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Objective: There has been a trend toward hospital systems and insurers acquiring privately owned physician practices and subsequently converting them into vertically integrated practices. The purpose of this study is to observe whether this change in ownership of a medical practice influences adherence to clinical guidelines for the management of type 1 and type 2 diabetes. Methods: This is an observational study using pooled cross-sectional data (2014-2016 and 2018-2019) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. A total of 7499 chronic routine follow ups and preventative care visits to non-integrated (solo and group physician practices) and integrated practices were analyzed to see whether guideline concordant care was provided. Measures included 7 services that are recommended annually for individuals with type 1 and type 2 diabetes (HbA1c, lipid panel, serum creatinine, depression screening, influenza immunization, foot examination, and BMI). Results: Compared to non-integrated physician practices, vertically integrated practices had higher rates of hemoglobin A1C testing (odds ratio 1.58 [95% CI 1.07-2.33], P <.05), serum creatine testing (odds ratio 1.53 [95% CI 1.02-2.29], P <.05), foot examinations (odds ratio 2.03 [95% CI 0.98-4.22], P =.058), and BMI measuring (odds ratio 1.54 [95% CI 0.99-2.39], P =.054). There was no significant difference in lipid panel testing, depression screenings, or influenza immunizations. Conclusions: Our results show that integrated medical practices have a higher adherence to diabetes practice guidelines than non-integrated practices. However, rates of services provided regardless of ownership were low. [ABSTRACT FROM AUTHOR]

Objective: This study examines the relationship between increasing certified nursing assistants (CNAs) and licensed nurse staffing ratios and deficiencies in Florida nursing homes over a 4-year period. Methods: Data from Florida staffing reports and the Online Survey Certification and Reporting database examine the relationship among staffing levels and deficiency citations for 663 Florida nursing homes between 2002 and 2005. Using a generalized estimating equation approach in SAS Proc Genmod, we estimate the relationship between CNA and licensed nursing staff, and facilities' total deficiency score and quality of care deficiency scores--calculated using the Centers for Medicare and Medicaid Services' Nursing Home Compare Five-Star Quality Rating System, which accounts for the complexity of the scope and severity of the citations. Results: Our results confirmed that higher CNA staffing levels were predictors of lower total deficiency scores and quality of care deficiency scores after controlling for facility characteristics. Conclusion: With a large sample size, repeated measure design, and advanced methods, we have found a relationship between CNA staffing and nursing home quality.

Objective: To assess the association between rurality and depression care. Methods: Data were extracted for 10,319 individuals with self-reported depression in the Medical Expenditure Panel Survey. Pharmacotherapy was defined as an antidepressant prescription fill, and minimally adequate pharmacotherapy was defined as receipt of at least 4 antidepressant fills. Psychotherapy was defined as an outpatient counseling visit, and minimally adequate psychotherapy was defined as [greater than or equal to] 8 visits. Rurality was defined using Metropolitan Statistical Areas (MSAs) and Rural Urban Continuum Codes (RUCCs). Results: Over the year, 65.1% received depression treatment, including 58.8% with at least 1 antidepressant prescription fill and 24.5% with at least 1 psychotherapy visit. Among those in treatment, 56.2% had minimally adequate pharmacotherapy treatment and 36.3% had minimally adequate psychotherapy treatment. Overall, there were no significant rural-urban differences in receipt of any type of formal depression treatment. However, rural residence was associated with significantly higher odds of receiving pharmacotherapy (MSA: OR 1.16 [95% CI, 1.01-1.34; P= 0.04] and RUCC: OR 1.04 [95% CI, 1.00-1.08; P= 0.05]), and significantly lower odds of receiving psychotherapy (MSA: OR 0.62 [95% CI, 0.53-0.74; P less than 0.01] and RUCC: OR 0.91 [95% CI, 0.88-0.94; P less than 0.001]). Rural residence was not significantly associated with the adequacy of pharmacotherapy, but it was significantly associated with the adequacy of psychotherapy (MSA: OR 0.53 [95% CI, 0.41-0.69; P less than 0.01] and RUCC: OR 0.92 [95% CI, 0.86-0.99; P= 0.02]). Psychiatrists per capita were a mediator in the psychotherapy analyses. Conclusions: Rural individuals are more reliant on pharmacotherapy than psychotherapy. This may be a concern if individuals in rural areas turn to pharmacotherapy because psychotherapists are unavailable rather than because they have a preference for pharmacotherapy.

Purpose: We explore how nursing home characteristics affect the number of lawsuits filed against the facilities in Florida during the period from 1997 to 2001. Design and Methods: We examined data from 478 nursing homes in 30 Florida counties from 1997 to 2001. We obtained the data from Westlaw's Adverse Filings: Lawsuits database, the Online Survey, Certification, and Reporting system database from the Centers for Medicare and Medicaid Services, and state complaint surveys, and we also used primary data. We used negative binomial regression to explain total lawsuit variance by year. We controlled for acuity and year effects, and our explanatory variables included (a) facility characteristics--including staffing, number of beds, multistate system membership, and for-profit ownership--and (b) quality measures--including total number and type of state licensing survey deficiencies, pressure-sore development, and medication errors per resident. Results: Higher registered nurse and certified nursing assistant staffing levels were associated with Fewer lawsuits. More deficiencies on the licensing survey and larger and for-profit nursing homes were positively related with higher numbers of lawsuits. Implications: This study suggests that nursing homes that meet long-stay staffing standards, meet minimum quality measures, are not for profit, and are smaller will experience fewer lawsuits.