Medical Care最新文献

{"title":"An Expert-Derived Data-Driven Approach to Identifying Medicaid Children at Risk of Out-of-Home Placement: Development, Application, and Data-Sharing Considerations.","authors":"Rose Y Hardy, David P Ciccone, Emelie Bailey, Samantha Bozada, Erin Donnelly, Krystel Tossone, Deena J Chisolm","doi":"10.1097/MLR.0000000000002307","DOIUrl":"10.1097/MLR.0000000000002307","url":null,"abstract":"<p><strong>Background: </strong>Out-of-home placement (OOHP) through child welfare, residential substance treatment, or extended inpatient care has life-altering impacts on child health and generates an outsized proportion of pediatric Medicaid costs. Early risk identification may prevent OOHP but is challenged by the difficulty of navigating state and federal data sharing regulations and multiple disconnected data systems. Identifying ways to streamline and simplify this process are critical to OOHP prevention.</p><p><strong>Objectives: </strong>To describe the development and implementation of an expert-derived data-driven algorithm to identify OOHP risk among Medicaid-enrolled children residing in 2 Ohio counties between 2022 and 2024 (n=27,000), discuss practical considerations for data sharing and linkage across multiple agencies, and identify lessons learned.</p><p><strong>Findings: </strong>A cross-sector team of government and academic partners developed a 3-category OOHP risk stratification algorithm incorporating data from Medicaid claims, child welfare information systems, area-level social determinants of health, and patient-reported health risk assessments as part of Ohio's Integrated Care for Kids Model. Substantial administrative and legal processes were required to link data sources. Lessons learned include: (1) understanding legal, political, and security structures associated with use of administrative data is critical; (2) strong working relationships with data partners can ensure success; (3) as administrative data are dynamic and may be retroactively updated, appropriate lookback periods are necessary for accuracy; and (4) while executing data use agreements can be challenging, the relationships built can have lasting benefits.</p><p><strong>Conclusions: </strong>Data-driven risk stratification models have the potential to reduce cost, time, and redundancies in identifying families who would benefit from OOHP prevention supports. Balancing data-sharing challenges with the value gained from linking data is vital.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"64 10","pages":"696-704"},"PeriodicalIF":1.9,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13552560/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148912975","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":"Building Data Capacity to Study Health Equity in Patient-Centered Outcomes Research.","authors":"Joshua Breslau, Wendy Hawkins, Rachel Landis, Robert Weech-Maldonado","doi":"10.1097/MLR.0000000000002358","DOIUrl":"10.1097/MLR.0000000000002358","url":null,"abstract":"<p><p>This paper introduces a special issue examining data infrastructure for patient-centered outcomes research that addresses health equity. Addressing the persistence and breadth of health inequalities in the United States requires ongoing expansion of the capacity to detect, monitor, and understand them. Data infrastructure is itself an equity policy matter: decisions about what data to collect, on whom, and in what form determine whose health inequities can be observed and, consequently, addressed. The 9 research papers in this issue are organized around 4 themes. The first examines new data sources and standards that extend what health systems can observe about the populations they serve. The second demonstrates how linking data across sectors enables analysis of social determinants that clinical records alone cannot capture. The third addresses strategies for disaggregating populations that are small, internally heterogeneous, or historically excluded from data collection. The fourth considers implementation-the organizational and institutional conditions under which new data systems are successfully adopted in practice. Together, the papers illustrate both the scientific possibilities created by deliberate investment in data capacity and the policy stakes of sustaining it.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"64 10","pages":"637-640"},"PeriodicalIF":1.9,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148912988","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":"Discrimination Experiences of Latino Health Care Workers in the US Health Care System.","authors":"Ana P Milan Hinostroza, Gabriel Sanchez","doi":"10.1097/MLR.0000000000002381","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002381","url":null,"abstract":"<p><strong>Objectives: </strong>To examine whether Afro-Latino ancestry, nativity, and survey completion language among Latino health care workers are associated with experiences of workplace discrimination, witnessing discrimination against patients, and observing lower-quality care due to patients' race or ethnicity.</p><p><strong>Research design: </strong>Cross-sectional observational study using nationally representative survey data from the 2023 Commonwealth Fund, African American Research Collaborative Healthcare Workforce Survey, conducted from March 14 to April 5, 2023.</p><p><strong>Results: </strong>Among Latino health care workers, 49.1% reported personally experiencing discrimination, 57.6% reported witnessing discrimination against patients, and 48.6% reported observing lower-quality care. In adjusted logistic regression models, reporting Afro-Latino ancestry was associated with 2.58 times the odds (95% CI: 1.66-4.02, P<0.01) of reporting personal experiences of discrimination, 2.13 times the odds (95% CI: 1.35-3.38, P<0.01) of reporting witnessing discrimination against patients, and 1.78 times the odds (95% CI: 1.13-2.79, P<0.05) of reporting observing lower-quality care due to a patient's race or ethnicity, compared with workers not reporting Afro-Latino ancestry. Foreign-born status and Spanish-language survey completion were not significantly associated with any of the 3 outcomes.</p><p><strong>Conclusion: </strong>Reported discrimination experiences among Latino health care workers vary substantially by Afro-Latino ancestry. Workers reporting Afro-Latino ancestry face and observe higher levels of racial discrimination, highlighting the importance of disaggregating Latino populations in research and policy efforts aimed at reducing inequities in health care delivery and the health care workforce.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149081430","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":"Nurse Staffing and Emergency Department Crowding: A 10-State Study.","authors":"K Jane Muir, Linda H Aiken, Karen B Lasater, Matthew D McHugh, Daniela Golinelli","doi":"10.1097/MLR.0000000000002379","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002379","url":null,"abstract":"<p><strong>Background: </strong>The purpose of this study was to determine the relationship between nurse staffing inadequacy in the emergency department (ED) and inpatient units on objective ED crowding measures.</p><p><strong>Methods: </strong>Three datasets from 2024 were linked: the Penn Nurses4All survey, CMS Hospital Compare, and the AHA Annual Hospital Survey. Nurses4All provided measures of nurse staffing inadequacy. The proportion of nurses reporting staffing inadequacy was the main exposure variable. Crowding measures included the percentage of patients who left the ED without being seen and patient length of stay (in minutes) for patients with and without psychiatric/mental health presentations. The analysis included hospital-level regression models adjusted for hospital characteristics.</p><p><strong>Results: </strong>The sample included 410 hospitals in 10 states. A 1 SD increase in ED nurses reporting staffing inadequacy was associated with higher hospital left without being seen rates (β=0.4, 95% CI: 0.2-0.6, P<0.001), longer lengths of stay for ED patients (β=8.5, 95% CI: 3.5-13.6, P<0.001), and patients with psychiatric/mental health concerns in the ED (β=18.4, 95% CI: 3.6-33.1, P<0.05). A 1 SD increase in inpatient nurses reporting staffing inadequacy was associated with longer ED lengths of stay for patients with psychiatric/mental health concerns (β=18.0, 95% CI: 5.8-30.3, P<0.01).</p><p><strong>Conclusion: </strong>Staffing a sufficient number of nurses in both the ED and inpatient units is a promising strategy to alleviate ED crowding.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13641136/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149111807","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":"Variability, Reliability, and Multilevel Determinants of Care Quality for Substance Use Disorders.","authors":"Edwin S Wong, Arvind Ramaprasan, Jubi Y L Lin, Joseph E Glass","doi":"10.1097/MLR.0000000000002378","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002378","url":null,"abstract":"<p><strong>Objective: </strong>Two quality measures, initiation and engagement in substance use disorder (SUD) treatment (IET), have been adopted by stakeholders. Further evidence is needed to inform optimal use of these measures to support quality improvement efforts. The objective of this study was to examine variability, reliability, and multilevel correlates of IET.</p><p><strong>Methods: </strong>Retrospective cohort study of members of a large integrated health system in the Pacific Northwest. Descriptive statistics were used to characterize variation in quality. Mixed-effects models with random intercepts were applied to quantify variability and reliability at different health system levels. We examined associations between quality measures and a wide set of patient-, provider-, clinic-, and area-level characteristics. We examined 32,960 care episodes subject to IET quality criteria between 2017 and 2022.</p><p><strong>Results: </strong>Overall, 30.0% and 7.8% of episodes met the criteria for initiation and engagement in SUD treatment, respectively. Little variation in initiation (2.8%) and engagement (3.9%) was collectively explained at the provider and clinic levels. No providers met the threshold for 70% reliability on an annual basis. Across varying assumptions of provider-level annual episode volume, clinics were unlikely to meet reliability thresholds. Factors consistently associated with IET included insurance type and history of behavioral health conditions.</p><p><strong>Conclusion: </strong>A low proportion of variation explained implies a larger number of episodes is needed to ensure reliable estimates. Stakeholders should apply IET measures cautiously, ensuring sufficient sample sizes to support robust measurement. Factors associated with a lower probability of meeting quality criteria can inform specific patients who may benefit from efforts to increase IET.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148945235","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":"Delays in Breast Cancer Surgical Care Following Oncology Surgeon Departures.","authors":"Sarah L Cornelius, Bruno T Scodari, A James O'Malley, Gabriel A Brooks, Anna N A Tosteson, Andrew Schaefer, Erika L Moen","doi":"10.1097/MLR.0000000000002374","DOIUrl":"10.1097/MLR.0000000000002374","url":null,"abstract":"<p><strong>Background: </strong>Timely cancer treatment is a major component of high-quality cancer care and is associated with better outcomes. Disruption caused by physician departures may adversely affect timely care.</p><p><strong>Objective: </strong>To examine the effects of breast cancer surgeon departures on timely breast cancer surgery.</p><p><strong>Methods: </strong>Using Medicare fee-for-service claims, we identified patients 66-99 years of age diagnosed with breast cancer between 2017 and 2019 who underwent a cancer-directed surgery. Surgical oncologists, plastic and reconstructive surgeons, and general surgeons performing these surgeries were included in our breast cancer surgeon cohort. Surgeon movement was tracked using changes in billing locations. The exposure variable was the number of surgeon departures in the prior 12 months from the hospital service area (HSA) where a patient's diagnostic biopsy was performed. Multivariable hierarchical logistic regression was used to estimate the associations between surgeon departures and surgical delays of more than 60 days.</p><p><strong>Results: </strong>Our study cohort included 122,159 patients with breast cancer, of whom 108,239 (89%) were non-Hispanic white and 97,565 (80%) resided in a metropolitan area. We found that 52,708 (43.1%) received care within an HSA that experienced at least 1 surgeon departure. Each additional surgeon departure was associated with a 4% increase in odds of delay >60 days (95% CI: 1.02-1.05; P <0.001).</p><p><strong>Conclusions: </strong>We found a modest association between surgeon departures and the odds of breast cancer surgical delay. These results suggest that, on average, hospitals are often able to deliver timely care in the context of surgeon departures. Additional research is needed to determine whether this finding generalizes to other cancer types and to identify the strategies that enable health system resilience to surgeon departures.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-09-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148906712","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":"Patient Outcomes and Nurse Understaffing in For-Profit Hospitals.","authors":"Matthew D McHugh, Karen B Lasater, K Jane Muir, Angelo Petto, Trissa Lyman, Linda H Aiken","doi":"10.1097/MLR.0000000000002376","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002376","url":null,"abstract":"<p><strong>Background: </strong>For-profit hospital ownership has been associated with worse patient outcomes, but the mechanisms remain unclear. Underinvestment in nurse staffing is a plausible pathway linking for-profit ownership to performance.</p><p><strong>Objectives: </strong>To examine whether differences in nurse staffing mediate associations between for-profit hospital ownership and patient, nurse, and hospital outcomes.</p><p><strong>Design: </strong>Cross-sectional study using 2024 data on hospital ownership, registered nurse survey responses, Medicare claims, and Hospital Compare measures.</p><p><strong>Subjects: </strong>A total of 143 for-profit and 798 nonprofit adult, nonfederal, acute care hospitals across 10 US states; >1.17 million Medicare fee-for-service admissions; and 17,368 direct-care bedside registered nurses.</p><p><strong>Measures: </strong>Patient-level 30-day mortality and readmission (Medicare Provider Analysis and Review); hospital-level hybrid risk-standardized mortality and readmission and HCAHPS overall hospital rating (CMS Hospital Compare); nurse burnout (Maslach Burnout Inventory emotional exhaustion subscale) and related outcomes (Penn Nurses All survey). The hypothesized mediator was hospital-level nurse staffing.</p><p><strong>Results: </strong>Among surgical patients, for-profit ownership was associated with a 0.48 percentage-point higher 30-day mortality (95% CI: 0.24-0.73), 45% mediated through staffing. Among medical patients, 1.13 percentage-point higher 30-day mortality (95% CI: 0.52-1.73), 40% mediated. Readmission findings were similar. For-profit status was associated with worse HCAHPS ratings (-4.45 percentage points; 95% CI: -5.20 to -3.60), 31% mediated. Nurse burnout was 9 percentage points higher (95% CI: 5.8-12.4), 67% mediated.</p><p><strong>Conclusions: </strong>For-profit hospital ownership is associated with worse patient and nurse outcomes, and differences in nurse staffing account for a share of these disparities.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148887411","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":"Availability of Hospital-Based Childbirth Services and Higher-Level Neonatal Care in Rural and Urban US Counties, 2010-2023.","authors":"Katy B Kozhimannil, Emily C Sheffield, Clara E Busse, Khadija Abdi, Julia D Interrante, Corrie E McDaniel, Sara C Handley","doi":"10.1097/MLR.0000000000002377","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002377","url":null,"abstract":"<p><strong>Background: </strong>Availability of childbirth services is declining nationally, especially in rural communities, where risks of maternal and infant mortality are elevated.</p><p><strong>Objective: </strong>The study aims to describe the availability of hospital-based childbirth services and higher-level neonatal care in rural and urban US counties from 2010 to 2023 and to examine trends in availability.</p><p><strong>Methods: </strong>Survey, administrative data, and primary sources were used to identify childbirth services (obstetric and basic well-infant services) and higher-level neonatal care (intermediate or intensive care) at short-term acute care hospitals in rural (n=1958) and urban (n=1186) US counties. For each year (2010-2023), counties were categorized into 3 mutually exclusive service categories: having (1) no childbirth services, (2) only childbirth services, or (3) both childbirth services and higher-level neonatal care. We estimated predicted percentages of rural and urban births occurring to residents of counties by service category using multinomial logistic regression models.</p><p><strong>Results: </strong>The predicted percent of urban births occurring to residents of counties with both childbirth services and higher-level neonatal care increased from 87.0% in 2010 to 88.6% in 2023 (P=0.007), while this percent remained statistically stable among rural counties at 17.0% in 2010 and 16.6% in 2023 (P=0.762). In 2023, 83.4% of rural births occurred to residents of counties without higher-level neonatal care, compared with 11.4% of urban births.</p><p><strong>Conclusions: </strong>In 2023, 88.6% of urban births occurred to residents of counties with both childbirth services and higher-level neonatal care, compared with 16.6% of rural births. From 2010 to 2023, rural-urban differences in the availability of specialized care for high-risk infants widened.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":""},"PeriodicalIF":1.9,"publicationDate":"2026-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148887452","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":"Temporal Misalignment and Selection Bias in \"Burn Pit Smoke Exposure and Sleep Apnea in US Veterans\".","authors":"Zhi Wang, Leping Shao","doi":"10.1097/MLR.0000000000002348","DOIUrl":"10.1097/MLR.0000000000002348","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"632"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148330877","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":"Association of Neighborhood Socioeconomic Disadvantage and Uptake of Diabetes Prevention Interventions.","authors":"Portia Buchongo, Jie Chen, Quynh Nguyen, Kellee White-Whilby, Dushanka Kleinman, Luisa Franzini","doi":"10.1097/MLR.0000000000002351","DOIUrl":"10.1097/MLR.0000000000002351","url":null,"abstract":"<p><strong>Background: </strong>Intensive lifestyle change intervention (LCI) programs and metformin are recommended to prevent the progression of prediabetes to type 2 diabetes. While social drivers of health are known to influence access to preventive health care the impact of neighborhood socioeconomic disadvantage on the uptake of diabetes prevention interventions remains underexplored.</p><p><strong>Objective: </strong>Examine the relationship between the social deprivation index and the use of diabetes prevention interventions among people with prediabetes.</p><p><strong>Methods: </strong>We analyzed commercial and Medicaid claims data from the Maryland Medical Care Data Base (2017-2019) to identify claims for LCIs and metformin prescriptions and Social Deprivation Index (SDI) 2015 data to measure enrollees' neighborhood socioeconomic disadvantage and examine associations between one or more diabetes prevention interventions. An adjusted multinomial logistic regression model estimating relative risk ratios was used to compare the relationship between SDI quintiles and use of LCI only, LCI and metformin, and metformin only (reference).</p><p><strong>Results: </strong>Among enrollees who used any intervention those living in neighborhoods with SDI scores in the fifth quintile had a significantly higher relative risk (RRR: 1.49; 95% CI: 1.12-1.99) of using LCI only versus metformin only compared with those living in neighborhoods with SDI scores in the first quintile.</p><p><strong>Conclusion: </strong>Enrollees with prediabetes living in neighborhoods with higher levels of socioeconomic disadvantage were more likely to use LCI and more likely to use LCI only compared with metformin only as a diabetes prevention intervention. These findings are relevant for states targeting diabetes prevention in communities of high need.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"577-584"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148352346","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}