This study assessed the extent to which recommended pediatric outpatient care is delivered and documented. On average, children received 46.5% of the overall indicated care, 67.6% of the indicated ...care for acute medical problems, 53.4% of the indicated care for chronic conditions, and 40.7% of the indicated preventive care.
This study assessed the extent to which recommended pediatric outpatient care is delivered and documented. On average, children received 46.5% of the overall indicated care.
Serious problems with the quality and safety of health care in the United States have been widely documented.
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However, this evidence comes mainly from studies of care delivered to adults
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and the elderly.
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Comprehensive, national studies of the quality of care delivered to children and adolescents are needed. Previous studies of children have examined few quality measures
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; have involved self-reported data from parents, patients, or providers
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; or have been limited to Medicaid enrollees
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or to one geographic area.
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Research and policy related to children have focused on expanding eligibility for public . . .
Evidence for the effectiveness of menthol cigarette bans comes mostly from studies of adults that smoke. This experiment evaluated whether the absence of menthol products from a convenience store ...influenced young people’s susceptibility to cigarette smoking after they shopped in the store.
This experiment took place in the RAND StoreLab (RSL), a life-sized research convenience store. A three-group, between-subjects design was used. Study conditions differed in the mix of flavored tobacco products the RSL displayed: 1) All tobacco-, sweet-, and menthol-flavors displayed; 2) only tobacco- and menthol-flavors displayed; and 3) only tobacco-flavors displayed. Participants were randomly assigned to shop in the RSL under one of these conditions and after shopping, completed measures of their susceptibility to cigarette smoking, one measure for menthol cigarettes and one for unflavored cigarettes (scores on each susceptibility measure was dichotomized: 0 = not susceptible; 1 = susceptible).
Multivariable logistic regression assessed the main effects of condition on susceptibility to smoking menthol and unflavored cigarettes. There was no condition effect on susceptibility to smoking unflavored cigarettes. However, removing menthol-flavored products significantly increased participants’ susceptibility to smoking menthol cigarettes compared to when all flavored products were available (OR = 3.66, 95% CI 1.33, 10.03). This significant effect was only found among young people with some pre-existing risk of cigarette smoking (OR = 5.92, 95% CI 1.81, 19.39).
Results suggest the need to consider that menthol bans could unintentionally increase the appeal of menthol cigarettes among youth already at risk of smoking.
•Removing menthol cigarettes from convenience stores increases their appeal.•These effects are strongest for adolescents with a pre-existing risk of smoking.•Policies that restrict menthol should anticipate potential iatrogenic consequences.
Abstract Purpose Prior studies suggest that cohesion among members of military units has a positive impact on behavioral and mental health sequelae of combat deployment. However, these studies have ...not distinguished variation in cohesion across units from variation in perception of cohesion across individuals within units. Methods A sample of U.S. Marines was assessed before and after deployment to Iraq or Afghanistan in 2010 or 2011. Within-group centering was used to distinguish unit-level from individual-level associations of cohesion with four behavioral and mental health outcomes assessed after deployment: alcohol misuse, violation of the Uniform Code of Military Justice (UCMJ), probable posttraumatic stress disorder (PTSD) and a positive screen for depression. Results Unit-level cohesion is associated positively with alcohol misuse (OR=1.86, 95% CI 1.05-3.29) and negatively with UCMJ violations (OR=0.41, 95% CI 0.20-0.83) but not with probable PTSD (OR=1.00, 95% CI 0.60-1.6) or a positive screen for depression (OR=1.00 95% CI 0.58-1.72). Lower perception of cohesion relative to the other members of the same unit is associated with higher likelihood of UCMJ violations, probable PTSD and a positive screen for depression. Limitations Data on all members of the studied units were not available. Conclusions Distinguishing unit-level from individual-level variation in cohesion among military unit members reveals more varied associations with behavioral and mental health outcomes of deployment than have been reported in previous studies, in which these levels have been collapsed. Associations between individual-level variation in cohesion and mental health outcomes may result from pre-existing traits related to both perception of cohesion and risk for psychiatric disorders.
Background Unplanned follow-up care is the focus of intense health policy interest, as evidenced by recent financial penalties imposed under the Affordable Care Act. To date, however, unplanned ...postoperative care remains poorly characterized, particularly for patients with kidney stones. Our objective was to describe the frequency, variation, and financial impact of unplanned, high-acuity, follow-up visits in the treatment of patients with urinary stone disease. Methods We identified privately insured patients undergoing percutaneous nephrostolithotomy, ureteroscopy, or shock-wave lithotripsy for stone disease. The primary outcome was occurrence of an emergency department visit or hospital admission within 30 days of the procedure. Multivariable models estimated the odds of an unplanned visit and the incremental cost of those visits, controlling for important covariates. Results We identified 93,523 initial procedures to fragment or remove stones. Overall, 1 in 7 patients had an unplanned postprocedural visit. Unplanned visits were least common after shock-wave lithotripsy (12%) and occurred with similar frequency after ureteroscopy and percutaneous nephrostolithotomy (15%). Procedures at high-volume facilities were substantially less likely to result in an unplanned visit (odds ratio 0.80, 95% confidence interval 95% CI 0.74–0.87, P < .001). When an unplanned visit occurred, adjusted incremental expenditures per episode were greater after shock-wave lithotripsy ($32,156 95% CI $30,453–33,859) than after ureteroscopy ($23,436 95% CI $22,281–24,590). Conclusion Patients not infrequently experience an unplanned, high-acuity visit after low-risk procedures to remove urinary stones, and the cost of these encounters is substantial. Interventions are indicated to identify and reduce preventable unplanned visits.
•Many localities have banned sales of flavored tobacco products to help reduce teen nicotine vaping.•Experimentally removing flavored products from a store display did not change teens’ intentions to ...vape flavored products.•Among teens who had vaped previously, removing flavored products increased intentions to use tobacco-flavored vaping products.•In addition to flavor bans, other strategies may be needed to reduce vaping among teens who have already initiated use.
Some U.S. states and municipalities have banned the sale of flavored tobacco products to help curb youth vaping. However, evidence supporting such bans is limited. This experiment tested whether removing flavored tobacco products from a retail setting diminished adolescents’ (ages 11–20) future intentions to use vaping products.
The study was implemented in the RAND StoreLab, a life-sized model convenience store. The display of flavored tobacco products in the store was manipulated with these conditions: 1) tobacco, sweet, and menthol/mint flavors displayed; 2) only tobacco and menthol/mint displayed; and 3) only tobacco flavors displayed. Participants were randomly assigned to shop in one of these conditions and completed measures of future vaping intentions post-shopping. Separate logistic regression models assessed effect of condition on future intentions to use different flavors (tobacco-, menthol/mint-, and sweet-flavored) and any flavor (composite score across flavor categories) of vaping products.
Study condition was not associated with intentions to use menthol/mint-, sweet-flavored, or any flavor. Compared to the condition in which all flavored products were displayed, removing menthol/mint- and sweet-flavored products significantly increased future intentions to use tobacco-flavored vaping products (OR = 3.97, 95 % CI 1.01, 15.58, p < .05). This effect was only observed among adolescents with history of vaping (OR = 11.30, 95 % CI 1.42, 89.96, p = .02).
Flavor bans may not affect adolescents’ intentions to use menthol/mint, sweet, or “any” flavor of vaping products but may increase intentions to use tobacco-flavored products for teens who have already started vaping.
Single-institution series have documented the adverse impact of a 12-week delay between resection of muscle-invasive bladder cancer and radical cystectomy. These data are derived from tertiary ...centers, in which referral populations may confound outcomes. The authors sought to examine the survival impact of a delay in radical cystectomy using nationally representative data.
From the linked Surveillance, Epidemiology, and End Results-Medicare dataset, the authors identified subjects with stage II transitional cell carcinoma (TCC) of the bladder who underwent radical cystectomy between 1992 and 2001. They examined delays of 8, 12, and 24 weeks and incorporated these delay cutoffs into multivariate Cox proportional hazards survival models. Covariates included age, race/ethnicity, marital status, Charlson comorbidity index, and cancer grade.
The authors identified 441 subjects with stage II TCC who underwent cystectomy during the study period. Compared with immediate surgery (ie, within 4-8 weeks of transurethral resection), longer time to cystectomy increased the risk of both disease-specific and overall mortality (hazard ratio HR, 2.0; P < .01 and HR, 1.6; P < .01, respectively, for those delayed 12-24 weeks; HR, 2.0; P < .01 for disease-specific and overall death among those delayed beyond 24 weeks 1 year after diagnosis). Covariates associated with overall mortality included older age (HR, 1.04; P < .01) and comorbidity (HR, 2.0 for Charlson >or=3 vs Charlson 0-1; P < .01).
Delay in definitive surgical treatment beyond 12 weeks conferred an increased risk of disease-specific and all-cause mortality among subjects with stage II bladder cancer.
To counter the high prevalence of flavored tobacco use among youth, many U.S. localities have passed policies that restrict youth access to these products. This study aims to evaluate the short-term ...impact of a flavored tobacco restriction policy on youth access to, and use of, flavored tobacco products in a Massachusetts community.
A community with the policy (Lowell) was matched to a community without the policy (Malden) with similar demographics, retailer characteristics, and point-of-sale tobacco policies. Product inventories were assessed in tobacco retailers in the 2 communities, and surveys were administered to high school–aged youth in those communities. Inventories and surveys were conducted around the time the policy took effect in October 2016 (baseline) and approximately 6 months later (follow-up); all data were analyzed in 2017. Chi-squared tests and difference-in-difference models were used to estimate the impact of the policy on flavored tobacco availability and youth perceptions and behaviors related to flavored tobacco use.
Flavored tobacco availability decreased significantly in Lowell from baseline to follow-up periods by 70 percentage points (p<0.001), whereas no significant changes in flavored tobacco availability were seen in Malden. In addition, current use of both flavored and non-flavored tobacco decreased in Lowell, but increased in Malden from baseline to follow-up; these changes were significantly different between communities (flavored tobacco: −5.7%, p=0.03; non-flavored tobacco: −6.2%, p=0.01).
Policies that restrict the sale of flavored tobacco have the potential to curb youth tobacco use in as few as 6 months.
Previous research has found differences in health care access and quality among sociodemographic groups. In this study of patients who had made at least one visit to a health care provider during the ...previous two years, quality-of-care scores were suboptimal overall but were not lower for women than for men or for black or Hispanic patients than for whites. Poorer patients had a slightly lower quality of care: recommended care was received by 53 percent of those with annual family incomes below $15,000 and 57 percent of those with incomes above $50,000.
In this study of patients who had made at least one visit to a health care provider during the previous two years, quality-of-care scores were suboptimal overall but were not lower for women than for men or for black or Hispanic patients than for whites. Poorer patients had a slightly lower quality of care.
The quality of American medical care falls short of expectations.
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We have previously reported that U.S. adults receive about half of recommended health care services.
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How much variation is there among population subgroups in the likelihood of receiving needed care? Previous studies have found that patients who are women, older, members of racial and ethnic minorities, poorer, less educated, or uninsured are less likely to receive needed care, largely as a result of lack of access to care (determined by whether an encounter with a health care provider occurs), rather than a deficiency in the quality of care (determined . . .
Retail clinics have been viewed by policy makers and insurers as a mechanism to decrease health care spending, by substituting less expensive clinic visits for more expensive emergency department or ...physician office visits. However, retail clinics may actually increase spending if they drive new health care utilization. To assess whether retail clinic visits represent new utilization or a substitute for more expensive care, we used insurance claims data from Aetna for the period 2010-12 to track utilization and spending for eleven low-acuity conditions. We found that 58 percent of retail clinic visits for low-acuity conditions represented new utilization and that retail clinic use was associated with a modest increase in spending, of $14 per person per year. These findings do not support the idea that retail clinics decrease health care spending.
Purpose
End-stage renal disease patients’ experience of care is an integral part of the assessment of the quality of the care provided at hemodialysis centers and is needed to promote patient choice, ...quality improvement, and accountability. The purpose of this study is to evaluate the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS®) survey and its equivalence in different age, gender, race, and education subgroups.
Methods
The ICH-CAHPS survey was administered to 1454 patients from 32 dialysis facilities. For the characteristics compared, the sample had 756 participants younger than 65 years old, 739 men, 516 Black, 567 White, and 970 with less than high school diploma. Three different patient experience constructs were studied including nephrologist’s communication and caring, quality of care and operations, and providing information to patients. We used item response theory analysis to examine the possibility of differential item functioning (DIF) by patient age, gender, race, and education separately after controlling for the other DIF characteristics and additional confounding variables including survey mode, mental, and general health status as well as duration on dialysis.
Results
The three constructs studied were unidimensional and no major DIF was observed on the composites. Some non-equivalences were observed when confounders were not controlled for, suggesting that such covariates can be important factors in understanding the possibility of disparity in patients’ experience.
Conclusions
The ICH-CAHPS is a promising survey to elicit hemodialysis patients’ experience that has good psychometric properties and provides a standardized tool for assessing age, gender, race, or education disparity.
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