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Objective To examine the relationship between continuity of care for children with medical complexity (CMC) and emergency department (ED) utilization, care coordination quality, and family effects related to care coordination. Methods We measured ED utilization and primary care continuity with the Bice-Boxerman continuity of care index for 1477 CMC using administrative data from Minnesota and Washington state Medicaid agencies. For a subset of 186 of these CMC a caregiver survey was used to measure care coordination quality (using items adapted from the Consumer Assessment of Healthcare Providers and System Adult Health Plan Survey) and family impact (using items adapted from the National Survey of Children with Special Health Care Needs). Multivariable regression was used to examine the relationship between continuity, entered as a continuous variable ranging from 0 to 1, and the outcomes. Results The median continuity was 0.27 (interquartile range [IQR], 0.12–0.48) in the administrative data cohort and 0.27 (IQR, 0.14–0.43) in the survey cohort. Compared with children with a continuity score of 0, children with a score of 1 had lower odds of having ≥1 ED visit (odds ratio, 0.65; 95% confidence interval [CI], 0.46–0.93; P = .017) and their caregivers reported higher scores for the measure of receipt of care coordination (β = 35.2 on a 0–100 scale; 95% CI, 11.5–58.9; P = .004). There was no association between continuity and family impact. Conclusions Continuity of care holds promise as a quality measure for CMC because of its association with lower ED utilization and more frequent receipt of care coordination.

Previous studies have identified an increasing number of gastroenterology (GI) procedures using anesthesia services to provide sedation, with a majority of these services delivered to low-risk patients. The aim of this study was to update these trends with the most recent years of data.We used Medicare and commercial claims data from 2010 to 2013 to identify GI procedures and anesthesia services based on CPT codes, which were linked together using patient identifiers and dates of service. We defined low-risk patients as those who were classified as ASA (American Society of Anesthesiologists) physical status class I or II. For those patients without an ASA class listed on the claim, we used a prediction algorithm to impute an ASA physical status.Over 6.6 million patients in our sample had a GI procedure between 2010 and 2013. GI procedures involving anesthesia service accounted for 33.7% in 2010 and 47.6% in 2013 in Medicare patients, and 38.3% in 2010 and 53.0% in 2013 in commercially insured patients. Overall, as more patients used anesthesia services, total anesthesia service use in low-risk patients increased 14%, from 27,191 to 33,181 per million Medicare enrollees. Similarly, we observed a nearly identical uptick in commercially insured patients from 15,871 to 22,247 per million, an increase of almost 15%. During 2010-2013, spending associated with anesthesia services in low-risk patients increased from US$3.14 million to US$3.45 million per million Medicare enrollees and from US$7.69 million to US$10.66 million per million commercially insured patients.During 2010 to 2013, anesthesia service use in GI procedures continued to increase and the proportion of these services rendered for low-risk patients remained high.

Objective To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality. Data Sources Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012. Study Design We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals. Data Collection Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association. Principal Findings Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals. Conclusions Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options.

Assess whether adding more components to a workplace wellness program is associated with better outcomes by measuring the relationship of program components to one another and to employee participation and perceptions of program effectiveness.Data came from a 2014 survey of 24,393 employees of 81 employers about services offered, leadership, incentives, and promotion. Logistic regressions were used to model the relationship between program characteristics and outcomes.Components individually are related to better outcomes, but this relationship is weaker in the presence of other components and non-significant for incentives. Within components, a moderate level of services and work time participation opportunities are associated with higher participation and effectiveness.The "more of everything" approach does not appear to be advisable for all programs. Programs should focus on providing ample opportunities for employees to participate and initiatives like results-based incentives.

Purpose. We aimed to understand how employer characteristics relate to the use of incentives to promote participation in wellness programs and to explore the relationship between incentive type and participation rates. Design. A cross-sectional analysis of nationally representative survey data combined with an administrative business database was employed. Settings/Subjects. Random sampling of U.S. companies within strata based on industry and number of employees was used to determine a final sample of 3000 companies. Of these, 19% returned completed surveys. Measures. The survey asked about employee participation rate, incentive type, and gender composition of employees. Incentive types included any incentives, high-value rewards, and rewards plus penalties. Analysis. Logistic regressions of incentive type on employer characteristics were used to determine what types of employers are more likely to offer which type of incentives. A generalized linear model of participation rate was used to determine the relationship between incentive type and participation. Results. Employers located in the Northeast were 5 to 10 times more likely to offer incentives. Employers with a large number of employees, particularly female employees, were up to 1.25 times more likely to use penalties. Penalty and high-value incentives were associated with participation rates of 68% and 52%, respectively. Conclusion. Industry or regional characteristics are likely determinants of incentive use for wellness programs. Penalties appear to be effective, but attention should be paid to what types of employees they affect.

This article aims to test whether a workplace wellness program reduces health care cost for higher risk employees or employees with greater participation.The program effect on costs was estimated using a generalized linear model with a log-link function using a difference-in-difference framework with a propensity score matched sample of employees using claims and program data from a large US firm from 2003 to 2011.The program targeting higher risk employees did not yield cost savings. Employees participating in five or more sessions aimed at encouraging more healthful living had about $20 lower per member per month costs relative to matched comparisons (P = 0.002).Our results add to the growing evidence base that workplace wellness programs aimed at primary prevention do not reduce health care cost, with the exception of those employees who choose to participate more actively.

Background Knowing the temporal trend central line–associated bloodstream infection (CLABSI) rates among U.S. pediatric intensive care units (PICUs), the current extent of central line bundle compliance, and the impact of compliance on rates is necessary to understand what has been accomplished and can be improved in CLABSI prevention. Methods This is a longitudinal study of PICUs in National Healthcare Safety Network hospitals and a cross-sectional survey of directors and managers of infection prevention and control departments regarding PICU CLABSI prevention practices, including self-reported compliance with elements of central line bundles. Associations between 2011-2012 PICU CLABSI rates and infection prevention practices were examined. Results Reported CLABSI rates decreased during the study period, from 5.8 per 1,000 line days in 2006 to 1.4 in 2011-2012 ( P Conclusion There was a nonsignificant trend in decreasing CLABSI rates as PICUs improved bundle policy compliance. Given that few PICUs reported full compliance with these policies, PICUs increasing their efforts to comply with these policies may help reduce CLABSI rates.

Debate continues on whether nurse practitioners (NPs) and physician assistants (PAs) are more likely to order ancillary services, or order more costly services among alternatives, than primary care physicians (PCPs). We compared prescription medication and diagnostic service orders associated with NP/PA versus PCP visits for management of neck or back (N/B) pain or acute respiratory infection (ARI).Retrospective, observational study of visits from January 2006 through March 2008 in the adult primary care practice of Kaiser Permanente in Atlanta, Georgia.Data were obtained from electronic health records. NP/PA and PCP visits for N/B pain or ARI were propensity score matched on patient age, gender, and comorbidities.On propensity score-matched N/B pain visits (n = 6724), NP/PAs were less likely than PCPs to order a computed tomography (CT)/magnetic resonance image (MRI) scan (2.1% vs 3.3%, respectively) or narcotic analgesic (26.9% vs 28.5%) and more likely to order a nonnarcotic analgesic (13.5% vs 8.5%) or muscle relaxant (45.8% vs 42.5%) (all P ≤.05). On propensity score-matched ARI visits (n = 24,190), NP/PAs were more likely than PCPs to order any antibiotic medication (73.7% vs 65.8%), but less likely to order an x-ray (6.3% vs 8.6%), broad-spectrum antibiotic (41.5% vs 42.5%), or rapid strep test (6.3% vs 9.7%) (all P ≤.05).In the multidisciplinary primary care practice of this health maintenance organization, NP/PAs attending visits for N/B pain or ARI were less likely than PCPs to order advanced diagnostic radiology imaging services, to prescribe narcotic analgesics, and/or to prescribe broad-spectrum antibiotics.

ObjectiveTo determine the association between state legal mandates for data submission of central line–associated bloodstream infections (CLABSIs) in neonatal intensive care units (NICUs) with process and outcome measures.DesignCross-sectional study.Participants. National sample of level II/III and III NICUs participating in National Healthcare Safety Network (NHSN) surveillance.MethodsState mandates for data submission of CLABSIs in NICUs in place by 2011 were compiled and verified with state healthcare-associated infection coordinators. A web-based survey of infection control departments in October 2011 assessed CLABSI prevention practices, ie, compliance with checklist/bundle components (process measures) in ICUs including NICUs. Corresponding 2011 NHSN NICU CLABSI rates (outcome measures) were used to calculate standardized infection ratios (SIRs). Association between mandates and process and outcome measures was assessed by multivariable logistic regression.ResultsAmong 190 study NICUs, 107 (56.3%) were located in states with mandates, with mandates in place >3 years in 52 (49%). More NICUs in states with mandates reported ≥95% compliance to at least 1 CLABSI prevention practice (52.3%–66.4%) than NICUs in states without mandates (28.9%–48.2%). Mandates were predictors of ≥95% compliance with all practices (odds ratio, 2.8; 95% confidence interval, 1.4–6.1). NICUs in states with mandates reported lower mean CLABSI rates in the ≤750-g birth weight group (2.4 vs 5.7 CLABSIs/1,000 central line–days) but not in others. Mandates were not associated with SIR ConclusionsState mandates for NICU CLABSI data submission were significantly associated with ≥95% compliance with CLABSI prevention practices, which declined with the duration of mandate but not with lower CLABSI rates.Infect Control Hosp Epidemiol 2014;35(9):1133-1139

Background Bundles and checklists have been shown to decrease the rates of central line–associated bloodstream infections (CLABSIs), but implementation of these practices and association with CLABSI rates have not been described nationally. We describe implementation and levels of compliance with preventive practices in a sample of US neonatal intensive care units (NICUs) and assess their association with CLABSI rates. Methods An online survey assessing infection prevention practices was sent to hospitals participating in National Healthcare Safety Network CLABSI surveillance in October 2011. Participating hospitals permitted access to their NICU CLABSI rates. Multivariable regressions were used to test the association between compliance with NICU-specific CLABSI prevention practices and corresponding CLABSI rates. Results Overall, 190 level II/III and level III NICUs participated. The majority of NICUs had written policies (84%-93%) and monitored compliance with bundles and checklists (88%-91%). Reporting ≥95% compliance for any of the practices ranged from 50%-63%. Reporting of ≥95% compliance with insertion checklist and assessment of daily line necessity were significantly associated with lower CLABSI rates ( P Conclusions Most of the NICUs in this national sample have instituted CLABSI prevention policies and monitor compliance, although reporting compliance ≥95% was suboptimal. Reporting ≥95% compliance with select CLABSI prevention practices was associated with lower CLABSI rates. Future studies should focus on identifying and improving compliance with effective CLABSI prevention practices in neonates.

Workplace wellness programs are increasingly popular. Employers expect them to improve employee health and well-being, lower medical costs, increase productivity, and reduce absenteeism. To test whether such expectations are warranted, we evaluated the cost impact of the lifestyle and disease management components of PepsiCo's wellness program, Healthy Living. We found that seven years of continuous participation in one or both components was associated with an average reduction of $30 in health care cost per member per month. When we looked at each component individually, we found that the disease management component was associated with lower costs and that the lifestyle management component was not. We estimate disease management to reduce health care costs by $136 per member per month, driven by a 29 percent reduction in hospital admissions. Workplace wellness programs may reduce health risks, delay or avoid the onset of chronic diseases, and lower health care costs for employees with manifest chronic disease. But employers and policy makers should not take for granted that the lifestyle management component of such programs can reduce health care costs or even lead to net savings.

This article investigates the characteristics of workplace wellness programs, their prevalence, their impact on employee health and medical cost, facilitators of their success, and the role of incentives in such programs. The authors employ four data collection and analysis streams: a review of the scientific and trade literature, a national survey of employers, a longitudinal analysis of medical claims and wellness program data from a sample of employers, and five case studies of existing wellness programs in a diverse set of employers to gauge the effectiveness of wellness programs and employees' and employers' experiences.

This article leverages existing data on wellness programs to explore patterns of wellness program availability, employers' use of incentives, and program participation and utilization among employees. Researchers used two sets of data for this project: The first included data from the 2012 RAND Employer Survey, which used a nationally representative sample of U.S. employers that had detailed information on wellness program offerings, program uptake, incentive use, and employer characteristics. These data were used to answer questions on program availability, configuration, uptake, and incentive use. The second dataset included health care claims and wellness program information for a large employer. These data were analyzed to predict program participation and changes in utilization and health. The findings underscore the increasing prevalence of worksite wellness programs. About four-fifths of all U.S. employers with more than 1,000 employees are estimated to offer such programs. For those larger employers, program offerings cover a range of screening activities, interventions to encourage healthy lifestyles, and support for employees with manifest chronic conditions. Smaller employers, especially those with fewer than 100 employees, appear more reserved in their implementation of wellness programs. The use of financial incentives appears to increase employee participation in wellness programs, but only modestly. Employee participation in lifestyle management aspects of workplace wellness programs does not reduce healthcare utilization or cost regardless of whether we focus on higher-risk employees or those who are more engaged in the program.

The Center for Medicare and Medicaid Innovation within the Centers for MedicareMedicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.

BACKGROUND The Center for Medicare & Medicaid Services recently defined "screening colonoscopy" to include separately furnished anesthesia services. OBJECTIVE To examine the relationship between anesthesia service use and the uptake of screening colonoscopies. STUDY DESIGN We correlated metropolitan statistical area (MSA) level anesthesia service use rates, derived from the 2008, 2010, and 2012 Medicare and MarketScan claims data, with the presence of individual level guideline concordant screening colonoscopy using the Behavioral Risk Factor Surveillance System data for the same years. MEASURES Proportion of colonoscopies with anesthesia service was calculated at the MSA level. A guideline concordant screening colonoscopy was defined as a colonoscopy received within the past 10 years. RESULTS The average MSA level anesthesia service use rate in colonoscopy significantly increased from 25.34% in 2008 to 44.25% in 2012; but only a moderate increase in the rate of guideline concordant colonoscopies was observed, from 57.36% in 2008 to 65.32% in 2012. After adjusting for patient characteristics, we found a nonsignificant negative association between anesthesia service use rate and colonoscopy screening rate, with an odds ratio of 0.90 for receiving a guideline concordant colonoscopy for each percentage point increase in anesthesia service use rate (P=0.27). The relationship between anesthesia service use and the overall colorectal cancer screening rate followed the same pattern and was also not statistically significant. CONCLUSIONS No significant association between anesthesia service use and colonoscopy screening or colorectal cancer screening rates was found, suggesting that more evidence is needed to support the Center for Medicare & Medicaid Services rule change.

Objective To examine the effect of mandated state health care–associated infection (HAI) reporting laws on central line–associated bloodstream infection (CLABSI) rates in adult intensive care units (ICUs). Data Sources We analyzed 2006–2012 adult ICU CLABSI and hospital annual survey data from the National Healthcare Safety Network. The final analytic sample included 244 hospitals, 947 hospital years, 475 ICUs, 1,902 ICU years, and 16,996 ICU months. Study Design We used a quasi-experimental study design to identify the effect of state mandatory reporting laws. Several secondary models were conducted to explore potential explanations for the plausible effects of HAI laws. Principal Findings Controlling for the overall time trend, ICUs in states with laws had lower CLABSI rates beginning approximately 6 months prior to the law's effective date (incidence rate ratio = 0.66; p

Objectives: To compare outcomes and measures of efficiency for hospitalized elderly adults managed by geriatricians with those managed by other physicians. Design: Secondary data analysis using a system that integrates clinical and financial information for inpatient and outpatient services delivered throughout the University of Pittsburgh Medical Center (UPMC). Propensity scores were developed based on participant sociodemographic and clinical characteristics and used to match participants based on the attending physician's specialty (geriatrician, n = 701; nongeriatrician, n = 11,549). Multivariate analyses using generalized estimating equations methods were performed. Setting: Two UPMC hospitals in Pittsburgh, Pennsylvania. Participants: Patients aged 65 and older admitted in 2002 in a medical diagnosis-related group (DRG). Measurements: Outcomes (inpatient mortality, 30-day mortality, readmission) and efficiency measures (length of stay, total costs, and surplus, which is the difference between hospital costs and payment received for an admission). Results: Elderly adults managed by geriatricians were significantly older (P < .001) and more likely to be male (P < .001) and had more diagnoses (P < .001). Propensity scores successfully balanced characteristics managed by the two groups. Patients of geriatricians had shorter length of stay (P < .001), lower costs per admission (P < .001), and greater surplus (P < .001) with no differences in outcomes. In multivariate analyses, there were not significant differences in outcomes, but patients of geriatricians had significantly shorter length of stay and lower costs per admission and generated more surplus for the hospitals. Conclusion: Geriatricians were more efficient than other physicians in managing hospitalized elderly adults with medical DRGs frequently managed by geriatricians. This efficiency did not compromise patient outcomes.

The study evaluated the accuracy of Medicare claims in identifying elderly patients with depression compared with diagnoses of depression made with validated self-report depression scales.The study included 1,551 participants in the Medicare Primary and Consumer-Directed Care Demonstration. They resided in 19 counties in three states. Depression diagnoses made by two validated self-rated scales- the Mini-International Neuropsychiatric Interview-Major Depressive Episode Module (MINI-MDE) and the 15-item Geriatric Depression Scale (GDS) were compared with depression identified diagnoses listed in Medicare claims. The main outcome measures were the sensitivity, specificity, and positive and negative predictive values for ICD-9-CM depression codes included in Medicare claims. For validation, two-year periods and additional diagnostic codes were also considered.Compared with the MINI-MDE or GDS, the sensitivity and positive predictive values for Medicare claims were below 50%, and specificity and negative predictive values were over 70%.The study demonstrated the predictive power and limitations of using administrative claims data for identifying patients with depression in the Medicare population. Using Medicare claims to identify patients with depression may lead to underestimation of depression prevalence and may compromise researchers' ability to examine issues related to quality, costs, and utilization.

Objective To evaluate the ability of the structure and code sets specified in the National Council for Prescription Drug Programs Structured and Codified Sig Format to represent ambulatory electronic prescriptions. Design We parsed the Sig strings from a sample of 20 161 de-identified ambulatory e-prescriptions into variables representing the fields of the Structured and Codified Sig Format. A stratified random sample of these representations was then reviewed by a group of experts. For codified Sig fields, we attempted to map the actual words used by prescribers to the equivalent terms in the designated terminology. Measurements Proportion of prescriptions that the Format could fully represent; proportion of terms used that could be mapped to the designated terminology. Results The fields defined in the Format could fully represent 95% of Sigs (95% CI 93% to 97%), but ambiguities were identified, particularly in representing multiple-step instructions. The terms used by prescribers could be codified for only 60% of dose delivery methods, 84% of dose forms, 82% of vehicles, 95% of routes, 70% of sites, 33% of administration timings, and 93% of indications. Limitations The findings are based on a retrospective sample of ambulatory prescriptions derived mostly from primary care physicians. Conclusion The fields defined in the Format could represent most of the patient instructions in a large prescription sample, but prior to its mandatory adoption, further work is needed to ensure that potential ambiguities are addressed and that a complete set of terms is available for the codified fields.

This study examined the associations of prenatal psychosocial factors, including depressive symptoms, post-traumatic stress disorder symptoms, trauma exposure including intimate partner violence, perceived stress, and social support, with perceived postpartum health status. Low-income Latinas (N = 203) were recruited from two health plans within the first 12 weeks of their pregnancies and followed through 3 months after birth. Participants completed semi-structured interviews conducted in English or Spanish within the first 12 weeks of pregnancy, and again at 12 weeks postpartum. Perceived health status was measured by the SF-12. Participants with complete follow-up data (n = 193) were used in data analysis. Women were mostly foreign-born (75%) with low-incomes (59%) and reported postpartum health status in the average range (M = 102.5; SD = 12.2). Overall health status was positively associated with decreased levels of perceived stress (P

To examine whether low-income parents of children enrolled in the New York State Children's Health Insurance Program (SCHIP) choose managed care plans with better quality of care.2001 New York SCHIP evaluation data; 2001 New York State Managed Care Plan Performance Report; 2000 New York State Managed Care Enrollment Report.Each market was defined as a county. A final sample of 2,325 new enrollees was analyzed after excluding those in markets with only one SCHIP plan. Plan quality was measured using seven Consumer Assessment of Health Plans Survey (CAHPS) and three Health Plan Employer Data and Information Set (HEDIS) scores. A conditional logit model was applied with plan and individual/family characteristics as covariates.There were 30 plans in the 45 defined markets. The choice probability increased 2.5 percentage points for each unit increase in the average CAHPS score, and the association was significantly larger in children with special health care needs. However, HEDIS did not show any statistically significant association with plan choice.Low-income parents do choose managed care plans with higher CAHPS scores for their newly enrolled children, suggesting that overall quality could improve over time because of the dynamics of enrollment.

Most rural or suburban high-speed isolated intersections have higher traffic volumes on the major approach compared with the minor approach. Often these intersections are not close enough to one another to provide coordination and are not far enough apart to disperse vehicle platoons completely on the major approach. These major-approach vehicle platoons are forced to stop frequently because of conflicting calls placed by a few vehicles on the minor approach. As a result, these intersections operate poorly, especially during peak periods. In addition, advance warning flashers are used at these intersections to warn motorists of the end of the green. The conventional method uses the trailing overlap green, which holds the green for a fixed time after gap-out. This trailing overlap green replaces the existing dilemma-zone protection provided by loop detectors and also increases delay on the minor approach. Recently, platoon-priority signal control systems have been developed to progress platoons efficiently at these intersections. In addition, the Texas Transportation Institute has developed the advance warning end-of-green system to provide advance warning at these intersections without the necessity of holding the green after gap-out. In this study, these systems are integrated and the performance of the system is evaluated in terms of delay, stops, and advance warning time. Cabinet-in-the-loop tests performed with a real scenario suggested potential benefits of 50% reduction in delay and stops on the major approach experiencing platoons. It was also found that the total intersection delay and stops were reduced by as much as 20%.

For decades, traffic conditions have been measured using aggregated point measurements from loop detectors. However, new technologies have become available recently that can assess traffic conditions by tracking vehicle trajectories and travel times. Among these new technologies is cell phone tracking, a concept that has received strong interest from the transportation community. AirSage, Inc., a private firm in the United States, has constructed a proprietary system that, using the Sprint PCS network, can track cell phone movements in Minneapolis, Minnesota, and deliver travel times for most of the urban roads, including both limited access freeways and signalized arterials. A University of Minnesota research team was consulted to evaluate the system's travel times against measured conditions and assess the level of accuracy and reliability of the technology through statistical analysis. The system's performance during its first-stage deployment in May and early June of 2007 was evaluated, including the system's accuracy on a limited access freeway and a signalized arterial during the peak hours over a 16-day period. The technology produced results with varied accuracies. Whether this system would produce acceptable margins of error for speeds and travel times depends on the guidelines set forth by interested transportation agencies.

In this article, the authors explore why medical device innovation has traditionally been geared so thoroughly toward improving performance, with little regard to cost. They argue that the changing incentives in the health care sector and the move to value-based payment models, accelerated by the implementation of the Affordable Care Act, will force device manufacturers to redirect investments from the spectacular toward the prudent, which they dub “the end of sexy.” The authors explore consequences for manufacturers, investors, and policymakers.

The U.S. government is deeply involved in the health care market, and in the price control settings, one of the government's concerns is quality of care. Since managed care started expanding throughout the country in the 1980s, government and private organizations have been trying to develop quality measurement tools and monitor the quality of care. For example, the Consumer Assessment of Health Plans Survey (CAHPS®) and the Health Plan Employer Data and Information Set (HEDIS®) were developed to assess the quality of managed care plans in the 1990s. Starting in 1999, Congress has required the Agency of Healthcare Research and Quality (AHRQ) to produce an annual National Health Quality Report (AHRQ 2003). In recent years, an increasing number of states have switched their Medicaid or State Children's Health Insurance Program (SCHIP) from fee-for-service to managed care (Kaiser Family Foundation 2001). For example, New York State and the State of Florida rely on managed care plans to provide health care for SCHIP enrollees. In New York State, mandatory Medicaid managed care has been implemented in about 30 counties (NYSDOH 2005). The New York State government sets the monthly capitation rate for participating managed care plans and releases an annual quality report of all the managed care plans operating in the state. The relationship between quality of care and competition has been one of the focuses of researchers for the last several decades. Most prior studies are about hospital competition, which is subject to price control under the Medicare Prospective Payment System (PPS). Based on the data before 1983 when the PPS was implemented, many studies show a positive association between competition and quality or cost (e.g., Joskow 1980; Robinson and Luft 1985, 1987; Noether 1988). Those studies analyzing the data after 1983, however, provide mixed evidence on the relationship between competition and quality or cost because there are two forces at play: the PPS and the penetration of managed care. The PPS actually acts as a price control mechanism, and higher price is associated with higher quality if assuming the same market competition level, as shown in the study by Cutler (1995). Alternatively, if the price is held constant, increasing market competition would result in higher quality and higher cost. Theoretically, managed care penetration would lower the cost of care, but the PPS would lead to higher costs in more competitive markets. Not surprisingly, the evidence about cost or quality is mixed (e.g., Shortell and Hughes 1988; Zwanziger and Melnick 1988; Dranove, Shanley, and Simon 1992; Manheim, Bazzoli, and Sohn 1994; Kessler and McClellan 2000; Mukamel, Zwanziger, and Tomaszewski 2001; Gowrisankaran and Town 2003). Because managed care plans have financial incentives to reduce cost at the expense of quality of care, the effect of managed care competition on quality is worthy of investigation. However, only a few studies have been conducted in this area. Using a national representative sample from the Community Tracking Study, Sommers and Wholey (2003) regress evaluation of physician thoroughness on health maintenance organization (HMO) competition and other control variables, and conclude that HMO competition increases the evaluation of physician thoroughness among HMO enrollees. Scanlon et al. (2005) assess the association between HMO competition and plan performance as measured by CAHPS and HEDIS, and find that competition is negatively correlated with three out of six quality domains. Another study using longitudinal data by Scanlon et al. (2006), however, shows that more HMO competition is associated with better overall ratings of health plans, but is not consistently correlated with HEDIS measures. Despite the states' increasing dependence on managed care to provide comprehensive coverage for the low-income population, few studies have been conducted to examine the effect of nonprice competition on the quality of care. Nonprice competition means a situation where price does not play a role in market competition. Using the 2002 New York State Managed Care Plan Performance Report and 2001 Annual Managed Care Enrollment Report, we are able to assess the effect of nonprice competition on quality of care within the New York SCHIP market,1 which is subject to the price control from the state government.

After the 11 September tragedy, 20% of the scheduled US airline flights were cancelled and the passenger load factor was down to 56% from 66.6% a year ago. Was the high death toll or the nature of the attack itself responsible for this dramatic decline? Using the US data, we find that the demand for air travel did fall in years of relatively high fatality rate, but the demand is not sensitive to whether the high fatality rate is due to any terrorist activities. Our estimation results suggest that even after controlling for the sharp increase in the fatality rate because of the 11 September tragedy, a considerable proportion of the decline in demand for air travel that year is still unexplained. This evidence could suggest that there has been a fundamental shift in consumers' perception of air travel safety in the aftermath of the tragedy.

Study Purpose Administrative databases are commonly used to examine use of healthcare service, with researchers relying on diagnostic codes to identify medical conditions. This study evaluates the accuracy of administrative claims in identifying Parkinsonism cases compared to the self-reported Parkinson's disease (PD). Methods The reference cases were identified based on the self-reported PD status and the use of PD drugs collected by the 1992–2000 Medicare Current Beneficiary Survey that contained 72,922 observations from 30,469 individuals. Using ICD-9 CM, cases with PD were extracted from the corresponding Medicare claims. We compared prevalence of PD obtained using different types of claims. Results The sensitivities were the highest when all claims were used (66%). All the specificities were greater than 99%. When drug use information was included in the gold standard, the sensitivities became lower, while the specificities and positive predictive values (PPVs) increased. Using more diagnostic codes improved the sensitivity of the identification process but reduced PPVs. Conclusions Administrative claims can provide fairly accurate and practical approach to “rule in” patients with PD. Depending on the purpose of evaluation, researchers may consider using more categories of claims to improve the sensitivity of the identification algorithm or use fewer diagnoses to minimize number of false positive cases. © 2006 Movement Disorder Society

Objectives: To compare the effectiveness and costs of telephone-only approach to in-person plus telephone for delivering an evidence-based, coordinated care management program for dementia. Methods: We randomized 151 patient–caregiver dyads from an underserved predominantly Latino community to two arms that shared a care management protocol but implemented in different formats: in-person visits at home and/or in the community plus telephone and mail, versus telephone and mail only. We compared between-arm caregiver burden and care-recipient problem behaviors (primary outcomes) and patient–caregiver dyad retention, care quality, health care utilization, and costs (secondary outcomes) at 6- and 12-months follow-up. Results: Care quality improved substantially over time in both arms. Caregiver burden, care-recipient problem behaviors, retention, and health care utilization did not differ across arms but the in-person program cost more to deliver. Discussion: Dementia care quality improved regardless of how care management was delivered; large differences in effectiveness or cost offsets were not detected.

Previous studies have demonstrated that Medicare risk-adjusted capitation models do not adequately compensate programs serving primarily disabled or frail populations. Using the Medicare Current Beneficiary Survey, we demonstrate that the Centers for Medicare and Medicaid Services-Hierarchical Condition Categories (CMS-HCC) model calculates Medicare capitation payments for Parkinson's patients more accurately than for the general population. The discrepancies between the predicted and actual expenditures estimated at various disability levels were smaller for Parkinson's patients than for other beneficiaries. If the CMS-HCC payment model were to apply to programs that draw a significant percentage of their participants from the Parkinson's disease community, these programs likely would be compensated fairly.

Child sexual abuse (CSA) has been shown to enhance risk for HIV infection and other adverse outcomes. However, most studies examine the effects of a single incident of CSA rather than the full burden of abuse over the life span in predicting these adverse outcomes. A multi-dimensional approach was used in this study to examine the severity of abuse as a predictor of post-traumatic stress, depression, sexual symptoms, and risky sexual behaviors in a multi-ethnic sample of 147 HIV-positive women. Multivariate models indicated that experiencing both intrafamilial and extrafamilial CSA, adult sexual abuse (ASA) and Latina ethnicity predicted PTSD symptoms. ASA also predicted sexual trauma symptoms. Also, CSA and adult re-victimization contributed independently to risk for PTSD and sexual trauma symptoms, but not for risky sexual behaviors. The results support the need for interventions for HIV-positive women that address the full burden of abuse experienced and its sequelae.

We evaluated medical utilization and economic burden of self-reported Parkinson's disease (PD) on patients and society. Using the 1992–2000 Medicare Current Beneficiary Survey, we compared health care utilization and expenditures (in 2002 U.S. dollars) of Medicare subscribers with and without PD, adjusting for sociodemographic characteristics and comorbidities. PD patients used significantly more health care services of all categories and paid significantly more out of pocket for their medical services than other elderly (mean ± SE, $5,532 ± $329 vs. $2,187 ± $38; P < 0.001). After adjusting for other factors, PD patients had higher annual health care expenses than beneficiaries without PD ($18,528 vs. $10,818; P < 0.001). PD patients were more likely to use medical care (OR = 3.77; 95% CI = 1.44–9.88), in particular for long-term care (OR = 3.80; 95% CI = 3.02–4.79) and home health care (OR = 2.08; 95% CI = 1.76–2.46). PD is associated with a significant economic burden to patients and society. Although more research is needed to understand the relationship between PD and medical expenditures and utilization, these findings have important implications for health care providers and payers that serve PD populations. © 2005 Movement Disorder Society

OBJECTIVE: Eye injury in the workplace is common worldwide. This study proposed to explore both risk and preventive factors re eye injuries in Hong Kong. DESIGN: Case-control study. PARTICIPANTS: A total of 239 work-related eye injury patients, and 253 subjects without a history of any eye injury as controls. METHODS: Patients with all incident cases of work-related eye injuries attending the ophthalmology clinics of 3 major public hospitals in Hong Kong during the first 3 months of 2000 were invited to participate. Controls were selected from the general population and were frequency matched to patients based on gender. Patients were interviewed face-to-face by trained interviewers in the ophthalmology clinics, using a structured questionnaire. Telephone interviews were used for controls. MAIN OUTCOME MEASURES: Risk and protective factors associated with eye injuries. RESULTS: Among eye injury cases, 158 patients (66.1%) reported having incurred 1 episode of eye injury during employment, 49 (20.5%) having suffered 2 episodes, and 32 (13.4%) having experienced >/==" BORDER="0">3 eye injuries at work. Most of the patients (85.4%) did not wear any protective devices at the time of injury. Subjects who wore safety glasses regularly were less likely to have eye injuries (odds ratio [OR] = 0.29, 95% confidence interval [CI] = 0.14-0.62). Having a safety requirement for wearing safety glasses was negatively associated with eye injuries (OR = 0.31, 95% CI = 0.15-0.62). Multivariate analysis indicated that exposures to certain work hazards and working in the construction industry were positively associated with eye injuries. Subjects who worked longer in their current job, who reported having received job safety training before employment, or whose machines or equipment were maintained or repaired regularly by employers were at lower risk of experiencing eye injuries. CONCLUSIONS: Construction workers and those exposed to multiple hazards may get eye injuries at work. They should be provided with protective devices that are effective in preventing such exposures. Health education and safety training are important in preventing eye injuries. Maintenance and repair of machines and equipment may effectively reduce or eliminate the sources of exposures.

The recent passage of the Affordable Care Act has heightened the importance of workplace wellness programs. This paper used administrative data from 2002 to 2007 for PepsiCo’s self-insured plan members to evaluate the effect of its wellness program on medical costs and utilization. We used propensity score matching to identify a comparison group who were eligible for the program but did not participate. No significant changes were observed in inpatient admissions, emergency room visits, or per-member per-month (PMPM) costs. The discrepancy between our findings and those of prior studies may be due to the difference in intervention intensity or program implementation.

Using recently available data from China's Disease Surveillance Points system, we estimate that there are over 300,000 suicides in China per year; this makes suicide one of the most important causes of death in the country and makes the suicide rate in China one of the highest in the world. Moreover, the pattern of suicides in China is quite different than in other parts of the world--there are more completed suicides among females than males and rural rates are three-fold urban rates. The lack of reliable suicide data prior to 1987 makes it difficult to determine whether the rates are currently rising, falling, or staying constant. However, reports of suicides in the Chinese press and case studies conducted by the authors suggest (but do not prove) that the high rates of suicide currently experienced are related to the social changes that have occurred with the economic reforms (which started in 1978). Another possible explanation for the high rates of suicide is the large numbers of persons with depressive illness in China who remain untreated. Single-cause models of suicide (i.e., social factors or mental illness) do not do justice to the complexity of the processes involved and, therefore, do not provide useful information about the etiology and prevention of suicide in China or elsewhere. We describe our own dynamic model of suicide that includes five interacting factors which, we believe, collectively determine the suicide rates in a community.

Several million American workers wear respirators on a regular basis, and the Occupational Safety and Health Administration (OSHA) requires that nonagricultural firms have a respiratory protection program. This article uses the OSHA inspection data base to examine all inspections in manufacturing in 47 states from 1999 through 2006; the examination starts with 1999 because an expanded OSHA respiratory program standard became effective in late 1998. The article identifies all inspections and all establishments at which respiratory protection (RP) violations were cited, and it compares the prevalence of violations by industry with the prevalence reported in a recent Bureau of Labor Statistics survey of respirator use. Multivariate analyses are used to identify the roles of industry, establishment size, union status, and employee participation in the inspection on noncompliance at the inspection level and for repeated inspections at the same establishment. The authors find that the pattern of noncompliance across industries mostly mirrors the survey findings about the prevalence of requirements for respirator use, although the chemical industry has fewer violations than expected. The probability of citing an RP violation is similar across establishment size categories, except for a large drop for establishments with over 200 workers. The presence of a worker accompanying the inspector increases the probability that a respiratory program violation will be cited; the presence of a union slightly decreases it.

Medicare's approximately 250 accountable care organizations (ACOs) care for a growing portion of all fee-for-service beneficiaries across the United States. We examined where ACOs have formed and what regional factors are predictive of ACO formation. Understanding these factors could help policy makers foster growth in areas with limited ACO development. We found wide variation in ACO formation, with large areas, such as the Northwest, essentially empty of ACOs, and others, such as the Northeast and Midwest, dense with the organizations. Key regional factors associated with ACO formation include a greater fraction of hospital risk sharing (capitation), larger integrated hospital systems, and primary care physicians practicing in large groups. Area income, Medicare per capita spending, Medicare Advantage enrollment rates, and physician density were not associated with ACO formation. Together, these results imply that underlying provider integration in a region may help drive the formation of ACOs.

The objective of this study was to examine the impact of PepsiCo's health and wellness program on medical cost and utilization. The authors analyzed health plan and program data of employees and dependents 19-64 years of age, who had 2 years of baseline data (2002 and 2003) and at least 1 year of data from the intervention period (2004 to 2007), resulting in a sample of 55,030 members. Program effects were measured using a difference-in-difference approach based on a multivariate regression model with an individual-level random effect. In its first year, the program was associated with a relative increase in per member per month (PMPM) cost ($66, P0.01); a relative reduction in PMPM costs of $76 (P0.01) and $61 (P0.01) was seen in the second and third year, respectively. Over all 3 years, the program was associated with reduced PMPM costs of $38 (P0.01), a decrease of 50 emergency room visits per 1000 member years (P0.01), and a decrease of 16 hospital admissions per 1000 member years (P0.01). The disease management component reduced PMPM costs by $154 (P0.01), case management increased PMPM costs by $2795 (P0.01), but no significant effects were observed for lifestyle management over the 3 intervention years. The implementation of a comprehensive health and wellness program was associated with a cost increase in the first year, followed by a decrease in the following years. These results highlight the importance of taking a long-term perspective when implementing such programs and evaluating their effectiveness.

Context The frequency with which anesthesiologists or nurse anesthetists provide sedation for gastrointestinal endoscopies, especially for low-risk patients, is poorly understood and controversial. Objective To quantify temporal comparisons and regional variation in the use of and payment for gastroenterology anesthesia services. Design, Setting, and Patients A retrospective analysis of claims data for a 5% representative sample of Medicare fee-for-service patients (1.1 million adults) and a sample of 5.5 million commercially insured patients between 2003 and 2009. Main Outcome Measures Total number of upper gastrointestinal endoscopies and colonoscopies, proportion of gastroenterology procedures with associated anesthesia claims, payments for gastroenterology anesthesia services, and proportion of services and spending for gastroenterology anesthesia delivered to low-risk patients (American Society of Anesthesiologists physical status class 1 or 2). Results The number of gastroenterology procedures per million enrollees remained largely unchanged in Medicare patients (mean, 136 718 procedures), but increased more than 50% in commercially insured patients (from 33 599 in 2003 to 50 816 in 2009). In both populations, the proportion of procedures using anesthesia services increased from approximately 14% in 2003 to more than 30% in 2009, and more than two-thirds of anesthesia services were delivered to low-risk patients. There was substantial regional variation in the proportion of procedures using anesthesia services in both populations (ranging from 13% in the West to 59% in the Northeast). Payments for gastroenterology anesthesia services doubled in Medicare patients and quadrupled in commercially insured patients. Conclusions Between 2003 and 2009, utilization of anesthesia services during gastroenterology procedures increased substantially. Anesthesia services are predominantly used in low-risk patients and show considerable regional variation.

The use of dedicated anesthesia providers for routine gastroenterology (GI) procedures is seen as medically justifiable only for high-risk patients. Eliminating these services for low-risk patients could generate $1.1 billion in savings per year.

This study assessed the course of perinatal depression among 210 Latinas who were and were not affected by intimate partner violence (IPV) and identified associated psychosocial factors. Peak depression prevalence occurred prenatally among 45.7% of IPV-exposed and 24.6% of non-IPV-exposed Latinas. At each assessment, depression was significantly higher for IPV-exposed compared to non-IPV-exposed mothers. Mastery and social support were associated with lower depression, whereas history of IPV, perceived stress, and avoidant coping behaviors were associated with higher depression. Findings support recommendations for routine depression and IPV screening of Latinas in perinatal clinical settings.

During the past decade, experts have devoted substantial efforts to quality improvement for managed care. Although a handful of studies have examined the effect of quality on enrollment, few have systematically investigated the association between managed care quality and plan disenrollment, especially among lowincome populations.To examine whether higher-quality measures in managed care plans are associated with lower disenrollment from the State Children's Health Insurance Program (SCHIP) in New York State.Observational study of managed care plan disenrollment for a New York statewide cohort of 2206 new SCHIP enrollees.Managed care quality was measured by 7 Consumer Assessment of Health Plans Survey (CAHPS) scores and 3 Healthcare Effectiveness Data and Information Set (HEDIS) scores, obtained from the 2002 New York State Managed Care Plan Performance Report. Disenrollment was defined as being disenrolled from an SCHIP plan for 2 or more consecutive months based on the New York SCHIP universal billing files.Nearly 40% of children were disenrolled during the study period. No overall effects of plan quality on disenrollment were detected, but plans with higher scores in "preventive care visits" had a significantly lower disenrollment rate. The disenrollment rate in the eligibility recertification period was 3.2 percentage points higher than that in other time periods.Disenrollment was not associated with overall managed care plan quality as measured by CAHPS and HEDIS, suggesting that further study is warranted to determine optimal strategies for enhancing managed care quality in the SCHIP population.

Proposals to use episodes of care as a basis for payment and performance measurement are largely conceptual at this stage, with little empirical work or experience in applied settings to guide their design. Based on analyses of Medicare data, we identified key issues that will need to be considered related to defining episodes and determining which provider is accountable for an episode. We suggest a number of applied studies and demonstrations that would facilitate more rapid movement of episode-based approaches from concept to implementation.

Retail clinics are an increasingly popular source for medical care. Concerns have been raised about the effect of these clinics on the cost, quality, and delivery of preventive care.To compare the care received at retail clinics for 3 acute conditions with that received at other care settings.Claims data from 2005 and 2006 from the health plan were aggregated into care episodes (units that included initial and follow-up visits, pharmaceuticals, and ancillary tests). After 2100 episodes (700 each) were identified in which otitis media, pharyngitis, and urinary tract infection (UTI) were treated first in retail clinics, these episodes were matched with other episodes in which these illnesses were treated first in physician offices, urgent care centers, or emergency departments.Enrollees of a large Minnesota health plan.Enrollees who received care for otitis media, pharyngitis, or UTI.Costs per episode, performance on 14 quality indicators, and receipt of 7 preventive care services at the initial appointment or subsequent 3 months.Overall costs of care for episodes initiated at retail clinics were substantially lower than those of matched episodes initiated at physician offices, urgent care centers, and emergency departments ($110 vs. $166, $156, and $570, respectively; P0.001 for each comparison). Prescription costs were similar in retail clinics, physician offices, and urgent care centers ($21, $21, and $22), as were aggregate quality scores (63.6%, 61.0%, and 62.6%) and patient's receipt of preventive care (14.5%, 14.2%, and 13.7%) (P0.05 vs. retail clinics). In emergency departments, average prescription costs were higher and aggregate quality scores were significantly lower than in other settings.A limited number of quality measures and preventive care services were studied. Despite matching, patients at different care sites might differ in their severity of illness.Retail clinics provide less costly treatment than physician offices or urgent care centers for 3 common illnesses, with no apparent adverse effect on quality of care or delivery of preventive care.California HealthCare Foundation.

While the HIV epidemic has disproportionately affected African American and Latino men who have sex with men (MSM), few HIV prevention interventions have focused on African American and Latino men who have sex with both men and women (MSMW). Even fewer interventions target HIV-positive African American and Latino MSM and MSMW with histories of childhood sexual abuse (CSA), a population that may be vulnerable to high-risk sexual behaviors, having multiple sexual partners, and depression. The Men’s Health Project, a small randomized clinical trial, compared the effects of two 6-session interventions, the Sexual Health Intervention for Men (S-HIM), guided by social learning theory and aimed at decreasing high-risk sexual behaviors, number of sexual partners, and depressive symptoms, and a standard health promotion control (SHP). A community sample of 137 HIV-positive gay and non-gay identifying African American and Latino MSM and MSMW with histories of CSA was recruited. Results were based on an “intent to treat” analyses of baseline to post, 3 and 6 month follow-ups. The sample as a whole reported reductions in sexual risk behaviors and number of sexual partners from baseline to post-test, and from the 3 to 6 month follow-ups, although the decrease in sexual risk behavior from baseline to post-test was significant only for S-HIM participants. No significant differences between conditions were reported for depressive symptoms, but the total sample reported a significant decrease at 6 months. These findings highlight the importance of addressing sexual decision-making and psychological adjustment for ethnic men, while being sensitive to CSA histories and sexual minority status, and suggest the need to develop additional strategies to heighten HIV risk reduction over time.

To examine the effect of nonprice competition among managed care plans on the quality of care in the New York SCHIP market.U.S. Census 2000; 2002 New York State Managed Care Plan Performance Report; and 2001 New York State Managed Care Annual Enrollment Report.Each market is defined as a county, and competition is measured as the number of plans in a market. Quality of care is measured in percentages using three Consumer Assessment of Health Plans Survey and three Health Plan Employer Data and Information Set scores. Two-stage least squares is applied to address the endogeneity between competition and the quality of care, using population as an instrument.We find a negative association between competition and quality of care. An additional managed care plan is significantly associated with a decrease of 0.40-2.31 percentage points in four out of six quality measures. After adjusting for production cost, a positive correlation is observed between price and quality measures across different pricing regions.It seems likely that pricing policy is a constraint on quality production, although it may not be interpreted as a causal relationship and further study is needed.

Perceived waiting time at signalized intersections differs from the actual waiting time and varies with signal design. The onerousness of delay depends on the conditions under which it is experienced. Using weighted travel time may contribute to optimal signal control if it can improve on the assumption that all time is weighted equally by users. This research explores the perception of waiting time at signalized intersections on the basis of the results of an online virtual experience stated preference survey. This survey directly collected the perceived waiting times and the user ratings of the signal designs of each intersection on an arterial that included three intersections. Statistically analyzing the survey data suggests that the perception of waiting time is a function of the actual time, and a quadratic model describes the relationship. The survey also indicates that there exists a trade-off between total waiting time and individual waiting time at each intersection. Drivers prefer to split the total waiting time across multiple intersections at the price of a longer total wait if the difference in the total waiting time of two signal designs is within 30 s. Survey data show that the perceived waiting time, instead of the actual waiting time, better explains how users rate the individual signal designs for intersections and arterials, including multiple intersections.