Examining the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling

OBJECTIVE

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.

STUDY DESIGN

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.

RESULT

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.

CONCLUSION

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.

Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers

BACKGROUND

Federally Qualified Health Centers (FQHCs) serve as regular sources of preventive and primary care for low-income families within their communities and are key parts of the health care safety net.

OBJECTIVES

Compare admissions and emergency room visits for ambulatory care sensitive conditions (ACSCs) among Medicaid beneficiaries relying on FQHCs to other Medicaid beneficiaries.

RESEARCH DESIGN

Retrospective analysis of 1992 Medicaid claims data for 48,738 Medicaid beneficiaries in 24 service areas across five states.

SUBJECTS

Medicaid beneficiaries receiving more than 50% of their preventive and primary care services from FQHCs are compared with Medicaid beneficiaries receiving outpatient care from other providers in the same areas. Exclusions-managed care enrollees, beneficiaries more than age 65, dual eligibles (Medicaid and Medicare), and institutionalized populations.

MEASURES

Admissions and emergency room (ER) visits for a set of chronic and acute conditions, known in the literature as ambulatory care sensitive conditions (ACSCs).

RESULTS

Medicaid beneficiaries receiving outpatient care from FQHCs were less likely to be hospitalized (1.5% vs. 1.9%, P < 0.007) or seek ER care (14.9% vs. 15.7%, P < 0.02) for ACSCs than the comparison group. Controlling for case mix and other demographic variables, the odds ratios were, for hospitalizations, OR, 0.80; 95% CI, 0.67 to 0.95; P < 0.01, and for ER visits, OR, 0.87; 95% CI, 0.82 to 0.92; P < 0.001.

CONCLUSIONS

Having a regular source of care such as FQHCs can significantly reduce the likelihood of hospitalizations and ER visits for ACSCs. If the reported differentials in ACSC admissions and ER visits were consistently achieved for all Medicaid beneficiaries, substantial savings might be realized.

Uncompensated care and hospital conversions in Florida

Hospital conversions to for-profit ownership have prompted concern about continuing access to care for the poor or uninsured. This DataWatch presents an analysis of the rate of uncompensated care provided by Florida hospitals before and after converting to for-profit ownership. Uncompensated care declined greatly in the converting public hospitals, which had a significant commitment to uncompensated care before conversion. Among converting nonprofit hospitals, uncompensated care levels were low before conversion and did not change following conversion. The study suggests that policymakers should assess the risk entailed in a conversion by considering the hospital's historic mission and its current role in the community.

Nonprofit to for-profit conversions by hospitals, health insurers, and health plans

Conversion of hospitals, health insurers, and health plans from nonprofit to for-profit ownership has become a focus of national debate. The author examines why nonprofit ownership has been dominant in the US health system and assesses the strength of the argument that nonprofits provide community benefits that would be threatened by for-profit conversion. The author concludes that many of the specific community benefits offered by nonprofits, such as care for the poor, could be maintained or replaced by adequate funding of public programs and that quality and fairness in treatment can be better assured through clear standards of care and adequate monitoring systems. As health care becomes increasingly commercialized, the most difficult parts of nonprofits' historic mission to preserve are the community orientation, leadership role, and innovation that nonprofit hospitals and health plans have provided out of their commitment to a community beyond those to whom they sell services.

State trends in hospital uncompensated care

In recent years hospital uncompensated care has been declining in the seven states studied here: California, Florida, Washington, Connecticut, Maryland, New Jersey, and New York. We document these declines and compare trends in uncompensated care in safety-net and other hospitals between the early 1980s and the early to mid-1990s. We discuss state responses to deal with the declines in hospital uncompensated care and their likely impact on the observed trends.

Hospital conversion trends

This DataWatch presents information on the extent, geographic distribution, and other issues related to hospital conversions during the 1980s and 1990s. On average, 1 percent of hospitals convert each year. Many states experienced hospital conversions, but much of the conversion activity was concentrated in California, Florida, Georgia, and Texas. While conversions of not-for-profit hospitals to for-profit status have received significant attention, conversions of public hospitals and for-profit hospitals raise complex policy issues, as well.

Pennsylvania's medically uninsured population: findings from a statewide survey

Pennsylvania is currently considering legislative options to expand coverage and improve access to medical care for state residents who lack health insurance. Relevant data are presented from a telephone survey of 10,809 Pennsylvania households. Almost nine percent (8.5%) of the state's population lacks health insurance, representing over one million people. Those most likely to be uninsured are children and young adults, non-whites and the poor. A substantial number of poor people are not covered by the state's Medicaid program. The uninsured report poorer health status, more obstacled to receiving care and greater use of hospital services for primary care.

Managed care: the answer to quality and cost concerns

More and more providers and third-party payers are developing or at least participating in 'managed care systems,' which attempt to coordinate the activities of different health care providers in a variety of settings. The authors discuss the reasons behind the push toward managed care, and the ways in which hospitals can respond.

Consumer participation

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