs were $7,792 for HIH services and $10,960 for traditional inpatient care (P<0.001). HIH veterans were less likely to use a nursing home within 30 days of discharge (3.1%) than non-HIH veterans (12.6%) (P<0.001). Thirty-day readmission rates and mortality were not statistically different between HIH and non-HIH veterans.The substitutive HIH model implemented in the Cincinnati VAMC delivered acute services in veterans' homes at lower cost and with lower likelihood of postdischarge nursing home use. Broader implementation of this innovative delivery model may benefit older adults in need of care while reducing healthcare system costs.
View details for PubMedID 29676782
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Use of Veterans Affairs and Medicaid Services for Dually Enrolled Veterans
HEALTH SERVICES RESEARCH
2018; 53 (3): 1539–61
Abstract
To examine how dual coverage for nonelderly, low-income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care.Veterans Affairs utilization data and Medicaid Analytic Extract Files.A retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006-2010.Veterans Affairs reliance, or proportion of care provided by VA, was estimated with beta-binomial models, adjusting for patient and state Medicaid program factors.In a cohort of 19,890 nonelderly veterans, VA utilization levels were similar before and after enrolling in Medicaid. VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service-connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater Medicaid eligibility generosity, and better Medicaid quality.Veterans Affairs utilization following new Medicaid enrollment remained relatively unchanged, and the VA continued to provide the large majority of care for dually enrolled veterans. There was variation among patients as Medicaid eligibility and other program factors influenced their use of Medicaid services.
View details for PubMedID 28608413
View details for PubMedCentralID PMC5980176
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Deployment and Preterm Birth Among US Army Soldiers.
American journal of epidemiology
2018; 187 (4): 687-695
Abstract
With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.
View details for DOI 10.1093/aje/kwy003
View details for PubMedID 29370332
View details for PubMedCentralID PMC5889029
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Choice of Hospital as a Source of Racial/Ethnic Disparities in Neonatal Mortality and Morbidity Rates
JAMA PEDIATRICS
2018; 172 (3): 221–23
View details for PubMedID 29297051
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INTERACT in VA Community Living Centers (CLCs): Training and Implementation Strategies
GERIATRIC NURSING
2018; 39 (2): 212–18
Abstract
Studies have shown that hospitalizations of nursing home (NH) residents lead to complications and poorer quality of life. The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement (QI) Program assists licensed NH staff in avoiding such hospitalizations. INTERACT aims to improve the management of acute changes in residents' conditions by providing tools to help staff recognize subtle changes in condition, improve communication, and implement QI strategies. INTERACT has been vetted by national clinical leaders and experts in long term care (LTC). Multiple NHs have implemented INTERACT and it has been adopted in Canada, the United Kingdom, and Singapore. QI initiatives involve adaptation to the organizational context in which it is being implemented. We report adaptation of the INTERACT QI program and implementation training into Veteran Affairs (VA) Community Living Centers (CLCs) (VA equivalent NH) and summarize the efforts to introduce and train nursing leadership to integrate the intervention into selected CLCs.
View details for PubMedID 28988835
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Deployment and Preterm Birth Among United States Army Soldiers
American Journal of Epidemiology
2018: 687–95
Abstract
With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.
View details for DOI 10.1093/aje/kwy003
View details for PubMedCentralID PMC5889029
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Quantitative Evaluation of the Structure of Neonatal Referral Networks in California
AMER ACAD PEDIATRICS. 2018
View details for DOI 10.1542/peds.141.1_MeetingAbstract.552
View details for Web of Science ID 000540809200559
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Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community
JOURNAL OF AGING & SOCIAL POLICY
2018; 30 (2): 93–108
Abstract
The United States Department of Veterans Affairs (VA) is facing pressures to rebalance its long-term care system. Using VA administrative data from 2004-2011, we describe changes in the VA's nursing homes (called Community Living Centers [CLCs]) following enactment of directives intended to shift CLCs' focus from providing long-term custodial care to short-term rehabilitative and post-acute care, with safe and timely discharge to the community. However, a concurrent VA hospice and palliative care expansion resulted in an increase in hospice stays, the most notable change in type of stay during this time period. Nevertheless, outcomes for Veterans with non-hospice short and long stays, such as successful discharge to the community, improved. We discuss the implications of our results for simultaneous implementation of two initiatives in VA CLCs.
View details for PubMedID 29308990
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Repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depression (TRMD) Veteran patients: study protocol for a randomized controlled trial
TRIALS
2017; 18: 409
Abstract
Evaluation of repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depression (TRMD) in Veterans offers unique clinical trial challenges. Here we describe a randomized, double-blinded, intent-to-treat, two-arm, superiority parallel design, a multicenter study funded by the Cooperative Studies Program (CSP No. 556) of the US Department of Veterans Affairs.We recruited medical providers with clinical expertise in treating TRMD at nine Veterans Affairs (VA) medical centers as the trial local investigators. We plan to enroll 360 Veterans diagnosed with TRMD at the nine VA medical centers over a 3-year period. We will randomize participants into a double-blinded clinical trial to left prefrontal rTMS treatment or to sham (control) rTMS treatment (180 participants each group) for up to 30 treatment sessions. All participants will meet Diagnostic and statistical manual of mental disorders, 4 th edition (DSM-IV) criteria for major depression and will have failed at least two prior pharmacological interventions. In contrast with other rTMS clinical trials, we will not exclude Veterans with posttraumatic stress disorder (PTSD) or history of substance abuse and we will obtain detailed history regarding these disorders. Furthermore, we will maintain participants on stable anti-depressant medication throughout the trial. We will evaluate all participants on a wide variety of potential predictors of treatment response including cognitive, psychological and functional parameters.The primary dependent measure will be remission rate (Hamilton Rating Scale for Depression (HRSD24) ≤ 10), and secondary analyses will be conducted on other indices. Comparisons between the rTMS and the sham groups will be made at the end of the acute treatment phase to test the primary hypothesis. The unique challenges to performing such a large technically challenging clinical trial with Veterans and potential avenues for improvement of the design in future trials will be described.ClinicalTrials.gov, NCT01191333 . Registered on 26 August 2010. This report is based on the protocol version 4.6 amended in February 2016. All items from the World Health Organization Trial Registration Data Set are listed in Appendix A.
View details for PubMedID 28865495
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Racial/Ethnic Disparity in NICU Quality of Care Delivery
PEDIATRICS
2017; 140 (3)
View details for DOI 10.1542/peds.2017-0918
View details for Web of Science ID 000408820300034
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Evaluation of a Hospital-in-Home Program Implemented Among Veterans
AMERICAN JOURNAL OF MANAGED CARE
2017; 23 (8): 482–87
Abstract
To examine the outcomes (ie, costs, hospitalizations, and mortality) associated with a Hospital-in-Home (HIH) program implemented in 2010 by the Veterans Affairs (VA) Pacific Islands Healthcare System in Honolulu, Hawaii.Retrospective cohort study.We obtained medical information for veterans who were enrolled in the HIH program in Honolulu, Hawaii, between 2010 and 2013. For purposes of comparison, we also gathered VA data to identify a cohort of hospitalized veterans in Honolulu who were eligible for, but not enrolled in, the HIH program. Using VA administrative data, we extracted a set of individual-level variables at baseline to account for the differences between program enrollees and comparators. In total, 99 HIH program enrollees and 322 unenrolled veterans were included. We identified 3 sets of outcome variables: total costs of care related to the index event (ie, HIH services for enrollees and hospitalizations for comparators), hospitalizations, and mortality after discharge from the index event. We used a propensity score-matching approach to examine the difference in related outcomes between enrollees and comparators.The average medical cost was $5150 per person for veterans receiving HIH services, and $8339 per person for veterans receiving traditional inpatient services. The difference was statistically significant (P <.01). There was no statistically significant difference in mortality or hospitalization rates after the index event.This study provides evidence of the potential benefits of a model that delivers acute care in patients' homes. Considering the emergence of accountable healthcare organizations, interest in broader implementation of such programs may be worthy of investigation.
View details for Web of Science ID 000408656100007
View details for PubMedID 29087145
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Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease
HEART
2017; 103 (11): 818-826
Abstract
To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD.Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years.There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.
View details for DOI 10.1136/heartjnl-2016-309266
View details for Web of Science ID 000401028400006
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Network analysis: a novel method for mapping neonatal acute transport patterns in California.
Journal of perinatology
2017; 37 (6): 702-708
Abstract
The objectives of this study are to use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions and to determine factors associated with transport outside the originating sub-network.This cross-sectional database study included 6546 infants <28 days old transported within California in 2012. After generating a graph representing acute transfers between hospitals (n=6696), we used community detection techniques to identify more tightly connected sub-networks. These empirically derived sub-networks were compared with state-defined regional referral networks. Reasons for transfer between empirical sub-networks were assessed using logistic regression.Empirical sub-networks showed significant overlap with regulatory regions (P<0.001). Transfer outside the empirical sub-network was associated with major congenital anomalies (P<0.001), need for surgery (P=0.01) and insurance as the reason for transfer (P<0.001).Network analysis accurately reflected empirical neonatal transfer patterns, potentially facilitating quantitative, rather than qualitative, analysis of regionalized health care delivery systems.Journal of Perinatology advance online publication, 23 March 2017; doi:10.1038/jp.2017.20.
View details for DOI 10.1038/jp.2017.20
View details for PubMedID 28333155
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Triple Therapy Versus Biologic Therapy for Active Rheumatoid Arthritis: A Cost-Effectiveness Analysis.
Annals of internal medicine
2017
Abstract
The RACAT (Rheumatoid Arthritis Comparison of Active Therapies) trial found triple therapy to be noninferior to etanercept-methotrexate in patients with active rheumatoid arthritis (RA).To determine the cost-effectiveness of etanercept-methotrexate versus triple therapy as a first-line strategy.A within-trial analysis based on the 353 participants in the RACAT trial and a lifetime analysis that extrapolated costs and outcomes by using a decision analytic cohort model.The RACAT trial and sources from the literature.Patients with active RA despite at least 12 weeks of methotrexate therapy.24 weeks and lifetime.Societal and Medicare.Etanercept-methotrexate first versus triple therapy first.Incremental costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs).The within-trial analysis found that etanercept-methotrexate as first-line therapy provided marginally more QALYs but accumulated substantially higher drug costs. Differences in other costs between strategies were negligible. The ICERs for first-line etanercept-methotrexate and triple therapy were $2.7 million per QALY and $0.98 million per QALY over 24 and 48 weeks, respectively. The lifetime analysis suggested that first-line etanercept-methotrexate would result in 0.15 additional lifetime QALY, but this gain would cost an incremental $77 290, leading to an ICER of $521 520 per QALY per patient.Considering a long-term perspective, an initial strategy of etanercept-methotrexate and biologics with similar cost and efficacy is unlikely to be cost-effective compared with using triple therapy first, even under optimistic assumptions.Data on the long-term benefit of triple therapy are uncertain.Initiating biologic therapy without trying triple therapy first increases costs while providing minimal incremental benefit.The Cooperative Studies Program, Department of Veterans Affairs Office of Research and Development, Canadian Institutes for Health Research, and an interagency agreement with the National Institutes of Health-American Recovery and Reinvestment Act.
View details for DOI 10.7326/M16-0713
View details for PubMedID 28554192
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Factors Associated With Provider Burnout in the NICU
PEDIATRICS
2017; 139 (5)
Abstract
NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs.Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t-test comparison of quartiles, univariable regression, and multivariable regression.Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence.Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions.
View details for DOI 10.1542/peds.2016-4134
View details for Web of Science ID 000400371500040
View details for PubMedID 28557756
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Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia
PAEDIATRIC AND PERINATAL EPIDEMIOLOGY
2017; 31 (3): 185-194
Abstract
Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.
View details for DOI 10.1111/ppe.12349
View details for Web of Science ID 000400170000004
View details for PubMedID 28328031
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The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans.
Journal of general internal medicine
2017
Abstract
Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services.To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients.Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant.Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients).We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations.Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%).Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.
View details for DOI 10.1007/s11606-016-3962-1
View details for PubMedID 28271422
View details for PubMedCentralID PMC5359156
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Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (from the TREAT-AF Study)
AMERICAN JOURNAL OF CARDIOLOGY
2017; 119 (2): 268-274
Abstract
Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively) but can cause hemorrhage. The time in international normalized ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relation between baseline stroke, bleeding risk, and TTR. Using data from The Retrospective Evaluation and Assessment of Therapies in Atrial Fibrillation (TREAT-AF) retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003 to 2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2DS2-VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR and INR monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2DS2-VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% were significantly associated with high CHA2DS2-VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin's efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort.
View details for DOI 10.1016/j.amjcard.2016.09.045
View details for PubMedID 27836133
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Racial/Ethnic Disparity in NICU Quality of Care Delivery.
Pediatrics
2017
Abstract
Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking.Prospective observational analysis of 18 616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs.We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents.Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities.
View details for PubMedID 28847984
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Increasing Veterans' Hospice Use: The Veterans Health Administration's Focus On Improving End-Of-Life Care.
Health affairs (Project Hope)
2017; 36 (7): 1274–82
Abstract
In 2009 the Department of Veterans Affairs (VA) began a major, four-year investment in improving the quality of end-of-life care. The Comprehensive End of Life Care Initiative increased the numbers of VA medical center inpatient hospice units and palliative care staff members as well as the amount of palliative care training, quality monitoring, and community outreach. We divided male veterans ages sixty-six and older into categories based on their use of the VA and Medicare and examined whether the increases in their rates of hospice use in the last year of life differed from the concurrent increase among similar nonveterans enrolled in Medicare. After adjusting for age, race and ethnicity, diagnoses, nursing home use in the last year of life, census region, and urbanicity of a person's last residence, we found a 6.9-7.9-percentage-point increase in hospice use over time for the veteran categories, compared to a 5.6-percentage-point increase for nonveterans (the relative increases were 20-42 percent and 16 percent, respectively). The VA's substantial investment in palliative care appears to have resulted in greater hospice use by older male veterans enrolled in the VA, a critical step forward in caring for veterans with serious illnesses.
View details for PubMedID 28679815
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Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease.
Heart
2016
Abstract
To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD.Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years.There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.
View details for DOI 10.1136/heartjnl-2016-309266
View details for PubMedID 27852694
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Women's prepregnancy underweight as a risk factor for preterm birth: a retrospective study.
bjog-an international journal of obstetrics and gynaecology
2016; 123 (12): 2001-2007
Abstract
To investigate the distribution of known factors for preterm birth (PTB) by severity of maternal underweight; to investigate the risk-adjusted relation between severity of underweight and PTB, and to assess whether the relation differed by gestational age.Retrospective cohort study.State of California, USA.Maternally linked hospital and birth certificate records of 950 356 California deliveries in 2007-2010 were analysed. Singleton live births of women whose prepregnancy body mass index (BMI) was underweight (<18.5 kg/m(2) ) or normal (18.50-24.99 kg/m(2) ) were analysed. Underweight BMI was further categorised as: severe (<16.00), moderate (16.00-16.99) or mild (17.00-18.49). PTB was grouped as 22-27, 28-31, 32-36 or <37 weeks (compared with 37-41 weeks). Adjusted multivariable Poisson regression modeling was used to estimate relative risk for PTB.Risk of PTB.About 72 686 (7.6%) women were underweight. Increasing severity of underweight was associated with increasing percent PTB: 7.8% (n = 4421) in mild, 9.0% (n = 1001) in moderate and 10.2% (475) in severe underweight. The adjusted relative risk of PTB also significantly increased: adjusted relative risk (aRR) = 1.22 (95% CI 1.19-1.26) in mild, aRR = 1.41 (95% CI 1.32-1.50) in moderate and aRR = 1.61 (95% CI 1.47-1.76) in severe underweight. These findings were similar in spontaneous PTB, medically indicated PTB, and the gestational age groupings.Increasing severity of maternal prepregnancy underweight BMI was associated with increasing risk-adjusted PTB at <37 weeks. This increasing risk was of similar magnitude in spontaneous and medically indicated births and in preterm delivery at 28-31 and at 32-36 weeks of gestation.Increasing severity of maternal underweight BMI was associated with increasing risk of preterm birth.
View details for DOI 10.1111/1471-0528.14027
View details for PubMedID 27172996
View details for PubMedCentralID PMC5069076
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Costs of Keratinocyte Carcinoma (Nonmelanoma Skin Cancer) and Actinic Keratosis Treatment in the Veterans Health Administration
DERMATOLOGIC SURGERY
2016; 42 (9): 1041-1047
Abstract
The Veterans Health Administration (VHA) provides health care to large numbers of veterans afflicted with keratinocyte carcinoma (KC).To estimate the number of veterans treated for KCs and the related diagnosis, actinic keratosis (AK) and the costs of treating these conditions over a 1-year period.The authors conducted a cross-sectional analysis of veterans diagnosed with KC or AK during fiscal year 2012 using administrative data on outpatient encounters and prescription drugs provided or paid by VHA. Marginal costs of each condition were estimated from a regression model. The authors estimated counts of outpatient encounters, procedures, and costs related to KC and AK care.In 2012, there were 49,229 veterans with basal cell carcinoma, 26,310 veterans with squamous cell carcinoma, and 8,050 veterans with unspecified invasive KC. There were also 197,041 veterans with AK and 6,388 veterans with KC-related diagnoses. The VHA spent $356 million on KC and AK outpatient treatment for procedures, prescription drugs, and other dermatologic care during FY2012.There was high prevalence of KC and AK and considerable spending to treat these conditions in VHA. Treatment costs are not generalizable to care provided by non-VHA providers where a facility fee was not incurred.
View details for DOI 10.1097/DSS.0000000000000820
View details for Web of Science ID 000383908300003
View details for PubMedID 27465252
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At-Home Versus In-Clinic INR Monitoring: A Cost-Utility Analysis from The Home INR Study (THINRS).
Journal of general internal medicine
2016; 31 (9): 1061-1067
Abstract
Effective management of patients using warfarin is resource-intensive, requiring frequent in-clinic testing of the international normalized ratio (INR). Patient self-testing (PST) using portable at-home INR monitoring devices has emerged as a convenient alternative. As revealed by The Home INR Study (THINRS), event rates for PST were not significantly different from those for in-clinic high-quality anticoagulation management (HQACM), and a cumulative gain in quality of life was observed for patients undergoing PST.To perform a cost-utility analysis of weekly PST versus monthly HQACM and to examine the sensitivity of these results to testing frequency.In this study, 2922 patients taking warfarin for atrial fibrillation or mechanical heart valve, and who demonstrated PST competence, were randomized to either weekly PST (n = 1465) or monthly in-clinic testing (n = 1457). In a sub-study, 234 additional patients were randomized to PST once every 4 weeks (n = 116) or PST twice weekly (n = 118). The endpoints were quality of life (measured by the Health Utilities Index), health care utilization, and costs over 2 years of follow-up.PST and HQACM participants were similar with regard to gender, age, and CHADS2 score. The total cost per patient over 2 years of follow-up was $32,484 for HQACM and $33,460 for weekly PST, representing a difference of $976. The incremental cost per quality-adjusted life year gained with PST once weekly was $5566 (95 % CI, -$11,490 to $25,142). The incremental cost-effectiveness ratio (ICER) was sensitive to testing frequency: weekly PST dominated PST twice weekly and once every 4 weeks. Compared to HQACM, weekly PST was associated with statistically significant and clinically meaningful improvements in quality of life. The ICER for weekly PST versus HQACM was well within accepted standards for cost-effectiveness, and was preferred over more or less frequent PST. These results were robust to sensitivity analyses of key assumptions.Weekly PST is a cost-effective alternative to monthly HQACM and a preferred testing frequency compared to twice weekly or monthly PST.
View details for DOI 10.1007/s11606-016-3700-8
View details for PubMedID 27234663
View details for PubMedCentralID PMC4978674
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Cost of Care for Veterans Receiving Primary Care in Patient Aligned Care Teams (PACT) vs. Geriatric PACT
WILEY-BLACKWELL. 2016: S7
View details for Web of Science ID 000374763800018
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Evaluation of A Hospital-In-Home Program Implemented Among Veterans
WILEY-BLACKWELL. 2016: S5–S6
View details for Web of Science ID 000374763800014
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The Association of Level of Care With NICU Quality.
Pediatrics
2016; 137 (3): 1-9
Abstract
Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500 g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.We conducted a cross-sectional analysis of 21 051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.
View details for DOI 10.1542/peds.2014-4210
View details for PubMedID 26908663
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WHO USES BEHAVIORAL WEIGHT LOSS PROGRAMS? KEY GENDER DIFFERENCES IN PREDICTORS OF PARTICIPATION
OXFORD UNIV PRESS INC. 2016: S26
View details for Web of Science ID 000526998300095
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Economic evaluation of registered nurse tenure on nursing home resident outcomes
APPLIED NURSING RESEARCH
2016; 29: 89-95
Abstract
Little is known about the economic implications of nursing home (NH) registered nurse (RN) tenure on resident outcomes. This study evaluated the cost-effectiveness of two nurse workforce scenarios focusing on RN tenure (high versus low), and the associated transfers from NH to the hospital.A decision tree was constructed to compare the incremental costs and effects of RN tenure scenarios on NH resident transfers to the hospital under two NH staffing scenarios: high versus low levels of RN tenure. Three outcomes were modeled: 1) dollars per hospitalization avoided, 2) dollars per hospitalization and death avoided, and 3) dollars per death avoided.The total costs of care for the low tenure scenario were $34,108 per month compared to the high tenure scenario at $29,442 per month. Effectiveness of the high tenure was greater across all 3 outcomes (incremental effectiveness ranged from 0.925 to 0.974 depending on outcome), indicating that high tenure was the dominant strategy (that is less costly and more effective).Higher RN tenure was a dominant strategy across the 3 outcomes. This was a fairly robust finding despite the variations in the model and uncertainty in the input parameters. Aligning quality outcomes with cost effectiveness is imperative to driving the direction of health policy in the United States. Better prevention of hospitalizations by having an experienced RN workforce will not only improve resident quality of care but will allow NHs to realize the value of retaining a skilled workforce.
View details for DOI 10.1016/j.apnr.2015.05.001
View details for Web of Science ID 000370881800017
View details for PubMedID 26856495
View details for PubMedCentralID PMC4748169
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Racial Differences in Quality of Anticoagulation Therapy for Atrial Fibrillation (from the TREAT-AF Study)
AMERICAN JOURNAL OF CARDIOLOGY
2016; 117 (1): 61-68
Abstract
The influence of race on quality of anticoagulation control is not well described. We examined the association between race, international normalized ratio (INR) monitoring intensity, and INR control in warfarin-treated patients with atrial fibrillation (AF). Using data from the Veterans Health Administration (VHA), we performed a retrospective cohort study of 184,161 patients with a new diagnosis of AF/flutter from 2004 to 2012 who received any VHA prescription within 90 days of diagnosis. The primary predictor was race, ascertained from multiple VHA and linked Medicare demographic files. The primary outcome was first-year and long-term time in therapeutic range (TTR) of INR 2.0 to 3.0. Secondary outcomes were INR monitoring intensity and warfarin persistence. Of the 116,021 patients who received warfarin in the cohort, INR monitoring intensity was similar across racial groups. However, TTR was lowest in blacks and highest in whites (first year 0.49 ± 0.23 vs 0.57 ± 0.21, p <0.001; long term 0.52 ± 0.20 vs 0.59 ± 0.18, p <0.001); 64% of whites and 49% of blacks had long-term TTR >55% (p <0.001). After adjusting for site and patient-level covariates, black race was associated with lower first-year and long-term TTRs (4.2% and 4.1% below the conditional mean, relative to whites; p <0.0001 for both). One-year warfarin persistence was slightly lower in blacks compared to whites (58% vs 60%, p <0.0001). In conclusion, in patients with AF anticoagulated with warfarin, differences in INR control are most evident among blacks, underscoring the need to determine if other types of intensive management or warfarin alternatives may be necessary to improve anticoagulation among vulnerable AF populations.
View details for DOI 10.1016/j.amjcard.2015.09.047
View details for Web of Science ID 000368048900010
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The hospital matters: the impact of level of care on cesarean delivery rates in pregnancies complicated by preeclampsia
MOSBY-ELSEVIER. 2016: S430–S431
View details for DOI 10.1016/j.ajog.2015.10.877
View details for Web of Science ID 000367092800816
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Does Distance Modify the Effect of Self-Testing in Oral Anticoagulation?
AMERICAN JOURNAL OF MANAGED CARE
2016; 22 (1): 65-?
Abstract
Patient self-testing (PST) improves anticoagulation control and patient satisfaction. It is unknown whether these effects are more pronounced when the patient lives farther from the anticoagulation clinic (ACC). If the benefits of PST are limited to a subset of patients (those living farther from care), selectively providing PST to that subset could enhance cost-effectiveness.This is a secondary analysis of a randomized trial of PST versus usual ACC care, which involved 2922 patients of the Veterans Health Administration (VHA).Our 3 outcomes were the primary composite clinical end point (stroke, major hemorrhage, or death), anticoagulation control (percent time in therapeutic range), and satisfaction with anticoagulation care. We measured the driving distance between the patient's residence and the nearest VHA facility. We divided patients into quartiles by distance and looked for evidence of an interaction between distance and the effect of the intervention on the 3 outcomes.The median driving distance was 12 miles (interquartile range = 6-21). Patients living in the farthest quartile had higher rates of the primary composite clinical end point in both groups compared with patients living in the nearest quartile. For PST, the hazard ratio (HR) was 1.77 (95% CI, 1.18-2.64), and for usual care, the HR was 1.81 (95% CI, 1.19-2.75). Interaction terms did not suggest that distance to care modified the effect of the intervention on any outcome.The benefits of PST were not enhanced among patients living farther from care. Restricting PST to patients living more than a certain distance from the ACC is not likely to improve its cost-effectiveness.
View details for Web of Science ID 000373570700010
View details for PubMedID 26799126
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Racial Differences in Quality of Anticoagulation Therapy for Atrial Fibrillation (from the TREAT-AF Study).
The American journal of cardiology
2016; 117 (1): 61-8
Abstract
The influence of race on quality of anticoagulation control is not well described. We examined the association between race, international normalized ratio (INR) monitoring intensity, and INR control in warfarin-treated patients with atrial fibrillation (AF). Using data from the Veterans Health Administration (VHA), we performed a retrospective cohort study of 184,161 patients with a new diagnosis of AF/flutter from 2004 to 2012 who received any VHA prescription within 90 days of diagnosis. The primary predictor was race, ascertained from multiple VHA and linked Medicare demographic files. The primary outcome was first-year and long-term time in therapeutic range (TTR) of INR 2.0 to 3.0. Secondary outcomes were INR monitoring intensity and warfarin persistence. Of the 116,021 patients who received warfarin in the cohort, INR monitoring intensity was similar across racial groups. However, TTR was lowest in blacks and highest in whites (first year 0.49 ± 0.23 vs 0.57 ± 0.21, p <0.001; long term 0.52 ± 0.20 vs 0.59 ± 0.18, p <0.001); 64% of whites and 49% of blacks had long-term TTR >55% (p <0.001). After adjusting for site and patient-level covariates, black race was associated with lower first-year and long-term TTRs (4.2% and 4.1% below the conditional mean, relative to whites; p <0.0001 for both). One-year warfarin persistence was slightly lower in blacks compared to whites (58% vs 60%, p <0.0001). In conclusion, in patients with AF anticoagulated with warfarin, differences in INR control are most evident among blacks, underscoring the need to determine if other types of intensive management or warfarin alternatives may be necessary to improve anticoagulation among vulnerable AF populations.
View details for DOI 10.1016/j.amjcard.2015.09.047
View details for PubMedID 26552504
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Amiodarone and risk of death in contemporary patients with atrial fibrillation: Findings from The Retrospective Evaluation and Assessment of Therapies in AF study.
American heart journal
2015; 170 (5): 1033-1041 e1
Abstract
There are limited data on mortality outcomes associated with use of amiodarone in atrial fibrillation and flutter (AF).We evaluated the association of amiodarone use with mortality in patients with newly diagnosed AF using complete data from the Department of Veterans Affairs national health care system. We included patients seen in an outpatient setting within 90 days of a new diagnosis for nonvalvular AF between Veterans Affairs fiscal years 2004 and 2008. Multivariate analysis and propensity-matched Cox proportional hazards regression were used to evaluate the association of amiodarone use to death.Of 122,465 patients (353,168 person-years of follow-up, age 72.1 ± 10.3 years, 98.4% males), amiodarone was prescribed in 11,655 (9.5%). Cumulative, unadjusted mortality rates were higher for amiodarone recipients than for nonrecipients (87 vs 73 per 1,000 person-years, P < .001). However, in multivariate and propensity-matched survival analyses, there was no significant difference in mortality (multivariate hazard ratio 1.01, 95% CI 0.97-1.05, P = .51, and propensity-matched hazard ratio 1.02, 95% CI 0.97-1.07, P = .45). The hazard of death was not modified by age, sex, heart failure, kidney function, β-blocker use, or warfarin use, but there was evidence of effect modification among patients diagnosed with AF as an inpatient versus outpatient.In a national health care system population of newly diagnosed AF, overall use of amiodarone as an early treatment strategy was not associated with mortality.
View details for DOI 10.1016/j.ahj.2015.07.023
View details for PubMedID 26542514
View details for PubMedCentralID PMC4800972
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Anticoagulation in Atrial Fibrillation: Impact of Mental Illness
AMERICAN JOURNAL OF MANAGED CARE
2015; 21 (11): E609-E617
Abstract
To characterize warfarin eligibility and receipt among Veterans Health Administration (VHA) patients with and without mental health conditions (MHCs).Retrospective cohort study.This observational study identified VHA atrial fibrillation (AF) patients with and without MHCs in 2004. We examined unadjusted MHC-related differences in warfarin eligibility and warfarin receipt among warfarin-eligible patients, using logistic regression for any MHC and for specific MHCs (adjusting for sociodemographic and clinical characteristics).Of 125,670 patients with AF, most (96.8%) were warfarin-eligible based on a CHADS2 stroke risk score. High stroke risk and contraindications to anticoagulation were both more common in patients with MHC. Warfarin-eligible patients with MHC were less likely to receive warfarin than those without MHC (adjusted odds ratio [AOR], 0.90; 95% CI, 0.87-0.94). The association between MHC and warfarin receipt among warfarin-eligible patients varied by specific MHC. Patients with anxiety disorders (AOR, 0.86; 95% CI, 0.80-0.93), psychotic disorders (AOR, 0.77; 95% CI, 0.65-0.90), and alcohol use disorders (AOR 0.62, 95% CI 0.54-0.72) were less likely to receive warfarin than patients without these conditions, whereas patients with depressive disorders and posttraumatic stress disorder were no less likely to receive warfarin than patients without these conditions.Compared with patients with AF without MHCs, those with MHCs are less likely to be eligible for warfarin receipt and, among those eligible, are less likely to receive such treatment. Although patients with AF with MHC need careful assessment of bleeding risk, this finding suggests potential missed opportunities for more intensive therapy among some individuals with MHCs.
View details for Web of Science ID 000379911700003
View details for PubMedID 26735294
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Invasive Mechanical Ventilation in California Over 2000-2009: Implications for Emergency Medicine.
The western journal of emergency medicine
2015; 16 (5): 696-706
Abstract
Patients who require invasive mechanical ventilation (IMV) often represent a sequence of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most populous state, little information exists to define patterns of IMV use within the state of California.We examined data from the masked Patient Discharge Database of California's Office of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV during their stay were identified using the International Classification of Diseases 9th Revision and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age strata (18-34yr, 35-64yr, and >65yr). Using descriptive statistics and regression analyses, for IMV discharges during the study period, we quantified the number of ED vs. non-ED based admissions; changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV; determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96hr); and projected the number of IMV discharges and ED-based admissions by year 2020.There were 696,634 IMV discharges available for analysis. From 2000-2009, IMV discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868 (328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35-64 year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by 29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for younger patients (ages 18-34yr), non-whites, and publicly insured patients. Some of the strongest predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p<0.05); non-Whites; and non-Medicare public insurance. Our models suggest that by 2020, IMV discharges will grow to n=153,153 (377 IMV discharges/100,000 persons) with 99,095 admitted through the ED.Based on sustained growth over the past decade, by the year 2020, we project a further increase to 153,153 IMV discharges with 99,095 admitted through the ED. Given limited ICU bed capacities, ongoing increases in the number and type of IMV patients have the potential to adversely affect California EDs that often admit patients to ICUs.
View details for DOI 10.5811/westjem.2015.6.25736
View details for PubMedID 26587094
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Long-term Efficacy of Topical Fluorouracil Cream, 5%, for Treating Actinic Keratosis A Randomized Clinical Trial
JAMA DERMATOLOGY
2015; 151 (9): 952-960
Abstract
Topical fluorouracil was demonstrated to be effective in reducing the number of actinic keratoses (AKs) for up to 6 months, but no randomized trials studied its long-term efficacy.To evaluate the long-term efficacy of a single course of fluorouracil cream, 5%, for AK treatment.The Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) trial was a randomized, double-blinded, placebo-controlled trial with patients from dermatology clinics at 12 VA medical centers recruited from 2009 to 2011 and followed up until 2013. Our study population comprised 932 veterans with 2 or more keratinocyte carcinomas in the 5 years prior to enrollment. The mean follow-up duration was 2.6 years in both treatment and control groups.Participants applied either topical fluorouracil cream, 5% (n = 468), or vehicle control cream (n = 464) to the face and ears twice daily for up to 4 weeks.This study reports on AK counts and treatments, which were secondary outcomes of the VAKCC trial. Actinic keratoses on the face and ears were counted by study dermatologists at enrollment and at study visits every 6 months. The number of spot treatments for AKs on the face and ears at semiannual study visits and in between study visits was recorded.The number of AKs on the face and ears per participant was not different between the fluorouracil and control groups at randomization (11.1 vs 10.6, P > .10). After randomization, the fluorouracil group had fewer AKs compared with the control group at 6 months (3.0 vs 8.1, P < .001) and for the overall study duration (P < .001). The fluorouracil group also had higher complete AK clearance rates (38% vs 17% at 6 months) and fewer spot treatments at 6-month intervals, at study visits, and in between study visits during the trial (P < .01 for all). The fluorouracil group took longer to require the first spot AK treatment (6.2 months) compared with the control group (6.0 months) (hazard ratio, 0.69; 95% CI, 0.60-0.79). The number of hypertrophic AKs was not different between the 2 groups overall (P = .60), although there were fewer hypertrophic AKs in the fluorouracil group at 6 months (0.23 vs 0.41) (P = .05).Our results indicate that a single course of fluorouracil cream, 5%, effectively reduces AK counts and the need for spot treatments for longer than 2 years.clinicaltrials.gov Identifier:NCT00847912.
View details for DOI 10.1001/jamadermatol.2015.0502
View details for PubMedID 25950503
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The impact of frequency of patient self-testing of prothrombin time on time in target range within VA Cooperative Study #481: The Home INR Study (THINRS), a randomized, controlled trial
JOURNAL OF THROMBOSIS AND THROMBOLYSIS
2015; 40 (1): 17-25
Abstract
Anticoagulation (AC) is effective in reducing thromboembolic events for individuals with atrial fibrillation (AF) or mechanical heart valve (MHV), but maintaining patients in target range for international normalized ratio (INR) can be difficult. Evidence suggests increasing INR testing frequency can improve time in target range (TTR), but this can be impractical with in-clinic testing. The objective of this study was to test the hypothesis that more frequent patient-self testing (PST) via home monitoring increases TTR. This planned substudy was conducted as part of The Home INR Study, a randomized controlled trial of in-clinic INR testing every 4 weeks versus PST at three different intervals. The setting for this study was 6 VA centers across the United States. 1,029 candidates with AF or MHV were trained and tested for competency using ProTime INR meters; 787 patients were deemed competent and, after second consent, randomized across four arms: high quality AC management (HQACM) in a dedicated clinic, with venous INR testing once every 4 weeks; and telephone monitored PST once every 4 weeks; weekly; and twice weekly. The primary endpoint was TTR at 1-year follow-up. The secondary endpoints were: major bleed, stroke and death, and quality of life. Results showed that TTR increased as testing frequency increased (59.9 ± 16.7 %, 63.3 ± 14.3 %, and 66.8 ± 13.2 % [mean ± SD] for the groups that underwent PST every 4 weeks, weekly and twice weekly, respectively). The proportion of poorly managed patients (i.e., TTR <50 %) was significantly lower for groups that underwent PST versus HQACM, and the proportion decreased as testing frequency increased. Patients and their care providers were unblinded given the nature of PST and HQACM. In conclusion, more frequent PST improved TTR and reduced the proportion of poorly managed patients.
View details for DOI 10.1007/s11239-014-1128-8
View details for Web of Science ID 000355219300003
View details for PubMedID 25209313
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Spatial and temporal patterns in preterm birth in the United States
PEDIATRIC RESEARCH
2015; 77 (6): 836-844
Abstract
Despite years of research, the etiologies of preterm birth remain unclear. In order to help generate new research hypotheses, this study explored spatial and temporal patterns of preterm birth in a large, total-population dataset.Data on 145 million US births in 3,000 counties from the Natality Files of the National Center for Health Statistics for 1971-2011 were examined. State trends in early (<34 wk) and late (34-36 wk) preterm birth rates were compared. K-means cluster analyses were conducted to identify gestational age distribution patterns for all US counties over time.A weak association was observed between state trends in <34 wk birth rates and the initial absolute <34 wk birth rate. Significant associations were observed between trends in <34 wk and 34-36 wk birth rates and between white and African American <34 wk births. Periodicity was observed in county-level trends in <34 wk birth rates. Cluster analyses identified periods of significant heterogeneity and homogeneity in gestational age distributional trends for US counties.The observed geographic and temporal patterns suggest periodicity and complex, shared influences among preterm birth rates in the United States. These patterns could provide insight into promising hypotheses for further research.
View details for DOI 10.1038/pr.2015.55
View details for PubMedID 25760546
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Travel Time and Attrition From VHA Care Among Women Veterans: How Far is Too Far?
Medical care
2015; 53 (4): S15-22
Abstract
Travel time, an access barrier, may contribute to attrition of women veterans from Veterans Health Administration (VHA) care.We examined whether travel time influences attrition: (a) among women veterans overall, (b) among new versus established patients, and (c) among rural versus urban patients.This retrospective cohort study used logistic regression to estimate the association between drive time and attrition, overall and for new/established and rural/urban patients.In total, 266,301 women veteran VHA outpatients in the Fiscal year 2009.An "attriter" did not return for VHA care during the second through third years after her first 2009 visit (T0). Drive time (log minutes) was between the patient's residence and her regular source of VHA care. "New" patients had no VHA visits within 3 years before T0. Models included age, service-connected disability, health status, and utilization as covariates.Overall, longer drive times were associated with higher odds of attrition: drive time adjusted odds ratio=1.11 (99% confidence interval, 1.09-1.14). The relationship between drive time and attrition was stronger among new patients but was not modified by rurality.Attrition among women veterans is sensitive to longer drive time. Linking new patients to VHA services designed to reduce distance barriers (telemedicine, community-based clinics, mobile clinics) may reduce attrition among women new to VHA.
View details for DOI 10.1097/MLR.0000000000000296
View details for PubMedID 25767970
View details for PubMedCentralID PMC4386926
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In reply.
Obstetrics and gynecology
2015; 125 (4): 989-?
View details for DOI 10.1097/AOG.0000000000000783
View details for PubMedID 25798980
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Readying the Workforce: Evaluation of VHA's Comprehensive Women's Health Primary Care Provider Initiative.
Medical care
2015; 53 (4): S39-46
Abstract
Veterans Health Administration (VHA) primary care providers (PCPs) often see few women, making it challenging to maintain proficiency in women's health (WH). Therefore, VHA in 2010 established Designated WH Providers, who would maintain proficiency in comprehensive WH care and be preferentially assigned women patients.To evaluate early implementation of this national policy.At each VHA health care system (N=140), the Women Veterans Program Manager completed a Fiscal Year 2012 workforce capacity assessment (response rate, 100%), representing the first time the national Designated WH Provider workforce had been identified. Assessment data were linked to administrative data.Of all VHA PCPs, 23% were Designated WH Providers; 100% of health care systems and 83% of community clinics had at least 1 Designated WH Provider. On average, women veterans comprised 19% (SD=27%) of the patients Designated WH Providers saw in primary care, versus 5% (SD=7%) for Other PCPs (P<0.001). For women veterans using primary care (N=313,033), new patients were less likely to see a Designated WH Provider than established women veteran patients (52% vs. 64%; P<0.001).VHA has achieved its goal of a Designated WH Provider in every health care system, and is approaching its goal of a Designated WH Provider at every hospital/community clinic. Designated WH Providers see more women than do Other PCPs. However, as the volume of women patients remains low for many providers, attention to alternative approaches to maintaining proficiency may prove necessary, and barriers to assigning new women patients to Designated WH Providers merit attention.
View details for DOI 10.1097/MLR.0000000000000298
View details for PubMedID 25767974
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Reproductive health diagnoses of women veterans using department of veterans affairs health care.
Medical care
2015; 53 (4): S63-7
Abstract
Little is known regarding the reproductive health needs of women Veterans using Department of Veterans Affairs (VA) health care.To describe the reproductive health diagnoses of women Veterans using VA health care, how these diagnoses differ across age groups, and variations in sociodemographic and clinical characteristics by presence of reproductive health diagnoses.This study is a cross-sectional analysis of VA administrative and clinical data.The study included women Veterans using VA health care in FY10.Reproductive health diagnoses were identified through presence of International Classification of Disease, 9th Revision (ICD-9) codes in VA clinical and administrative records. The prevalence of specific diagnosis categories were examined by age group (18-44, 45-64, ≥65 y) and the most frequent diagnoses for each age group were identified. Sociodemographic and clinical characteristics were compared by presence of at least 1 reproductive health diagnosis.The most frequent reproductive health diagnoses were menstrual disorders and endometriosis among those aged 18-44 years (n=16,658, 13%), menopausal disorders among those aged 45-64 years (n=20,707, 15%), and osteoporosis among those aged ≥65 years (n=8365, 22%). Compared with women without reproductive health diagnoses, those with such diagnoses were more likely to have concomitant mental health (46% vs. 37%, P<0.001) and medical conditions (75% vs. 63%, P<0.001).Women Veterans using VA health care have diverse reproductive health diagnoses. The high prevalence of comorbid medical and mental health conditions among women Veterans with reproductive health diagnoses highlights the importance of integrating reproductive health expertise into all areas of VA health care, including primary, mental health, and specialty care.
View details for DOI 10.1097/MLR.0000000000000295
View details for PubMedID 25767978
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Nurse Workforce Characteristics and Infection Risk in VA Community Living Centers: A Longitudinal Analysis.
Medical care
2015; 53 (3): 261-267
Abstract
To examine effects of workforce characteristics on resident infections in Veterans Affairs (VA) Community Living Centers (CLCs).A 6-year panel of monthly, unit-specific data included workforce characteristics (from the VA Decision Support System and Payroll data) and characteristics of residents and outcome measures (from the Minimum Data Set).A resident infection composite was the dependent variable. Workforce characteristics of registered nurses (RN), licensed practical nurses (LPN), nurse aides (NA), and contract nurses included: staffing levels, skill mix, and tenure. Descriptive statistics and unit-level fixed effects regressions were conducted. Robustness checks varying workforce and outcome parameters were examined.Average nursing hours per resident day was 4.59 hours (SD=1.21). RN tenure averaged 4.7 years (SD=1.64) and 4.2 years for both LPN (SD=1.84) and NA (SD=1.72). In multivariate analyses RN and LPN tenure were associated with decreased infections by 3.8% (incident rate ratio [IRR]=0.962, P<0.01) and 2% (IRR=0.98, P<0.01) respectively. Robustness checks consistently found RN and LPN tenure to be associated with decreased infections.Increasing RN and LPN tenure are likely to reduce CLC resident infections. Administrators and policymakers need to focus on recruiting and retaining a skilled nursing workforce.
View details for DOI 10.1097/MLR.0000000000000316
View details for PubMedID 25634087
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Patient-centered mental health care for female veterans.
Psychiatric services
2015; 66 (2): 155-162
Abstract
Mental health services for women vary widely across the Veterans Health Administration (VHA) system, without consensus on the need for, or organization of, specialized services for women. Understanding women's needs and priorities is essential to guide the implementation of patient-centered behavioral health services.In a cross-sectional, multisite survey of female veterans using primary care, potential stakeholders were identified for VHA mental health services by assessing perceived or observed need for mental health services. These stakeholders (N=484) ranked priorities for mental health care among a wide range of possible services. The investigators then quantified the importance of having designated women's mental health services for each of the mental health services that emerged as key priorities.Treatment for depression, pain management, coping with chronic general medical conditions, sleep problems, weight management, and posttraumatic stress disorder (PTSD) emerged as women's key priorities. Having mental health services specialized for women was rated as extremely important to substantial proportions of women for each of the six prioritized services. Preference for primary care colocation was strongly associated with higher importance ratings for designated women's mental health services. For specific types of services, race, ethnicity, sexual orientation, PTSD symptoms, and psychiatric comorbidity were also associated with higher importance ratings for designated women's services.Female veterans are a diverse population whose needs and preferences for mental health services vary along demographic and clinical factors. These stakeholder perspectives can help prioritize structural and clinical aspects of designated women's mental health care in the VHA.
View details for DOI 10.1176/appi.ps.201300551
View details for PubMedID 25642611
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Making smart investment decisions in clinical research.
Trials
2015; 16: 590
Abstract
A recent trial in rheumatoid arthritis found an inexpensive, but infrequently used, combination of therapies is neither inferior nor less safe than an expensive biologic drug. If the trial had been conducted over 10 years ago, arguably 100's of millions of dollars since spent on biologics could have been released to other, more effective treatments. Given the ever increasing number of trials proposed, this commentary uses the trial as an example to challenge payers and research funders to make smarter investments in clinical research to save potential future costs.NCT00405275 , registered 29 November 2006.
View details for PubMedID 26712327
View details for PubMedCentralID PMC4693420
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Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth
OBSTETRICS AND GYNECOLOGY
2014; 124 (6): 1111-1119
Abstract
To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.
View details for DOI 10.1097/AOG.0000000000000542
View details for Web of Science ID 000345341100008
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Variations in inpatient pediatric anesthesia in California from 2000 to 2009: a caseload and geographic analysis.
Paediatric anaesthesia
2014; 24 (12): 1295-1301
Abstract
Regional referral systems are considered important for children hospitalized for surgery, but there is little information on existing systems.To examine geographic variations in anesthetic caseloads in California for surgical inpatients ≤6 years and to evaluate the feasibility of regionalizing anesthetic care.We reviewed California's unmasked patient discharge database between 2000 and 2009 to determine surgical procedures, dates, and inpatient anesthetic caseloads. Hospitals were classified as urban or rural and were further stratified as low, intermediate, high, and very high volume.We reviewed 257,541 anesthetic cases from 402 hospitals. Seventeen California Children's Services (CCS) hospitals conducted about two-thirds of all inpatient anesthetics; 385 non-CCS hospitals accounted for the rest. Urban hospitals comprised 82% of low- and intermediate-volume centers (n = 297) and 100% of the high- and very high-volume centers (n = 41). Ninety percent (n = 361) of hospitals performed <100 cases annually. Although potentially lower risk procedures such as appendectomies were the most frequent in urban low- and intermediate-volume hospitals, fairly complex neurosurgical and general surgeries were also performed. The median distance from urban lower-volume hospitals to the nearest high- or very high-volume center was 12 miles. Up to 98% (n = 40,316) of inpatient anesthetics at low- or intermediate-volume centers could have been transferred to higher-volume centers within 25 miles of smaller centers.Many urban California hospitals maintained low annual inpatient anesthetic caseloads for children ≤6 years while conducting potentially more complex procedures. Further efforts are necessary to define the scope of pediatric anesthetic care at urban low- and intermediate-volume hospitals in California.
View details for DOI 10.1111/pan.12500
View details for PubMedID 25203670
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Posttraumatic stress disorder and risk of spontaneous preterm birth.
Obstetrics and gynecology
2014; 124 (6): 1111-1119
Abstract
To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.
View details for DOI 10.1097/AOG.0000000000000542
View details for PubMedID 25415162
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Variations in inpatient pediatric anesthesia in California from 2000 to 2009: a caseload and geographic analysis
PEDIATRIC ANESTHESIA
2014; 24 (12): 1295-1301
Abstract
Regional referral systems are considered important for children hospitalized for surgery, but there is little information on existing systems.To examine geographic variations in anesthetic caseloads in California for surgical inpatients ≤6 years and to evaluate the feasibility of regionalizing anesthetic care.We reviewed California's unmasked patient discharge database between 2000 and 2009 to determine surgical procedures, dates, and inpatient anesthetic caseloads. Hospitals were classified as urban or rural and were further stratified as low, intermediate, high, and very high volume.We reviewed 257,541 anesthetic cases from 402 hospitals. Seventeen California Children's Services (CCS) hospitals conducted about two-thirds of all inpatient anesthetics; 385 non-CCS hospitals accounted for the rest. Urban hospitals comprised 82% of low- and intermediate-volume centers (n = 297) and 100% of the high- and very high-volume centers (n = 41). Ninety percent (n = 361) of hospitals performed <100 cases annually. Although potentially lower risk procedures such as appendectomies were the most frequent in urban low- and intermediate-volume hospitals, fairly complex neurosurgical and general surgeries were also performed. The median distance from urban lower-volume hospitals to the nearest high- or very high-volume center was 12 miles. Up to 98% (n = 40,316) of inpatient anesthetics at low- or intermediate-volume centers could have been transferred to higher-volume centers within 25 miles of smaller centers.Many urban California hospitals maintained low annual inpatient anesthetic caseloads for children ≤6 years while conducting potentially more complex procedures. Further efforts are necessary to define the scope of pediatric anesthetic care at urban low- and intermediate-volume hospitals in California.
View details for DOI 10.1111/pan.12500
View details for Web of Science ID 000345151700015
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Increased Mortality Associated With Digoxin in Contemporary Patients With Atrial Fibrillation: Findings From the TREAT-AF Study.
Journal of the American College of Cardiology
2014; 64 (7): 660-668
Abstract
Despite endorsement of digoxin in clinical practice guidelines, there exist limited data on its safety in atrial fibrillation/flutter (AF).The goal of this study was to evaluate the association of digoxin with mortality in AF.Using complete data of the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the U.S. Department of Veterans Affairs (VA) healthcare system, we identified patients with newly diagnosed, nonvalvular AF seen within 90 days in an outpatient setting between VA fiscal years 2004 and 2008. We used multivariate and propensity-matched Cox proportional hazards to evaluate the association of digoxin use with death. Residual confounding was assessed by sensitivity analysis.Of 122,465 patients with 353,168 person-years of follow-up (age 72.1 ± 10.3 years, 98.4% male), 28,679 (23.4%) patients received digoxin. Cumulative mortality rates were higher for digoxin-treated patients than for untreated patients (95 vs. 67 per 1,000 person-years; p < 0.001). Digoxin use was independently associated with mortality after multivariate adjustment (hazard ratio [HR]: 1.26, 95% confidence interval [CI]: 1.23 to 1.29, p < 0.001) and propensity matching (HR: 1.21, 95% CI: 1.17 to 1.25, p < 0.001), even after adjustment for drug adherence. The risk of death was not modified by age, sex, heart failure, kidney function, or concomitant use of beta-blockers, amiodarone, or warfarin.Digoxin was associated with increased risk of death in patients with newly diagnosed AF, independent of drug adherence, kidney function, cardiovascular comorbidities, and concomitant therapies. These findings challenge current cardiovascular society recommendations on use of digoxin in AF.
View details for DOI 10.1016/j.jacc.2014.03.060
View details for PubMedID 25125296
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Maternal prepregnancy body mass index and risk of spontaneous preterm birth.
Paediatric and perinatal epidemiology
2014; 28 (4): 302-311
Abstract
Findings from studies examining risk of preterm birth associated with elevated prepregnancy body mass index (BMI) have been inconsistent.Within a large population-based cohort, we explored associations between prepregnancy BMI and spontaneous preterm birth across a spectrum of BMI, gestational age, and racial/ethnic categories. We analysed data for 989 687 singleton births in California, 2007-09. Preterm birth was grouped as 20-23, 24-27, 28-31, or 32-36 weeks gestation (compared with 37-41 weeks). BMI was categorised as <18.5 (underweight); 18.5-24.9 (normal); 25.0-29.9 (overweight); 30.0-34.9 (obese I); 35.0-39.9 (obese II); and ≥40.0 (obese III). We assessed associations between BMI and spontaneous preterm birth of varying severity among non-Hispanic White, Hispanic, and non-Hispanic Black women.Analyses of mothers without hypertension and diabetes, adjusted for age, education, height, and prenatal care initiation, showed obesity categories I-III to be associated with increased risk of spontaneous preterm birth at 20-23 and 24-27 weeks among those of parity 1 in each race/ethnic group. Relative risks for obese III and preterm birth at 20-23 weeks were 6.29 [95% confidence interval (CI) 3.06, 12.9], 4.34 [95% CI 2.30, 8.16], and 4.45 [95% CI 2.53, 7.82] for non-Hispanic Whites, non-Hispanic Blacks, and Hispanics, respectively. A similar, but lower risk, pattern was observed for women of parity ≥2 and preterm birth at 20-23 weeks. Underweight was associated with modest risks for preterm birth at ≥24 weeks among women in each racial/ethnic group regardless of parity.The association between women's prepregnancy BMI and risk of spontaneous preterm birth is complex and is influenced by race/ethnicity, gestational age, and parity.
View details for DOI 10.1111/ppe.12125
View details for PubMedID 24810721
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Human Capital and Productivity in a Team Environment: Evidence from the Healthcare Sector
AMERICAN ECONOMIC JOURNAL-APPLIED ECONOMICS
2014; 6 (2): 231-259
View details for DOI 10.1257/app.6.2.231
View details for Web of Science ID 000333980000010
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Night and day in the VA: associations between night shift staffing, nurse workforce characteristics, and length of stay.
Research in nursing & health
2014; 37 (2): 90-97
Abstract
In hospitals, nurses provide patient care around the clock, but the impact of night staff characteristics on patient outcomes is not well understood. The aim of this study was to examine the association between night nurse staffing and workforce characteristics and the length of stay (LOS) in 138 veterans affairs (VA) hospitals using panel data from 2002 through 2006. Staffing in hours per patient day was higher during the day than at night. The day nurse workforce had more educational preparation than the night workforce. Nurses' years of experience at the unit, facility, and VA level were greater at night. In multivariable analyses controlling for confounding variables, higher night staffing and a higher skill mix were associated with reduced LOS.
View details for DOI 10.1002/nur.21582
View details for PubMedID 24403000
View details for PubMedCentralID PMC3959218
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Maternal Body Mass and Risk for Premature Birth among 1.2 Million California Births
SAGE PUBLICATIONS INC. 2014: 340A
View details for Web of Science ID 000333813003131
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The effect of health information technology implementation in Veterans Health Administration hospitals on patient outcomes.
Healthcare (Amsterdam, Netherlands)
2014; 2 (1): 40-47
Abstract
The impact of health information technology (HIT) in hospitals is dependent in large part on how it is used by nurses. This study examines the impact of HIT on the quality of care in hospitals in the Veterans Health Administration (VA), focusing on nurse-sensitive outcomes from 1995 to 2005.Data were obtained from VA databases and original data collection. Fixed-effects Poisson regression was used, with the dependent variables measured using the Agency for Healthcare Research and Quality Inpatient Quality Indicators and Patient Safety Indicators software. Dummy variables indicated when each facility began and completed implementation of each type of HIT. Other explanatory variables included hospital volume, patient characteristics, nurse characteristics, and a quadratic time trend.The start of computerized patient record implementation was associated with significantly lower mortality for two diagnoses but significantly higher pressure ulcer rates, and full implementation was associated with significantly more hospital-acquired infections. The start of bar-code medication administration implementation was linked to significantly lower mortality for one diagnosis, but full implementation was not linked to any change in patient outcomes.The commencement of HIT implementation had mixed effects on patient outcomes, and the completion of implementation had little or no effect on outcomes.This longitudinal study provides little support for the perception of VA staff and leaders that HIT has improved mortality rates or nurse-sensitive patient outcomes. Future research should examine patient outcomes associated with specific care processes affected by HIT.
View details for DOI 10.1016/j.hjdsi.2013.12.009
View details for PubMedID 26250088
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Five-year trends in women veterans' use of VA maternity benefits, 2008-2012.
Women's health issues : official publication of the Jacobs Institute of Women's Health
2014; 24 (1): e37-42
Abstract
An increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time.The goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits.We undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012.We included pregnant veterans using VHA maternity benefits for delivery.Measures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator.During the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran).Over a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care for pregnant veterans and ensure care coordination systems are in place to address the needs of pregnant veterans with service-connected disabilities.
View details for DOI 10.1016/j.whi.2013.10.002
View details for PubMedID 24439945
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Five-year Trends in Women Veterans' Use of VA Maternity Benefits, 2008-2012.
Women's health issues : official publication of the Jacobs Institute of Women's Health
2014; 24 (1): e37-42
Abstract
An increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time.The goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits.We undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012.We included pregnant veterans using VHA maternity benefits for delivery.Measures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator.During the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran).Over a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care for pregnant veterans and ensure care coordination systems are in place to address the needs of pregnant veterans with service-connected disabilities.
View details for DOI 10.1016/j.whi.2013.10.002
View details for PubMedID 24439945
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The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011.
journal of trauma and acute care surgery
2013; 75 (4): 704-716
Abstract
Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care.This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999-2011). DRG International Classification of Diseases-9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0-18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child's residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables.Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, -0.80 to -0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs.Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care.Therapeutic/care management, level III.
View details for DOI 10.1097/TA.0b013e31829a0a65
View details for PubMedID 24064887
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Therapies for Active Rheumatoid Arthritis after Methotrexate Failure
NEW ENGLAND JOURNAL OF MEDICINE
2013; 369 (4): 307-318
Abstract
Few blinded trials have compared conventional therapy consisting of a combination of disease-modifying antirheumatic drugs with biologic agents in patients with rheumatoid arthritis who have active disease despite treatment with methotrexate--a common scenario in the management of rheumatoid arthritis.We conducted a 48-week, double-blind, noninferiority trial in which we randomly assigned 353 participants with rheumatoid arthritis who had active disease despite methotrexate therapy to a triple regimen of disease-modifying antirheumatic drugs (methotrexate, sulfasalazine, and hydroxychloroquine) or etanercept plus methotrexate. Patients who did not have an improvement at 24 weeks according to a prespecified threshold were switched in a blinded fashion to the other therapy. The primary outcome was improvement in the Disease Activity Score for 28-joint counts (DAS28, with scores ranging from 2 to 10 and higher scores indicating more disease activity) at week 48.Both groups had significant improvement over the course of the first 24 weeks (P=0.001 for the comparison with baseline). A total of 27% of participants in each group required a switch in treatment at 24 weeks. Participants in both groups who switched therapies had improvement after switching (P<0.001), and the response after switching did not differ significantly between the two groups (P=0.08). The change between baseline and 48 weeks in the DAS28 was similar in the two groups (-2.1 with triple therapy and -2.3 with etanercept and methotrexate, P=0.26); triple therapy was noninferior to etanercept and methotrexate, since the 95% upper confidence limit of 0.41 for the difference in change in DAS28 was below the margin for noninferiority of 0.6 (P=0.002). There were no significant between-group differences in secondary outcomes, including radiographic progression, pain, and health-related quality of life, or in major adverse events associated with the medications.With respect to clinical benefit, triple therapy, with sulfasalazine and hydroxychloroquine added to methotrexate, was noninferior to etanercept plus methotrexate in patients with rheumatoid arthritis who had active disease despite methotrexate therapy. (Funded by the Cooperative Studies Program, Department of Veterans Affairs Office of Research and Development, and others; CSP 551 RACAT ClinicalTrials.gov number, NCT00405275.)
View details for DOI 10.1056/NEJMoa1303006
View details for Web of Science ID 000322223900006
View details for PubMedID 23755969
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Perceptions and observations of off-shift nursing
JOURNAL OF NURSING MANAGEMENT
2013; 21 (2): 283-292
Abstract
The purpose of this paper is to qualitatively explore registered nurse perceptions of off-shift (e.g. nights and weekends) nursing care and quality compared with regular hours.Patients admitted to hospitals on off-shifts have worse outcomes than patients admitted on more regular hours. The underlying mechanism for this association is not well understood.In-depth semi-structured interviews of 23 registered nurses and four observer-as-participant observations were conducted on both medical-surgical and intensive care units in two large (>850 beds) tertiary hospitals. Content analysis was used to identify themes.Six themes emerged: (1) collaboration among self-reliant night nurses; (2) completing tasks; (3) taking a breather on weekend day shift; (4) new nurse requirement to work at night; (5) mixture of registered nurse personnel; and (6) night nurse perception of under-appreciation.Although nurses collaborate, complete more tasks and work with other types of registered nurses, the decreased resources available on off-shifts may affect quality care delivered in hospitals.These findings support the importance of management to provide sufficient resources in terms of ancillary personnel and balance less experienced staff. Facilitating communication between night and day nurses may help allay night nurses' feelings of under-appreciation.
View details for DOI 10.1111/j.1365-2834.2012.01417.x
View details for Web of Science ID 000316127500009
View details for PubMedID 23409837
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Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study.
American heart journal
2013; 165 (1): 93-101 e1
Abstract
Atrial fibrillation and flutter (AF, collectively) cause stroke. We evaluated whether treating specialty influences warfarin prescription in patients with newly diagnosed AF.In the TREAT-AF study, we used Veterans Health Administration health record and claims data to identify patients with newly diagnosed AF between October 2004 and November 2008 and at least 1 internal medicine/primary care or cardiology outpatient encounter within 90 days after diagnosis. The primary outcome was prescription of warfarin.In 141,642 patients meeting the inclusion criteria, the mean age was 72.3 ± 10.2 years, 1.48% were women, and 25.8% had cardiology outpatient care. Cardiology-treated patients had more comorbidities and higher mean CHADS2 scores (1.8 vs 1.6, P < .0001). Warfarin use was higher in cardiology-treated vs primary care only-treated patients (68.6% vs 48.9%, P < .0001). After covariate and site-level adjustment, cardiology care was significantly associated with warfarin use (odds ratio [OR] 2.05, 95% CI 1.99-2.11). These findings were consistent across a series of adjusted models (OR 2.05-2.20), propensity matching (OR 1.98), and subgroup analyses (OR 1.58-2.11). Warfarin use in primary-care-only patients declined from 2004 to 2008 (51.6%-44.0%, P < .0001), whereas the adjusted odds of warfarin receipt with cardiology care (vs primary care) increased from 2004 to 2008 (1.88-2.24, P < .0001).In patients with newly diagnosed AF, we found large differences in anticoagulation use by treating specialty. A divergent 5-year trend of risk-adjusted warfarin use was observed. Treating specialty influences stroke prevention care and may impact clinical outcomes.
View details for DOI 10.1016/j.ahj.2012.10.010
View details for PubMedID 23237139
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The VA Women's Health Practice-Based Research Network: Amplifying Women Veterans' Voices in VA Research.
Journal of general internal medicine
2013; 28 Suppl 2: 504–9
View details for DOI 10.1007/s11606-013-2476-3
View details for PubMedID 23807057
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Impact of Baseline Stroke Risk and Bleeding Risk on INR Control among Patients with Atrial Fibrillation on Warfarin: the TREAT-AF Study
LIPPINCOTT WILLIAMS & WILKINS. 2012
View details for Web of Science ID 000208885006200
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Twenty-four/seven: a mixed-method systematic review of the off-shift literature
JOURNAL OF ADVANCED NURSING
2012; 68 (7): 1454-1468
Abstract
This article is a report of a review that aimed to synthesize qualitative and quantitative evidence of 'off-shifts' (nights, weekends and/or holidays) on quality and employee outcomes in hospitals.Healthcare workers provide 24-hour-a-day, 7-day-a-week service. Quality and employee outcomes may differ on off-shifts as compared to regular hours.Searches for studies occurred between the years 1985-2011 using computerized databases including Business Source Complete, EconLit, ProQuest, PubMed and MEDLINE. REVIEW DESIGN AND METHODS: Design was a mixed-method systematic review with quantitative and qualitative studies. To be included, studies met the following criteria: (1) the independent variable was an off-shift; (2) the article was a research study and peer-reviewed; (3) the article could be obtained in English; and (4) the article pertained to health care. Studies were not excluded on design.Sixty studies were included. There were 37 quality outcome, 19 employee outcome and four qualitative studies. In the quality outcome studies, researchers often used quantitative, longitudinal study designs with large sample sizes. Researchers found important differences between patients admitted on weekends and mortality. Important differences were also found between nighttime birth and mortality and rotating night work and fatigue, stress and low mental well-being. Most studies (9 of 12) did not find an important association between patients admitted at night and mortality.Patient outcomes on weekends and employee outcomes at night are worse than during the day. It is important to further investigate why care on off-shifts differs from weekly day shifts.
View details for DOI 10.1111/j.1365-2648.2012.05976.x
View details for Web of Science ID 000305514900003
View details for PubMedID 22905343
View details for PubMedCentralID PMC3428734
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Trends in Rates and Attributable Costs of Conditions among Female VA Patients, 2000 and 2008
WOMENS HEALTH ISSUES
2012; 22 (3): E337-E344
Abstract
We examined rates of specific health conditions among female veteran patients and how the share of health care costs attributable to these conditions changed in the Veterans Affairs system between 2000 and 2008.Veterans' Administration (VA)-provided and VA-sponsored inpatient, outpatient, and pharmacy utilization and cost files were analyzed for women veterans receiving care in 2000 and 2008. We estimated rates of 42 common health conditions and per-patient condition costs from a regression model and calculated the total population costs attributable to each condition and changes by year.The number of female VA patients increased from 156,305 in 2000 to 266,978 in 2008; 88% were under 65 years of age. The rate of women treated for specific conditions increased substantially for many gender-specific and psychiatric conditions: For example, pregnancy increased 133%, diagnosed posttraumatic stress disorder increased 106%, and diagnosed depression increased 41%. Mean costs of care increased from $4,962 per woman in 2000 to $6,570 per woman in 2008. Psychiatric conditions accounted for more than one quarter of population health care costs in 2008. Gender-specific conditions and musculoskeletal diseases accounted for a rising share of population costs and rose to 8.2% and 8.7% of population costs in 2008, respectively.Gender-specific, cancer, musculoskeletal, and mental health and substance use disorders accounted for a greater share of overall costs during the study period and were primarily driven by higher rates of diagnosed conditions and, for several conditions, higher treatment costs.
View details for DOI 10.1016/j.whi.2012.03.002
View details for Web of Science ID 000209039000012
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Trends in rates and attributable costs of conditions among female VA patients, 2000 and 2008.
Women's health issues : official publication of the Jacobs Institute of Women's Health
2012; 22 (3): e337-44
Abstract
We examined rates of specific health conditions among female veteran patients and how the share of health care costs attributable to these conditions changed in the Veterans Affairs system between 2000 and 2008.Veterans' Administration (VA)-provided and VA-sponsored inpatient, outpatient, and pharmacy utilization and cost files were analyzed for women veterans receiving care in 2000 and 2008. We estimated rates of 42 common health conditions and per-patient condition costs from a regression model and calculated the total population costs attributable to each condition and changes by year.The number of female VA patients increased from 156,305 in 2000 to 266,978 in 2008; 88% were under 65 years of age. The rate of women treated for specific conditions increased substantially for many gender-specific and psychiatric conditions: For example, pregnancy increased 133%, diagnosed posttraumatic stress disorder increased 106%, and diagnosed depression increased 41%. Mean costs of care increased from $4,962 per woman in 2000 to $6,570 per woman in 2008. Psychiatric conditions accounted for more than one quarter of population health care costs in 2008. Gender-specific conditions and musculoskeletal diseases accounted for a rising share of population costs and rose to 8.2% and 8.7% of population costs in 2008, respectively.Gender-specific, cancer, musculoskeletal, and mental health and substance use disorders accounted for a greater share of overall costs during the study period and were primarily driven by higher rates of diagnosed conditions and, for several conditions, higher treatment costs.
View details for DOI 10.1016/j.whi.2012.03.002
View details for PubMedID 22555220
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What Determines Successful Implementation of Inpatient Information Technology Systems?
AMERICAN JOURNAL OF MANAGED CARE
2012; 18 (3): 157-162
Abstract
To identify the factors and strategies that were associated with successful implementation of hospital-based information technology (IT) systems in US Department of Veterans Affairs (VA) hospitals, and how these might apply to other hospitals.Qualitative analysis of 118 interviews conducted at 7 VA hospitals. The study focused on the inpatient setting, where nurses are the main patient-care providers; thus, the research emphasized the impact of Computerized Patient Record System and Bar Code Medication Administration on nurses. Hospitals were selected to represent a range of IT implementation dates, facility sizes, and geography. The subjects included nurses, pharmacists, physicians, IT staff, and managers. Interviews were guided by a semi-structured interview protocol, and a thematic analysis was conducted, with initial codes drawn from the content of the interview guides. Additional themes were proposed as the coding was conducted.Five broad themes arose as factors which affected the process and success of implementation: (1) organizational stability and implementation team leadership, (2) implementation timelines, (3) equipment availability and reliability, (4) staff training, and (5) changes in work flowOverall IT implementation success in the VA depended on: (1) whether there was support for change from both leaders and staff, (2) development of a gradual and flexible implementation approach, (3) allocation of adequate resources for equipment and infrastructure, hands-on support, and deployment of additional staff, and (4) how the implementation team planned for setbacks, and continued the process to achieve success. Problems that developed in the early stages of implementation tended to become persistent, and poor implementation can lead to patient harm.
View details for Web of Science ID 000308442600004
View details for PubMedID 22435909
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Recent Trends in Veterans Affairs Chronic Condition Spending
POPULATION HEALTH MANAGEMENT
2011; 14 (6): 293-298
Abstract
The change in prevalence and total Veterans Affairs (VA) spending were estimated for 16 chronic condition categories between 2000 and 2008. The drivers of changes in spending also were examined. Chronic conditions were identified through diagnoses in encounter records, and treatment costs per patient were estimated using VA cost data and regression models. The estimated differences in total VA spending between 2000 and 2008 and the contributions of population increase, differences in prevalence, and differences in treatment costs were evaluated. Most of the spending increases during the study period were driven by the increase in the VA patient population from 3.3 million in 2000 to 4.9 million in 2008. Spending on renal failure increased the most, by more than $1.5 billion, primarily because of higher prevalence. Higher treatment costs did not contribute much to higher spending; lower costs per patient for several conditions may have helped to slow spending for diabetes, chronic obstructive pulmonary disease, heart conditions, renal failure, dementia, and stroke. Lowering treatment costs per patient for common conditions can help slow spending for chronic conditions, but most of the increase in spending in the study period was the result of more patients seeking care from VA providers and the higher prevalence of conditions among patients. As the VA patient population continues to age and to develop more co-morbidities, and as returning veterans seek care for service-related problems, higher spending on chronic conditions will become a more prominent issue for the VA health care system.
View details for DOI 10.1089/pop.2010.0079
View details for Web of Science ID 000298292600004
View details for PubMedID 22044350
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Examining the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling
JOURNAL OF PERINATOLOGY
2011; 31 (12): 770-775
Abstract
The objective of this study was to examine the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling.This is a secondary data analysis of California maternal-infant hospital discharge data from 1997 to 2002. The study population was limited to singleton, non-anomalous, very low birth weight infants, who delivered in hospitals providing neonatal intensive care services (level-2 and higher). Hierarchical generalized linear modeling, also known as multilevel modeling, was used to adjust for individual-level confounders.In a multilevel model, increasing hospital volume of very low birth weight deliveries was associated with lower odds of very low birth weight mortality. Characteristics of a particular hospital's obstetrical and neonatal services (the presence of residency and fellowship training programs and the availability of perinatal and neonatal services) had no independent effect.Using multilevel modeling, hospital volume of very low birth weight deliveries appears to be the primary driver of reduced mortality among very low birth weight infants.
View details for DOI 10.1038/jp.2011.29
View details for Web of Science ID 000297646000006
View details for PubMedID 21494232
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Mental Illness and Warfarin Use in Atrial Fibrillation
AMERICAN JOURNAL OF MANAGED CARE
2011; 17 (9): 617-624
Abstract
To determine whether atrial fibrillation (AF) patients with mental health conditions (MHCs) were less likely than AF patients without MHCs to be prescribed warfarin and, if receiving warfarin, to maintain an International Normalized Ratio (INR) within the therapeutic range.Detailed chart review of AF patients using a Veterans Health Administration (VHA) facility in 2003.For a random sample of 296 AF patients, records identified clinician-diagnosed MHCs (independent variable) and AF-related care in 2003 (dependent variables), receipt of warfarin, INR values below/above key thresholds, and time spent within the therapeutic range (2.0-3.0) or highly out of range. Differences between the MHC and comparison groups were examined using X2 tests and logistic regression controlling for age and comorbidity.Among warfarin-eligible AF patients (n = 246), 48.5% of those with MHCs versus 28.9% of those without MHCs were not treated with warfarin (P = .004). Among those receiving warfarin and monitored in VHA, highly supratherapeutic INRs were more common in the MHC group; for example, 27.3% versus 1.6% had any INR >5.0 (P <.001). Differences persisted after adjusting for age and comorbidity.MHC patients with AF were less likely than those without MHC to have adequate management of their AF care. Interventions directed at AF patients with MHC may help to optimize their outcomes.
View details for Web of Science ID 000295129700008
View details for PubMedID 21902447
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New Women Veterans in the VHA: A Longitudinal Profile
WOMENS HEALTH ISSUES
2011; 21 (4): S103-S111
Abstract
The number of women veterans using Veterans Health Administration (VHA) services has increased rapidly, but the characteristics of women joining VHA are not well understood. We sought to describe sociodemographic characteristics, utilization, and retention of new and returning women VHA patients over a 7-year period.We identified women veterans who used VHA outpatient services from VHA Enrollment and Utilization files for fiscal years 2003 through 2009. "New" patients in a given year had no outpatient use within the prior 3 years. Patients were "retained" if they continued to use VHA in subsequent years.Of the 287,447 women veteran VHA outpatients in 2009, 40,000 (14%) were new to VHA in that year and over half had joined VHA since 2003. Nearly two thirds of these new patients were younger than 45, and 43% carried a service-connected disability status. Most new patients (88%) received primary care services in 2008, and 40% used mental health services. Repeated use of mental health services (at least three visits per year) nearly doubled among new patients (from 11% in 2003 to 20% in 2008). Among those using VHA primary care in 2006, 68% of new patients versus 91% of returning patients were retained in either of the subsequent 2 years.The influx of new women veterans seeking VHA services in recent years, combined with their high rate of retention within VHA, contribute to the marked increase in numbers of women veterans using VHA. Many require fairly intensive VHA services.
View details for DOI 10.1016/j.whi.2011.04.025
View details for Web of Science ID 000292785100008
View details for PubMedID 21724129
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Effect of Home Testing of International Normalized Ratio on Clinical Events.
NEW ENGLAND JOURNAL OF MEDICINE
2010; 363 (17): 1608-1620
Abstract
Warfarin anticoagulation reduces thromboembolic complications in patients with atrial fibrillation or mechanical heart valves, but effective management is complex, and the international normalized ratio (INR) is often outside the target range. As compared with venous plasma testing, point-of-care INR measuring devices allow greater testing frequency and patient involvement and may improve clinical outcomes.We randomly assigned 2922 patients who were taking warfarin because of mechanical heart valves or atrial fibrillation and who were competent in the use of point-of-care INR devices to either weekly self-testing at home or monthly high-quality testing in a clinic. The primary end point was the time to a first major event (stroke, major bleeding episode, or death).The patients were followed for 2.0 to 4.75 years, for a total of 8730 patient-years of follow-up. The time to the first primary event was not significantly longer in the self-testing group than in the clinic-testing group (hazard ratio, 0.88; 95% confidence interval, 0.75 to 1.04; P=0.14). The two groups had similar rates of clinical outcomes except that the self-testing group reported more minor bleeding episodes. Over the entire follow-up period, the self-testing group had a small but significant improvement in the percentage of time during which the INR was within the target range (absolute difference between groups, 3.8 percentage points; P<0.001). At 2 years of follow-up, the self-testing group also had a small but significant improvement in patient satisfaction with anticoagulation therapy (P=0.002) and quality of life (P<0.001).As compared with monthly high-quality clinic testing, weekly self-testing did not delay the time to a first stroke, major bleeding episode, or death to the extent suggested by prior studies. These results do not support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode, and death among patients taking warfarin therapy. (Funded by the Department of Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT00032591.).
View details for Web of Science ID 000283242700005
View details for PubMedID 20961244
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An evaluation of patient self-testing competency of prothrombin time for managing anticoagulation: pre-randomization results of VA Cooperative Study #481-The Home INR Study (THINRS)
JOURNAL OF THROMBOSIS AND THROMBOLYSIS
2010; 30 (3): 263-275
Abstract
Prior studies suggest patient self-testing (PST) of prothrombin time (PT) can improve the quality of anticoagulation (AC) and reduce complications (e.g., bleeding and thromboembolic events). "The Home INR Study" (THINRS) compared AC management with frequent PST using a home monitoring device to high-quality AC management (HQACM) with clinic-based monitoring on major health outcomes. A key clinical and policy question is whether and which patients can successfully use such devices. We report the results of Part 1 of THINRS in which patients and caregivers were evaluated for their ability to perform PST. Study-eligible patients (n = 3643) were trained to use the home monitoring device and evaluated after 2-4 weeks for PST competency. Information about demographics, medical history, warfarin use, medications, plus measures of numeracy, literacy, cognition, dexterity, and satisfaction with AC were collected. Approximately 80% (2931 of 3643) of patients trained on PST demonstrated competency; of these, 8% (238) required caregiver assistance. Testers who were not competent to perform PST had higher numbers of practice attempts, higher cuvette wastage, and were less able to perform a fingerstick or obtain blood for the cuvette in a timely fashion. Factors associated with failure to pass PST training included increased age, previous stroke history, poor cognition, and poor manual dexterity. A majority of patients were able to perform PST. Successful home monitoring of PT with a PST device required adequate levels of cognition and manual dexterity. Training a caregiver modestly increased the proportion of patients who can perform PST.
View details for DOI 10.1007/s11239-010-0499-8
View details for Web of Science ID 000282215300002
View details for PubMedID 20628787
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The Effect of Neonatal Intensive Care Level and Hospital Volume on Mortality of Very Low Birth Weight Infants
MEDICAL CARE
2010; 48 (7): 635-644
Abstract
To determine the adjusted effect of hospital level of care and volume on mortality of very low birth weight (VLBW) infants in the state of California, where deregionalization of perinatal care has occurred.Secondary data analysis of California maternal-infant hospital discharge data from 1997 to 2002 was performed. Logistic regression was used to evaluate the odds of mortality among VLBW infants by hospital level of neonatal intensive care and volume of VLBW deliveries, in the context of differences in antenatal and delivery factors by hospital site of delivery.Both maternal and fetal antenatal risk profiles and delivery characteristics vary by hospital site of delivery. After risk adjustment, lower-level, lower-volume units were associated with a higher odds of mortality. The highest odds of mortality occurred in level-1 units with < or =10 VLBW deliveries per year (odds ratio, 1.69; 95% confidence interval, 1.43-1.99). In isolation, hospital volume, rather than level of care, had the greater effect.Although deregionalization of perinatal services may increase access to care for high-risk mothers and newborns, its impact on hospital volume may outweigh its potential benefit.
View details for DOI 10.1097/MLR.0b013e3181dbe887
View details for Web of Science ID 000279428200011
View details for PubMedID 20548252
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Is There Monopsony in the Labor Market? Evidence from a Natural Experiment
Conference on Modern Models of Monopsony in Labor Markets
UNIV CHICAGO PRESS. 2010: 211–36
View details for Web of Science ID 000279608000002
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Matching prosthetics order records in VA National Prosthetics Patient Database to healthcare utilization databases
JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT
2010; 47 (8): 725-737
Abstract
The National Prosthetics Patient Database (NPPD) is the national Department of Veterans Affairs (VA) dataset that records characteristics of individual prosthetic and assistive devices. It remains unknown how well NPPD records can be matched to encounter records for the same individuals in major VA utilization databases. We compared the count of prosthetics records in the NPPD with the count of prosthetics-related procedures for the same individuals recorded in major VA utilization databases. We then attempted to match the NPPD records to the utilization records by person and date. In general, 40% to 60% of the NPPD records could be matched to outpatient utilization records within a 14-day window around the NPPD dataset entry date. Match rates for inpatient data were lower: 10% to 16% within a 14-day window. The NPPD will be particularly important for studies of certain veteran groups, such as those with spinal cord injury or blast-related polytraumatic injury. Health services researchers should use both the NPPD and utilization databases to develop a full understanding of prosthetics use by individual patients.
View details for DOI 10.1682/JRRD.2009.07.0098
View details for Web of Science ID 000285074300008
View details for PubMedID 21110248
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Regionalization and Mortality in Neonatal Intensive Care
PEDIATRIC CLINICS OF NORTH AMERICA
2009; 56 (3): 617-?
Abstract
This article examines the outcome data for very low birth weight infants in low-volume, mid-volume, and high-volume neonatal ICUs (NICUs) and argues for regionalization of NICU services on the basis of both medical outcomes and economic rationality. It recognizes some of the obstacles to regionalization of these services and presents ways to surmount them.
View details for DOI 10.1016/j.pcl.2009.04.006
View details for Web of Science ID 000267523700011
View details for PubMedID 19501695
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Gender disparities in veterans health administration care - Importance of accounting for veteran status
MEDICAL CARE
2008; 46 (5): 549-553
Abstract
In an effort to assess and reduce gender-related quality gaps, the Veterans Health Administration (VHA) has promoted gender-based research. Historically, such appraisals have often relied on secondary databases, with little attention to methodological implications of the fact that VHA provides care to some nonveteran patients.To determine whether conclusions about gender differences in utilization and cost of VHA care change after accounting for veteran status.Cross-sectional.All users of VHA in 2002 (N = 4,429,414).Veteran status, outpatient/inpatient utilization and cost, from centralized 2002 administrative files.Nonveterans accounted for 50.7% of women (the majority employees) but only 3.0% of men. Among all users, outpatient and inpatient utilization and cost were far lower in women than in men, but in the veteran subgroup these differences decreased substantially or, in the case of use and cost of outpatient care, reversed. Utilization and cost were very low among women employees; women spouses of fully disabled veterans had utilization and costs similar to those of women veterans.By gender, nonveterans represent a higher proportion of women than of men in VHA, and some large nonveteran groups have low utilization and costs; therefore, conclusions about gender disparities change substantially when veteran status is taken into account. Researchers seeking to characterize gender disparities in VHA care should address this methodological issue, to minimize risk of underestimating health care needs of women veterans and other women eligible for primary care services.
View details for Web of Science ID 000255452100014
View details for PubMedID 18438204
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Readmission for neonatal jaundice in California, 1991-2000: Trends and implications
PEDIATRICS
2008; 121 (4): E864-E869
Abstract
We sought to describe population-based trends, potential risk factors, and hospital costs of readmission for jaundice for term and late preterm infants.Birth-cohort data were obtained from the California Office of Statewide Health Planning and Development and contained infant vital statistics data linked to infant and maternal hospital discharge summaries. The study population was limited to healthy, routinely discharged infants through the use of multiple exclusion criteria. All linked readmissions occurred within 14 days of birth. International Classification of Diseases, Ninth Revision, codes were used to further limit the sample to readmission for jaundice. Hospital discharge records were the source of diagnoses, hospital charges, and length-of-stay information. Hospital costs were estimated using hospital-specific ratios of costs to charges and adjusted to 1991.Readmission rates for jaundice generally rose after 1994 and peaked in 1998 at 11.34 per 1000. The readmission rate for late preterm infants (as a share of all infants) over the study period remained at <2 per 1000. Factors associated with increased likelihood of hospital readmission for jaundice included gestational age 34 to 39 weeks, birth weight of <2500 g, male gender, Medicaid or private insurance, and Asian race. Factors associated with a decreased likelihood of readmission for jaundice were cesarean section delivery and black race. The mean cost of readmission for all infants was $2764, with a median cost of $1594.Risk-adjusted readmission rates for jaundice rose following the 1994 hyperbilirubinemia guidelines and declined after postpartum length-of-stay legislation in 1998. In 2000, the readmission rate remained 6% higher than in 1991. These findings highlight the complex relationship among newborn physiology, socioeconomics, race or ethnicity, public policy, clinical guidelines, and physician practice. These trend data provide the necessary baseline to study whether revised guidelines will change practice patterns or improve outcomes. Cost data also provide a break-even point for prevention strategies.
View details for DOI 10.1542/peds.2007-1214
View details for PubMedID 18381515
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Gender and use of care: Planning for tomorrow's veterans health administration
JOURNAL OF WOMENS HEALTH
2007; 16 (8): 1188-1199
Abstract
Historically, men have been the predominant users of Veterans Health Administration (VHA) care. With more women entering the system, a systematic assessment of their healthcare use and costs of care is needed. We examined how utilization and costs of VHA care differ in women veterans compared with men veterans.In this cross-sectional study using centralized VHA administrative databases, main analyses examined annual outpatient and inpatient utilization and costs of care (outpatient, inpatient, and pharmacy) for all female (n = 178,849) and male (n = 3,943,532) veterans using VHA in 2002, accounting for age and medical/mental health conditions.Women had 11.8% more outpatient encounters, 25.9% fewer inpatient days, and 11.4% lower total cost than men; after adjusting for age and medical comorbidity, differences were less pronounced (1.3%, 10.9%, and 2.8%, respectively). Among the 30.8% of women and 24.4% of men with both medical and mental health conditions, women used outpatient services more heavily than men (31.0 vs. 27.3 annual encounters).VHA's efforts to build capacity for women veterans must account for their relatively high utilization of outpatient services, which is especially prominent in women who have both medical and mental health conditions. Meeting their needs may require delivery systems integrating medical and mental healthcare.
View details for DOI 10.1089/jwh.2006.0205
View details for Web of Science ID 000250506100063
View details for PubMedID 17937572
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Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants
NEW ENGLAND JOURNAL OF MEDICINE
2007; 356 (21): 2165-2175
Abstract
There has been a large increase in both the number of neonatal intensive care units (NICUs) in community hospitals and the complexity of the cases treated in these units. We examined differences in neonatal mortality among infants with very low birth weight (below 1500 g) among NICUs with various levels of care and different volumes of very-low-birth-weight infants.We linked birth certificates, hospital discharge abstracts (including interhospital transfers), and fetal and infant death certificates to assess neonatal mortality rates among 48,237 very-low-birth-weight infants who were born in California hospitals between 1991 and 2000.Mortality rates among very-low-birth-weight infants varied according to both the volume of patients and the level of care at the delivery hospital. The effect of volume also varied according to the level of care. As compared with a high level of care and a high volume of very-low-birth-weight infants (more than 100 per year), lower levels of care and lower volumes (except for those of two small groups of hospitals) were associated with significantly higher odds ratios for death, ranging from 1.19 (95% confidence interval [CI], 1.04 to 1.37) to 2.72 (95% CI, 2.37 to 3.12). Less than one quarter of very-low-birth-weight deliveries occurred in facilities with NICUs that offered a high level of care and had a high volume, but 92% of very-low-birth-weight deliveries occurred in urban areas with more than 100 such deliveries.Mortality among very-low-birth-weight infants was lowest for deliveries that occurred in hospitals with NICUs that had both a high level of care and a high volume of such patients. Our results suggest that increased use of such facilities might reduce mortality among very-low-birth-weight infants.
View details for Web of Science ID 000246673100006
View details for PubMedID 17522400
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Differences in neonatal mortality among whites and Asian American subgroups - Evidence from California
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE
2007; 161 (1): 69-76
Abstract
To obtain information about health outcomes in neonates in 9 subgroups of the Asian population in the United States.Cross-sectional comparison of outcomes for births to mothers of Cambodian, Chinese, Filipino, Indian, Japanese, Korean, Laotian, Thai, and Vietnamese origin and for births to non-Hispanic white mothers. Regression models were used to compare neonatal mortality across groups before and after controlling for various risk factors.All California births between January 1,1991, and December 31, 2001.More than 2.3 million newborn infants.Racial and ethnic groups.Neonatal mortality (death within 28 days of birth).The unadjusted mortality rate for births to non-Hispanic white mothers was 2.0 per 1000. The unadjusted mortality rate for births to Chinese and Japanese mothers was significantly lower (Chinese: 1.2 per 1000, P<.001; Japanese: 1.2 per 1000, P=.004), and for births to Korean mothers the rate was significantly higher (2.7 per 1000, P=.003). For infants of Chinese mothers, observed risk factors explain the differences observed in unadjusted data. For infants of Cambodian, Japanese, Korean, and Thai mothers, differences persist or widen after risk factors are considered. After risk adjustment, infants of Cambodian, Japanese, and Korean mothers have significantly lower neonatal mortality rates compared with infants born to non-Hispanic white mothers (adjusted odds ratios, 0.58 for infants of Cambodian mothers, 0.67 for infants of Japanese mothers, and 0.69 for infants of Korean mothers; all P<.05); infants of Thai mothers have higher neonatal mortality rates (adjusted odds ratio, 1.89; P<.05).There are significant variations in neonatal mortality between subgroups of the Asian American population that are not entirely explained by differences in observable risk factors. Efforts to improve clinical care that treat Asian Americans as a homogeneous group may miss important opportunities for improving infant health in specific subgroups.
View details for Web of Science ID 000243273800010
View details for PubMedID 17199070
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Effect of opening midlevel neonatal intensive care units on the location of low birth weight births in California
PEDIATRICS
2006; 118 (6): E1667-E1679
Abstract
Despite evidence and recommendations encouraging the delivery of high-risk newborns in hospitals with subspecialty or high-level NICUs, increasing numbers are being delivered in other facilities. Causes for this are unknown. We sought to explore the impact of diffusion of specialty or midlevel NICUs on the types of hospitals in which low birth weight newborns are born.We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level).The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (-15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (-2 points). Similar patterns were observed in 1500- to 2499-g newborns.The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed.
View details for DOI 10.1542/peds.2006-0612
View details for Web of Science ID 000242478900060
View details for PubMedID 17116699
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Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants
EARLY HUMAN DEVELOPMENT
2006; 82 (2): 85-95
Abstract
To estimate the potential savings, both in terms of costs and lengths of stay, of one-week increases in gestational age for premature infants. The purpose is to provide population-based data that can be used to assess the potential savings of interventions that delay premature delivery.Cohort data for all births in California in 1998-2000 that linked vital records data with those from hospital discharge abstracts, including those of neonatal transport. All infants with a gestational age between 24 and 37 weeks were included. There were 193,167 infants in the sample after deleting cases with incomplete data or gestational age that was inconsistent with birth weight.Hospital costs were estimated by adjusting charges by hospital-specific costs-to-charges ratios. Data were aggregated across transport into episodes of care. Mean and median potential savings were calculated for increasing gestational age, in one-week intervals. The 25th and 75th percentiles were used to estimate ranges.The results are presented in matrix format, for starting gestational ages of 24-34 weeks, with ending gestational ages of 25 to 37 weeks. Costs and lengths of stay decreased with gestational age from a median of $216,814 (92 days) at 24 weeks to $591 (2 days) at 37 weeks. The potential savings from delaying premature labor are quite large; the median savings for a 2 week increase in gestational age were between $28,870 and $64,021 for gestational ages below 33 weeks, with larger savings for longer delays in delivery. Delaying deliveries <29 weeks to term (37 weeks) resulted in savings of over $122,000 per case, with the savings being over $206,000 for deliveries <26 weeks.These results provide population-based data that can be applied to clinical trials data to assess the impacts on costs and lengths of stay of interventions that delay premature labor. They show that the potential savings of delaying premature labor are quite large, especially for extremely premature deliveries.
View details for DOI 10.1016/j.earlhumdev.2006.01.001
View details for Web of Science ID 000236171200003
View details for PubMedID 16459031
View details for PubMedCentralID PMC1752207
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The effect of geriatrics evaluation and management on nursing home use and health care costs - Results from a randomized trial
MEDICAL CARE
2006; 44 (1): 91-95
Abstract
The Geriatric Evaluation and Management study was developed to assess the impact of a comprehensive geriatric assessment service on the care of the elderly.We sought to evaluate the cost and clinical impact of inpatient units and outpatient clinics for geriatric evaluation and management.We undertook a prospective, randomized, controlled trial using a 2x2 factorial design, with 1-year follow-up.A total of 1388 participants hospitalized on either a medical or surgical ward at 11 participating Veterans Affairs medical centers were randomized to receive either inpatient geriatric unit (GEMU) or usual inpatient care (UCIP), followed by either outpatient care from a geriatric clinic (GEMC) versus usual outpatient care (UCOP).We measured health care utilization and costs.Patients assigned to the GEMU had a significantly decreased rate of nursing home placement (odds ratio=0.65; P=0.001). Neither the GEMU nor GEMC had any statistically significant improvement effects on survival and only modest effects on health status. There were statistically insignificant mean cost savings of $1027 (P=0.29) per patient for the GEMU and $1665 (P=0.69) per patient for the GEMC.Inpatient or outpatient geriatric evaluation and management units didn't increase the costs of care. Although there was no effect on survival and only modest effects on SF-36 scores at 1-year follow-up, there was a statistically significant reduction in nursing home admissions for patients treated in the GEMU.
View details for Web of Science ID 000234342600013
View details for PubMedID 16365618
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Costs of newborn care in California: A population-based study
PEDIATRICS
2006; 117 (1): 154-160
Abstract
We sought to describe the current costs of newborn care by using population-based data, which includes linked vital statistics and hospital records for both mothers and infants. These data allow costs to be reported by episode of care (birth), instead of by hospitalization.Data for this study were obtained from the linked 2000 California birth cohort data. These data (n = 518,704), provided by the California Office of Statewide Health Planning and Development (OSHPD), contain infant vital statistics data (birth and death certificate data) linked to infant and maternal hospital discharge summaries. In addition to the infant and maternal hospital discharge summaries associated with delivery, these data include discharge summaries for all infant hospital-to-hospital transfers and maternal prenatal hospitalizations. The linkage algorithm that is used by OSHPD in creating the linked cohort data file is highly accurate. More than 99% of the maternal and infant discharge abstracts were linked successfully with the birth certificates. These data were also linked successfully with the infant discharge abstracts from the receiving hospital for 99% of the infants who were transferred to another hospital. The hospital discharge records were the source of the hospital charges and length-of-stay information summarized in this study. Hospital costs were estimated by adjusting charges by hospital-specific ratios of costs to charges obtained from the OSHPD Hospital Financial Reporting data. Costs, lengths of stay, and mortality were summarized by birth weight groups, gestational age, cost categories, and types of admissions.Low birth weight (LBW) and very low birth weight (VLBW) infants had significantly longer hospital stays and accounted for a significantly higher proportion of total hospital costs. The average hospital stay for LBW infants ranged from 6.2 to 68.1 days, whereas the average hospital stay for infants who weighed >2500 g at birth was 2.3 days. Overall, VLBW infants accounted for 0.9% of cases but 35.7% of costs, whereas LBW infants accounted for 5.9% of cases but 56.6% of total hospital costs. Although total maternal and infant costs were similar (approximately 1.6 billion dollars), the distribution of maternal costs was much less skewed. For infants, 5% of infants accounted for 76% of total infant hospital costs. Conversely, the most expensive 3% of deliveries accounted for only 17% of total maternal costs.The very smallest infants make up a hugely disproportionate share of costs; more than half of all neonatal costs are incurred by LBW or premature infants. Maternal costs are similar in magnitude to newborn costs, but they are much less skewed than for infants. Preventing premature deliveries could yield very large cost savings, in addition to saving lives.
View details for DOI 10.1542/peds.2005-0484
View details for Web of Science ID 000234406100021
View details for PubMedID 16396873
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The impact of patient self-testing of prothrombin time for managing anticoagulation: Rationale and design of VA cooperative study #481 - The Home INR Study (THINRS)
JOURNAL OF THROMBOSIS AND THROMBOLYSIS
2005; 19 (3): 163-172
Abstract
Anticoagulation (AC) with warfarin reduces the risk of thromboembolism (TE) in a variety of applications, yet despite compelling evidence of the value and importance of high quality AC, warfarin remains underused, and dosing is often suboptimal. Approaches to improve AC quality include (1) an AC service (ACS), which allows the physician to delegate day-to-day details of AC management to another provider dedicated to AC care, and (2) incorporating into the treatment plan patient self-testing (PST) under which, after completing a training program, patients perform their own blood testing (typically, using a finger-stick blood analyzer), have dosage adjustments guided by a standard protocol, and forward test results, dosing and other information to the provider. Studies have suggested that PST can improve the quality of AC and perhaps lower TE and bleed rates. The purpose of Department of Veterans Affairs (VA) Cooperative Studies Program (CSP) #481, "The Home INR Study" (THINRS) is to compare AC management with frequent PST using a home monitoring device to high quality AC management (HQACM) implemented by an ACS with conventional monitoring of prothrombin time by international normalized ratio (INR) on major health outcomes. PST in THINRS involves use of an INR monitoring device that is FDA approved for home use.Sites are VA Medical Centers where the ACS has an active roster of more than 400 patients. THINRS includes patients with atrial fibrillation (AF) and/or mechanical heart valve (MHV) expected to be anticoagulated indefinitely. THINRS has two parts. In Part 1, candidates for PST are evaluated for 2 to 4 weeks for their ability to use home monitoring devices. In Part 2, individuals capable of performing PST are randomized to (1) HQACM with testing every 4 weeks and as indicated for out of range values, medication/clinical changes, or (2) PST with testing every week and as indicated for out of range values, medication/clinical changes. The primary outcome measure is event rates, defined as the percent of patients who have a stroke, major bleed, or die. Secondary outcomes include total time in range (TTR), other events (myocardial infarction (MI), non-stroke TE, minor bleeds), competence and compliance with PST, satisfaction with AC, AC associated quality of life (QOL), and cost-effectiveness. To assess the effect of PST frequency on TTR and other outcomes, at selected sites patients randomized to perform PST are assigned one of three test frequencies (weekly, twice weekly, or once every four weeks).
View details for DOI 10.1007/s11239-005-1452-0
View details for Web of Science ID 000231020500003
View details for PubMedID 16082603
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Kernicterus: epidemiological strategies for its prevention through systems-based approaches.
Journal of perinatology
2004; 24 (10): 650-662
Abstract
Kernicterus, thought to be due to severe hyperbilirubinemia, is an uncommon disorder with tragic consequences, especially when it affects healthy term and near-term infants. Early identification, prevention and treatment of severe hyperbilirubinemia should make kernicterus a preventable disease. However, national epidemiologic data are needed to monitor any preventive strategies. Recommendations are provided to obtain prospective data on the prevalence and incidence of severe hyperbilirubinemia and associate mortality and neurologic injury using standardized definitions, explore the clinical characteristics and root causes of kernicterus in children identified in the Kernicterus Pilot Registry, identify and test an indicator for population surveillance, validating systems-based approaches to the management of newborn jaundice, and explore the feasibility of using biologic or genetic markers to identify infants at risk for hyperbilirubinemia. Increased knowledge about the incidence and consequences of severe hyperbilirubinemia is essential to the planning, implementation and assessment of interventions to ensure that infants discharged as healthy from their birth hospitals have a safer transition to home, avoiding morbidity due to hyperbilirubinemia and other disorders. At a recent NIHCD-sponsored conference, key questions were raised about kernicterus and the need for additional strategies for its prevention. These questions and an approach to their answers form the basis of this report.
View details for PubMedID 15254556
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Predictors of medical service utilization among individuals with co-occurring HIV infection and substance abuse disorders
AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV
2004; 16 (6): 744-755
Abstract
This study examined factors affecting medical service use among HIV-infected persons with a substance abuse disorder. The sample comprised 190 participants enrolled in a randomized trial of a case management intervention. Participants were interviewed about their backgrounds, housing status, income, alcohol and drug use problems, health status and depressive symptoms at study entry. Electronic medical records were used to assess medical service use. Poisson regression models were tested to determine the effects of need, enabling and predisposing factors on the dependent variables of emergency department visits, inpatient admissions and ambulatory care visits. During a two-year period, 71% were treated in the emergency department, 64% had been hospitalized and the sample averaged 12.9 ambulatory care visits. Homelessness was associated with higher utilization of emergency department and inpatient services; drug use severity was associated with higher inpatient and ambulatory care service use; and alcohol use severity was associated with greater use of emergency medical services. Homelessness and substance abuse exacerbate the health care needs of HIV-infected persons and result in increased use of emergency department and inpatient services. Interventions are needed that target HIV-infected persons with substance abuse disorders, particularly those that increase entry and retention in outpatient health care and thus decrease reliance on acute hospital-based services.
View details for DOI 10.1080/09540120412331269585
View details for Web of Science ID 000223102900008
View details for PubMedID 15370062
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Within-year variation in hospital utilization and its implications for hospital costs
JOURNAL OF HEALTH ECONOMICS
2004; 23 (1): 191-211
Abstract
Variability in demand for hospital services may have important effects on hospital costs, but this has been difficult to examine because data on within-year variations in hospital use have not been available for large samples of hospitals. We measure daily occupancy in California hospitals and examine variation in hospital utilization at the daily level. We find substantial day-to-day variation in hospital utilization, and noticeable differences between hospitals in the amount of day-to-day variation in utilization. We examine the impact of variation on hospital costs, showing that increases in variance are associated with increases in hospital expenditures, but that the effects are qualitatively modest.
View details for DOI 10.1016/j.jhealeco.2003.09.005
View details for Web of Science ID 000189210600009
View details for PubMedID 15154694
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Prevalence and costs of chronic conditions in the VA health care system
MEDICAL CARE RESEARCH AND REVIEW
2003; 60 (3): 146S-167S
Abstract
Chronic conditions are among the most common causes of death and disability in the United States. Patients with such conditions receive disproportionate amounts of health care services and therefore cost more per capita than the average patient. This study assesses the prevalence among the Department of Veterans Affairs (VA) health care users and VA expenditures (costs) of 29 common chronic conditions. The authors used regression to identify the marginal impact of these conditions on total, inpatient, outpatient, and pharmacy costs. Excluding costs of contracted medical services at non-VA facilities, total VA health care expenditures in fiscal year 1999 (FY1999) were $14.3 billion. Among the 3.4 million VA patients in FY1999, 72 percent had 1 or more of the 29 chronic conditions, and these patients accounted for 96 percent of the total costs ($13.7 billion). In addition, 35 percent (1.2 million) of VA health care users had 3 or more of the 29 chronic conditions. These individuals accounted for 73 percent of the total cost. Overall, VA health care users have more chronic diseases than the general population.
View details for DOI 10.1177/1077558703257000
View details for Web of Science ID 000184825000011
View details for PubMedID 15095551
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Estimating the costs of VA ambulatory care
MEDICAL CARE RESEARCH AND REVIEW
2003; 60 (3): 54S-73S
Abstract
This article reports how we matched Common Procedure Terminology (CPT) codes with Medicare payment rates and aggregate Veterans Affairs (VA) budget data to estimate the costs of every VA ambulatory encounter. Converting CPT codes to encounter-level costs was more complex than a simple match of Medicare reimbursements to CPT codes. About 40 percent of the CPT codes used in VA, representing about 20 percent of procedures, did not have a Medicare payment rate and required other cost estimates. Reconciling aggregated estimated costs to the VA budget allocations for outpatient care produced final VA cost estimates that were lower than projected Medicare reimbursements. The methods used to estimate costs for encounters could be replicated for other settings. They are potentially useful for any system that does not generate billing data, when CPT codes are simpler to collect than billing data, or when there is a need to standardize cost estimates across data sources.
View details for DOI 10.1177/1077558703256725
View details for Web of Science ID 000184825000006
View details for PubMedID 15095546
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The influence of distance on utilization of outpatient mental health aftercare following inpatient substance abuse treatment
ADDICTIVE BEHAVIORS
2003; 28 (6): 1183-1192
Abstract
This study examined whether substance abuse patients who live farther from their source of outpatient mental health care were less likely to obtain aftercare following an inpatient treatment episode. For those patients who did receive aftercare, distance was evaluated as a predictor of the volume of care received. A national sample of 33,952 veterans discharged from Department of Veterans Affairs (VA) inpatient substance abuse treatment programs was analyzed using a two-part choice model utilizing logistic and linear regression. Patients living farther from their source of outpatient mental health care were less likely to obtain aftercare following inpatient substance abuse treatment. Patients who traveled 10 miles or less were 2.6 times more likely to obtain aftercare than those who traveled more than 50 miles. Only 40% of patients who lived more than 25 miles from the nearest aftercare facility obtained any aftercare services. Patients who received aftercare services had fewer visits if they lived farther from their source of aftercare. Lack of geographic access (distance) is a barrier to outpatient mental health care following inpatient substance abuse treatment, and influences the volume of care received once the decision to obtain aftercare is made. Aftercare services must be geographically accessible to ensure satisfactory utilization.
View details for DOI 10.1016/S0306-4603(02)00218-6
View details for Web of Science ID 000184353900014
View details for PubMedID 12834661
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Case management for substance abusers with HIV/AIDS: A randomized clinical trial
AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
2003; 29 (1): 133-150
Abstract
In a random assignment study, substance-abusing patients with HIV/AIDS in a public general hospital received a brief contact condition or received 12 months of case management delivered by paraprofessionals. Patient outcomes included substance use, HIV transmission risk, physical health, psychological status, and quality of living situation. In both conditions, a significant decrease occurred in a range of problems from Intake to the 6-month interview, followed by no significant pattern of change at 12- and 18-month interviews. On major outcome variables, there were no significant differences between the brief contact and case management conditions. Sixteen percent had died by the 18-month interview. Process data indicated wide variation in the amount of case management received by participants, and the amount of case management was not related to improvement in the outcome measures. The study has limitations yet does not support the hypothesis that case management improves outcomes better than brief contact for this population.
View details for DOI 10.1081/ADA-120018843
View details for Web of Science ID 000182445900007
View details for PubMedID 12731685
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Managed care, technology adoption, and health care: the adoption of neonatal intensive care
Conference on the Industrial-Organization-of-Medical-Care
BLACKWELL PUBLISHING. 2002: 524–48
Abstract
Managed care may influence technology diffusion in health care. This article empirically examines the relationship between HMO market share and the diffusion of neonatal intensive care units. Higher HMO market share is associated with slower adoption of mid-level units, but not with adoption of the most advanced high-level units. Opposite the common supposition that slowing technology growth will harm patients, results suggest that health outcomes for seriously ill newborns are better in higher-level units and that reduced availability of mid-level units may increase their chance of receiving care in a high-level center, so that slower mid-level growth could have benefitted patients.
View details for Web of Science ID 000179256800010
View details for PubMedID 12585306
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Commentary: Does patient volume matter for low-risk deliveries?
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
2002; 31 (5): 1069–70
View details for DOI 10.1093/ije/31.5.1069
View details for Web of Science ID 000179593600032
View details for PubMedID 12435786
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Mortality in low birth weight infants according to level of neonatal care at hospital of birth
PEDIATRICS
2002; 109 (5): 745-751
Abstract
In 1976, the Committee on Perinatal Health recommended that hospitals with no neonatal intensive care unit (NICU) or intermediate NICUs transfer high-risk mothers and infants that weigh <2000 g to a regional NICU. This standard was based on expert opinion and has not been validated carefully. This study evaluated the effect of NICU level and patient volume at the hospital of birth on neonatal mortality of infants with a birth weight (BW) of <2000 g.Birth certificates of 16 732 singleton infants who had a BW of <2000 g and were born in nonfederal hospitals in California in 1992 and 1993 were linked to death certificates and to discharge abstracts. The hospitals were classified by the level of NICU: no NICU, no intensive care; intermediate NICU, intermediate intensive care; community NICU, expanded intermediate intensive care; and regional NICU, tertiary intensive care. A logistic regression model that controlled for demographic risks, diagnoses, transfer, average NICU census, and NICU level was estimated using death within the first 28 days or first year of life if continuously hospitalized as the main outcome measure.Compared with birth in a hospital with a regional NICU, risk-adjusted mortality of infants with BW of <2000 g was higher when birth occurred in hospitals with no NICU (odds ratio [OR]: 2.38; 95% confidence interval [CI]: 1.81-3.13), an intermediate NICU (OR: 1.92; 95% CI: 1.44-2.54), or a small (average census <15) community NICU (OR: 1.42; 95% CI: 1.14-1.76). Risk-adjusted mortality for infants who were born in hospitals with a large (average census > or =15) community NICU was not statistically different compared with those with a regional NICU (OR: 1.11; 95% CI: 0.87-1.43). Except for large community NICUs, all of these ORs are larger when the data are restricted to infants with BW of <1500 g or BW of <1250 g and smaller for BW between 1250 g and 1999 g and 1500 g and 1999 g. For large community NICUs, the results are similar for the smaller BW intervals and significant only for the larger BW interval.These results support the recommendation that hospitals with no NICU or intermediate NICUs transfer high-risk mothers with estimated fetal weight of <2000 g to a regional NICU. For infants with BW of <2000 g, birth at a hospital with a regional NICU is associated with a lower risk-adjusted mortality than birth at a hospital with no NICU, intermediate NICU of any size, or small community NICU. Subsequent neonatal transfer to a regional NICU only marginally decreases the disadvantage of birth at these hospitals. The evidence for the few hospitals with large community NICUs is mixed. Although the data point to higher mortality in large community NICUs, they are not conclusive and additional study is needed on the mortality effects of large community NICUs. Greater efforts should be made to deliver infants with expected BW of <2000 g at hospitals with regional NICUs.
View details for Web of Science ID 000175321200020
View details for PubMedID 11986431
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A controlled trial of inpatient and outpatient geriatric evaluation and management
NEW ENGLAND JOURNAL OF MEDICINE
2002; 346 (12): 905-912
Abstract
Over the past 20 years, both inpatient units and outpatient clinics have developed programs for geriatric evaluation and management. However, the effects of these interventions on survival and functional status remain uncertain.We conducted a randomized trial involving frail patients 65 years of age or older who were hospitalized at 11 Veterans Affairs medical centers. After their condition had been stabilized, patients were randomly assigned, according to a two-by-two factorial design, to receive either care in an inpatient geriatric unit or usual inpatient care, followed by either care at an outpatient geriatric clinic or usual outpatient care. The interventions involved teams that provided geriatric assessment and management according to Veterans Affairs standards and published guidelines. The primary outcomes were survival and health-related quality of life, measured with the use of the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36), one year after randomization. Secondary outcomes were the ability to perform activities of daily living, physical performance, utilization of health services, and costs.A total of 1388 patients were enrolled and followed. Neither the inpatient nor the outpatient intervention had a significant effect on mortality (21 percent at one year overall), nor were there any synergistic effects between the two interventions. At discharge, patients assigned to the inpatient geriatric units had significantly greater improvements in the scores for four of the eight SF-36 subscales, activities of daily living, and physical performance than did those assigned to usual inpatient care. At one year, patients assigned to the outpatient geriatric clinics had better scores on the SF-36 mental health subscale, even after adjustment for the score at discharge, than those assigned to usual outpatient care. Total costs at one year were similar for the intervention and usual-care groups.In this controlled trial, care provided in inpatient geriatric units and outpatient geriatric clinics had no significant effects on survival. There were significant reductions in functional decline with inpatient geriatric evaluation and management and improvements in mental health with outpatient geriatric evaluation and management, with no increase in costs.
View details for Web of Science ID 000174464100007
View details for PubMedID 11907291
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The effect of passing an "anti-immigrant" ballot proposition on the use of prenatal care by foreign-born mothers in California.
Journal of immigrant health
2000; 2 (4): 203-212
Abstract
This study examines whether the passage of California's Proposition 187, a proposition designed to restrict undocumented immigrants from using public services, had a negative effect on the use of prenatal care and birth outcomes. Comparisons of prenatal care use and birth outcomes before and after the passage of the proposition are made between low-education foreign-born and U.S.-born mothers using California's Birth Public Use files. Multivariate linear and logistic regressions were used to control for regional and maternal characteristics. We find a significant but small decline in the use of prenatal care by low-education foreign-born women after Proposition 187 passed; however, there was no detectable deterioration of birth outcomes. Whether future reductions in the availability of prenatal care would damage the health of children is unclear.
View details for PubMedID 16228741
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Is travel distance a barrier to veterans' use of VA hospitals for medical surgical care?
SOCIAL SCIENCE & MEDICINE
2000; 50 (12): 1743-1755
Abstract
Lengthy travel distances may explain why relatively few veterans in the United States use VA hospitals for inpatient medical/surgical care. We used two approaches to distinguish the effect of distance on VA use from other factors such as access to alternatives and veterans' characteristics. The first approach describes how disparities in travel distance to the VA are related to other characteristics of geographic areas. The second approach involved a multivariate analysis of VA use in postal zip code areas (ZCAs). We used several sources of data to estimate the number of veterans who had priority access to the VA so that use rates could be estimated. Access to hospitals was characterized by estimated travel distance to inpatient providers that typically serve each ZCA. The results demonstrate that travel distance to the VA is variable, with veterans in rural areas traveling much farther for VA care than veterans in areas of high population density. However, Medicare recipients also travel farther in areas of low population density. In some areas veterans must travel lengthy distances for VA care because VA hospitals which were built over the past few decades are not located close to areas in which veterans reside in the 1990s. The disparities in travel distance suggest inequitable access to the VA. Use of the VA decreases with increases in travel distance only up to about 15 miles, after which use is relatively insensitive to further increases in distance. The multivariate analyses indicate that those over 65 are less sensitive to distance than younger veterans, even though those over 65 are Medicare eligible and therefore have inexpensive access to alternatives. The results suggest that proximity to a VA hospital is only one of many factors determining VA use. Further research is indicated to develop an appropriate response to the needs of the small but apparently dedicated group of VA users who are traveling very long distances to obtain VA care.
View details for Web of Science ID 000086375400004
View details for PubMedID 10798329
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Short-term health and economic benefits of smoking cessation: Low birth weight
PEDIATRICS
1999; 104 (6): 1312-1320
Abstract
To estimate excess direct medical costs of low birth weight from maternal smoking and short-term cost savings from smoking cessation programs before or during the first trimester of pregnancy.Simulations using data on neonatal costs per live birth. Outcome measures are mean US excess direct medical cost per live birth, total excess direct medical cost, reductions in low birth weight, and savings in medical costs from an annual 1 percentage point drop in smoking prevalence among pregnant women.Mean average excess direct medical cost per live birth for each pregnant smoker (in 1995 dollars) was $511; total cost was $263 million. An annual drop of 1 percentage point in smoking prevalence would prevent 1300 low birth weight live births and save $21 million in direct medical costs in the first year of the program; it would prevent 57,200 low birth weight infants and save $572 million in direct medical costs in 7 years.Smoking cessation before the end of the first trimester produces significant cost savings from the prevention of low birth weight.
View details for Web of Science ID 000084069000011
View details for PubMedID 10585982
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Gender differences in physician-patient communication - Evidence from pediatric visits
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE
1997; 151 (6): 586-591
Abstract
To determine whether physician gender and patient gender influence the process of communication and parent and child satisfaction during pediatric office visits.Content analysis of videotaped pediatric office visits.University-based pediatric primary care practice.Videotaped communication between 212 children, ages 4 to 14 years, parents, and physicians. Thirty-eight percent were child health supervision visits, and 62% were for the management of minor or chronic illnesses.An established coding system of physician-patient communication and measures of parent and child satisfaction with medical care.Female physician visits were 29% longer than those of male physicians (P < .001). Compared with male physicians, female physicians engaged in more social exchange (P < .01), more encouragement and reassurance (P < .01), more communication during the physical examination (P < .05), and more information gathering (P < .01) with children. Male and female physicians engaged in similar amounts of discussions regarding illness management. Children were more satisfied with physicians of the same gender (P < .05), while parents were more satisfied with female physicians (P < .05).Children communicate more with female than with male physicians and show preferences for physicians of the same gender. These findings are consistent with communication patterns in adult patients and may have a significant influence on gender disparities in health care. Efforts at improving the process and outcome of medical care should address gender differences.
View details for Web of Science ID A1997XE00800011
View details for PubMedID 9193244
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The hospital cost of congenital syphilis
JOURNAL OF PEDIATRICS
1997; 130 (5): 752-758
Abstract
To determine the hospital cost of caring for newborn infants with congenital syphilis.All live-born singleton neonates with birth weight greater than 500 gm at an inner-city municipal hospital in New York City in 1989.We compared the characteristics of 114 infants with case-compatible congenital syphilis with those of 2906 infants without syphilis. Cost estimates were based on New York State newborn diagnosis-related groups (DRG) reimbursements adjusted for length of stay, birth weight, preterm delivery, and selected maternal risk factors, including infection with the human immunodeficiency virus, cocaine use during pregnancy, and history of injected drug use.For infants with congenital syphilis, the unadjusted mean cost ($11,031) and the median cost ($4961) were more than three times larger than those for infants without syphilis (p < 0.01). After adjustment, congenital syphilis was associated with an additional length of hospitalization of 7 1/2 days and an additional cost of $4690 (both p < 0.01) above mean study population values (7.13 days, $3473).Based on the number of reported cases (1991 to 1994), the average annual national cost of treating infants with congenital syphilis is approximately $18.4 million (1995 dollars). This estimate provides a benchmark to assess the cost-effectiveness of strategies to prevent, diagnose, and treat the disease.
View details for Web of Science ID A1997WY38700016
View details for PubMedID 9152285
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Does case mix matter for substance abuse treatment? A comparison of observed and case mix-adjusted readmission rates for inpatient substance abuse treatment in the Department of Veterans Affairs
HEALTH SERVICES RESEARCH
1997; 31 (6): 755-771
Abstract
To develop a case mix model for inpatient substance abuse treatment to assess the effect of case mix on readmission across Veterans Affairs Medical Centers (VAMCs).The computerized patient records from the 116 VAMCs with inpatient substance abuse treatment programs between 1987 and 1992.Logistic regression was used on patient data to model the effect of demographic, psychiatric, medical, and substance abuse factors on readmission to VAMCs for substance abuse treatment within six months of discharge. The model predictions were aggregated for each VAMC to produce an expected number of readmissions. The observed number of readmissions for each VAMC was divided by its expected number to create a measure of facility performance. Confidence intervals and rankings were used to examine how case mix adjustment changed relative performance among VAMCs.Ward where care was provided and ICD-9-CM diagnosis codes were used to identify patients receiving treatment for substance abuse (N = 313,886).The case mix model explains 36 percent of the observed facility level variation in readmission. Over half of the VAMCs had numbers of readmissions that were significantly different than expected. There were also noticeable differences between the rankings based on actual and case mix-adjusted readmissions.Secondary data can be used to build a reasonably stable case mix model for substance abuse treatment that will identify meaningful variation across facilities. Further, case mix has a large effect on facility level readmission rates for substance abuse treatment. Uncontrolled facility comparisons can be misleading. Case mix models are potentially useful for quality assurance efforts.
View details for Web of Science ID A1997WG83500009
View details for PubMedID 9018215
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The meaning of authorship
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1996; 276 (17): 1385-1385
View details for Web of Science ID A1996VQ46400014
View details for PubMedID 8892708
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Addressing self-selection effects in evaluations of mutual help groups and professional mental health services: An introduction to two-stage sample selection models
EVALUATION AND PROGRAM PLANNING
1996; 19 (4): 301-308
View details for Web of Science ID A1996VZ90400003
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The effects of patient volume and level of care at the hospital of birth on neonatal mortality
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1996; 276 (13): 1054-1059
Abstract
To examine the effects of neonatal intensive care unit (NICU) patient volume and the level of NICU care available at the hospital of birth on neonatal mortality.Birth certificate data linked to infant death certificates and to infant discharge abstracts were used in a logistic regression model to control for differences in each patient's clinical and demographic risks. Hospitals were classified by the level of NICU care available (no NICU: level I; intermediate NICU: level II; expanded intermediate NICU: level II+: tertiary NICU: level III) and by the average patient census in the NICU.All nonfederal hospitals in California with maternity services.All births in nonfederal hospitals in California in 1990 (N=594104), 473209 (singletons only) of which were successfully linked with discharge abstracts. Of these infants, 53229 were classified as likely NICU admissions.Death within the first 28 days of life, or within the first year of life, if continuously hospitalized.Patient volume and level of NICU care at the hospital of birth both had significant effects on mortality. Compared with hospitals without an NICU, infants born in a hospital with a level III NICU with an average NICU census of at least 15 patients per day had significantly lower risk-adjusted neonatal mortality (odds ratio, 0.62; 95% confidence interval, 0.47-0.82; P=.002). Risk-adjusted neonatal mortality for infants born in smaller level III NICUs, and in level II+ and level II NICUs, regardless of size, was not significantly different from hospitals without an NICU, and was significantly higher than hospitals with large level III NICUS.Risk-adjusted neonatal mortality was significantly lower for births that occurred in hospitals with large (average census, >15 patients per day) level III NICUs. Despite the differences in outcomes, costs for the birth of infants born at hospitals with large level III NICUs were not more than those for infants born at other hospitals with NICUs. Concentration of high-risk deliveries in urban areas in a smaller number of hospitals that could provide level III NICU care has the potential to decrease neonatal mortality without increasing costs.
View details for Web of Science ID A1996VK03500026
View details for PubMedID 8847767
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Correlation of travel time on roads versus straight line distance
MEDICAL CARE RESEARCH AND REVIEW
1995; 52 (4): 532-542
Abstract
Studies of hospital demand and choice of hospital have used straight line distance from a patient's home to hospitals as a measure of geographic access, but there is the potential for bias if straight line distance does not accurately reflect travel time. Travel times for unimpeded travel between major intersections in upstate New York were compared with distances between these points. The correlation between distance and travel time was 0.987 for all observations and 0.826 for distances less than 15 miles. These very high correlations indicate that straight line distance is a reasonable proxy for travel time in most hospital demand or choice models, especially those with large numbers of hospitals. The authors' outlier analyses show some exceptions, however, so this relationship may not hold for studies focusing on specific hospitals, very small numbers of hospitals, or studies in dense urban areas with high congestion and reliance on surface streets.
View details for Web of Science ID A1995TK89800006
View details for PubMedID 10153313
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Inpatient treatment for substance abuse patients with psychiatric disorders: a national study of determinants of readmission.
Journal of substance abuse
1995; 7 (1): 79-97
Abstract
This study examined the patient case mix and program determinants of 6-month readmission rates and early treatment dropout for 7,711 VA inpatients with both substance abuse and major psychiatric disorders treated in one of 104 substance abuse programs. Patients were treated in one of three types of inpatient programs: explicitly designed dual diagnosis specialty programs, substance abuse programs with a dual diagnosis psychotherapy group or standard substance abuse programs. Dual diagnosis specialty programs differed from regular substance abuse programs in that they had a more severe case mix, a higher 180-day readmission rate, greater dual diagnosis treatment orientation, used more psychotropic medication, had longer lengths of stay, had greater tolerance of relapse and medication noncompliance, and a higher rate of psychiatric aftercare in the 30 days after discharged. Programs with less severe case mix, longer intended and actual length of stay, lower 7-day dropout rates, greater tolerance of problem behavior, 12-step groups, and higher immediate postdischarge utilization of outpatient mental health treatment lower 180-day readmission rates. Programs with less severe patient case mix, more use of psychotropic medications but less of methadone and antabuse, less varied and diverse treatment activities, and low use of patient-led groups had lower dropout rates.
View details for PubMedID 7655313
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DETERMINANTS OF READMISSION FOLLOWING INPATIENT SUBSTANCE-ABUSE TREATMENT - A NATIONAL STUDY OF VA PROGRAMS
MEDICAL CARE
1994; 32 (6): 535-550
Abstract
This study examines program determinants of one aspect of VA inpatient substance abuse treatment program performance. Performance was measured by the ratio of a program's readmission rate to the expected rate for programs with similar patients. Six-month readmission rates in 101 VA treatment programs were analyzed. Preliminary analyses indicated that patient differences across programs accounted for 36% of the variance in readmission rates. Program differences accounted for 47% of the variance in case-mix-adjusted readmission rate. Among program factors selected through a literature review, better than expected readmission performance was associated with having fewer early discharges, a longer intended treatment duration, more patient participation in aftercare, more family or friend assessment interviews, and treating more patients on a compulsory basis. Performance was not related to stress management training, patient attendance at more self-help meetings during treatment, staff characteristics, or average staff costs per patient day. The findings indicate that treatment retention, duration, and increased aftercare may be targeted to reduce high readmission rates. Last, there were only small differences in the model over 30, 60, 90, and 365 day follow-up intervals, suggesting substantial stability of the findings.
View details for Web of Science ID A1994NQ01400001
View details for PubMedID 8189773
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PRENATAL-CARE NEEDS ASSESSMENT COMPARING SERVICE USE AND OUTCOMES IN FRESNO, CA
PUBLIC HEALTH REPORTS
1994; 109 (1): 68-76
Abstract
The authors performed a prenatal care needs assessment for Fresno County, CA, using data from a sample of 11,878 birth certificates for the county for 1989. Birth records, patterns of prenatal care utilization, and low birth weight outcomes in the county were compared with those in a random sample of 11,826 certificates derived from births in the remainder of the State. Bivariate techniques were used in calculating care utilization rates. Multivariate logistic regression analysis was used in associating rates of prenatal care visits and gestational month of initiation of prenatal care with low weight birth outcomes. County women entered prenatal care as early as women in the remainder of the State, but did not return as often for prenatal care visits. Their rate of return for followup visits was 29.9 percent, compared with 24.8 percent for women in all other counties (P < 0.001). County women with the lowest rates of visits had 1.4 to 1.9 times the risk of having a low weight birth than other county women with higher rates of visits, and a significantly higher risk than for women of all other counties. An intensive visit schedule for high-risk care was provided 28.9 percent of county women, compared with 33.0 percent of women in all other counties (P < 0.001). County women who received a high-risk intensive visit schedule were 2.5 times more likely to have a low weight birth than county women who did not receive the schedule. For all other women in the State, the comparable risk was 2.1 times. Improvements in the number and content of prenatal care visits were shown to have a high likelihood of substantially improving birth weight outcomes for pregnancies among Fresno County women.
View details for Web of Science ID A1994MW86400010
View details for PubMedID 8303017
View details for PubMedCentralID PMC1402244
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COST EFFECTS OF SURFACTANT THERAPY FOR NEONATAL RESPIRATORY-DISTRESS SYNDROME
JOURNAL OF PEDIATRICS
1993; 123 (6): 953-962
Abstract
To examine the cost effects of a single dose (5 ml/kg) of a protein-free synthetic surfactant (Exosurf) as therapy for neonatal respiratory distress syndrome, for both rescue and prophylactic therapy.Nonblinded, randomized clinical trials of both rescue and prophylactic therapy. Regression analyses were used to control for the independent effects of sex, multiple birth, delivery method, birth weight, and surfactant therapy.The prophylactic trial was conducted at a university medical center only; the rescue trial also included a tertiary community hospital.Prophylaxis was administered immediately after birth to 36 infants (38 control subjects) with birth weights between 700 and 1350 gm. Rescue therapy was administered at 4 to 24 hours of age to 53 infants (51 control subjects) with established respiratory distress syndrome and birth weights > or = 650 gm (no upper limit). Infants in the prophylactic trial were not eligible for the rescue trial.For the rescue trial, there was a $16,600 reduction in average hospital costs (p = 0.18), which was larger than the cost of the surfactant ($450 to $900), yielding a probable net savings. For the prophylactic trial, hospital costs were larger for treated infants versus control subjects who weighed less than about 1100 gm at birth and lower for treated infants versus control subjects who weighed more than 1100 gm at birth (p < 0.05). For the prophylactic sample, the result was an average cost per life saved of $71,500.Single-dose rescue surfactant therapy is probably a cost-effective therapy because it produced a lower mortality rate for the same (and probably lower) expenditure. Single-dose prophylactic therapy for smaller infants (< or = 1350 gm) appeared to yield a reduction in mortality rate for a small additional cost. The use of multiple-dose therapy in infants who do not respond to initial therapy may alter the effects described above to either increase or decrease the observed cost-effectiveness of surfactant therapy. Regardless, surfactant therapy will remain a cost-effective method of reducing mortality rates, relative to other commonly used health care interventions.
View details for Web of Science ID A1993MK82700017
View details for PubMedID 8229530
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A VARIABLE-RADIUS MEASURE OF LOCAL HOSPITAL MARKET-STRUCTURE
HEALTH SERVICES RESEARCH
1993; 28 (3): 313-324
Abstract
To provide a radius measure of the structure of local hospital markets that varies with hospital characteristics and is available for all hospitals in the United States.1982 American Hospital Association (AHA) Survey of Hospitals, 1982 Area Resource File (ARF), and 1983 California Office of Statewide Health Planning and Development (OSHPD) discharge abstracts.The OSHPD data were used to measure the radii necessary to capture 75 percent and 90 percent of each hospital's admissions. These radii were used as the dependent variables in regression models in which the independent variables were from the AHA and ARF. To estimate predicted market radii, the estimated parameters from the California models were applied to all nonfederal, short-term, general hospitals in the continental United States. These radii were used to define each hospital's service area, and all other hospitals within the calculated radii were considered potential competitors. Using this definition, we calculated two measures of local market structure: the number of other hospitals within the radius and a Herfindahl-Hirschman Index based on the distribution of hospital bed shares in the market.These measures were calculated for all nonfederal, short-term, acute care hospitals in the continental United States for whom complete data were available (N = 4,884).These measures are available from the authors on computer-readable diskette, matched to hospital identifiers.
View details for Web of Science ID A1993LT02200003
View details for PubMedID 8344822
View details for PubMedCentralID PMC1069938
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CHOICE OF HOSPITAL FOR DELIVERY - A COMPARISON OF HIGH-RISK AND LOW-RISK WOMEN
HEALTH SERVICES RESEARCH
1993; 28 (2): 201-222
Abstract
This article tests whether or not the factors that affect hospital choice differ for selected subgroups of the population.1985 California Office of Statewide Health Planning and Development (OSHPD) discharge abstracts and hospital financial data were used.Models for hospital choice were estimated using McFadden's conditional logit model. Separate models were estimated for high-risk and low-risk patients, and for high-risk and low-risk women covered either by private insurance or by California Medicaid. The model included independent variables to control for quality, price, ownership, and distance to the hospital.Data covered all maternal deliveries in the San Francisco Bay Area in 1985 (N = 61,436). ICD-9 codes were used to classify patients as high-risk or low-risk. The expected payment code on the discharge abstract was used to identify insurance status.The results strongly reject the hypothesis that high-risk and low-risk women have the same choice process. Hospital quality tended to be more important for high-risk than low-risk women. These results also reject the hypothesis that factors influencing choice of hospital are the same for women covered by private insurance as for those covered by Medicaid. Further, high-risk women covered by Medicaid were less likely than high-risk women covered by private insurance to deliver in hospitals with newborn intensive care units.The results show that the choice factors vary across several broadly defined subgroups of patients with a specific condition. Thus, estimates aggregating all patients may be misleading. Specifically, such estimates will understate actual patient response to quality of care indicators, since patient sensitivity to quality of care varies with the patients' risk status.
View details for Web of Science ID A1993LH64800004
View details for PubMedID 8514500
View details for PubMedCentralID PMC1069930
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BIRTH-WEIGHT AND ILLNESS SEVERITY - INDEPENDENT PREDICTORS OF NEONATAL-MORTALITY
PEDIATRICS
1993; 91 (5): 969-975
Abstract
Low birth weight is a major determinant of neonatal mortality. Yet birth weight, even in conjunction with other demographic markers, is inadequate to explain the large variations in neonatal mortality between intensive care units. This variation probably reflects differences in admission severity. The authors have recently developed the Score for Neonatal Acute Physiology (SNAP), an illness severity index specific for neonatal intensive care, and demonstrated illness severity to be a major determinant of neonatal mortality.To define the relative contributions of birth weight and illness severity to the risk of neonatal mortality and to identify other significant independent risk factors.Logistic regression was used to analyze data from a cohort of 1621 consecutive admissions to three neonatal intensive care units (92 deaths), to test six alternative predictive models. The best logistic model was then used to develop a simple additive clinical score, the SNAP Perinatal Extension (SNAP-PE).These analyses demonstrated that birth weight and illness severity are powerful independent predictors across a broad range of birth weights and that their effects are additive. Below 750 g, there is an interaction between birth weight and SNAP. Other factors that showed independent predictive power were low Apgar score at 5 minutes and small size for gestational age. Separate derivation and test samples were used to demonstrate that the SNAP-PE is comparable to the best logistic model and has a sensitivity and specificity superior to either birth weight or SNAP alone (receiver-operator characteristic area .92 +/- .02) as well as excellent goodness of fit.This simplified clinical score provides accurate mortality risk estimates for application in a broad array of clinical and research settings.
View details for Web of Science ID A1993KZ79200018
View details for PubMedID 8474818
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BACK TRANSPORTING INFANTS FROM NEONATAL INTENSIVE-CARE UNITS TO COMMUNITY HOSPITALS FOR RECOVERY CARE - EFFECT ON TOTAL HOSPITAL CHARGES
PEDIATRICS
1992; 90 (1): 22-26
Abstract
Many neonates are referred to neonatal intensive care units (NICUs) for specialized care far from their parents' residence. This distance can add to the stress of the parents and reduce the contact of the parents with their newborn. Small studies have found that back transporting these neonates to hospitals closer to their homes is safe and cost-effective. Despite these findings, the reluctance of many insurers to pay for back transports prevents or delays many back transports. Insurers may not consider the findings of the previous studies to be conclusive, given that the comparisons were between small numbers of neonates back transported and neonates who remained in tertiary care, and the potential for differences in severity of illness between the groups is significant. In this study the effect on hospital charges of back transports was examined by comparing the charges for care in community hospitals with what these charges would have been in a tertiary care center. The advantage of this method is that it avoids case-mix differences between the groups and thus minimizes the potential for small-sample bias. Data were collected for all back transports from a NICU to non-tertiary care centers (n = 90) for a 9-month period. We were able to obtain the itemized bills for the care at community hospitals for 42 of these patients. Each bill was recalculated using the charges for the NICU to determine potential for savings. The average charges for recovery care were about $6200 lower at the community hospital than they would have been at the NICU.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1992JA85400005
View details for PubMedID 1614772
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PROFESSIONAL LIABILITY REFORM AND ACCESS TO MEDICAID OBSTETRIC CARE IN NEW-YORK-STATE
NEW YORK STATE JOURNAL OF MEDICINE
1992; 92 (6): 237-245
Abstract
Professional liability costs and fear of lawsuits have made participation in Medicaid difficult for office-based physicians who provide prenatal care, both obstetricians and family physicians. We assessed the possible impact of changes in three liability policy reforms on expanding access of Medicaid-eligible pregnant women to these private physicians. We surveyed members of the New York State District of the American College of Obstetricians and Gynecologists and the New York Academy of Family Physicians to explore whether they would start, expand, or resume obstetric service to Medicaid patients in response to a ceiling on litigation awards, no-fault insurance and a subsidy for liability expenses. We then compared the reported increases in participation on the basis of liability reforms to those in response to changes in Medicaid policies. We found in general that the three liability reforms would have similar impacts on Medicaid participation, although a subsidy was indicated by fewer physicians than the ceiling or no-fault approaches. The support for the liability reforms was as effective as proposals of greater reimbursement rates. The proportion of obstetricians or family physicians increasing their participation depended more on whether they would be starting Medicaid participation, expanding existing Medicaid participation or resuming former Medicaid participation than on the particular liability policy.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1992JA60500004
View details for PubMedID 1641207
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PREVENTION - THE COST-EFFECTIVENESS OF THE CALIFORNIA DIABETES AND PREGNANCY PROGRAM
AMERICAN JOURNAL OF PUBLIC HEALTH
1992; 82 (2): 168-175
Abstract
The California Diabetes and Pregnancy Program is a new preventive approach to improving pregnancy outcomes through intensive diabetes management preconception and early in pregnancy.Hospital charges and length of stay data were collected on 102 program enrollees and 218 control cases. Ninety program enrollees and 90 control cases were matched on mother's age. White's classification, and race. Regression models controlled for these variables in addition to MediCal status, birth weight, and enrollment in the program.Hospital charges were about 30% less for program participants and days in the hospital were roughly 25% less. The program effects were larger for women that enrolled before 8 weeks gestation. More serious diabetics were also found to have larger reductions in charges and days.After adjusting for inflation and differences in charges across hospitals, $5.19 is saved for every dollar spent on the program.
View details for Web of Science ID A1992HL39800003
View details for PubMedID 1739141
View details for PubMedCentralID PMC1694303
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THE NEONATAL COSTS OF MATERNAL COCAINE USE
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1991; 266 (11): 1521-1526
Abstract
--To examine the added neonatal cost and length of hospital stay associated with fetal cocaine exposure.--All cocaine-exposed infants in the study population (n = 355) were compared with a random sample of unexposed infants (n = 199). Regression analysis was used to control for the independent effects of maternal age, smoking, alcohol consumption, prenatal care, race, gravidity, and sex of the infant.--A large, public, inner-city hospital studied from 1985 to 1986.--All infants were routinely tested for illicit substances, records were reviewed for maternal histories of substance abuse, and all known cocaine-exposed singleton infants were included.--Cost and length of stay until each infant was medically cleared for hospital discharge and cost and length of stay until each infant was actually discharged from the hospital.--Neonatal hospital costs until medically cleared for discharge were $5200 more for cocaine-exposed infants than for unexposed infants (a difference of $7957 vs $2757 [P = .003]). The costs of infants remaining in the nursery while awaiting home and social evaluation or foster care placement increased this difference by more than $3500 (P less than .0001). Compared with other forms of cocaine, fetal exposure to crack was associated with much larger cost increases ($6735 vs $1226). Exposure to other illicit substances in addition to cocaine was also associated with much larger cost increases ($8450 vs $1283).--At the national level, we estimate that these individual medical costs add up to about $500 million. The large magnitude of these costs indicates that effective treatment programs for maternal cocaine abusers could yield savings within their first year of operation.
View details for Web of Science ID A1991GE45800032
View details for PubMedID 1880883
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Modeling the effect of hospital charges and quality on choice.
Journal of health care marketing
1991; 11 (3): 2-11
Abstract
The authors apply a conditional choice model to simulate the results of patient and physician choices of hospitals for a specific surgical procedure in response to improvements in quality or changes in charges. The model includes all zip code areas and relevant hospitals in a large metropolitan area and estimates the impact on admissions at each hospital. It can be used to estimate both the impact of decisions by a given hospital and the potential responses of competitors, as well as the effects of selective contracting with hospitals by certain payors.
View details for PubMedID 10116316
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INITIAL CLINICAL-TRIAL OF EXOSURF, A PROTEIN-FREE SYNTHETIC SURFACTANT, FOR THE PROPHYLAXIS AND EARLY TREATMENT OF HYALINE-MEMBRANE DISEASE
PEDIATRICS
1991; 88 (1): 1-9
Abstract
EXOSURF is a protein-free surfactant composed of 85% dipalmitoylphosphatidylcholine, 9% hexadecanol, and 6% tyloxapol by weight. A single dose of 5 mL of EXOSURF per kilogram body weight, which gave 67 mg of dipalmitoylphosphatidylcholine per kilogram body weight, or 5 mL/kg air was given intratracheally in each of two controlled trials: at birth to neonates 700 through 1350 g (the prophylactic trial, n = 74) or at 4 to 24 hours after birth to neonates greater than 650 g who had hyaline membrane disease severe enough to require mechanical ventilation (the rescue trial, n = 104). In both studies, time-averaged inspired oxygen concentrations and mean airway pressures during the 72 hours after entry decreased significantly (P less than .05) in the treated neonates when compared with control neonates. Thirty-six percent of the treated neonates in the rescue study had an incomplete response to treatment or relapsed within 24 hours, suggesting the need for retreatment in some neonates. In the rescue trial, risk-adjusted survival increased significantly in the treated group. There were no significant differences in intracranial hemorrhages, chronic lung disease, or symptomatic patent ductus arteriosus between control and treated infants in either trial.
View details for Web of Science ID A1991FV06200001
View details for PubMedID 2057244
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Explaining resource consumption among non-normal neonates.
Health care financing review
1991; 13 (2): 19-28
Abstract
The adoption by Medicare in 1983 of prospective payment using diagnosis-related groups (DRGs) has stimulated research to develop case-mix grouping schemes that more accurately predict resource consumption by patients. In this article, the authors explore a new method designed to improve case-mix classification for newborns through the use of birth weight in combination with DRGs to adjust the unexplained case-mix severity. Although the findings are developmental in nature, they reveal that the model significantly improves our ability to explain resource use.
View details for PubMedID 10122360
View details for PubMedCentralID PMC4193221
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DOES QUALITY INFLUENCE CHOICE OF HOSPITAL
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1990; 263 (21): 2899-2906
Abstract
In recent years, much information has been provided to the public and to physicians about hospital quality measured in terms of patient outcomes. To examine if, before these public data releases, quality influenced the attractiveness of a hospital to referring or admitting physicians and to patients, we estimated the influences of quality, charges, ownership, and distance on the choice of hospitals for patients with seven surgical procedures and five medical diagnoses in hospitals in three geographic areas in California in 1983. Greater distance and public or proprietary ownership consistently reduced the likelihood of selection while medical school affiliation increased the likelihood of selection. For five of seven surgical procedures and two of five medical diagnoses, hospitals with poorer than expected outcomes attracted significantly fewer admissions. The reverse held for two surgical procedures and one medical diagnosis. The results suggest that quality played an important role in choices among hospitals even before explicit data were widely available.
View details for Web of Science ID A1990DF97200028
View details for PubMedID 2110985
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THE SENSITIVITY OF CONDITIONAL CHOICE MODELS FOR HOSPITAL-CARE TO ESTIMATION TECHNIQUE
JOURNAL OF HEALTH ECONOMICS
1990; 8 (4): 377-397
Abstract
It is plausible that distance, quality, and hospital charges all influence which hospital patients (and their referring physicians) choose. Several researchers have estimated conditional choice models that explicitly incorporate the existence of competing hospitals. To be useful for hospital administrators, health planners and insurers, however, estimates must be made for specific types of patients and include entire market areas. Data sets meeting these requirements have many combinations of hospitals and locations with zero patients. This raises computational difficulties with the linear estimation techniques used previously. In this paper, we use data on patients undergoing cardiac catheterization in several market areas to assess alternative estimation techniques. First, we estimate the conditional choice model with the two techniques used previously to transform the non-linear choice model. These involve using as a reference (1) a single hospital, or (2) the geometric mean of all the hospitals in the market. When there are many zeros, these techniques require extensive adjustments to the data which may lead to biased estimators. We then compare these results with maximum likelihood estimates. The latter results are substantively and significantly different from those using traditional techniques. More importantly, the linear estimates are much more sensitive to the proportion of zeros. We thus conclude that maximum likelihood estimates are preferable when there are many zeros.
View details for Web of Science ID A1990CW53900002
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AN EVALUATION OF MEDICAID SELECTIVE CONTRACTING IN CALIFORNIA
JOURNAL OF HEALTH ECONOMICS
1990; 8 (4): 437-455
View details for Web of Science ID A1990CW53900005
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The sensitivity of conditional choice models for hospital care to estimation technique.
Journal of health economics
1989; 8 (4): 377-397
Abstract
It is plausible that distance, quality, and hospital charges all influence which hospital patients (and their referring physicians) choose. Several researchers have estimated conditional choice models that explicitly incorporate the existence of competing hospitals. To be useful for hospital administrators, health planners and insurers, however, estimates must be made for specific types of patients and include entire market areas. Data sets meeting these requirements have many combinations of hospitals and locations with zero patients. This raises computational difficulties with the linear estimation techniques used previously. In this paper, we use data on patients undergoing cardiac catheterization in several market areas to assess alternative estimation techniques. First, we estimate the conditional choice model with the two techniques used previously to transform the non-linear choice model. These involve using as a reference (1) a single hospital, or (2) the geometric mean of all the hospitals in the market. When there are many zeros, these techniques require extensive adjustments to the data which may lead to biased estimators. We then compare these results with maximum likelihood estimates. The latter results are substantively and significantly different from those using traditional techniques. More importantly, the linear estimates are much more sensitive to the proportion of zeros. We thus conclude that maximum likelihood estimates are preferable when there are many zeros.
View details for PubMedID 10296934
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An evaluation of Medicaid selective contracting in California.
Journal of health economics
1989; 8 (4): 437-455
Abstract
This study used 1982-1986 data on 262 private community hospitals to evaluate the effects of selective contracting for inpatient services by California's Medicaid program. Selective contracting by Medicaid significantly reduced the rate of inflation in average costs per admission and per patient day, while slightly increasing average lengths of patient stays. Private sector contracting also reduced cost inflation rates significantly and caused small, non-significant, reductions in lengths of stays. Hospital savings in 1986 due to Medicaid selective contracting were $836 million, 7.6% of what hospital expenditures would have been in the absence of contracting.
View details for PubMedID 10313470
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ALTERNATIVE TO DIAGNOSIS-RELATED GROUPS FOR NEWBORN INTENSIVE-CARE
PEDIATRICS
1986; 78 (5): 829-836
Abstract
Clinical and billing data were collected on all admissions to six California newborn intensive care units during a 6-month period. Charges were adjusted to costs using Medicaid cost to charge ratios and for inflation, and patients were classified by the diagnosis-related group (DRG) system. Costs were from 97% to 708% more than the proposed DRG reimbursement levels. Regression analysis showed that DRGs explained 22% of the variation in costs. An alternative model using binary variables to control for birth weight, assisted ventilation, surgery, survival, multiple births, and mode of discharge explained 42% of the variation in costs. In contrast to other proposed DRG alternatives, this simple model does not require special training or subjective decision-making.
View details for Web of Science ID A1986E633300010
View details for PubMedID 3093968
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NEWBORN RISK-FACTORS AND COSTS OF NEONATAL INTENSIVE-CARE
PEDIATRICS
1981; 68 (3): 313-321
Abstract
To understand the sources of the high costs of neonatal intensive care, financial and medical information on 1,185 admissions to an intensive care nursery was gathered. Multiple regression analysis showed that a significant portion of the variation in individual costs was explained by three measures of risk: low birth weight, surgical intervention, and assisted ventilation. There was a highly skewed distribution of costs. Nearly half of all admissions had none of the above risk factors, had an average cost of about $2,000, and accounted for only 13% of the total costs for the whole sample. In contrast, less than one quarter of the admissions had two or more of the risk factors, had an average cost of $19,800, and accounted for nearly 60% of the total costs. Models that predict costs and length of stay on a basis of seven risk factors were developed to allow for differences in patient populations.
View details for Web of Science ID A1981ME20700001
View details for PubMedID 6792583