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Abstract Objective To investigate competing explanations for why Medicare Fee for Service (FFS) and private sector payments lead to hospital cost variations in Californian counties. Data sources Ratios of private to Medicare hospital costs were obtained from state-based all-payer claims databases. Demographics were estimated from the U.S. Census Bureau and the California Health Interview Survey. Medicaid and Medicare spending was obtained from Kaiser Family Foundation. Medicare Advantage enrollment was obtained from the California Department of Health Care Services and market consolidation was estimated using the Herfindahl–Hirschman Index (HHI). Study design Per capita costs, demographics, Medicaid and Medicare spending, Medicare Advantage enrollment, and HHI scores were compared for San Francisco (SF), Sacramento, Los Angeles (LA), and San Diego (SD). Principal findings LA hospitals had the lowest per capita private insurer costs, but the highest Medicare FFS costs. The findings might be explained by a lower HHI for LA, indicating a more competitive market, than SD, SF, and Sacramento. Conclusions Medicare FFS hospital costs do not provide an accurate representation of health care spending in Californian counties. In more competitive markets, private insurance companies can negotiate lower prices, while oversupply may allow facilities to increase volume in Medicare FFS.

Background: India implemented a basket of public health developmental packages to achieve the Sustainable Development Goal (SDG) 6—providing access to clean water and adequate sanitation for all by 2030. Though the country is getting closer to being free of open defecation, the pace of progress varies spatially. Therefore, the current study is relevant to explore determinants of practicing open defecation at the small area level in India. Methods: The present study included the latest National Family and Health Survey (2019–21) and applied both non-spatial (bivariate statistics with ꭔ2 test and multivariate logistic regression) and spatial analyses (Univariate and bivariate LISA Moran I, OLS, SLM, and SEM) to assess the national level predictors and spatially auto-correlated determinants of practicing open defecation. Results: In India, almost one-fifth of households practiced open defecation, mainly clustered in the Middle Ganges Plain, central, and eastern region. A significant rural-urban and poor-rich gap in open defecation practice was also observed. The spatial clusters of lower-educated individuals, poorest wealth quintile, backward social groups, and rural residence were found to be prone to open defecation practice. Housing condition and water supply with the house were also significantly auto-correlated with open defecation practice. Conclusion: Open defecation remains a public health challenge in India, particularly in the north and central parts, among rural populations, and in socioeconomically deprived areas. It is crucial to focus on small area-level program implementation and assessment approaches to eliminate open defecation in India by 2030.

Objective: To investigate competing explanations for why Medicare Fee for Service (FFS) and private sector payments lead to hospital cost variations in Californian counties. Data sources: Ratios of private to Medicare hospital costs were obtained from state-based all-payer claims databases. Demographics were estimated from the U.S. Census Bureau and the California Health Interview Survey. Medicaid and Medicare spending was obtained from Kaiser Family Foundation. Medicare Advantage enrollment was obtained from the California Department of Health Care Services and market consolidation was estimated using the Herfindahl–Hirschman Index (HHI). Study design: Per capita costs, demographics, Medicaid and Medicare spending, Medicare Advantage enrollment, and HHI scores were compared for San Francisco (SF), Sacramento, Los Angeles (LA), and San Diego (SD). Principal findings: LA hospitals had the lowest per capita private insurer costs, but the highest Medicare FFS costs. The findings might be explained by a lower HHI for LA, indicating a more competitive market, than SD, SF, and Sacramento. Conclusions: Medicare FFS hospital costs do not provide an accurate representation of health care spending in Californian counties. In more competitive markets, private insurance companies can negotiate lower prices, while oversupply may allow facilities to increase volume in Medicare FFS. [ABSTRACT FROM AUTHOR]

Background: India implemented a basket of public health developmental packages to achieve the Sustainable Development Goal (SDG) 6dproviding access to clean water and adequate sanitation for all by 2030. Though the country is getting closer to being free of open defecation, the pace of progress varies spatially. Therefore, the current study is relevant to explore determinants of practicing open defecation at the small area level in India. Methods: The present study included the latest National Family and Health Survey (2019-21) and applied both non-spatial (bivariate statistics with x² test and multivariate logistic regression) and spatial analyses (Univariate and bivariate LISA Moran I, OLS, SLM, and SEM) to assess the national level predictors and spatially auto-correlated determinants of practicing open defecation. Results: In India, almost one-fifth of households practiced open defecation, mainly clustered in the Middle Ganges Plain, central, and eastern region. A significant rural-urban and poor-rich gap in open defecation practice was also observed. The spatial clusters of lower-educated individuals, poorest wealth quintile, backward social groups, and rural residence were found to be prone to open defecation practice. Housing condition and water supply with the house were also significantly auto-correlated with open defecation practice. Conclusion: Open defecation remains a public health challenge in India, particularly in the north and central parts, among rural populations, and in socioeconomically deprived areas. It is crucial to focus on small area-level program implementation and assessment approaches to eliminate open defecation in India by 2030. [ABSTRACT FROM AUTHOR]

Childhood stunting prevalence varies across small geographic areas, which may reflect social and built environmental characteristics. Though literacy is a known predictor of stunting, small area research on adult literacy shaping childhood stunting prevalence has not been investigated for Bangladesh. This study examines small area variation in childhood stunting prevalence and estimates the association between small area stunting prevalence and adult literacy rate controlling for other covariates. Data on stunting prevalence, adult literacy rates and other covariates were extracted for 478 subdistricts of Bangladesh. Spatial regression models were used to estimate the relationship between adult literacy rates and childhood stunting prevalence at the subdistrict-level. Stunting prevalence substantially varied across subdistricts in Bangladesh. Subdistrict-level stunting prevalence was inversely associated with the subdistrict-level adult literacy rate. Furthermore, the estimated effect for the female literacy rate was slightly more than the male literacy rate. Among other covariates, higher levels of people without access to a sanitary toilet was linked to greater stunting. The findings of small-area variation in stunting prevalence and its associated area-level compositional and contextual features could be useful for planning and targeting the geographic area-specific interventions to alleviate the extent of childhood stunting in Bangladesh. This study may also help policymakers allocate resources in geographical hotspots of higher stunting prevalence. An integrated approach to improving adult literacy and increasing sanitation coverage through multisectoral collaboration can help reduce the childhood stunting burden in Bangladesh. [ABSTRACT FROM AUTHOR]

India is home to the highest global number of women and children suffering from anemia, with one in every two women impacted. India's current strategy for targeting areas with a high anemia burden is based on district-level averages, yet this fails to capture the substantial small area variation in micro-geographical (small area) units such as villages. We conducted statistical and econometric analyses to quantify the extent of small area variation in the three grades of anemia (severe, moderate, and mild) among women and children across 36 states/union territories and 707 districts of India. We utilized data from the fifth round of the National Family Health Survey conducted in 2019–21. The final analytic sample for analyses was 183,883 children aged 6–59 months and 690,153 women aged 15–49 years. The primary outcome variable for the analysis was the three anemia grades among women and children. We adopted a three-level and four-level logistic regression model to compute variance partitioning of anemia among women and children. We also computed precision-weighted prevalence estimates of women and childhood anemia across 707 districts and within-district, between-cluster variation using standard deviation (SD). For severe anemia among women, small area (villages or urban blocks) account for highest share (46.1%; Var: 0.494; SE: 0.150) in total variation followed by states (39.4%; Var: 0.422; SE: 0.134) and districts (12.8%; Var: 0.156; SE: 0.012). Similarly, clusters account for the highest share in the variation in severe (61.3%; Var: 0.899; SE: 0.069) and moderate (46.4%: Var: 0.398; SE: 0.011) anemia among children. For mild and moderate anemia among women, however, states were the highest source of variation. Additionally, we found a high and positive correlation between mean prevalence and inter-cluster SD of moderate and severe anemia among women and children. In contrast, the correlation was weaker for mild anemia among women (r = 0.61) and children (0.66). In this analysis, we are positing the critical importance of small area variation within districts when designing strategies for targeting high burden areas for anemia interventions.

Objectives: To compare health service use and clinical outcomes for patients with and without direct discharge to home (DDH) from ICUs in Ontario.Design: Population-based, observational, cohort study using propensity scoring to match patients who were DDH to those not DDH and a preference-based instrumental variable (IV) analysis using ICU-level DDH rate as the IV.Setting: ICUs in Ontario.Patients: Patients discharged home from a hospitalization either directly or within 48 hours of care in an ICU between April 1, 2015, and March 31, 2017.Intervention: DDH from ICU.Measurements and Main Results: Among 76,737 patients in our cohort, 46,859 (61%) were DDH from the ICU. In the propensity matched cohort, the odds for our primary outcome of hospital readmission or emergency department (ED) visit within 30 days were not significantly different for patients DDH (odds ratio [OR], 1.00; 95% CI, 0.96-1.04), and there was no difference in mortality at 90 days for patients DDH (OR, 1.08; 95% CI, 0.97-1.21). The effect on hospital readmission or ED visits was similar in the subgroup of patients discharged from level 2 (OR, 0.98; 95% CI, 0.92-1.04) and level 3 ICUs (OR, 1.02; 95% CI, 0.96-1.09) and in the subgroups with cardiac conditions (OR, 1.03; 95% CI, 0.96-1.12) and noncardiac conditions (OR, 0.98; 95% CI, 0.94-1.03). Similar results were obtained in the IV analysis (coefficient for hospital readmission or ED visit within 30 d = -0.03 ± 0.03 ( se ); p = 0.3).Conclusions: There was no difference in outcomes for patients DDH compared with ward transfer prior to discharge when two approaches were used to minimize confounding within a large health systemwide observational cohort. We did not evaluate how patients are selected for DDH. Our results suggest that with careful patient selection, this practice might be feasible for routine implementation to ensure efficient and safe use of limited healthcare resources. [ABSTRACT FROM AUTHOR]

Abstract Background Variation in health care delivery among regions and hospitals has been observed worldwide and reported to have resulted in health inequalities. Regional variation of percutaneous coronary intervention (PCI) was previously reported in Japan. This study aimed to assess the small-area and hospital-level variations and to examine the influence of patient and hospital characteristics on the use of PCI. Methods Data provided by the Fukuoka Prefecture Latter-stage Elderly Insurance Association was used. There were 11,821 patients aged ≥65 years with acute coronary syndromes who were identified from 2015 to 2017. Three-level multilevel logistic regression analyses were performed to quantify the small-area and hospital variations, as well as, to identify the determinants of PCI use. Results The results showed significant variation (δ2 = 0.744) and increased PCI use (MOR = 2.425) at the hospital level. After controlling patient- and hospital-level characteristics, a large proportional change in cluster variance was found at the hospital level (PCV 14.7%). Fixed-effect estimation results showed that females, patients aged ≥80 years old, hypertension and dyslipidemia had significant association with the use of PCI. Hospitals with high physician density had a significantly positive relationship with PCI use. Conclusions Patients receiving care in hospitals located in small areas have equitable access to PCI. Hospital-level variation might be originated from the oversupply of physicians. A balanced number of physicians and beds should be taken into consideration during healthcare allocation. A treatment process guideline on PCI targeting older patients is also needed to ensure a more equitable access for healthcare resources.

Introduction: Chest pain is a common emergency department (ED) presentation accounting for 8-10million visits per year in the United States. Physician-level factors such as risk tolerance are predictive ofadmission rates. The recent advent of accelerated diagnostic pathways and ED observation units mayhave an impact in reducing variation in admission rates on the individual physician level.Methods: We conducted a single-institution retrospective observational study of ED patients with adiagnosis of chest pain as determined by diagnostic code from our hospital administrative database.We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram(ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into twogroups: “admission” (this included observation and inpatients) and “discharged.” We stratified physiciansby age, gender, residency location, and years since medical school. We controlled for patient- andhospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values.Results: Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to thehospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) weredischarged. Median number of patients per physician was 132 (interquartile range 89-172). Averageadmission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) wereto observation. There was significant variation in the admission rate at the individual physician level withadjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians’characteristics, years elapsed since finishing medical school demonstrated a trend towards associationwith a higher admission probability.Conclusion: There is substantial variation among physicians in the management of patients presentingwith chest pain, with physician experience playing a role.

Aims: The aim of this study was to describe variation in hip fracture treatment in Norway expressed as adherence to international and national evidence-based treatment guidelines, to study factors influencing deviation from guidelines, and to analyze consequences of non-adherence. Methods: International and national guidelines were identified and treatment recommendations extracted. All 43 hospitals routinely treating hip fractures in Norway were characterized. From the Norwegian Hip Fracture Register (NHFR), hip fracture patients aged > 65 years and operated in the period January 2014 to December 2018 for fractures with conclusive treatment guidelines were included (n = 29,613: femoral neck fractures (n = 21,325), stable trochanteric fractures (n = 5,546), inter- and subtrochanteric fractures (n = 2,742)). Adherence to treatment recommendations and a composite indicator of best practice were analyzed. Patient survival and reoperations were evaluated for each recommendation. Results: Median age of the patients was 84 (IQR 77 to 89) years and 69% (20,427/29,613) were women. Overall, 79% (23,390/29,613) were treated within 48 hours, and 80% (23,635/29,613) by a surgeon with more than three years’ experience. Adherence to guidelines varied substantially but was markedly better in 2018 than in 2014. Having a dedicated hip fracture unit (OR 1.06, 95%CI 1.01 to 1.11) and a hospital hip fracture programme (OR 1.16, 95% CI 1.06 to 1.27) increased the probability of treatment according to best practice. Surgery after 48 hours increased one-year mortality significantly (OR 1.13, 95% CI 1.05 to 1.22; p = 0.001). Alternative treatment to arthroplasty for displaced femoral neck fractures (FNFs) increased mortality after 30 days (OR 1.29, 95% CI 1.03 to 1.62)) and one year (OR 1.45, 95% CI 1.22 to 1.72), and also increased the number of reoperations (OR 4.61, 95% CI 3.73 to 5.71). An uncemented stem increased the risk of reoperation significantly (OR 1.23, 95% CI 1.02 to 1.48; p = 0.030). Conclusion: Our study demonstrates a substantial variation between hospitals in adherence to evidence-based guidelines for treatment of hip fractures in Norway. Non-adherence can be ascribed to in-hospital factors. Poor adherence has significant negative consequences for patients in the form of increased mortality rates at 30 and 365 days post-treatment and in reoperation rates.

Equal access for equal needs is a key goal for many healthcare systems but geographical variation research has shown that this is often not the case in areas other than vascular surgery. This study assessed the variation across specialised vascular centres of an entire healthcare system in the costs and outcomes for patients having first time revascularisation for peripheral arterial occlusive disease. This was a national study of all first time revascularisations performed in the Danish healthcare system between 2009 and 2014. Episodes were identified in the Danish Vascular Registry (n = 10 300) and data on one year follow up in terms of the costs of specialised healthcare (€) and amputation status were acquired from national registers. Generalised gamma and logit regressions were used to predict margins between centres while adjusting for population heterogeneity (age, sex, education, smoking, hypertension, diabetes, use of prophylactic pharmacological therapy, indication and type of revascularisation). Cost effectiveness frontiers were used to identify efficient providers and to illustrate the cost of reducing the system level risk of amputation. For each of the indications of chronic limb threatening and acute limb ischaemia, the one year amputation risks varied from 11% to 16% across centres (p =.003, p =.006) whereas for intermittent claudication there was no significant difference across centres. The corresponding costs of care varied across centres for all indications (p =.027, p =.028, p =.030). Linking costs and outcomes, three of seven centres were observed to provide poorer quality at higher costs. Exponentially increasing costs to obtain the maximum reduction of the amputation risk were observed. The results suggest that there is substantial variation in the clinical management of peripheral arterial occlusive disease across the Danish healthcare system and that this results in very different levels of efficiency – on top of potentially unequal treatment for equal needs. Further research is warranted. [ABSTRACT FROM AUTHOR]

Supplemental digital content is available in the text. Objective: The aims of the study were to demonstrate a method for developing rehabilitation service areas and to compare service areas based on postacute care rehabilitation admissions to service areas based on acute care hospital admissions. Design: We conducted a secondary analysis of 2013–2014 Medicare records for older patients in Texas (N = 469,172). Our analysis included admission records for inpatient rehabilitation facilities, skilled nursing facilities, long-term care hospitals, and home health agencies. We used Ward's algorithm to cluster patient ZIP Code Tabulation Areas based on which facilities patients were admitted to for rehabilitation. For comparison, we set the number of rehabilitation clusters to 22 to allow for comparison to the 22 hospital referral regions in Texas. Two methods were used to evaluate rehabilitation service areas: intraclass correlation coefficient and variance in the number of rehabilitation beds across areas. Results: Rehabilitation service areas had a higher intraclass correlation coefficient (0.081 vs. 0.076) and variance in beds (27.8 vs. 21.4). Our findings suggest that service areas based on rehabilitation admissions capture has more variation than those based on acute hospital admissions. Conclusions: This study suggests that the use of rehabilitation service areas would lead to more accurate assessments of rehabilitation geographic variations and their use in understanding rehabilitation outcomes. [ABSTRACT FROM AUTHOR]

Background: Variation in health care delivery among regions and hospitals has been observed worldwide and reported to have resulted in health inequalities. Regional variation of percutaneous coronary intervention (PCI) was previously reported in Japan. This study aimed to assess the small-area and hospital-level variations and to examine the influence of patient and hospital characteristics on the use of PCI. Methods: Data provided by the Fukuoka Prefecture Latter-stage Elderly Insurance Association was used. There were 11,821 patients aged ≥65 years with acute coronary syndromes who were identified from 2015 to 2017. Three-level multilevel logistic regression analyses were performed to quantify the small-area and hospital variations, as well as, to identify the determinants of PCI use. Results: The results showed significant variation (δ2 = 0.744) and increased PCI use (MOR = 2.425) at the hospital level. After controlling patient- and hospital-level characteristics, a large proportional change in cluster variance was found at the hospital level (PCV 14.7%). Fixed-effect estimation results showed that females, patients aged ≥80 years old, hypertension and dyslipidemia had significant association with the use of PCI. Hospitals with high physician density had a significantly positive relationship with PCI use. Conclusions: Patients receiving care in hospitals located in small areas have equitable access to PCI. Hospital-level variation might be originated from the oversupply of physicians. A balanced number of physicians and beds should be taken into consideration during healthcare allocation. A treatment process guideline on PCI targeting older patients is also needed to ensure a more equitable access for healthcare resources. [ABSTRACT FROM AUTHOR]

Abstract Background Senior high cost health care users (HCU) are a priority for many governments. Little research has addressed regional variation of HCU incidence and outcomes, especially among incident HCU. This study describes the regional variation in healthcare costs and mortality across Ontario’s health planning districts [Local Health Integration Networks (LHIN)] among senior incident HCU and non-HCU and explores the relationship between healthcare spending and mortality. Methods We conducted a retrospective population-based matched cohort study of incident senior HCU defined as Ontarians aged ≥66 years in the top 5% most costly healthcare users in fiscal year (FY) 2013. We matched HCU to non-HCU (1:3) based on age, sex and LHIN. Primary outcomes were LHIN-based variation in costs (total and 12 cost components) and mortality during FY2013 as measured by variance estimates derived from multi-level models. Outcomes were risk-adjusted for age, sex, ADGs, and low-income status. In a cost-mortality analysis by LHIN, risk-adjusted random effects for total costs and mortality were graphically presented together in a cost-mortality plane to identify low and high performers. Results We studied 175,847 incident HCU and 527,541 matched non-HCU. On average, 94 out of 1000 seniors per LHIN were HCU (CV = 4.6%). The mean total costs for HCU in FY2013 were 12 times higher that of non-HCU ($29,779 vs. $2472 respectively), whereas all-cause mortality was 13.6 times greater (103.9 vs. 7.5 per 1000 seniors). Regional variation in costs and mortality was lower in senior HCU compared with non-HCU. We identified greater variability in accessing the healthcare system, but, once the patient entered the system, variation in costs was low. The traditional drivers of costs and mortality that we adjusted for played little role in driving the observed variation in HCUs’ outcomes. We identified LHINs that had high mortality rates despite elevated healthcare expenditures and those that achieved lower mortality at lower costs. Some LHINs achieved low mortality at excessively high costs. Conclusions Risk-adjusted allocation of healthcare resources to seniors in Ontario is overall similar across health districts, more so for HCU than non-HCU. Identified important variation in the cost-mortality relationship across LHINs needs to be further explored.

: Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to describe county-level variation in use of surgery for stage I-II pancreatic ductal adenocarcinoma (PDAC) and the association between county surgery rates and cancer-specific survival (CSS). Background: The degree of small geographic area variation in use of surgery for stage I-II PDAC and the association between area surgery rates and CSS remain incompletely defined. Methods: This is a retrospective cohort study of patients aged 18 to 80 years in the 2007 to 2015 Surveillance, Epidemiology, and End Results database with stage I-II PDAC without contraindications to surgery or refusal. Multilevel models were used to characterize county-level variation in use of surgery and CSS. County-specific risk- and reliability-adjusted surgery rates and CSS rates were calculated. Results: Of 18,100 patients living in 581 counties, 10,944 (60.5%) underwent surgery. Adjusted county-specific surgery rates varied 1.5-fold from 49.9% to 74.6%. Median CSS increased in a graded fashion from 13 months [interquartile range (IQR) 13-14] in counties with surgery rates of 49.9% to 56.9% to 18 months (IQR 17-19) in counties with surgery rates of 68.0% to 74.6%. Results were similar in multivariable analyses. Adjusted county 18-month CSS rates varied 1.6-fold from 32.7% to 53.7%. Adjusted county surgery and 18-month CSS rates were correlated (r = 0.54; P < 0.001) and county surgery rates explained approximately half of county-level variation in CSS. Only 18 (3.1%) counties had adjusted surgery rates of 68.0% to 74.6%, which was associated with the longest CSS. Conclusions: County-specific rates of surgery varied substantially, and patients living in areas with higher surgery rates lived longer. These data suggest that increasing use of surgery in stage I-II PDAC could lead to improvements in survival. [ABSTRACT FROM AUTHOR]

Objective: To describe trends and patient and system factors associated with direct discharge from critical care to home in a large health system.Design: Population-based cohort study of direct discharge to home rates annually over 10 years. We used a multivariable, multilevel random-effects regression model to analyze current factors associated with direct discharge home in a subcohort from the most recent 2 years.Setting: One hundred seventy-four ICUs in 101 hospitals in Ontario.Patients: All patients discharged from an ICU between April 1, 2007, and March 31, 2017.Interventions: None.Measurements and Main Results: Overall, 237,200 patients (21.1%) were discharged directly home from an ICU. The rate of direct discharge to home increased from 18.6% in 2007 to 23.1% in 2017 (annual increase of 1.02; 95% CI, 1.02-1.03). There were marked variations in rates of direct discharge to home across all critical care units. For medical and surgical units, the median odds ratio was 1.76 (95% CI, 1.59-1.92). In these units, direct discharge to home was associated with younger age (odds ratio, 0.36; 95% CI, 0.34-0.39 for age 80-105 vs age 18-39), fewer comorbidities (odds ratio, 1.74; 95% CI, 1.63-1.85 for Charlson comorbidity index of 0 vs 2), diagnoses of overdose/poisoning (odds ratio, 1.35; 95% CI, 1.23-1.47) and diabetic complications (odds ratio, 1.35; 95% CI, 1.2-1.51), and admission after a same-day procedure (odds ratio, 2.82; 95% CI, 2.46-3.23 compared with emergency department). ICU occupancy was inversely associated with direct discharge to home with an odds ratio of 0.88 (95% CI, 0.87-0.88) for each 10% increase.Conclusions: High rates of direct discharge to home with evidence of significant practice variation combined with identifiable patient characteristics suggest that further evaluation of this increasingly common transition in care is warranted. [ABSTRACT FROM AUTHOR]

Despite a multi-decade decrease in cardiovascular disease, geographic disparities have widened, with excess mortality concentrated within the United States (U.S.) South. Petroleum production and refining, a major contributor to climate change, is concentrated within the U.S. South and emits multiple classes of atherogenic pollutants. We investigated whether residential exposure to oil refineries could explain variation in self-reported coronary heart disease (CHD) prevalence among adults in southern states for the year 2018, where the majority of oil refinery activity occurs (Alabama, Mississippi, Louisiana, Arkansas, Texas, New Mexico, and Oklahoma). We examined census tract-level association between oil refineries and CHD prevalence. We used a double matching method to adjust for measured and unmeasured spatial confounders: one-to-n distance matching and one-to-one generalized propensity score matching. Exposure metrics were constructed based on proximity to refineries, activities of refineries, and wind speed/direction. For all census tracts within 10 km of refineries, self-reported CHD prevalence ranged from 1.2% to 17.6%. Compared to census tracts located at ≥5 km and <10 km, one standard deviation increase in the exposure within 5 km of refineries was associated with a 0.33 (95% confidence interval: 0.04, 0.63) percentage point increase in the prevalence. A total of 1119.0 (123.5, 2114.2) prevalent cases or 1.6% (0.2, 3.1) of CHD prevalence in areas within 5 km from refineries were potentially explained by exposure to oil refineries. At the census tract-level, the prevalence of CHD explained by exposure to oil refineries ranged from 0.02% (0.00, 0.05) to 47.4% (5.2, 89.5). Thus, although we cannot rule out potential confounding by other personal risk factors, CHD prevalence was found to be higher in populations living nearer to oil refineries, which may suggest that exposure to oil refineries can increase CHD risk, warranting further investigation. • Association of oil refineries with coronary heart disease (CHD) was examined. • We found positive association in seven states of the southern U.S. • The prevalence of CHD explained ranged from 0.02% to 47.4%. • Residents living nearer to oil refineries may have a higher risk of CHD. • Oil refineries may explain small area variation in the risk of CHD. [ABSTRACT FROM AUTHOR]

Background: Senior high cost health care users (HCU) are a priority for many governments. Little research has addressed regional variation of HCU incidence and outcomes, especially among incident HCU. This study describes the regional variation in healthcare costs and mortality across Ontario's health planning districts [Local Health Integration Networks (LHIN)] among senior incident HCU and non-HCU and explores the relationship between healthcare spending and mortality.Methods: We conducted a retrospective population-based matched cohort study of incident senior HCU defined as Ontarians aged ≥66 years in the top 5% most costly healthcare users in fiscal year (FY) 2013. We matched HCU to non-HCU (1:3) based on age, sex and LHIN. Primary outcomes were LHIN-based variation in costs (total and 12 cost components) and mortality during FY2013 as measured by variance estimates derived from multi-level models. Outcomes were risk-adjusted for age, sex, ADGs, and low-income status. In a cost-mortality analysis by LHIN, risk-adjusted random effects for total costs and mortality were graphically presented together in a cost-mortality plane to identify low and high performers.Results: We studied 175,847 incident HCU and 527,541 matched non-HCU. On average, 94 out of 1000 seniors per LHIN were HCU (CV = 4.6%). The mean total costs for HCU in FY2013 were 12 times higher that of non-HCU ($29,779 vs. $2472 respectively), whereas all-cause mortality was 13.6 times greater (103.9 vs. 7.5 per 1000 seniors). Regional variation in costs and mortality was lower in senior HCU compared with non-HCU. We identified greater variability in accessing the healthcare system, but, once the patient entered the system, variation in costs was low. The traditional drivers of costs and mortality that we adjusted for played little role in driving the observed variation in HCUs' outcomes. We identified LHINs that had high mortality rates despite elevated healthcare expenditures and those that achieved lower mortality at lower costs. Some LHINs achieved low mortality at excessively high costs.Conclusions: Risk-adjusted allocation of healthcare resources to seniors in Ontario is overall similar across health districts, more so for HCU than non-HCU. Identified important variation in the cost-mortality relationship across LHINs needs to be further explored. [ABSTRACT FROM AUTHOR]

Abstract: Rationale, Aims, and Objectives: The physician is often implicated as an important cause of observed variations in health care service use. However, it is not clear if physician‐related variation is problematic for patient care. This paper illustrates that observed physician‐related variation is not necessarily unwarranted. Methods: This is a narrative review. Results: Many studies have attributed observed variations to the physician, but little attention is given towards discriminating between those variations that exist for good reasons and those that are unwarranted. Two arguments can be made for why physician‐related variation is unwarranted. The first posits that physician‐related factors should not play a role in management of care decisions because such decisions should be driven by science (which is imagined to be definitive). The second considers the possibility of supplier‐induced demand as a factor driving observed variations. We show that neither argument is sufficient to rule out that physician‐related variations may be warranted. Furthermore, the claim that such variations are necessarily problematic for patients has yet to be substantiated empirically. Conclusions: It is not enough to simply show that physician‐related variation can exist—one must also show where it is unwarranted and what is the magnitude of unwarranted variations. Failure to show this can have significant implications on how we interpret and respond to observed variations. Improved measurement of the sources of variation, especially with respect to patient preferences and context, may help us start to disentangle physician‐related variation that is desirable from that which is unwarranted. [ABSTRACT FROM AUTHOR]

Background: Use of antipsychotics in elderly patients with dementia has decreased in the past decade due to safety regulations; however use is still high. Geographical variation may indicate discrepancies in clinical practice and lack of adherence to evidence-based guidelines for the management of behavioral symptoms. Objective: To investigate potential geographical variances in use of antipsychotic drugs in dementia care. Methods: A registry-based cross-sectional study in the entire elderly population of Denmark (≥65 years) conducted in 2012. Data included place of residence, prescriptions filled, and hospital discharge diagnoses. Antipsychotic drug use among elderly with (n = 34,536) and without (n = 931,203) a dementia diagnosis was compared across the five regions and 98 municipalities in Denmark, adjusted for age and sex. Results: In 2012, the national prevalence of antipsychotic drug use was 20.7% for elderly patients with dementia, with a national incidence of 3.9%. The prevalence ranged from 17.0% to 23.3% in the five regions and from 7.5% to 33.1% in the 98 municipalities, demonstrating an over four-fold difference. Conclusion: The observed geographical variation was more pronounced at municipal level as compared to regional level, suggesting that the variation may be related to variances in clinical practice in primary care. This study highlights an urgent need for further educating professional carers and physicians to guide non-pharmacological as well as pharmacological management of neuropsychiatric symptoms in elderly patients with dementia. [ABSTRACT FROM AUTHOR]

In 2010-2012, new outpatient service locations were established in Hungarian micro-regions, which had lacked such capacities before. We exploit this quasi-experiment to estimate the effect of geographical accessibility on outpatient case numbers using both individual-level and semi-aggregate panel data. We find a 24-27 per cent increase of case numbers as a result of the establishments. Our specialty-by-specialty estimates imply that a 1-min reduction of travel time to the nearest outpatient unit increases case numbers for example by 0.9 per cent in internal care and 3.1 per cent in rheumatology. The size of the new outpatient capacities has a separate effect, raising the possibility of the presence of supplier-induced demand. By combining a fixed-effects logit and a fixed-effects truncated Poisson estimator, we decompose the effects into increases in the probability of ever visiting a doctor on the one hand and an increase of the frequency of visits on the other hand. We find that new visits were dominant in the vast majority of specialties, whereas both margins were important for example in rheumatology. Finally, we demonstrate the usefulness of the fixed-effects truncated Poisson estimator in modelling count data by examining its robustness by simulations. Copyright © 2015 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Area-level variation in treatment and outcomes may be a potential source of confounding bias in observational comparative effectiveness studies. This paper demonstrates how to use exploratory spatial data analysis (ESDA) and spatial statistical methods to investigate and control for these potential biases. The case presented compares the effectiveness of two antipsychotic treatment strategies: oral second-generation antipsychotics (SGAs) vs. long-acting paliperiodone palmitate (PP). Methods: A new-start cohort study was conducted analyzing patient-level administrative claims data (8/1/2008-4/30/ 2011) from Missouri Medicaid. ESDA techniques were used to examine spatial patterns of antipsychotic prescriptions and outcomes (hospitalization and emergency department (ED) visits). Likelihood of mental health-related outcomes were compared between patients starting PP (N = 295) and oral SGAs (N = 8,626) using multilevel logistic regression models adjusting for patient composition (demographic and clinical factors) and geographic region. Results: ESDA indicated significant spatial variation in antipsychotic prescription patterns and moderate variation in hospitalization and ED visits thereby indicating possible confounding by geography. In the multilevel models for this antipsychotic case example, patient composition represented a stronger source of confounding than geographic context. Conclusion: Because geographic variation in health care delivery is ubiquitous, it could be a comparative effectiveness research (CER) best practice to test for possible geographic confounding in observational data. Though the magnitude of the area-level geography effects were small in this case, they were still statistically significant and should therefore be examined as part of this observational CER study. More research is needed to better estimate the range of confounding due to geography across different types of observational comparative effectiveness studies and healthcare utilization outcomes. [ABSTRACT FROM AUTHOR]

The article relates a study which assesses the patterns and predictors of percutaneous vertebroplasty use among low-income Medicare beneficiaries from Pennsylvania, diagnosed with spine fracture between 2001 and 2004. The study found that 7.2% of patients underwent a vertebroplasty within 12 months after diagnosis, and has increased over the 4-year study period. Also, it was determined that substantial variation from zero to >15% patients undergoing vertebroplasty was observed.

This paper re-examines criticisms of cross-sectional methods used to test for supplier-induced demand (SID) and re-evaluates the empirical evidence using data from Australian medical services. Cross-sectional studies of SID have been criticised on two grounds. First, and most important, the inclusion of the doctor supply in the demand equation leads to an identification problem. This criticism is shown to be invalid, as the doctor supply variable is stochastic and depends upon a variety of other variables including the desirability of the location. Second, cross-sectional studies of SID fail diagnostic tests and produce artefactual findings due to model misspecification. Contrary to this, the re-evaluation of cross-sectional Australian data indicate that demand equations that do not include the doctor supply are misspecified. Empirical evidence from the re-evaluation of Australian medical services data supports the notion of SID. Demand and supply equations are well specified and have very good explanatory power. The demand equation is identified and the desirability of a location is an important predictor of the doctor supply. Results show an average price elasticity of demand of 0.22 and an average elasticity of demand with respect to the doctor supply of 0.46, with the impact of SID becoming stronger as the doctor supply rises. The conclusion we draw from this paper is that two of the main criticisms of the empirical evidence supporting the SID hypothesis have been inappropriately levelled at the methods used. More importantly, SID provides a satisfactory, and robust, explanation of the empirical data on the demand for medical services in Australia. [ABSTRACT FROM AUTHOR]

The aim of this study was to review the research evidence for a decreasing time trend in medical practice variation and to contribute to our theoretical understanding of trends in medical practice variations. We searched PubMed for articles reporting on time trends in medical practice variations. Eleven relevant articles were identified. The studies we found tend to show a downward trend in practice variation. Six of the eleven studies show a decrease in practice variation, three studies report more or less stable variation, and only two show increasing variation. The number of studies is, however, small and the aspects of medical practice that were studied in these articles are diverse. A trend in medical practice variation can probably best be explained by institutional changes within and outside health care, which on the one hand directly lead to decreased practice variation and on the other hand make the working environment of physicians more uniform. [ABSTRACT FROM AUTHOR]

Objective: To understand the role of race, ethnicity, and affluence in elderly patients' use of teaching hospitals when they have that option.Methods: Using a novel data set of 787,587 Medicare patients newly diagnosed with serious illness in 1993, we look at how sociodemographic factors influence whether patients use a teaching hospital for their initial hospitalization for their disease. We use hierarchical linear models to take into account differences in the availability of teaching hospitals to different groups. These models look within groups of people who live in the same county and ask what demographic factors make an individual within that county more or less likely to use a teaching hospital.Results: We find that blacks are much more likely than whites to use teaching hospitals (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.73 to 1.77). However, Hispanics and Asian-Americans are less likely to use teaching hospitals than are whites (Hispanic OR, 0.92; 95% CI, 0.88 to 0.97; Asian-American OR, 0.89; 95% CI, 0.82 to 0.97). Medicaid patients are less likely to use teaching hospitals (given their opportunities) than are non-Medicaid recipients (OR, 0.91; 95% CI, 0.90 to 0.92). And we find a curvilinear relationship with affluence, with those in the poorest and those in the wealthiest neighborhoods most likely to use a teaching hospital.Conclusion: The use of teaching hospitals is more complex that heretofore appreciated. Understanding why some groups do not go to teaching hospitals could be important for the health of those groups and of teaching hospitals. [ABSTRACT FROM AUTHOR]

The aim was to describe the regional variation of population based surgery rates in Finland with special reference to the comparison of surgical activities in individual hospitals. Data on 11 common procedures covering all Finnish hospitals were obtained from the Finnish Hospital Discharge Register and the Finnish Medical Birth Register of the years 1987 and 1988. The variations of age and sex standardized procedure rates were studied across the procedure specific hospital service areas. The variation was estimated by three methods: extremal quotient, coefficient of variation, and systematic component of variation. The statistical significance of the variation measures was tested with a computerized simulation model. The variation was small for mastectomy, inguinal hernia repair, and hip replacement due to fracture, and large for lumbar disc operations, haemorrhoidectomies, and uterus operations. The results are similar to those of comparable studies elsewhere. The results indicate that there are clear differences in surgical activities between Finnish hospitals. [ABSTRACT FROM PUBLISHER]

Background: Although effective care for type 2 diabetes (T2DM) is well known, considerable inadequate care has been still existed. Variations in achievement of the recommended quality indicators inT2DM care among small areas are not well known in Korea. This study examined the quality of care T2DM care and its geographical variations., Methods: We used the national health insurance database and national health screening database. Seven quality indicators were used to evaluate continuity of care (medication possession ratio), process of care (hemoglobin A1c test, lipid profile, microalbuminuria test, and eye examination), and intermediate outcome (blood pressure control, and low-density lipoprotein control). Crude and age-standardized proportions were calculated for each 252 districts in Korea., Results: All quality indicators failed to achieve the recommended level. Only about 3% and 15% of the patients underwent eye examination and microalbuminuria test, respectively. Other indicators ranged from 48% to 68%. Wide variation in the quality existed among districts and indicators. Eye examination and microalbuminuria test varied the most showing tenfold (0.9%-9.2%) and fourfold (6.3%-28.9%) variation by districts, respectively. There were 32.4 and 42.7 percentage point gap between the best and the worst districts in hemoglobin A1c test and blood pressure control, respectively., Conclusion: Considerable proportion of T2DM patients were not adequately managed and quality of care varied substantially district to district. To improve the quality of diabetes care, it is necessary to identify the poor performance areas and establish a well-coordinated care system tailored to the need of the district., Competing Interests: The authors have no potential conflicts of interest to disclose. This article was based on a KNHIS Atlas Project 2016, final report submitted by the authors to Korean National Health Insurance Service., (© 2019 The Korean Academy of Medical Sciences.)

This paper exploits rich SOEP microdata to analyze state-level variation in health care utilization in Germany. Unlike most studies in the field of the Small Area Variation (SAV) literature, our approach allows us to net out a large array of individual-level and state-level factors that may contribute to the geographic variation in health care utilization. The raw data suggest that state-level hospitalization rates vary from 65 to 165 percent of the national mean. Ambulatory doctor visits range from 90 to 120 percent of the national mean. Interestingly, in the former GDR states, doctor visit rates are significantly below the national mean, while hospitalization rates lie above the national mean. The significant state-level differences vanish once we control for individual-level socio-economic characteristics, the respondents' health status, their health behavior as well as supply-side state-level factors., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)