Medical Care最新文献

{"title":"Considerations for Risk Stratification in Hot Spotter Programs: Reply to Singh and Srivastav.","authors":"Daniel M Blonigen, Kathryn S Macia, Ivan Raikov, Jean Yoon, Jillian Weber","doi":"10.1097/MLR.0000000000002345","DOIUrl":"10.1097/MLR.0000000000002345","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"550-551"},"PeriodicalIF":1.9,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148143911","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 Between Team-Based Continuity of Care Measures and End-of-Life Health Care Outcomes: A Retrospective Cohort Study in Ontario, Canada.","authors":"Shuaib Hafid, Sarina Isenberg, Aaron Jones, Aria Wills, Taylor Shorting, Ana Gayowsky, Aleisha Fernandes, Kieran L Quinn, Colleen Webber, Erin Gallagher, Peter Tanuseputro, Michelle Howard","doi":"10.1097/MLR.0000000000002334","DOIUrl":"10.1097/MLR.0000000000002334","url":null,"abstract":"<p><strong>Background: </strong>Continuity of care (COC) measurements that reflect relational continuity have been used as quality indicators, yet their applicability near the end of life may be limited. Modified continuity indices-UPC-Team (Usual Provider of Care) and BB-Team (Bice-Boxerman)-were developed to reflect escalating care needs and capture associations with patient-centered outcomes.</p><p><strong>Objectives: </strong>To measure associations between the modified COC indices, UPC-Team, and BB-Team during the last year of life and end-of-life (EOL) health care outcomes.</p><p><strong>Methods: </strong>Retrospective cohort study of adults who died between January 1, 2018, and December 31, 2022, with advanced chronic obstructive pulmonary disease and/or heart failure prevalent ≥2 years before death, using health administrative data from Ontario, Canada. Multivariate regressions measured associations between the indices and days spent in community during the last 30 and 14 days of life, and place of death.</p><p><strong>Results: </strong>Among 175,323 included individuals (median age at death=80; 55.4% male), the median number of community days was 23 and 10 in the last 30 and 14 days of life; 56.5% died in a health care institution. Higher UPC-Team and BB-Team scores were associated with increased odds of institutional deaths and fewer community days.</p><p><strong>Conclusions: </strong>Higher continuity scores were associated with increased odds of institutional death and fewer days spent in the community, suggesting limited utility of these modified indices in predicting favorable EOL health care outcomes. Findings highlight the need for future research to incorporate all aspects of continuity (ie, relational, informational, and management) to better capture care coordination in this context.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"483-491"},"PeriodicalIF":1.9,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13331261/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147775725","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":"Consistency of a Dementia Diagnosis Between Systems for Patients Receiving Care Through the VA, Traditional Medicare, and Medicare Advantage.","authors":"Lianlian Lei, Sarah L Krein, Kierstdea Petzold, Hyungjin Myra Kim, Orna Intrator, Courtney Harold Van Houtven, Lillian Min, Julie Strominger, Donovan T Maust","doi":"10.1097/MLR.0000000000002342","DOIUrl":"10.1097/MLR.0000000000002342","url":null,"abstract":"<p><strong>Background: </strong>Older Veterans receive care through the Department of Veterans Affairs (VA) and Medicare, including Medicare Advantage (MA). We assessed the extent to which a dementia diagnosis recorded in one system is reflected in the other and factors associated with discordance among dual users.</p><p><strong>Design: </strong>Parallel cohort study of patients with dementia identified in the VA or Medicare, both overall and separated into traditional Medicare (TM) and MA.</p><p><strong>Participants: </strong>Patients aged 65 years or older enrolled in VA and Medicare with a 2018 face-to-face dementia diagnosis encounter in the VA (N=68,092; VA dementia cohort) or Medicare (N=76,622; Medicare dementia cohort).</p><p><strong>Measures: </strong>In both cohorts, our primary outcome was whether the dementia diagnosis was absent at each professional encounter in the other system during 1-year follow-up. Characteristics considered included patient sex, age, race, ethnicity, rurality, priority group, dementia type, and clinician specialty during follow-up.</p><p><strong>Results: </strong>For VA and Medicare cohorts, dementia diagnosis was absent in 88.7% and 80.5%, respectively, of follow-up encounters in the other system. For the VA cohort, the diagnosis was absent in 89.2% and 71.8% of TM and MA encounters, respectively. Encounters with a psychiatrist or neurologist (vs. primary care physician) were linked to lower absence during follow-up (eg, 25.3 and 20.3 percentage points lower for the VA cohort during Medicare follow-up; P <0.001 for both); those in TM (vs. MA) were 14.5 percentage points more likely to have an absent diagnosis.</p><p><strong>Conclusions: </strong>Absent dementia diagnoses across VA and Medicare among dual users was common, associated with clinician specialty and Medicare type.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"512-520"},"PeriodicalIF":1.9,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13240655/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148157171","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":"Community-Based Proactive Primary Care Reduces Emergency Health Care Use for Adults Without Insurance.","authors":"Heather Kitzman, Abdullah Mamun, Neil Fleming, Kevin Sykes, Jeffrey Zsohar","doi":"10.1097/MLR.0000000000002311","DOIUrl":"10.1097/MLR.0000000000002311","url":null,"abstract":"<p><strong>Background: </strong>Many Americans are in a coverage gap and unable to obtain affordable health insurance-particularly in non-Medicaid expanded states-which is associated with less preventative care, worse health outcomes, and a reliance on emergency care.</p><p><strong>Objective: </strong>To evaluate whether navigating uninsured patients to community-based primary care clinics that provide integrated care reduces preventable emergency visits and associated costs.</p><p><strong>Research design: </strong>This retrospective study evaluated the volume and costs of emergency department (ED) and inpatient hospitalization for patients accessing community-based integrated primary care (BCC) located near hospital centers as compared with those receiving usual care (non-BCC).</p><p><strong>Subjects: </strong>The BCC group included 16,069 patients, and a propensity score-matched control group included 16,069 non-BCC patients. Patients less than 18 years old, with documented mental health issues, or whose electronic health record data were incomplete were excluded from the study.</p><p><strong>Measures: </strong>ED and inpatient hospitalization (IP) visits and direct costs.</p><p><strong>Results: </strong>Overall, the average per-person-year direct IP costs of BCC patients was 48% lower ( P <.001) and direct ED costs 43% lower ( P <.0001) than non-BCC patients. BCC patients had ∼44% fewer IP visits, and 29% fewer ED visits compared with non-BCC at 1-2 years of follow-up. BCC patients with diabetes related complications had 28% less IP costs and 27% less ED costs compared with non-BCC patients over 4 years ( P =.03, P =.01, respectively).</p><p><strong>Conclusions: </strong>This study supports the strategic navigation of uninsured patients from emergency departments and community settings to community-based primary care clinics offering integrated services, highlighting a promising population health approach.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"436-441"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147581733","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":"US Medicaid Spending and Health Insurance Coverage for People Involved in the Criminal Legal System as Children.","authors":"Ian A Silver, Jenna L Dole, Daniel C Semenza","doi":"10.1097/MLR.0000000000002330","DOIUrl":"10.1097/MLR.0000000000002330","url":null,"abstract":"<p><strong>Introduction: </strong>Early involvement in the US criminal legal system (CLS) is linked to persistent health disadvantages, including reduced health insurance coverage in adulthood.</p><p><strong>Objectives: </strong>The current study examined the influence of increases and cuts to federal and state Medicaid expenditures on health insurance enrollment among individuals with varying levels of CLS involvement before age 18.</p><p><strong>Research design: </strong>The current study is a cohort study of individuals who participated in the National Longitudinal Survey of Youth 1997 (2003-2021).</p><p><strong>Patients and methods: </strong>The total sample included 8240 participants. This study applied Bayesian lagged random-intercept logistic regression to assess associations between Medicaid spending and uninsurance among individuals with and without CLS contact before age 18.</p><p><strong>Measures: </strong>Federal and State Medicaid expenditures were measured in total dollars spent by the federal government and state governments, respectively. Contact with the CLS before 18 was measured as arrested before 18, incarcerated in a juvenile facility before 18, or incarcerated in an adult facility before 18. Uninsurance was measured as the absence of insurance on the date of the interview.</p><p><strong>Results: </strong>Greater CLS severity was associated with higher odds of being uninsured, while higher federal Medicaid expenditures were associated with a lower uninsurance rate. Simulations indicated that a 50% federal Medicaid spending cut could increase uninsurance for those with CLS involvement before 18, whereas a 20% spending increase would increase the probability of insurance.</p><p><strong>Conclusions: </strong>Findings highlight the federal Medicaid's role in mitigating coverage inequities and suggest that reducing expenditures could exacerbate ongoing health disparities rooted in early CLS involvement.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"428-435"},"PeriodicalIF":2.8,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147690954","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":"Success Rates of Venture Capital Investment in Biopharmaceutical Development.","authors":"So-Yeon Kang, Mingqian Liu, Sean S Huang","doi":"10.1097/MLR.0000000000002325","DOIUrl":"10.1097/MLR.0000000000002325","url":null,"abstract":"<p><strong>Background: </strong>Large biopharmaceutical companies increasingly outsource early research and development (R&D) to startups funded by venture capital (VC). Yet little is known about how effective VC funding is at advancing new drugs to market.</p><p><strong>Objectives: </strong>To examine the outcomes of clinical trials conducted by VC-backed startups and identify factors associated with their progression.</p><p><strong>Research design: </strong>Retrospective cohort study of VC-backed biopharmaceutical clinical trials.</p><p><strong>Subjects: </strong>Index phase 1 trials initiated between January 2006 and December 2015, tracked through April 2024.</p><p><strong>Measures: </strong>Progression to phase 2, phase 3, and US Food and Drug Administration (FDA) approval. Associations between trial characteristics and progression were estimated using multinomial logistic regression.</p><p><strong>Results: </strong>Among 1357 VC-backed phase 1 trials, 10.9% failed to complete phase 1, 13.3% completed phase 1 and stopped, 42.5% progressed only to phase 2, 19.2% only to phase 3, and 14.1% ultimately received FDA approval. Cancer-related trials achieved FDA approval in 8.7% of cases. Compared with small-molecule trials, biological trials were less likely to progress to phase 3 [-11.3 percentage points (pp), P <0.001] or receive FDA approval (-14.1 pp, P <0.001). Greater initial investment in phase 1 was associated with higher progression, including a 6.2 pp higher probability of FDA approval ( P <0.001).</p><p><strong>Conclusions: </strong>Clinical trial success rates among VC-backed startups were within the range of approval rates previously reported for large manufacturers. Progression varied substantially by drug modality, therapeutic focus, and initial investment size, underscoring how capital allocation and development strategy shape R&D outcomes.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"413-418"},"PeriodicalIF":2.8,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147775712","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":"Safe Minimum Nurse Staffing Requirements for Hospitals: Evidence From Pennsylvania.","authors":"K Jane Muir, Linda H Aiken, Heather Brom, Vaneh Hovsepian, Karen B Lasater, Matthew D McHugh","doi":"10.1097/MLR.0000000000002332","DOIUrl":"10.1097/MLR.0000000000002332","url":null,"abstract":"<p><strong>Background: </strong>The Pennsylvania legislature is considering limiting the number of patients nurses care for to promote safe care.</p><p><strong>Objective: </strong>To determine whether variation in nurse workloads is associated with adverse consequences for patients, nurses, and hospital costs in Pennsylvania.</p><p><strong>Methods: </strong>Observational study of 547,689 medical and surgical patients and 2782 direct care nurses in 132 Pennsylvania hospitals. The independent variable was medical-surgical nurse staffing ratios. Patient outcomes included 30-day mortality, 30-day readmissions, and length of stay. Nurse outcomes included burnout, job dissatisfaction, intent to leave, and evaluations of hospital management and patient care. Hospital outcomes were HCAHPS Star Ratings and cost offsets associated with better staffing.</p><p><strong>Results: </strong>Hospital nurse staffing ranged from 3 to 9 patients per nurse (average 5.9). Each additional patient per nurse was associated with higher odds of 30-day mortality (AOR: 1.08, 95% CI: 1.03, 1.13, P <0.001), longer length of stay (IRR: 1.02, 95% CI: 1.00, 1.04, P <0.05) and higher odds of readmission (AOR: 1.04, 95% CI: 1.01, 1.07, P <0.05). Worse staffing was associated with higher odds of nurse burnout, job dissatisfaction, and intent to leave, and lower patient satisfaction. Cost savings from patient outcomes and nurse retention were projected to offset costs of additional nurses needed for hospitals to meet a minimum safe nurse staffing level proposed in legislation.</p><p><strong>Conclusions: </strong>Large differences across Pennsylvania hospitals in the amount of nursing care patients receive are associated with negative consequences. A state policy establishing minimum safe nurse staffing requirements in hospitals is in the public's interest.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"447-455"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13245930/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147816890","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":"RE: Compliance With Recommendations of the Surveillance, Epidemiology, and End Results (SEER) Treatment Data Use Agreement.","authors":"Jason Semprini","doi":"10.1097/MLR.0000000000002329","DOIUrl":"10.1097/MLR.0000000000002329","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"471"},"PeriodicalIF":2.8,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147674967","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":"Clinical Standardization Across a National Health System: Perspectives From the Veterans Affairs' Electronic Health Record Transition.","authors":"Julian Brunner, Courtney Bilodeau, Brianne Molloy-Paolillo, Christian D Helfrich, Krista Dashtestani, Adena Cohen-Bearak, Jan David Hauck, Jennifer Herout, Helen Fuller, Jonathan R Nebeker, Sarah L Cutrona, Seppo T Rinne","doi":"10.1097/MLR.0000000000002319","DOIUrl":"10.1097/MLR.0000000000002319","url":null,"abstract":"<p><strong>Background: </strong>Clinical standardization is widely debated. Advocates emphasize its potential to reduce unwarranted variation and improve quality, while critics warn it may constrain professional judgment or undermine local innovation. These tensions become especially salient during enterprise-wide electronic health record (EHR) transitions, when configuration and workflow decisions can institutionalize practices across facilities. The Department of Veterans Affairs (VA), undertaking the largest EHR transition in history, provides a critical case for understanding how frontline staff perceive system-wide standardization.</p><p><strong>Objectives: </strong>To assess VA employee attitudes toward care process standardization during VA's enterprise-wide EHR transition and identify implementation challenges and opportunities.</p><p><strong>Research design: </strong>Cross-sectional survey with mixed-methods analysis of a survey fielded in September 2024.</p><p><strong>Subjects: </strong>We surveyed n=1748 EHR users at the first 5 VA sites implementing a new EHR.</p><p><strong>Measures: </strong>Awareness of and support for VA's Enterprise Standardization Initiative, assessed using 5-point Likert items; free-text comments were analyzed thematically to identify perspectives on standardization.</p><p><strong>Results: </strong>Among respondents, 43% reported awareness of VA's standardization initiative, and 65% supported standardizing care processes across facilities. Qualitative analysis revealed 3 themes: (1) support for standardization as complementary to EHR transition; (2) preference for decoupling standardization from technical change; and (3) emphasis on appropriately targeting standardization to preserve innovation capacity.</p><p><strong>Conclusions: </strong>VA employees expressed support for standardization with important caveats about implementation approach and scope. Findings support iterative standardization that balances consistency with local adaptation, while carefully sequencing standardization relative to technical change.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"64 7","pages":"442-446"},"PeriodicalIF":2.8,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148205308","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":"Medicaid Home-Based and Community-Based Services Long-Term Care Expenditures: Evaluation of the Balancing Incentive Program.","authors":"Bonnie Ghosh-Dastidar, Michael W Robbins, Esther M Friedman, Nabeel Qureshi, Regina A Shih","doi":"10.1097/MLR.0000000000002333","DOIUrl":"10.1097/MLR.0000000000002333","url":null,"abstract":"<p><strong>Objective: </strong>The Balancing Incentive Program (BIP), legislated in the 2010 Affordable Care Act, offered states financial incentives to increase access to Medicaid home-based and community-based services (HCBS). Despite the major infrastructure changes required by BIP, no evaluation to date has quantified the increase in spending attributable to BIP, which is of concern to Medicaid HCBS policymakers, providers, and consumers. This is the first causal estimate of BIP's effects, including the timing of implementation in each state, compared with a counterfactual.</p><p><strong>Design: </strong>Using state-level expenditure data, we estimated the change in HCBS spending as a percentage of long-term services and supports (LTSS) spending in 17 BIP participant states compared with a counterfactual or synthetic control calculated as a weighted average of the outcome in 17 BIP eligible, nonparticipant states. Synthetic control weights were estimated using pre-BIP characteristics. To assess how BIP effects evolved over time, we estimated cumulative change in the outcome in multiple post-BIP years (2013, 2016, and 2019).</p><p><strong>Results: </strong>Our primary analysis indicates that cumulatively from FY 2013 to 2019, BIP states increased their HCBS spending as a percentage of LTSS spending by an average of 5.2 percentage points (95% CI: 0.0, 9.8), compared with the synthetic control.</p><p><strong>Implications: </strong>Although many state-run programs have sought to increase HCBS access, our study's causal estimate of BIP effects in 17 states, compared with 17 states that did not, represents a more substantial growth than findings of prior studies.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"463-470"},"PeriodicalIF":1.9,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13278527/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147839942","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}