An Apple a Day
Evidence That Consumers Are Skeptical About Evidence-Based Health Care
Kristin Carman, Maureen Maurer, Jill Mathews Yegian, Pamela Dardess, Jeanne McGee, Mark Evers & Karen Marlo
Health Affairs, July 2010, Pages 1400-1406
Abstract:
We undertook focus groups, interviews, and an online survey with health care consumers as part of a recent project to assist purchasers in communicating more effectively about health care evidence and quality. Most of the consumers were ages 18–64; had health insurance through a current employer; and had taken part in making decisions about health insurance coverage for themselves, their spouse, or someone else. We found many of these consumers’ beliefs, values, and knowledge to be at odds with what policy makers prescribe as evidence-based health care. Few consumers understood terms such as "medical evidence" or "quality guidelines." Most believed that more care meant higher-quality, better care. The gaps in knowledge and misconceptions point to serious challenges in engaging consumers in evidence-based decision making.
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Can We Predict "Problem Residents"?
Adam Brenner, Samuel Mathai, Satyam Jain & Paul Mohl
Academic Medicine, July 2010, Pages 1147-1151
Purpose: This study investigates whether data available at the time of residency application can be used to predict more accurately future problems of performance, both during and after residency.
Method: The authors identified all residents with reported problematic behavior across 20 years (1987–2007) at a single residency program and created a set of matched controls. Problems were further divided into “major” (leading to significant disruptions of performance and disciplinary action) and “minor” (remediable and resolved). Application materials were then reviewed for United States Medical Licensing Examination (USMLE) scores, evidence of academic failures, interviewer ratings, negative interviewer comments, negative comments in the dean's letter, and negative comments in letters of recommendation.
Results: The presence of any negative comments in the dean's letter yielded significant correlations with future problems. Further, those applicants with future major problems had significantly more negative comments in the dean's letter than did those with future minor problems. Other factors such as USMLE scores, failed courses, letters of recommendation, and interviewer ratings and comments did not predict future problems.
Conclusions: Most of the factors the authors assessed in prospective applicants did not predict future problems, with the exception of negative (even mildly so) comments in the dean's letter. The authors suggest that more attention should be paid to the use of the dean's letter to assess risk among applicants, and prospective study of this assessment should be performed.
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Medicare Part D and the Financial Protection of the Elderly
Gary Engelhardt & Jonathan Gruber
NBER Working Paper, July 2010
Abstract:
We examine the impact of the expansion of public prescription drug insurance coverage from Medicare Part D on the elderly and find evidence of substantial crowd-out. Using detailed data from the 2002-7 waves of the Medical Expenditure Panel Survey (MEPS), we estimate that the extension of Part D benefits resulted in 80% crowd-out of both prescription drug insurance coverage and prescription drug expenditures of those 65 and older. Part D is associated with only modest reductions in out-of-pocket spending. This suggests that the welfare gain from protecting the elderly from out-of-pocket spending risk through Part D has been small.
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Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients
Yi Yvonne Zhou, Michael Kanter, Jian Wang & Terhilda Garrido
Health Affairs, July 2010, Pages 1370-1375
Abstract:
The American Recovery and Reinvestment Act identified secure patient-physician e-mail messaging as an objective of the meaningful use of electronic health records. In our study of 35,423 people with diabetes, hypertension, or both, the use of secure patient-physician e-mail within a two-month period was associated with a statistically significant improvement in effectiveness of care as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). In addition, the use of e-mail was associated with an improvement of 2.0–6.5 percentage points in performance on other HEDIS measures such as glycemic (HbA1c), cholesterol, and blood pressure screening and control.
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Budget crises, health, and social welfare programmes
David Stuckler, Sanjay Basu & Martin McKee
British Medical Journal, June 2010, c3311
"...a comparable rise in social welfare spending was associated with over a sevenfold greater reduction in mortality of than a similar magnitude rise in GDP (0.80% v 0.11%). Furthermore, when we adjusted for social welfare spending, the association of GDP with lower mortality was cut by about two thirds (from 0.28% to 0.11%). This means that the potential health benefits of increased wealth crucially depend not just on increasing income but on what fraction goes into social welfare spending from governments..."
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The Effect of Hospital Nurse Staffing on Patient Health Outcomes: Evidence from California's Minimum Staffing Regulation
Andrew Cook, Martin Gaynor, Melvin Stephens & Lowell Taylor
NBER Working Paper, June 2010
Abstract:
Hospitals are currently under pressure to control the cost of medical care, while at the same time improving patient health outcomes. These twin concerns are at play in an important and contentious decision facing hospitals—choosing appropriate nurse staffing levels. Intuitively, one would expect nurse staffing ratios to be positively associated with patient outcomes. If so, this should be a key consideration in determining nurse staffing levels. A number of recent studies have examined this issue, however, there is concern about whether a causal relationship has been established. In this paper we exploit an arguably exogenous shock to nurse staffing levels. We look at the impact of California Assembly Bill 394, which mandated minimum levels of patients per nurse in the hospital setting. When the law was passed, some hospitals already had acceptable staffing levels, while others had nurse staffing ratios that did not meet mandated standards. Thus changes in hospital-level staffing ratios from the pre- to post-mandate periods are driven in part by the legislation. We find persuasive evidence that AB394 did have the intended effect of decreasing patient/nurse ratios in hospitals that previously did not meet mandated standards. However, our analysis suggests that patient outcomes did not disproportionately improve in these same hospitals. That is, we find no evidence of a causal impact of the law on patient safety.
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Reporting bias in medical research - a narrative review
Natalie McGauran, Beate Wieseler, Julia Kreis, Yvonne-Beatrice Schüler, Heike Kölsch & Thomas Kaiser
Trials, April 2010
Abstract:
Reporting bias represents a major problem in the assessment of health care interventions. Several prominent cases have been described in the literature, for example, in the reporting of trials of antidepressants, Class I anti-arrhythmic drugs, and selective COX-2 inhibitors. The aim of this narrative review is to gain an overview of reporting bias in the medical literature, focussing on publication bias and selective outcome reporting. We explore whether these types of bias have been shown in areas beyond the well-known cases noted above, in order to gain an impression of how widespread the problem is. For this purpose, we screened relevant articles on reporting bias that had previously been obtained by the German Institute for Quality and Efficiency in Health Care in the context of its health technology assessment reports and other research work, together with the reference lists of these articles. We identified reporting bias in 40 indications comprising around 50 different pharmacological, surgical (e.g. vacuum-assisted closure therapy), diagnostic (e.g. ultrasound), and preventive (e.g. cancer vaccines) interventions. Regarding pharmacological interventions, cases of reporting bias were, for example, identified in the treatment of the following conditions: depression, bipolar disorder, schizophrenia, anxiety disorder, attention-deficit hyperactivity disorder, Alzheimer's disease, pain, migraine, cardiovascular disease, gastric ulcers, irritable bowel syndrome, urinary incontinence, atopic dermatitis, diabetes mellitus type 2, hypercholesterolaemia, thyroid disorders, menopausal symptoms, various types of cancer (e.g. ovarian cancer and melanoma), various types of infections (e.g. HIV, influenza and Hepatitis B), and acute trauma. Many cases involved the withholding of study data by manufacturers and regulatory agencies or the active attempt by manufacturers to suppress publication. The ascertained effects of reporting bias included the overestimation of efficacy and the underestimation of safety risks of interventions. In conclusion, reporting bias is a widespread phenomenon in the medical literature. Mandatory prospective registration of trials and public access to study data via results databases need to be introduced on a worldwide scale. This will allow for an independent review of research data, help fulfil ethical obligations towards patients, and ensure a basis for fully-informed decision making in the health care system.
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Is There Monopsony in the Labor Market? Evidence from a Natural Experiment
Douglas Staiger, Joanne Spetz & Ciaran Phibbs
Journal of Labor Economics, April 2010, Pages 211-236
Abstract:
Recent theoretical and empirical advances have renewed interest in monopsonistic models of the labor market. However, there is little direct empirical support for these models. We use an exogenous change in wages at Department of Veterans Affairs (VA) hospitals as a natural experiment to investigate the extent of monopsony in the nurse labor market. We estimate that labor supply to individual hospitals is quite inelastic, with short‐run elasticity around 0.1. We also find that non‐VA hospitals responded to the VA wage change by changing their own wages.
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Competition and Inequality: Evidence from the English National Health Service 1991–2001
Richard Cookson, Mark Dusheiko, Geoffrey Hardman & Stephen Martin
Journal of Public Administration Research and Theory, July 2010, Pages i181-i205
Abstract:
Competition is often prescribed as an efficiency-enhancing tonic for ailing health systems. However, critics claim that competition exacerbates socioeconomic inequality in health care. This claim is tested in relation to the "internal market" reforms of the English National Health Service (NHS) from 1991 to 97, which injected a small dose of hospital competition into a state-funded, state-owned health system responsible for more than 90% of national health expenditure. Our dependent variables are NHS hospital utilization rates for hip replacement and heart revascularization in 8,500 English small areas from 1991 to 2001. We estimate small area level associations between deprivation and hospital utilization, allowing for need and supply variables. We then compare year-by-year inequality differences between areas with "potentially competitive" and "noncompetitive" local hospital markets, as competition was phased in and out. No evidence is found that competition had any effect on socioeconomic health care inequality.
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How Medicare’s Payment Cuts For Cancer Chemotherapy Drugs Changed Patterns Of Treatment
Mireille Jacobson, Craig Earle, Mary Price & Joseph Newhouse
Health Affairs, July 2010, Pages 1391-1399
Abstract:
The Medicare Prescription Drug, Improvement, and Modernization Act, enacted in 2003, substantially reduced payment rates for chemotherapy drugs administered on an outpatient basis starting in January 2005. We assessed how these reductions affected the likelihood and setting of chemotherapy treatment for Medicare beneficiaries with newly diagnosed lung cancer, as well as the types of agents they received. Contrary to concerns about access, we found that the changes actually increased the likelihood that lung cancer patients received chemotherapy. The type of chemotherapy agents administered also changed. Physicians switched from dispensing the drugs that experienced the largest cuts in profitability, carboplatin and paclitaxel, to other high-margin drugs, like docetaxel. We do not know what the effect was on cancer patients, but these changes may have offset some of the savings projected from passage of the legislation. The ultimate message is that payment reforms have real consequences and should be undertaken with caution.
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Changes in Emergency Department Access Between 2001 and 2005 Among General and Vulnerable Populations
Yu-Chu Shen & Renee Hsia
American Journal of Public Health, forthcoming
Objectives: We analyzed how ease of geographic access to emergency departments (EDs), defined as driving time to the closest ED, changed between 2001 and 2005, and whether access deterioration was more likely to occur in vulnerable communities.
Methods: We classified communities on the basis of American Hospital Association and Census data into 3 categories according to driving time to the nearest ED: no increase, less than a 10-minute increase, and a 10-minute or more increase. We estimated a multinomial logit model to examine the relative risk ratio (RRR) of various community characteristics.
Results: More than 95% of communities experienced no ED access deterioration. However, 11.4 million people experienced increased driving time to their nearest ED. Low-income communities had a higher risk of facing deteriorating access compared with high-income communities (urban: RRR=3.67; P<.01; rural: RRR=1.75; P<.10), and communities with higher shares of Hispanics also had higher risks of facing declines (urban: RRR=3.41; P<.10; rural: RRR=2.67; P<.01).
Conclusions: Deteriorating access to EDs is more likely to occur in communities with economic hardship and high shares of Hispanic populations. The uneven access to critical services warrants increased attention from policymaking bodies.
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Income and the Utilization of Long-Term Care Services: Evidence from the Social Security Benefit Notch
Gopi Shah Goda, Ezra Golberstein & David Grabowski
NBER Working Paper, June 2010
Abstract:
This paper estimates the impact of income on the long-term care utilization of elderly Americans using a natural experiment that led otherwise similar retirees to receive significantly different Social Security payments based on their year of birth. Using data from 1993 and 1995 waves of the AHEAD, we estimate instrumental variables models and find that a positive permanent income shock lowers nursing home use but increases the utilization of paid home care services. We find some suggestive evidence that the effects are due to substitution of home care for nursing home utilization. The magnitude of these estimates suggests that moderate reductions in post-retirement income would significantly alter long-term utilization patterns among elderly individuals.
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Enrolling Eligible Children In Medicaid And CHIP: A Research Update
Benjamin Sommers
Health Affairs, July 2010, Pages 1350-1355
Abstract:
Keeping children who are eligible for Medicaid and the Children’s Health Insurance Program (CHIP) enrolled in these programs remains an important policy challenge. An earlier study showed that one-third of all uninsured children in 2006 had been enrolled in Medicaid or CHIP the previous year. Updated results show that in 2008, children enrolled in Medicaid were somewhat more likely to remain in the program than in 2006. However, more than a quarter of all uninsured children in 2008 had been enrolled in Medicaid or CHIP the year before. In other words, roughly two million children became uninsured in 2008, despite their ongoing eligibility for these programs. It is possible that fewer children may also be enrolling in public programs since 2006 because of requirements that their U.S. citizenship status be documented.
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The Value of Planned Death
Leo Chan & Donald Lien
Journal of Socio-Economics, forthcoming
Abstract:
In this paper we propose a theoretical model of evaluating the economic costs and benefits of physician assisted suicide (euthanasia). The contemplation of euthanasia is modeled akin to the valuation of a real option. Our modeling of the decision shows that euthanasia is optimal when certain conditions are satisfied. The findings in this paper suggest that if more money is spent on medical research (such as pain management), the demand for Euthanasia could be reduced.
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The Incomplete Circle of the National Disaster Medical System: What Arkansas Hospitals Learned from Hurricane Gustav
William Mason
Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, June 2010, Pages 183-191
Abstract:
On August 31, 2008, during Hurricane Gustav, 225 patients from Louisiana hospitals were evacuated to 12 hospitals in the central region of Arkansas. The evacuation was a success for the National Disaster Medical System (NDMS) but left Arkansas NDMS hospitals on their own to repatriate patients and negotiate payments for care. This article examines repatriation and reimbursement issues of Arkansas hospitals that provided care for these NDMS patients. Consensus statements were obtained from key organization stakeholders focused on repatriation of NDMS patients and reimbursement to Arkansas NDMS hospitals. The stakeholders concurred with recommendations addressing changes in both federal and state agreements related to repatriation of NDMS patients and reimbursement for care. Surveys from 10 of 12 participating hospitals showed Medicare was the primary payer for 57% of NDMS patients, higher than the usual community average of 43%. Length of stay was 3 days longer for NDMS patients than for the patients usually served by the hospital. Thirty percent of hospitals reported that they would be unlikely to take NDMS patients in the future. Private sector hospitals were adversely affected by system difficulties in repatriation and reimbursement. The federal government should consider a new paradigm for reimbursement of hospitals and develop a single payer for all NDMS patients.
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Work stress of primary care physicians in the US, UK and German health care systems
Johannes Siegrist, Rebecca Shackelton, Carol Link, Lisa Marceau, Olaf von dem Knesebeck & John McKinlay
Social Science & Medicine, July 2010, Pages 298-304
Abstract:
Work-related stress among physicians has been an issue of growing concern in recent years. How and why this may vary between different health care systems remains poorly understood. Using an established theoretical model (effort–reward imbalance), this study analyses levels of work stress among primary care physicians (PCPs) in three different health care systems, the United States, the United Kingdom and Germany. Whether professional autonomy and specific features of the work environment are associated with work stress and account for possible country differences are examined.
Data are derived from self-administered questionnaires obtained from 640 randomly sampled physicians recruited for an international comparative study of medical decision making conducted from 2005 to 2007. Results demonstrate country-specific differences in work stress with the highest level in Germany, intermediate level in the US and lowest level among UK physicians. A negative correlation between professional autonomy and work stress is observed in all three countries, but neither this association nor features of the work environment account for the observed country differences.
Whether there will be adequate numbers of PCPs, or even a field of primary care in the future, is of increasing concern in several countries. To the extent that work-related stress contributes to this, identification of its organizational correlates in different health care systems may offer opportunities for remedial interventions.
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Universal Health Insurance and Health Care Access for Homeless Persons
Stephen Hwang, Joanna Ueng, Shirley Chiu, Alex Kiss, George Tolomiczenko, Laura Cowan, Wendy Levinson & Donald Redelmeier
American Journal of Public Health, forthcoming
Objectives: We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system.
Methods: We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs.
Results: Unmet health care needs were reported by 17% of participants. Compared with Toronto’s general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey.
Conclusions: Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.
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Racial And Ethnic Disparities In Dental Care For Publicly Insured Children
Nadereh Pourat & Len Finocchio
Health Affairs, July 2010, Pages 1356-1363
Abstract:
Poor oral health has important implications for the healthy development of children. Children in Medicaid, especially Latinos and African Americans, experience high rates of tooth decay, yet they visit dentists less often than privately insured children. Even Latino and African American children with private insurance are less likely than white children to visit dentists and have longer intervals between dental visits. Furthermore, Latino and African American children in Medicaid are more likely than white children in Medicaid to have longer intervals between visits. These findings raise concerns about Medicaid’s ability to address disparities in dental care access and, more broadly, in health care.