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Niedzwiecki MJ, Forrow LV, Gellar J, Pohl RV, Chen A, Miescier L, Kranker K. The Medicare Care Choices Model was associated with reductions in disparities in the use of hospice care for Medicare beneficiaries with terminal illness. Health Serv Res 2024. [PMID: 38419507 DOI: 10.1111/1475-6773.14289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE To assess the effects of the Medicare Care Choices Model (MCCM) on disparities in hospice use and quality of end-of-life care for Medicare beneficiaries from underserved groups-those from racial and ethnic minority groups, dually eligible for Medicare and Medicaid, or living in rural areas. DATA SOURCES AND STUDY SETTING Medicare enrollment and claims data from 2013 to 2021 for terminally ill Medicare fee-for-service beneficiaries nationwide. STUDY DESIGN Through MCCM, terminally ill enrolled Medicare beneficiaries received supportive and palliative care services from hospice providers concurrently with curative treatments. Using a matched comparison group, we estimated subgroup-specific effects on hospice use, days at home, and aggressive treatment and multiple emergency department visits in the last 30 days of life. DATA COLLECTION/EXTRACTION METHODS The sample included decedent Medicare beneficiaries enrolled in MCCM and a matched comparison group from the same geographic areas who met model eligibility criteria at time of enrollment: having a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or HIV/AIDS; living in the community; not enrolled in the Medicare hospice benefit in the previous 30 days; and having at least one hospital stay and three office visits in the previous 12 months. PRINCIPAL FINDINGS Eligible beneficiaries from underserved groups were underrepresented in MCCM. MCCM increased enrollees' hospice use and the number of days at home and reduced aggressive treatment among all subgroups analyzed. MCCM also reduced disparities in hospice use by race and ethnicity and dual eligibility by 4.1 (90% credible interval [CI]: 1.3-6.1) and 2.4 (90% CI: 0.6-4.4) percentage points, respectively. It also reduced disparities in having multiple emergency department visits for rural enrollees by 1.3 (90% CI: 0.1-2.7) percentage points. CONCLUSIONS MCCM increased hospice use and quality of end-of-life care for model enrollees from underserved groups and reduced disparities in hospice use and having multiple emergency department visits.
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Affiliation(s)
| | | | | | | | | | - Lynn Miescier
- Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland, USA
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Kranker K, Niedzwiecki MJ, Pohl RV, Saffer TL, Chen A, Gellar J, Forrow LV, Miescier L. Medicare Care Choices Model Improved End-Of-Life Care, Lowered Medicare Expenditures, And Increased Hospice Use. Health Aff (Millwood) 2023; 42:1488-1497. [PMID: 37931188 DOI: 10.1377/hlthaff.2023.00465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
The Medicare Care Choices Model (MCCM) tested a new option for eligible Medicare beneficiaries to receive conventional treatment for terminal conditions along with supportive and palliative care from participating hospice providers. Using claims data, we estimated differences in average outcomes from enrollment to death between deceased MCCM enrollees and matched comparison beneficiaries who received usual services covered by original Medicare. Enrollees were 15 percentage points less likely to receive an aggressive life-prolonging treatment at the end of life and spent more than five more days at home. MCCM also reduced net Medicare expenditures by 13 percent, decreased inpatient admissions by 26 percent, reduced outpatient emergency department visits by 12 percent, and increased hospice use by 18 percentage points. Although the Centers for Medicare and Medicaid Services did not expand the model, given concerns about generalizability, these results provide evidence that MCCM is a promising approach to transforming care delivery at the end of life.
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Affiliation(s)
| | | | | | - Tonya L Saffer
- Tonya L. Saffer, Centers for Medicare and Medicaid Services, Baltimore, Maryland
| | | | | | | | - Lynn Miescier
- Lynn Miescier, Centers for Medicare and Medicaid Services
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3
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Raven MC, Niedzwiecki MJ, Kushel M. A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services. Health Serv Res 2021; 55 Suppl 2:797-806. [PMID: 32976633 PMCID: PMC7518819 DOI: 10.1111/1475-6773.13553] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To examine whether randomization to permanent supportive housing (PSH) versus usual care reduces the use of acute health care and other services among chronically homeless high users of county‐funded services. Data Sources Between 2015 and 2019, we assessed service use from Santa Clara County, CA, administrative claims data for all county‐funded health care, jail and shelter, and mortality. Study Design We conducted a randomized controlled trial among chronically homeless high users of multiple systems. We compared postrandomization outcomes from county‐funded systems using multivariate regression analysis. Data Collection We extracted encounter data from an integrated database capturing health care at county‐funded facilities, shelter and jails, county housing placement, and death certificates. Principal Findings We enrolled 423 participants (199 intervention; 224 control). Eighty‐six percent of those randomized to PSH received housing compared with 36 percent in usual care. On average, the 169 individuals housed by the PSH intervention have remained housed for 28.8 months (92.9 percent of the study follow‐up period). Intervention group members had lower rates of psychiatric ED visits IRR 0.62; 95% CI [0.43, 0.91] and shelter days IRR 0.30; 95% CI [0.17, 0.53], and higher rates of ambulatory mental health services use IRR 1.84; 95% CI [1.43, 2.37] compared to controls. We found no differences in total ED or inpatient use, or jail. Seventy (37 treatment; 33 control) participants died. Conclusions The intervention placed and retained frequent user, chronically homeless individuals in housing. It decreased psychiatric ED visits and shelter use, and increased outpatient mental health care, but not medical ED visits or hospitalizations. Limitations included more than one‐third of usual care participants received another form of subsidized housing, potentially biasing results to the null, and loss of power due to high death rates. PSH can house high‐risk individuals and reduce emergent psychiatric services and shelter use. Reductions in hospitalizations may be more difficult to realize.
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Affiliation(s)
- Maria C Raven
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.,Mathematica Policy Research, Oakland, CA, USA
| | - Matthew J Niedzwiecki
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, USA
| | - Margot Kushel
- Mathematica Policy Research, Oakland, CA, USA.,Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,UCSF Benioff Homelessness and Housing Initiative, San Francisco, CA, USA
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4
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Valdovinos EM, Niedzwiecki MJ, Guo J, Hsia RY. The association of Medicaid expansion and racial/ethnic inequities in access, treatment, and outcomes for patients with acute myocardial infarction. PLoS One 2020; 15:e0241785. [PMID: 33175899 PMCID: PMC7657521 DOI: 10.1371/journal.pone.0241785] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction After having an acute myocardial infarction (AMI), racial and ethnic minorities have less access to care, decreased rates of invasive treatments such as percutaneous coronary intervention (PCI), and worse outcomes compared with white patients. The objective of this study was to determine whether the Affordable Care Act’s expansion of Medicaid eligibility was associated with changes in racial disparities in access, treatments, and outcomes after AMI. Methods Quasi-experimental, difference-in-differences-in-differences analysis of non-Hispanic white and minority patients with acute myocardial infarction in California and Florida from 2010–2015, using linear regression models to estimate the difference-in-differences. This population-based sample included all Medicaid and uninsured patients ages 18–64 hospitalized with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act beginning as early as July 2011 in certain counties, and Florida, which did not expand Medicaid. The main outcomes included rates of admission to hospitals capable of performing PCI, rates of transfer for patients who first presented to hospitals that did not perform PCI, rates of PCI during hospitalization and rates of early (within 48 hours of admission) PCI, rates of readmission to the hospital within 30 days, and rates of in-hospital mortality. Results A total of 55,991 hospital admissions met inclusion criteria, 32,540 of which were in California and 23,451 were in Florida. Among patients with AMI who initially presented to a non-PCI hospital, the likelihood of being transferred increased by 12 percentage points (95% CI 2 to 21) for minority patients relative to white patients after the Medicaid expansion. The likelihood of undergoing PCI increased by 3 percentage points (95% CI 0 to 5) for minority patients relative to white patients after the Medicaid expansion. We did not find an association between the Medicaid expansion and racial disparities in overall likelihood of admission to a PCI hospital, hospital readmissions, or in-hospital mortality. Conclusions The Medicaid expansion was associated with a decrease in racial disparities in transfers and rates of PCI after AMI. We did not find an association between the Medicaid expansion and admission to a PCI hospital, readmissions, and in-hospital mortality. Additional factors outside of insurance coverage likely continue to contribute to disparities in outcomes after AMI. These findings are crucial for policy makers seeking to reduce racial disparities in access, treatment and outcomes in AMI.
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Affiliation(s)
- Erica M Valdovinos
- Department of Emergency Medicine, Adventist Health Ukiah Valley, Ukiah, California, United States of America
| | - Matthew J Niedzwiecki
- Mathematica Policy Research.,Department of Emergency Medicine, University of California, San Francisco, California, United States of America.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, United States of America
| | - Joanna Guo
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, United States of America
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5
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Abstract
PURPOSE Changing market forces increasingly are leading academic medical centers (AMCs) to form or join health systems. But it is unclear how this shift is affecting the tripartite academic mission of education, research, and high-quality patient care. To explore this topic, the authors identified and characterized the types of health systems that owned or managed AMCs in the United States in 2016. METHOD The authors identified AMCs as any general acute care hospitals that had a resident-to-bed ratio of at least 0.25 and that were affiliated with at least one MD- or DO-granting medical school. Using the Agency for Healthcare Research and Quality 2016 Compendium of U.S. Health Systems, the authors also identified academic-affiliated health systems (AHSs) as those health systems that owned or managed at least one AMC. They compared AMCs and other general acute care hospitals, AHSs and non-AHSs, and AHSs by type of medical school relationship, using health system size, hospital characteristics, undergraduate and graduate medical education characteristics, services provided, and ownership. RESULTS Health systems owned or managed nearly all AMCs (361, 95.8%). Of the 626 health systems, 230 (36.7%) met the definition of an AHS. Compared with other health systems, AHSs included more hospitals, provided more services, and had a lower ratio of primary care doctors to specialists. Most AHSs (136, 59.1%) had a single, shared medical school relationship, whereas 38 (16.5%) had an exclusive medical school relationship and 56 (24.3%) had multiple medical school relationships. CONCLUSIONS These findings suggest that several distinct types of relationships between AHSs and medical schools exist. The traditional vision of a medical school having an exclusive relationship with a single AHS is no longer prominent.
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MESH Headings
- Academic Medical Centers/organization & administration
- Biomedical Research
- Education, Medical, Graduate/organization & administration
- Education, Medical, Undergraduate/organization & administration
- Hospitals, General/organization & administration
- Hospitals, Pediatric/organization & administration
- Hospitals, Proprietary/organization & administration
- Hospitals, Public/organization & administration
- Hospitals, Teaching/organization & administration
- Hospitals, Voluntary/organization & administration
- Humans
- Quality of Health Care
- Safety-net Providers/organization & administration
- Schools, Medical/organization & administration
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Affiliation(s)
- Matthew J Niedzwiecki
- M.J. Niedzwiecki is researcher, Mathematica Policy Research, Oakland, California. R.M. Machta is researcher, Mathematica Policy Research, Oakland, California. J.D. Reschovsky is a senior fellow, Mathematica Policy Research, Washington, DC. M.F. Furukawa is senior economist, Agency for Healthcare Research and Quality, Rockville, Maryland. E.C. Rich is a senior fellow, Mathematica Policy Research, Washington, DC
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6
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Abstract
OBJECTIVE To test the hypothesis that the earned income tax credit (EITC)-the largest US poverty alleviation program-affects short-term health care expenditures among US adults. DATA SOURCES Adult participants in the 1997-2012 waves of the US Medical Expenditure Panel Survey (MEPS) (N = 1 282 080). STUDY DESIGN We conducted difference-in-differences analyses, comparing health care expenditures among EITC-eligible adults in February (immediately following EITC refund receipt) with expenditures during other months, using non-EITC-eligible individuals to difference out seasonal variation in health care expenditures. Outcomes included total out-of-pocket expenditures as well as spending on specific categories such as outpatient visits and inpatient hospitalizations. We conducted subgroup analyses to examine heterogeneity by insurance status. PRINCIPAL FINDINGS EITC refund receipt was not associated with short-term changes in total expenditures, nor any expenditure subcategories. Results were similar by insurance status and robust to numerous alternative specifications. CONCLUSIONS EITC refunds are not associated with short-term changes in health care expenditures among US adults. This may be because the refund is spent on other expenses, because of income smoothing, or because of similar refund-related variation in health care expenditures among noneligible adults. Future studies should examine whether other types of income supplementation affect health care expenditures, particularly among individuals in poverty.
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Affiliation(s)
- Rita Hamad
- Department of Family & Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California
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Affiliation(s)
- Matthew J. Niedzwiecki
- Matthew J. Niedzwiecki is a health researcher at Mathematica Policy Research in Oakland, California
| | - Hemal K. Kanzaria
- Hemal K. Kanzaria is an associate professor in the Department of Emergency Medicine and an affiliated faculty member at the Philip R. Lee Institute for Health Policy Studies, both at the University of California San Francisco (UCSF)
| | - Juan Carlos Montoy
- Juan Carlos Montoy is an assistant professor in the Department of Emergency Medicine, UCSF
| | - Renee Y. Hsia
- Renee Y. Hsia is a professor in the Department of Emergency Medicine and a core faculty member at the Philip R. Lee Institute for Health Policy Studies, UCSF
| | - Maria C. Raven
- Maria C. Raven is an associate professor in the Department of Emergency Medicine and an affiliated faculty member at the Philip R. Lee Institute for Health Policy Studies, UCSF
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Hsia RY, Huang D, Mann NC, Colwell C, Mercer MP, Dai M, Niedzwiecki MJ. A US National Study of the Association Between Income and Ambulance Response Time in Cardiac Arrest. JAMA Netw Open 2018; 1:e185202. [PMID: 30646394 PMCID: PMC6324393 DOI: 10.1001/jamanetworkopen.2018.5202] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
IMPORTANCE Emergency medical services (EMS) provide critical prehospital care, and disparities in response times to time-sensitive conditions, such as cardiac arrest, may contribute to disparities in patient outcomes. OBJECTIVES To investigate whether ambulance 9-1-1 times were longer in low-income vs high-income areas and to compare response times with national benchmarks of 4, 8, or 15 minutes across income quartiles. DESIGN, SETTING, AND PARTICIPANTS A retrospective cross-sectional study was performed of the 2014 National Emergency Medical Services Information System data in June 2017 using negative binomial and logistic regressions to examine the association between zip code-level income and EMS response times. The study used ambulance 9-1-1 response data for out-of-hospital cardiac arrest from 46 of 50 state repositories (92.0%) in the United States. The sample included 63 600 cardiac arrest encounters of patients who did not die on scene and were transported to the hospital. MAIN OUTCOMES AND MEASURES Four time measures were examined, including response time, on-scene time, transport time, and total EMS time. The study compared response times with EMS response time benchmarks for responding to cardiac arrest calls within 4, 8, and 15 minutes. RESULTS The study sample included 63 600 cardiac arrest encounters of patients (mean [SD] age, 60.6 [19.0] years; 57.9% male), with 37 550 patients (59.0%) from high-income areas and 8192 patients (12.9%) from low-income areas. High-income areas had greater proportions of white patients (70.1% vs 62.2%), male patients (58.8% vs 54.1%), privately insured patients (29.4% vs 15.9%), and uninsured patients (15.3% vs 7.9%), while low-income areas had a greater proportion of Medicaid-insured patients (38.3% vs 15.8%). The mean (SD) total EMS time was 37.5 (13.6) minutes in the highest zip code income quartile and 43.0 (18.8) minutes in the lowest. After controlling for urban zip code, weekday, and time of day in regression analyses, total EMS time remained 10% longer (95% CI, 9%-11%; P < .001), translating to 3.8 minutes longer in the poorest zip codes. The EMS response time to patients in high-income zip codes was more likely to meet 8-minute and 15-minute cutoffs compared with low-income zip codes. CONCLUSIONS AND RELEVANCE Patients with cardiac arrest from the poorest neighborhoods had longer EMS times compared with those from the wealthiest, and response times were less likely to meet national benchmarks in low-income areas, which may lead to increased disparities in prehospital delivery of care over time.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Delphine Huang
- Department of Emergency Medicine, University of California, San Francisco
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | | | - Mary P. Mercer
- Department of Emergency Medicine, University of California, San Francisco
| | - Mengtao Dai
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Matthew J. Niedzwiecki
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Mathematica Policy Research, Oakland, California
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Abstract
IMPORTANCE An association between frequent use of the emergency department (ED) and mental health diagnoses is frequently documented in the literature, but little has been done to more thoroughly understand why mental illness is associated with increased ED use. OBJECTIVE To determine which factors were associated with higher ED use in the near future among patients with and without mental health diagnoses. DESIGN, SETTING, AND PARTICIPANTS A retrospective case-control study of all patients presenting to the ED in California in 2013 using past ED data to predict future ED use. Data from January 1, 2012, through December 31, 2014, from California's Office of Statewide Health Planning and Development were analyzed. MAIN OUTCOMES AND MEASURES Factors associated with higher ED use in the year following an index visit for patients with vs without a mental health diagnosis. RESULTS Among the 3 446 338 individuals in the study (accounting for 7 678 706 ED visits), 44.6% (1 537 067) were male; 31.6% (1 089 043) were between the ages of 18 and 30 years, 40.3% (1 338 874) were between the ages of 31 and 50 years, and 28.1% (968 421) were between the ages of 51 and 64 years. The mean (SD) number of ED visits per patient per year was 1.69 (2.56), and 29.1% of patients (1 002 884) had at least 1 mental health diagnosis. Previous hospitalization and high rates of lagged ED visits were associated with higher future ED use. The severity of the mental health diagnosis (mild, moderate, or severe) was associated with increased ED visits (incidence rate ratio [IRR], 1.029; 95% CI, 1.02-1.04 for mild; IRR, 1.121; 95% CI, 1.11-1.13 for moderate; and IRR, 1.226; 95% CI, 1.22-1.24 for severe). Little evidence was found for interaction effects between mental health diagnoses and other diagnoses in predicting increased future ED use. CONCLUSIONS AND RELEVANCE Certain classes of mental health diagnoses were associated with higher ED use. The presence of a mental illness diagnosis did not appear to interact with other patient-level factors in a way that meaningfully altered associations with future ED use.
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Affiliation(s)
- Matthew J. Niedzwiecki
- Mathematica Policy Research, Oakland, California
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Department of Emergency Medicine, University of California, San Francisco
| | - Pranav J. Sharma
- Alpert Medical School, Brown University, Providence, Rhode Island
| | - Hemal K. Kanzaria
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Department of Emergency Medicine, University of California, San Francisco
| | | | - Renee Y. Hsia
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Department of Emergency Medicine, University of California, San Francisco
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Hsia RY, Sabbagh SH, Guo J, Nuckton TJ, Niedzwiecki MJ. Trends in the utilisation of emergency departments in California, 2005-2015: a retrospective analysis. BMJ Open 2018; 8:e021392. [PMID: 30037870 PMCID: PMC6059325 DOI: 10.1136/bmjopen-2017-021392] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/27/2018] [Accepted: 05/15/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To examine current trends in the characteristics of patients visiting California emergency departments (EDs) in order to better direct the allocation of acute care resources. DESIGN A retrospective study. SETTING We analysed ED utilisation trends between 2005 and 2015 in California using non-public patient data from California's Office of Statewide Health Planning and Development. PARTICIPANTS We included all ED visits in California from 2005 to 2015. PRIMARY AND SECONDARY OUTCOME MEASURES We analysed ED visits and visit rates by age, sex, race/ethnicity, payer and urban/rural trends. We further examined age, sex, race/ethnicity and urban/rural trends within each payer group for a more granular picture of the patient population. Additionally, we looked at the proportion of patients admitted from the ED and distribution of diagnoses. RESULTS Between 2005 and 2015, the annual number of ED visits increased from 10.2 to 14.2 million in California. ED visit rates increased by 27.8% (p<0.001), with the greatest increases among patients aged 5-19 (37.4%, p<0.001) and 45-64 years (41.1%, p<0.001), non-Hispanic Black and Hispanic patients (56.8% and 48.8%, p<0.001), the uninsured and Medicaid-insured (36.1%, p=0.002; 28.6%, p<0.001) and urban residents (28.3%, p<0.001). The proportion of ED visits resulting in hospitalisation decreased by 18.3%, with decreases across all payer groups. CONCLUSIONS Our findings reveal an increasing demand for emergency care and may reflect current limitations in accessing care in other parts of the healthcare system. Policymakers may need to recognise the increasingly vital role that EDs are playing in the provision of care and consider ways to incorporate this changing reality into the delivery of health services.
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Affiliation(s)
- Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Sarah H Sabbagh
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Joanna Guo
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Thomas J Nuckton
- Department of Medicine, Sutter Eden Medical Center, Castro Valley, California, USA
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Matthew J Niedzwiecki
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
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11
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Niedzwiecki MJ, Hsia RY, Shen YC. Not All Insurance Is Equal: Differential Treatment and Health Outcomes by Insurance Coverage Among Nonelderly Adult Patients With Heart Attack. J Am Heart Assoc 2018; 7:JAHA.117.008152. [PMID: 29871858 PMCID: PMC6015377 DOI: 10.1161/jaha.117.008152] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The Affordable Care Act has provided health insurance to a large portion of the uninsured in the United States. However, different types of health insurance provide varying amounts of reimbursements to providers, which may lead to different types of treatment, potentially worsening health outcomes in patients covered by low‐reimbursement insurance plans, such as Medicaid. The objective was to determine differences in access, treatment, and health outcomes by insurance type, using hospital fixed effects. Methods and Results We conducted a multivariate regression analysis using patient‐level data for nonelderly adult patients with acute myocardial infarction in California from January 1, 2001, to December 31, 2014, as well as hospital‐level information to control for differences between hospitals. The probability of Medicaid‐insured and uninsured patients having access to catheterization laboratory was higher by 4.50 and 3.75 percentage points, respectively, relative to privately insured patients. When controlling for access to percutaneous coronary intervention facilities, however, Medicaid‐insured and uninsured patients had a 4.24– and 0.85–percentage point lower probability, respectively, in receiving percutaneous coronary intervention treatment compared with privately insured patients. They also had higher mortality and readmission rates relative to privately insured patients. Conclusions Although Medicaid‐insured and uninsured patients with acute myocardial infarction had better access to catheterization laboratories, they had significantly lower probabilities of receiving percutaneous coronary intervention treatment and a higher likelihood of death and readmission compared with privately insured patients. This provides empirical evidence that treatment received and health outcomes strongly vary between Medicaid‐insured, uninsured, and privately insured patients, with Medicaid‐insured patients most disproportionately affected, despite having better access to cardiac technology.
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Affiliation(s)
- Matthew J Niedzwiecki
- Department of Emergency Medicine, University of California at San Francisco, San Francisco, CA .,Philip R. Lee Institute for Health Policy Studies University of California at San Francisco, San Francisco, CA
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California at San Francisco, San Francisco, CA.,Philip R. Lee Institute for Health Policy Studies University of California at San Francisco, San Francisco, CA
| | - Yu-Chu Shen
- National Bureau of Economic Research, Cambridge, MA.,Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, CA
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Conelea CA, Philip NS, Yip AG, Barnes JL, Niedzwiecki MJ, Greenberg BD, Tyrka AR, Carpenter LL. Response to Letter to the Editor regarding "Transcranial magnetic stimulation for treatment-resistant depression: Naturalistic outcomes for younger versus older patients". J Affect Disord 2018; 225:773-774. [PMID: 28826888 PMCID: PMC6601341 DOI: 10.1016/j.jad.2017.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Noah S Philip
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA; Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence, RI, USA
| | - Augustin G Yip
- Mc Lean Hospital/Harvard Medical School, Boston, MA, USA
| | | | | | - Benjamin D Greenberg
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA; Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence, RI, USA
| | - Audrey R Tyrka
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA
| | - Linda L Carpenter
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA
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13
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Kanzaria HK, Niedzwiecki MJ, Montoy JC, Raven MC, Hsia RY. Persistent Frequent Emergency Department Use: Core Group Exhibits Extreme Levels Of Use For More Than A Decade. Health Aff (Millwood) 2017; 36:1720-1728. [DOI: 10.1377/hlthaff.2017.0658] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Hemal K. Kanzaria
- Hemal K. Kanzaria is an assistant professor in the Department of Emergency Medicine at the University of California, San Francisco (UCSF), and director for Complex Care Analytics for the San Francisco Health Network
| | - Matthew J. Niedzwiecki
- Matthew J. Niedzwiecki is an assistant professor in the Department of Emergency Medicine and a core faculty member at the Philip R. Lee Institute for Health Policy Studies (PRL-IHPS), both at UCSF
| | - Juan Carlos Montoy
- Juan Carlos Montoy is a clinical instructor in the Department of Emergency Medicine at UCSF
| | - Maria C. Raven
- Maria C. Raven is an associate professor in the Department of Emergency Medicine and an affiliated faculty member at the PRL-IHPS, both at UCSF
| | - Renee Y. Hsia
- Renee Y. Hsia is a professor in the Department of Emergency Medicine and a core faculty member at the PRL-IHPS, both at UCSF
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14
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Conelea CA, Philip NS, Yip AG, Barnes JL, Niedzwiecki MJ, Greenberg BD, Tyrka AR, Carpenter LL. Transcranial magnetic stimulation for treatment-resistant depression: Naturalistic treatment outcomes for younger versus older patients. J Affect Disord 2017; 217:42-47. [PMID: 28388464 PMCID: PMC5460629 DOI: 10.1016/j.jad.2017.03.063] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/28/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (TMS) has been shown to be safe and effective for treatment-resistant depression (TRD) in the general adult population. Efficacy among older (≥60 years) patients, who have a greater burden of cognitive, physical, and functional impairment compared to their younger counterparts, remains unclear. The current study aimed to characterize antidepressant response to an acute course of TMS therapy among patients aged ≥60 years compared to those <60 years in naturalistic clinical practice settings. METHODS Data were retrospectively collected and pooled for adults with TRD (N =231; n =75 aged ≥60 years and n = 156 <60 years) who underwent an acute course of outpatient TMS therapy at two outpatient clinics. Self-report depression scales were administered at baseline and end of acute treatment. Change on continuous measures and categorical outcomes were compared across older vs. younger patients. RESULTS Both age groups showed significant improvements in depression symptoms. Response and remission rates did not differ between groups. Age group was not a significant predictor of change in depression severity, nor of clinical response or remission, in a model controlling for other predictors (all p>.05). LIMITATIONS Limitations include reliance on self-report clinical measures and variability in comorbidity and concurrent pharmacotherapy due to the naturalistic nature of the study. CONCLUSIONS Results suggest that effectiveness of TMS for TRD is not differentially modified by age. Based on these naturalistic data, age alone should not be considered a contraindication or poor prognostic indicator of the antidepressant efficacy of TMS.
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Affiliation(s)
- Christine A. Conelea
- Bradley Hospital/Alpert Medical School of Brown University, Providence, RI, USA,Correspondence to: Department of Psychiatry, F282/2A West Building, 2450 Riverside Avenue, Minneapolis, MN 55454. (C.A. Conelea)
| | - Noah S. Philip
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA,Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence, RI, USA
| | - Agustin G. Yip
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA
| | - Jennifer L. Barnes
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Benjamin D. Greenberg
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA,Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence, RI, USA
| | - Audrey R. Tyrka
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA
| | - Linda L. Carpenter
- Butler Hospital/Alpert Medical School of Brown University, Providence, RI, USA
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15
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Chow JL, Niedzwiecki MJ, Hsia RY. Trends in the supply of California's emergency departments and inpatient services, 2005-2014: a retrospective analysis. BMJ Open 2017; 7:e014721. [PMID: 28495813 PMCID: PMC5566591 DOI: 10.1136/bmjopen-2016-014721] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/26/2017] [Accepted: 03/20/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Given increasing demand for emergency care, there is growing concern over the availability of emergency department (ED) and inpatient resources. Existing studies of ED bed supply are dated and often overlook hospital capacity beyond ED settings. We described recent statewide trends in the capacity of ED and inpatient hospital services from 2005 to 2014. DESIGN Retrospective analysis. SETTING Using California hospital data, we examined the absolute and per admission changes in ED beds and inpatient beds in all hospitals from 2005 to 2014. PARTICIPANTS Our sample consisted of all patients inpatient and outpatient) from 501 hospital facilities over 10-year period. OUTCOME MEASURES We analysed linear trends in the total annual ED visits, ED beds, licensed and staffed inpatient hospital beds and bed types, ED beds per ED visit, and inpatient beds per admission (ED and non-ED). RESULTS Between 2005 and 2014, ED visits increased from 9.8 million to 13.2 million (an increase of 35.0%, p<0.001). ED beds also increased (by 29.8%, p<0.001), with an average annual increase of 195.4 beds. Despite this growth, ED beds per visit decreased by 3.9%, from 6.0 ED beds per 10 000 ED visits in 2005 to 5.8 beds in 2014 (p=0.01). While overall admission numbers declined by 4.9% (p=0.06), inpatient medical/surgical beds per visit grew by 11.3%, from 11.6 medical/surgical beds per 1000 admissions in 2005 to 12.9 beds in 2014 (p<0.001). However, there were reductions in psychiatric and chemical dependency beds per admission, by -15.3% (p<0.001) and -22.4% (p=0.05), respectively. CONCLUSIONS These trends suggest that, in its current state, inadequate supply of ED and specific inpatient beds cannot keep pace with growing patient demand for acute care. Analysis of ED and inpatient supply should capture dynamic variations in patient demand. Our novel 'beds pervisit' metric offers improvements over traditional supply measures.
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Affiliation(s)
- Jessica L Chow
- UCSF/San Francisco General Hospital Emergency Medicine Residency Program, University of California at San Francisco, San Francisco, California, United States
| | - Matthew J Niedzwiecki
- Department of Emergency Medicine, University of California at San Francisco, San Francisco, California, United States
- Philip R Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California, United States
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California at San Francisco, San Francisco, California, United States
- Philip R Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California, United States
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