Medical Care最新文献

{"title":"Burnout and Turnover Among Veterans Health Administration Primary Care Providers From Fiscal Years 2017-2021.","authors":"Eric A Apaydin, Caroline K Yoo, Susan E Stockdale, Nicholas J Jackson, Elizabeth M Yano, Karin M Nelson, David C Mohr, Danielle E Rose","doi":"10.1097/MLR.0000000000002087","DOIUrl":"10.1097/MLR.0000000000002087","url":null,"abstract":"<p><strong>Objectives: </strong>We examined how individual-level turnover among Veterans Health Administration primary care providers (PCPs) from fiscal years 2017 to 2021 was associated with health care system-level burnout and turnover intent.</p><p><strong>Background: </strong>Burnout among PCPs has been well documented in recent studies, but less is known about the potential relationship between burnout and turnover.</p><p><strong>Methods: </strong>We identified a national cohort of 6444 PCPs (physicians, nurse practitioners, and physician assistants) in 129 Veterans Health Administration health care systems in the first quarter of fiscal year 2017 and tracked their employment status for 20 quarters. PCP employment data on turnover were linked to annual health care system-level employee survey data on burnout, turnover intent, and other covariates. We performed logistic regression to estimate the impact of health care system-level burnout and turnover intent on individual PCP turnover, controlling for individual and health care system-level covariates and adjusting for clustering at the health care system level.</p><p><strong>Results: </strong>Median health care system-level burnout ranged from 42.5% to 52.0% annually, and turnover among PCPs ranged from 6.3% to 8.4% (mean = 7.0%; SD = 0.9%). Separation from employment was higher among employees at health care systems with the highest burnout (odds ratio =1.14; 95% CI = 1.01-1.29) and turnover intent (OR = 1.18; 95% CI = 1.03-1.35).</p><p><strong>Conclusions: </strong>PCPs in health care systems with high burnout are more likely to separate from employment. Policymakers and administrators seeking to improve retention should consider system-level interventions to address organizational drivers of burnout.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"273-282"},"PeriodicalIF":3.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11888842/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142623594","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Medicaid Managed Care Penetration and Mental Health Service Use Among Adults.","authors":"Ju-Chen Hu, Janet R Cummings, Xu Ji, Adam S Wilk","doi":"10.1097/MLR.0000000000002105","DOIUrl":"10.1097/MLR.0000000000002105","url":null,"abstract":"<p><strong>Objective: </strong>To examine the association between Medicaid managed care (MMC) penetration and mental health (MH) service use among Medicaid-enrolled non-elderly adults, with a special focus on those with MH conditions.</p><p><strong>Background: </strong>Medicaid covers over 9 million adults living with MH conditions, with many enrolled in MMC. Despite increases in MMC enrollment over the past decade, nationwide evidence of MMC's association with MH service use during this period is lacking.</p><p><strong>Methods: </strong>Using 2015-2019 National Survey on Drug Use and Health data, we applied logistic and negative binomial regression models to examine the association between MMC penetration and MH service use among 35,500 non-elderly enrollees in 40 MMC states, and separately among 11,800 enrollees with MH conditions. Four dichotomous outcomes separately measured any MH service use in inpatient, outpatient, prescription medication, and any settings. Two additional count outcomes measured the number of inpatient MH stays and outpatient MH visits.</p><p><strong>Results: </strong>A 2-percentage point higher level of MMC penetration was associated with a 9% reduction (adjusted incidence rate ratio = 0.91, 95% CI = 0.87, 0.94) in days of inpatient MH stays among all enrollees and a 7% reduction (adjusted incidence rate ratio= 0.93, 95% CI = 0.87, 0.99) among enrollees with MH conditions. MMC penetration was not associated with significant changes in other outcomes.</p><p><strong>Conclusions: </strong>Among non-elderly adults and those with MH conditions, increased MMC enrollment was associated with reduced inpatient MH services with no significant changes in the use in other settings. Ongoing monitoring is crucial to assess the potential impact of shortened inpatient stays on MH outcomes.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":""},"PeriodicalIF":3.3,"publicationDate":"2025-03-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143649091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Community Benefit and Tax-Exemption Levels at Non-Profit Hospitals Across US States.","authors":"D August Oddleifson, Huaying Dong, Rishi K Wadhera","doi":"10.1097/MLR.0000000000002064","DOIUrl":"10.1097/MLR.0000000000002064","url":null,"abstract":"<p><strong>Objective: </strong>To assess the association between state policies and sociodemographic characteristics and state mean fair share spending at non-profit hospitals. Fair share spending is a hospital's charity care and community investment less the estimated value of their tax-exempt status.</p><p><strong>Background: </strong>Hospitals with non-profit status in the United States are exempt from paying taxes. In return, they are expected to provide community benefits by subsidizing medical care for those who cannot pay and investing in the health and social needs of their community.</p><p><strong>Methods: </strong>We used a multivariable linear regression model to determine the association of state-level sociodemographics and policies with state-level mean fair share spending in 2019. Fair share spending data was obtained from the Lown Institute.</p><p><strong>Results: </strong>We found no association between the percentage of people living in poverty, in rural areas, or US region and fair share spending. Similarly, there was no association found for state minimum community benefit and reporting requirements. The state percentage of racial/ethnic minorities was associated with higher mean fair share spending [+$1.48 million for every 10% increase (95% CI: 0.01 to 2.96 million)]. Medicaid expansion status was associated with a 6.9-million-dollar decrease (95% CI: -10.4 to -3.3 million).</p><p><strong>Conclusions: </strong>State-level community benefit policies have been ineffective at raising community benefit spending to levels comparable to the value of non-profit hospital tax-exempt status.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"222-226"},"PeriodicalIF":3.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142391711","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospital Artificial Intelligence/Machine Learning Adoption by Neighborhood Deprivation.","authors":"Jie Chen, Alice Shijia Yan","doi":"10.1097/MLR.0000000000002110","DOIUrl":"10.1097/MLR.0000000000002110","url":null,"abstract":"<p><strong>Objective: </strong>To understand the variation in artificial intelligence/machine learning (AI/ML) adoption across different hospital characteristics and explore how AI/ML is utilized, particularly in relation to neighborhood deprivation.</p><p><strong>Background: </strong>AI/ML-assisted care coordination has the potential to reduce health disparities, but there is a lack of empirical evidence on AI's impact on health equity.</p><p><strong>Methods: </strong>We used linked datasets from the 2022 American Hospital Association Annual Survey and the 2023 American Hospital Association Information Technology Supplement. The data were further linked to the 2022 Area Deprivation Index (ADI) for each hospital's service area. State fixed-effect regressions were employed. A decomposition model was also used to quantify predictors of AI/ML implementation, comparing hospitals in higher versus lower ADI areas.</p><p><strong>Results: </strong>Hospitals serving the most vulnerable areas (ADI Q4) were significantly less likely to apply ML or other predictive models (coef = -0.10, P = 0.01) and provided fewer AI/ML-related workforce applications (coef = -0.40, P = 0.01), compared with those in the least vulnerable areas. Decomposition results showed that our model specifications explained 79% of the variation in AI/ML adoption between hospitals in ADI Q4 versus ADI Q1-Q3. In addition, Accountable Care Organization affiliation accounted for 12%-25% of differences in AI/ML utilization across various measures.</p><p><strong>Conclusions: </strong>The underuse of AI/ML in economically disadvantaged and rural areas, particularly in workforce management and electronic health record implementation, suggests that these communities may not fully benefit from advancements in AI-enabled health care. Our results further indicate that value-based payment models could be strategically used to support AI integration.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 3","pages":"227-233"},"PeriodicalIF":3.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11809723/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143414672","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unchained Care: A Public Health Perspective on Ending Shackling of Incarcerated Patients Seeking Health Care, a Policy Statement Adopted by the American Public Health Association.","authors":"Ankita Patil, Marissa Brash, Lauren Brunet, Joy C Eckert, Renee Odom-Konja, Anisha Patel, Spencer Piston, Tiffani Than, Ben King","doi":"10.1097/MLR.0000000000002106","DOIUrl":"10.1097/MLR.0000000000002106","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"185-188"},"PeriodicalIF":3.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143008188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparison of Alternative Approaches to Using Race-and-Ethnicity Data in Estimating Differences in Health Care and Social Determinants of Health.","authors":"Steven C Martino, Jacob W Dembosky, Katrin Hambarsoomian, Amelia M Haviland, Robert Weech-Maldonado, Megan K Beckett, Torrey Hill, Marc N Elliott","doi":"10.1097/MLR.0000000000002108","DOIUrl":"10.1097/MLR.0000000000002108","url":null,"abstract":"<p><strong>Objective: </strong>The objective of this study was to compare 2 approaches for representing self-reported race-and-ethnicity, additive modeling (AM), in which every race or ethnicity a person endorses counts toward measurement of that category, and a commonly used mutually exclusive categorization (MEC) approach. The benchmark was a gold-standard, but often impractical approach that analyzes all combinations of race-and-ethnicity as distinct groups.</p><p><strong>Methods: </strong>Data came from 313,739 respondents to the 2021 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys who self-reported race-and-ethnicity. We used regression to estimate how accurately AM and MEC approaches predicted racial-and-ethnic differences in 5 CAHPS patient experience measures and 4 patient characteristics that we considered proxies for social determinants of health (SDOH): age, educational attainment, and self-reported general and mental health. We calculated average residual error proportions for AM and MEC estimates relative to all-combination estimates.</p><p><strong>Results: </strong>In predicting CAHPS scores by race-and-ethnicity, on average 0.9% of the variance across groups in the AM and MEC approaches represented a departure from the gold standard. In predicting proxy SDOH variables, on average 4.7% of the AM variance across groups and 7.1% of the MEC variance across groups represented departures from the gold standard.</p><p><strong>Conclusion: </strong>Researchers may want to consider AM over MEC when modeling outcomes by race-and-ethnicity given that AM outperforms MEC in predicting racial-and-ethnic differences in proxy SDOH characteristics and is comparably accurate in predicting differences in patient experience. Unlike MEC, AM does not assume that every multiracial person has similar outcomes and that Hispanic persons have similar outcomes irrespective of race.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"241-248"},"PeriodicalIF":3.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142910009","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Facility-Level Differences in Antipsychotic Drug Use: Impact on Quality Outcomes for Nursing Home Residents.","authors":"Amanda C Chen, David C Grabowski","doi":"10.1097/MLR.0000000000002111","DOIUrl":"10.1097/MLR.0000000000002111","url":null,"abstract":"<p><strong>Objective: </strong>To quantify quality of care following an admission to a nursing home with low or high antipsychotic drug use.</p><p><strong>Background: </strong>Misuse of antipsychotics in U.S. nursing homes is a huge concern for policymakers.</p><p><strong>Methods: </strong>We utilized an instrumental variable approach to estimate the effect of facility-level antipsychotic use on patient outcomes. The instrument was the differential distance to the nearest low-use antipsychotic nursing home relative to the nearest high-use antipsychotic nursing home. Post-acute care short-stay and long-stay residents in U.S. nursing homes were identified using Medicare administrative claims and the Minimum Dataset 3.0 (2014-2019). Outcomes included hospitalizations, falls, pressure ulcers, physical restraint use, medication use, and diagnosis of schizophrenia, bipolar disease, anxiety, or depression.</p><p><strong>Results: </strong>Among long-stay residents, receiving care from a low-use facility reduced the diagnosis of schizophrenia, use of restraints, and hospitalizations. There was also a reduction in the hospitalization rate [-0.9 percentage point (pp)], likelihood of long-stay status (-1.8 pp), and diagnosis of schizophrenia (-0.2 pp) at 90 days among short-stay residents. We also observed larger reductions among residents with dementia and serious mental illness.</p><p><strong>Conclusions: </strong>Admission to a nursing home with a low use of antipsychotics led to decreased hospitalizations, restraint use, and diagnosis of schizophrenia. Curbing the high use of antipsychotics remains a priority of policymakers as the centers for medicare and medicaid services conducts off-site audits to assess whether nursing homes accurately code residents with schizophrenia. It will be important to monitor if centers for medicare and medicaid services downgrades any quality star ratings due to inappropriate coding and assess the implications on quality of care.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"202-210"},"PeriodicalIF":3.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12148333/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142910010","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluating Not-For-Profit Hospital Community Benefit Spending: Transparency, Accountability, and Fair Share Spending.","authors":"Kelsey Owsley, Tatiane Santos","doi":"10.1097/MLR.0000000000002118","DOIUrl":"10.1097/MLR.0000000000002118","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 3","pages":"189-192"},"PeriodicalIF":3.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12173320/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143414667","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient-Physician Communication Experience Modifies Racial/Ethnic Health Care Disparities Among Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems Participants With Colorectal Cancer and Multiple Chronic Conditions.","authors":"Stephanie Navarro, Jessica Le, Jennifer Tsui, Afsaneh Barzi, Mariana C Stern, Trevor Pickering, Albert J Farias","doi":"10.1097/MLR.0000000000002112","DOIUrl":"10.1097/MLR.0000000000002112","url":null,"abstract":"<p><strong>Purpose: </strong>After cancer diagnosis, non-White patients and those with multimorbidity use less primary care and more acute care than non-Hispanic White (NHW) patients and those lacking comorbidities. Yet, positive patient experiences with physician communication (PC) are associated with more appropriate health care use. In a multimorbid cohort, we measured associations between PC experience, race and ethnicity, and health care use following colorectal cancer (CRC) diagnosis.</p><p><strong>Participants and methods: </strong>We identified 2606 participants using Surveillance, Epidemiology, and End Results (SEER)-Consumer Assessment of Health Care Providers and Systems (CAHPS) data who were diagnosed with CRC from 2001 to 2017 with pre-existing chronic conditions. Self-reported PC experiences were derived from Medicare CAHPS surveys. Chronic condition care, emergency department, and hospital use following CRC diagnosis were identified from Medicare claims. Simple survey-weighted multivariable logistic regression stratified by experiences with care analyzed associations between race and ethnicity and health care use.</p><p><strong>Results: </strong>Among patients reporting excellent PC experience, non-Hispanic Black (NHB), Hispanic, and non-Hispanic Asian (NHA) patients were more likely to use sufficient chronic condition care than NHW patients (NHB: OR=1.48, 99.38% CI=1.38-1.58; Hispanic: OR=1.34, 99.38% CI=1.26-1.42; NHA: OR=2.31, 99.38% CI=2.12-2.51). NHB and NHA patients were less likely than NHW patients to visit the emergency department when reporting excellent PC experience (NHB: OR=0.66, 99.38% CI=0.63-0.69; NHA: OR=0.67, 99.38% CI=0.64-0.71). Among patients reporting excellent PC, NHB, Hispanic, and NHA patients were less likely than NHW patients to be hospitalized (NHB: OR=0.93, 99.38% CI=0.87-0.99; Hispanic: OR=0.93, 99.38% CI=0.87-0.99; NHA: OR=0.20, 99.38% CI=0.19-0.22).</p><p><strong>Conclusion: </strong>Improving patient experiences with PC, particularly among older racial and ethnic minority cancer survivors with chronic conditions, may help reduce disparities in adverse healthcare use following CRC diagnosis.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"256-265"},"PeriodicalIF":3.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142910012","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"High-Intensity End-of-Life Care Among Young and Middle-Aged Hispanic Adults With Cancer in Puerto Rico.","authors":"Jessica Velazquez, Maira A Castañeda-Avila, Axel Gierbolini-Bermúdez, María R Ramos-Fernández, Karen J Ortiz-Ortiz","doi":"10.1097/MLR.0000000000002115","DOIUrl":"10.1097/MLR.0000000000002115","url":null,"abstract":"<p><strong>Background: </strong>Timely palliative and hospice care, along with advanced care planning, can reduce avoidable high-intensity care and improve quality of life at the end of life (EoL).</p><p><strong>Objective: </strong>We examined patterns of care at EoL and evaluated predictors of high-intensity care at EoL among adults aged 18-64 with cancer.</p><p><strong>Methods: </strong>Using data from the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database, we examined 1359 patients diagnosed with cancer in 2010-2019, who died of cancer between 2017 and 2019 at 64 years and younger, and who were enrolled in Medicaid or private health insurance in last 30 days before death. We used composite measures for high-intensity and recommended EoL care using claims-based indicators in the last 30 days before death. Multivariable logistic regression was used to examine predictors associated with high-intensity EoL care.</p><p><strong>Results: </strong>About 70.3% of young and middle-aged Hispanic cancer patients received high-intensity EoL care, whereas only 20.6% received recommended EoL care. Patients without recommended EoL care were more likely to receive high-intensity EoL care (aOR=4.23; 95% CI=3.18-5.61). High-intensity EoL care was more likely in female patients (aOR=1.43; 95% CI=1.11-1.85) and patients with hematologic cancers (aOR=1.91; 95% CI=1.13-3.20) and less likely in patients who survived >12 months after cancer diagnosis (aOR=0.55; 95% CI=0.43-0.71).</p><p><strong>Conclusions: </strong>A high proportion of Hispanic adults with cancer in Puerto Rico receive high-intensity EoL care and have unmet needs at EoL. Tailored interventions can reduce high-intensity EoL care and increase recommended EoL care. Recommended EoL care can ease pain, reduce distress, honor personal preferences, and cut unnecessary medical costs.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"193-201"},"PeriodicalIF":3.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11809722/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143008136","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}