Health Policy & Management

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Start date: 2012End date: 2019

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    Family structure and multiple domains of child well-being in the United States: a cross-sectional study
    (Springer Nature, 2015-02-21) Krueger, Patrick M; Jutte, Douglas P; Franzini, Luisa; Elo, Irma; Hayward, Mark D
    We examine the association between family structure and children’s health care utilization, barriers to health care access, health, and schooling and cognitive outcomes and assess whether socioeconomic status (SES) accounts for those family structure differences. We advance prior research by focusing on understudied but increasingly common family structures including single father families and five different family structures that include grandparents. Our data on United States children aged birth through 17 (unweighted N = 198,864) come from the 1997–2013 waves of the National Health Interview Survey, a nationally representative, publicly available, household-based sample. We examine 17 outcomes across nine family structures, including married couple, cohabiting couple, single mother, and single father families, with and without grandparents, and skipped-generation families that include children and grandparents but not parents. The SES measures include family income, home ownership, and parents’ or grandparents’ (depending on who is in the household) employment and education. Compared to children living with married couples, children in single mother, extended single mother, and cohabiting couple families average poorer outcomes, but children in single father families sometimes average better health outcomes. The presence of grandparents in single parent, cohabiting, or married couple families does not buffer children from adverse outcomes. SES only partially explains family structure disparities in children’s well-being. All non-married couple family structures are associated with some adverse outcomes among children, but the degree of disadvantage varies across family structures. Efforts to understand and improve child well-being might be most effective if they recognize the increasing diversity in children’s living arrangements.
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    Future expenditure risk of silent members: a statistical analysis
    (Springer Nature, 2016-07-29) Krause, Trudy Millard; Donderici, Elifnur Yay; Cazaban, Cecilia Ganduglia; Franzini, Luisa
    Silent-members are members of a medical health plan who submit no claims for healthcare services in a benefit year despite 12 months of continuous-enrollment. This study was conducted to evaluate the future expenditure risk of commercial-insured members who avoid all medical care despite coverage. In order to determine if the silent-members were at greater risk, we compared them to members who received care in the anchor year (2009) but had low-expenditures. The low-expenditure members were assumed to represent persons without significant medical conditions and without care-avoidance behaviors. We examined the claims experience of a cohort of silent members in the 2 years after the silent year (2009) and compared it with the corresponding claims experience for a cohort of low-expenditure members from the same anchor year (2009). Members of commercial health plans (BCBS of Texas) were selected based on continuous-enrollment in 2009. Two sub-groups were identified based on annual claims expenditure: Care avoiders were members with 12 months continuous-enrollment and no medical claims, and are thus referred to as “silent members” in the insurance industry. Low-Expenditure members were those with 12 months continuous-enrollment and total PMPY (per member per year) annual medical claims expenditure in the lowest 10th percentile of members with claims experience. “Low-expenditure” members served as a comparison group to the “silent members”, under the assumption that such claimants were using benefits for minor healthcare issues as needed. Key variables were enrollment and expenditures. Enrollment data identified demographics and continuous-enrollment. Medical claims data were used to calculate utilization and expenditures. All claims data were de-identified and no consent was required, as approved by the Institutional Review Board. No research involved human subjects. Multivariate logistic regression models were applied. Silent members who seek care in subsequent years have a greater probability of becoming high-expenditure claimants than those with low-expenditure experience. For silent members who subsequently seek treatment, the probability of becoming high-expenditure is significantly greater than low-expenditure members from the anchor year. The implications of future high costs for silent members who become claimants may support the need for additional research to address the risks of care avoidance behaviors.
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    A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits
    (Springer Nature, 2018-05-03) Mi, Ranran; Hollander, Matthew M.; Jones, Courtney M. C.; DuGoff, Eva H.; Caprio, Thomas V.; Cushman, Jeremy T.; Kind, Amy J. H.; Lohmeier, Michael; Shah, Manish N.
    Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role. This single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults’ ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged≥ 60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit. This is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits.
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    The impact of integrating medical assistants and community health workers on diabetes care management in community health centers
    (Springer Nature, 2018-11-20) Rodriguez, Hector P.; Friedberg, Mark W.; Vargas-Bustamante, Arturo; Chen, Xiao; Martinez, Ana E.; Roby, Dylan H.
    To compare the impact of implementing team-based diabetes care management involving community health workers (CHWs) vs. medical assistants (MA) in community health centers (CHCs) on diabetes care processes, intermediate outcomes, and patients’ experiences of chronic care. Patients in the CHW intervention arm had improved annual glycated hemoglobin testing (18.5%, p < 0.001), while patients in the MA intervention arm had improved low-density lipoprotein cholesterol control (8.4%, p < 0.05) and reported better chronic care experiences over time (β=7.5, p < 0.001). Except for chronic care experiences (p < 0.05) for patients in the MA intervention group, difference-in-difference estimates were not statistically significant because control group patients also improved over time. Some diabetes care processes improved significantly more for control group patients than intervention group patients. Key informant interviews revealed that immediate patient care issues sometimes crowded out diabetes care management activities, especially for MAs. Diabetes care improved in CHCs integrating CHWs and MAs onto primary care teams, but the improvements were no different than improvements observed among matched control group patients. Greater improvement using CHW and MA team-based approaches may be possible if practice leaders minimize use of these personnel to cover shortages that often arise in busy primary care practices.
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    The medical home functions of primary care practices that care for adults with psychological distress: a cross-sectional study
    (Springer Nature, 2019-01-09) Linman, Shawn; Benjenk, Ivy; Chen, Jie
    Primary care practices are changing the way that they provide care by increasing their medical home functionality. Medical home functionality can improve access to care and increase patient-centeredness, which is essential for persons with mental health issues. This study aims to explore the degree to which medical home functions have been implemented by primary care practices that care for adults with psychological distress. Analysis of the 2015 Medical Expenditure Panel Survey Household Component and Medical Organizations Survey. This unique data set links data from a nationally representative sample of US households to the practices in which they receive primary care. This study focused on adults aged 18 and above. As compared to adults without psychological distress, adults with psychological distress had significantly higher rates of chronic illness and poverty. Adults with psychological distress were more likely to receive care from practices that include advanced practitioners and are non-profit or hospital-based. Multivariate models that were adjusted for patient-level and practice-level characteristics indicated that adults with psychological distress are as likely to receive primary care from practices with medical home functionality, including case management, electronic health records, flexible scheduling, and PCMH certification, as adults without psychological distress. Practices that care for adults with mental health issues have not been left behind in the transition towards medical home models of primary care. Policy makers should continue to prioritize adults with mental health issues to receive primary care through this model of delivery due to this population’s great potential to benefit from improved access and care coordination.
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    Adverse Childhood Experiences and Preterm Birth: A Systematic Review
    (2019) Wiggan, Morgan Lynn; Franzin, Luisa; Shenassa, Edmond; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    Adverse childhood Experiences (ACEs) elevate one’s risk for poor health outcomes later in life such as psychiatric disorders, cardiovascular disease, depression, anxiety, obesity, diabetes, poor fetal health, and liver disease (Poulton et al., 2002, Anda et al., 2007, Jimenez et al., 2017, Talbot et al., 2009. While the association between ACEs and negative health outcomes is well established in the literature, only ten studies examine the effect of ACEs on one’s risk for preterm birth (Benedict et al. 1999; Bublitz et al., 2014; Cammack et al., 2019; Christiaens et al. 2015; Jacobs 1998; Gillespie et al. 2017; Grimstad et al. 1998; Leeners et al. 2010; Margerison-Zilko et al., 2016; Noll et al. 2007). Preterm birth accounts for 60% of neonatal deaths and elevates an infant’s risk for poor health outcomes later in life ranging from behavioral issues to heart disease (WHO, 2018) and the rate of preterm birth in the United States has steadily risen since 2015, reaching about 10% in 2018 (CDC, 2018). This systematic review seeks to critically assess and synthesize these ten studies and identify proposed mediators and identify gaps in the literature for future research.
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    Addressing refugee health through evidence-based policies: A case study
    (Elsevier, 2018-06) Thiel de Bocanegra, Heike; Carter-Pokras, Olivia; Ingleby, J. David; Pottie, Kevin; Tchangalova, Nedelina; Allen, Sophia I.; Smith-Gagen, Julie; Hidalgo, Bertha
    The cumulative total of persons forced to leave their country for fear of persecution or organized violence reached an unprecedented 24.5 million by the end of 2015. Providing equitable access to appropriate health services for these highly diverse newcomers poses challenges for receiving countries. In this case study, we illustrate the importance of translating epidemiology into policy to address the health needs of refugees by highlighting examples of what works as well as identifying important policy-relevant gaps in knowledge. First, we formed an international working group of epidemiologists and health services researchers to identify available literature on the intersection of epidemiology, policy, and refugee health. Second, we created a synopsis of findings to inform a recommendation for integration of policy and epidemiology to support refugee health in the United States and other high-income receiving countries. Third, we identified eight key areas to guide the involvement of epidemiologists in addressing refugee health concerns. The complexity and uniqueness of refugee health issues, and the need to develop sustainable management information systems, require epidemiologists to expand their repertoire of skills to identify health patterns among arriving refugees, monitor access to appropriately designed health services, address inequities, and communicate with policy makers and multidisciplinary teams.
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    The Impact of International Accreditation on The Quality of Health Services at King Fahd University Hospital, Saudi Arabia: A Mixed Methods Approach
    (2019) AL Shawan, Deema Saad; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    The Joint Commission International Accreditation (JCIA) is perceived worldwide as the symbol of exceptional quality of care. Despite the popularity of international accreditation, evidence of its effectiveness on improving health care quality is inconclusive. This dissertation research utilized a Convergent parallel mixed method framework to evaluate the impact of the JCIA process on quality and to identify the factors that influence the effectiveness of this process at King Fahd Hospital of the University in Khobar, Saudi Arabia. An interrupted time series analysis was conducted to assess the changes in a total of 12 quality outcomes pre and post accreditation. Furthermore, a qualitative approach was used to investigate the attitudes and perceptions of 31 health providers towards this process and the factors that influence its success. The quantitative results suggested that the JCIA had a positive impact on 9 out of 12 outcomes. The improved quality outcomes included: the average length of stay, the percentage of hand hygiene compliance, the rate of nosocomial infections, the percentage of radiology reporting outliers, the rate of pressure ulcers, the percentage of the correct identification of patients prior to medication administration, the percentage of critical lab reporting within 30 minutes, and the bed occupancy rate. The outcomes that did not improve were the rate of patients leaving the ER without being seen, the percentage of OR cancelations on the day of the or and the rate of patient falls. The qualitative analysis suggested that the JCIA was perceived positively by all participants. Some of the perceived advantages of international accreditation included the transformation of the organizational culture to a culture that promotes continuous quality improvement, standardization, and the reduced paperwork in some departments. The participants’ responses also indicated that there were many factors that influence the success of the process. Examples of the factors identified in the study include the increased workload and the providers’ resistance to participate in the JCIA process. In conclusion, international accreditation seemed to have a positive impact on quality outcomes and was received positively by providers. Nevertheless, the factors that hindered the JCIA process need to be addressed by the hospital’s leadership to ensure more efficient quality improvement efforts during future accreditation cycles.
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    Connecting the Dots Across the Care Continuum: Addressing Behavioral Health in ACO Networks
    (2019) Anderson, Andrew; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    Accountable Care Organizations (ACOs) represent a shift from traditional fee-for-service payment systems that reward volume to payment models that reward providers for value (e.g. quality improvement and cost reduction). Hospitals that lead or participate in ACOs have the potential to work with other providers to bridge the gap between traditional medical and behavioral health services. The goal of this dissertation was to examine the structures, processes, and outcomes of care for hospitals that lead or participate in ACO networks. The overarching hypothesis was that ACO-affiliated hospitals provide better behavioral health care due to increased care coordination and increased connections to behavioral health providers. This dissertation had three aims: 1) compare the implementation of care coordination strategies between ACO affiliated hospitals and unaffiliated hospitals and examine whether the implementation of care coordination strategies varies by hospital payment model types; 2) compare the use of care coordination strategies between ACO-affiliated hospitals with and without in-network behavioral health providers; and 3) compare rates of follow-up after a hospitalization for mental illness between ACO-affiliated and unaffiliated hospitals. These aims build on each other to illustrate how hospitals that participate in ACOs are improving care coordination and the provision of behavioral health services. There were several meaningful findings. ACO-affiliated hospitals were more likely to use care coordination strategies compared to unaffiliated hospitals. Participation in global capitation and shared savings models was associated with greater use of care coordination strategies. Nearly two-thirds of ACO-affiliated hospitals did not have in-network behavioral health providers. ACO-affiliated hospitals had a significantly higher average unadjusted rates of follow-up after a hospitalization for mental illness at 7 days and 30 days post-discharge compared to unaffiliated hospitals. Hospitals are important components of the care continuum and will play a critical role in improving outcomes for patients with behavioral health conditions. Policy makers should include behavioral health related performance measures tied to performance-based payment arrangements in ACO programs. ACOs can be used as way to bridge behavioral, clinical, and social services to address the unique needs of individuals with behavioral health conditions.
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    THE EXAMINATION OF NATIONAL-NUTRITION POLICIES ON NONCOMMUNICABLE DISEASE MORTALITY AT VARIOUS STAGES OF ECONOMIC DEVELOPMENT: A CROSS-COUNTRY PERSPECTIVE
    (2019) Gupta, Manisha; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    The acceleration of economic growth over the past few decades introduces the need to reorient policy to address the needs and challenges for a healthier population. This paper will review the effectiveness of national nutrition policies targeting overweight, healthy diets during pregnancy, infancy and childhood, and noncommunicable diseases (NCDs) across advanced economies and transitional economies. The level of expansion and industrialization of food systems around the world have had a direct impact on nutritional status and health. Considering the magnitude of nationwide public health responses to shifts in mortality have varied over time, this introduces the need to assess the ability for dietary-related policies to successfully reduce NCDs. Results from this analysis can provide a strong rationale as to when interventions will be most effective as well as ways in which we can carry out a timely response in establishing effective policies for countries at different levels of economic development.