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1.
Nature ; 625(7993): 134-147, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-38093007

RESUMO

Scientific evidence regularly guides policy decisions1, with behavioural science increasingly part of this process2. In April 2020, an influential paper3 proposed 19 policy recommendations ('claims') detailing how evidence from behavioural science could contribute to efforts to reduce impacts and end the COVID-19 pandemic. Here we assess 747 pandemic-related research articles that empirically investigated those claims. We report the scale of evidence and whether evidence supports them to indicate applicability for policymaking. Two independent teams, involving 72 reviewers, found evidence for 18 of 19 claims, with both teams finding evidence supporting 16 (89%) of those 18 claims. The strongest evidence supported claims that anticipated culture, polarization and misinformation would be associated with policy effectiveness. Claims suggesting trusted leaders and positive social norms increased adherence to behavioural interventions also had strong empirical support, as did appealing to social consensus or bipartisan agreement. Targeted language in messaging yielded mixed effects and there were no effects for highlighting individual benefits or protecting others. No available evidence existed to assess any distinct differences in effects between using the terms 'physical distancing' and 'social distancing'. Analysis of 463 papers containing data showed generally large samples; 418 involved human participants with a mean of 16,848 (median of 1,699). That statistical power underscored improved suitability of behavioural science research for informing policy decisions. Furthermore, by implementing a standardized approach to evidence selection and synthesis, we amplify broader implications for advancing scientific evidence in policy formulation and prioritization.


Assuntos
Ciências do Comportamento , COVID-19 , Prática Clínica Baseada em Evidências , Política de Saúde , Pandemias , Formulação de Políticas , Humanos , Ciências do Comportamento/métodos , Ciências do Comportamento/tendências , Comunicação , COVID-19/epidemiologia , COVID-19/etnologia , COVID-19/prevenção & controle , Cultura , Prática Clínica Baseada em Evidências/métodos , Liderança , Pandemias/prevenção & controle , Saúde Pública/métodos , Saúde Pública/tendências , Normas Sociais
2.
Am J Epidemiol ; 193(7): 951-958, 2024 07 08.
Artigo em Inglês | MEDLINE | ID: mdl-38400644

RESUMO

In 2008, Oregon expanded its Medicaid program using a lottery, creating a rare opportunity to study the effects of Medicaid coverage using a randomized controlled design (Oregon Health Insurance Experiment). Analysis showed that Medicaid coverage lowered the risk of depression. However, this effect may vary between individuals, and the identification of individuals likely to benefit the most has the potential to improve the effectiveness and efficiency of the Medicaid program. By applying the machine learning causal forest to data from this experiment, we found substantial heterogeneity in the effect of Medicaid coverage on depression; individuals with high predicted benefit were older and had more physical or mental health conditions at baseline. Expanding coverage to individuals with high predicted benefit generated greater reduction in depression prevalence than expanding to all eligible individuals (21.5 vs 8.8 percentage-point reduction; adjusted difference = +12.7 [95% CI, +4.6 to +20.8]; P = 0.003), at substantially lower cost per case prevented ($16 627 vs $36 048; adjusted difference = -$18 598 [95% CI, -156 953 to -3120]; P = 0.04). Medicaid coverage reduces depression substantially more in a subset of the population than others, in ways that are predictable in advance. Targeting coverage on those most likely to benefit could improve the effectiveness and efficiency of insurance expansion. This article is part of a Special Collection on Mental Health.


Assuntos
Depressão , Cobertura do Seguro , Aprendizado de Máquina , Medicaid , Humanos , Medicaid/estatística & dados numéricos , Estados Unidos , Feminino , Masculino , Adulto , Oregon , Pessoa de Meia-Idade , Cobertura do Seguro/estatística & dados numéricos , Adulto Jovem
3.
J Urban Health ; 99(1): 116-133, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34984636

RESUMO

Neighborhood characteristics may moderate the effects of Medicaid coverage on health outcomes. Identifying this interplay can inform the design, targeting, and implementation of health policy. We combine data from the Oregon Health Insurance Experiment, which randomized access to Medicaid, with rich new data on multiple domains of neighborhood characteristics to assess the interaction between the local environment and the effect of insurance on health. Overall, we do not find that neighborhood characteristics substantially affect the relationship between gaining insurance and health outcomes, suggesting that Medicaid expansions are similarly effective across neighborhoods. This analysis highlights the complex relationship between health insurance coverage, neighborhood characteristics, and health.


Assuntos
Medicaid , Características da Vizinhança , Acessibilidade aos Serviços de Saúde , Humanos , Cobertura do Seguro , Seguro Saúde , Oregon , Patient Protection and Affordable Care Act , Estados Unidos
4.
JAMA ; 328(1): 27-37, 2022 07 05.
Artigo em Inglês | MEDLINE | ID: mdl-35788794

RESUMO

Importance: Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes. Objective: To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality. Design, Setting, and Participants: This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021. Interventions: Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group. Main Outcomes and Measures: There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery. Results: Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups. Conclusions and Relevance: In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03360539.


Assuntos
Enfermagem Domiciliar , Visita Domiciliar , Complicações na Gravidez , Criança , Pré-Escolar , Feminino , Enfermagem Domiciliar/economia , Enfermagem Domiciliar/estatística & dados numéricos , Visita Domiciliar/economia , Visita Domiciliar/estatística & dados numéricos , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Medicaid/economia , Medicaid/estatística & dados numéricos , Mortalidade Perinatal , Pobreza/economia , Pobreza/estatística & dados numéricos , Gravidez , Complicações na Gravidez/economia , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/enfermagem , Complicações na Gravidez/prevenção & controle , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/prevenção & controle , South Carolina/epidemiologia , Estados Unidos/epidemiologia , Adulto Jovem
5.
JAMA ; 321(15): 1491-1501, 2019 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-30990549

RESUMO

Importance: Employers have increasingly invested in workplace wellness programs to improve employee health and decrease health care costs. However, there is little experimental evidence on the effects of these programs. Objective: To evaluate a multicomponent workplace wellness program resembling programs offered by US employers. Design, Setting, and Participants: This clustered randomized trial was implemented at 160 worksites from January 2015 through June 2016. Administrative claims and employment data were gathered continuously through June 30, 2016; data from surveys and biometrics were collected from July 1, 2016, through August 31, 2016. Interventions: There were 20 randomly selected treatment worksites (4037 employees) and 140 randomly selected control worksites (28 937 employees, including 20 primary control worksites [4106 employees]). Control worksites received no wellness programming. The program comprised 8 modules focused on nutrition, physical activity, stress reduction, and related topics implemented by registered dietitians at the treatment worksites. Main Outcomes and Measures: Four outcome domains were assessed. Self-reported health and behaviors via surveys (29 outcomes) and clinical measures of health via screenings (10 outcomes) were compared among 20 intervention and 20 primary control sites; health care spending and utilization (38 outcomes) and employment outcomes (3 outcomes) from administrative data were compared among 20 intervention and 140 control sites. Results: Among 32 974 employees (mean [SD] age, 38.6 [15.2] years; 15 272 [45.9%] women), the mean participation rate in surveys and screenings at intervention sites was 36.2% to 44.6% (n = 4037 employees) and at primary control sites was 34.4% to 43.0% (n = 4106 employees) (mean of 1.3 program modules completed). After 18 months, the rates for 2 self-reported outcomes were higher in the intervention group than in the control group: for engaging in regular exercise (69.8% vs 61.9%; adjusted difference, 8.3 percentage points [95% CI, 3.9-12.8]; adjusted P = .03) and for actively managing weight (69.2% vs 54.7%; adjusted difference, 13.6 percentage points [95% CI, 7.1-20.2]; adjusted P = .02). The program had no significant effects on other prespecified outcomes: 27 self-reported health outcomes and behaviors (including self-reported health, sleep quality, and food choices), 10 clinical markers of health (including cholesterol, blood pressure, and body mass index), 38 medical and pharmaceutical spending and utilization measures, and 3 employment outcomes (absenteeism, job tenure, and job performance). Conclusions and Relevance: Among employees of a large US warehouse retail company, a workplace wellness program resulted in significantly greater rates of some positive self-reported health behaviors among those exposed compared with employees who were not exposed, but there were no significant differences in clinical measures of health, health care spending and utilization, and employment outcomes after 18 months. Although limited by incomplete data on some outcomes, these findings may temper expectations about the financial return on investment that wellness programs can deliver in the short term. Trial Registration: ClinicalTrials.gov Identifier: NCT03167658.


Assuntos
Comportamentos Relacionados com a Saúde , Promoção da Saúde , Nível de Saúde , Saúde Ocupacional , Adulto , Comércio , Feminino , Gastos em Saúde , Promoção da Saúde/economia , Humanos , Masculino , Serviços de Saúde do Trabalhador/economia , Aceitação pelo Paciente de Cuidados de Saúde , Autorrelato , Inquéritos e Questionários , Estados Unidos , Local de Trabalho
8.
Milbank Q ; 96(1): 29-56, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29504203

RESUMO

Policy Points: We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage on mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression. Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications and reduced the share of respondents reporting unmet mental health care needs by almost 40%. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations. CONTEXT: Expanding Medicaid to previously uninsured adults has been shown to increase detection and reduce the prevalence of depression, but the ways that Medicaid affects mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression remain unclear. METHODS: We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage using a randomized-controlled design, drawing on both primary and administrative data sources. FINDINGS: Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications frequently prescribed to treat depression and related mental health conditions and reduced the share of respondents reporting unmet mental health care needs by almost 40%. The share of respondents screening positive for depression dropped by 9.2 percentage points overall, and by 13.1 for those with preexisting depression diagnoses, with greatest relief in symptoms seen primarily in feeling down or hopeless, feeling tired, and trouble sleeping-consistent with the increase observed not just in medications targeting depression but also in those targeting sleep. CONCLUSIONS: Medicaid coverage had significant effects on the diagnosis, treatment, and outcomes of a population with substantial unmet mental health needs. Coverage increased access to care, reduced the prevalence of untreated and undiagnosed depression, and substantially improved the symptoms of depression. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations.


Assuntos
Transtorno Depressivo/terapia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro , Medicaid , Adulto , Antidepressivos/uso terapêutico , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/epidemiologia , Feminino , Humanos , Masculino , Saúde Mental , Serviços de Saúde Mental , Pessoa de Meia-Idade , Oregon/epidemiologia , Prevalência , Estados Unidos , Adulto Jovem
9.
N Engl J Med ; 368(18): 1713-22, 2013 May 02.
Artigo em Inglês | MEDLINE | ID: mdl-23635051

RESUMO

BACKGROUND: Despite the imminent expansion of Medicaid coverage for low-income adults, the effects of expanding coverage are unclear. The 2008 Medicaid expansion in Oregon based on lottery drawings from a waiting list provided an opportunity to evaluate these effects. METHODS: Approximately 2 years after the lottery, we obtained data from 6387 adults who were randomly selected to be able to apply for Medicaid coverage and 5842 adults who were not selected. Measures included blood-pressure, cholesterol, and glycated hemoglobin levels; screening for depression; medication inventories; and self-reported diagnoses, health status, health care utilization, and out-of-pocket spending for such services. We used the random assignment in the lottery to calculate the effect of Medicaid coverage. RESULTS: We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (-9.15 percentage points; 95% confidence interval, -16.70 to -1.60; P=0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures. CONCLUSIONS: This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.


Assuntos
Custos de Cuidados de Saúde , Nível de Saúde , Cobertura do Seguro , Medicaid , Adulto , Transtorno Depressivo/epidemiologia , Transtorno Depressivo/terapia , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/terapia , Hemoglobinas Glicadas/análise , Serviços de Saúde/estatística & dados numéricos , Humanos , Hipercolesterolemia/tratamento farmacológico , Hipercolesterolemia/epidemiologia , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Cobertura do Seguro/economia , Medicaid/economia , Pessoa de Meia-Idade , Oregon/epidemiologia , Prevalência , Estados Unidos , Adulto Jovem
10.
Med Care ; 54(5): 498-503, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27078822

RESUMO

BACKGROUND: There is substantial interest in identifying low-acuity visits to emergency departments (EDs) that could be treated more appropriately in other settings. Systematic differences in illness severity between ED patients and comparable patients elsewhere could make such strategies unsafe, but little evidence exists to guide policy makers. OBJECTIVE: To compare illness severity between patients visiting EDs and outpatient clinics, by comparing short-term mortality and hospitalization, controlling for patient demographics, comorbidity, and visit acuity. RESEARCH DESIGN: Cross-sectional study of outcomes after medical encounters. SUBJECTS: Nationally representative 20% sample of Medicare fee-for-service beneficiaries discharged home from ED or clinic visit in 2011, and enrolled continuously for 1 year before the visit. MEASURES: All-cause mortality and hospitalization in the 8, 15, and 30 days after discharge home from ED or clinic visits. RESULTS: After risk-adjusting for patient demographic, comorbidity, disability, and dual-eligibility status, as well as visit acuity as measured by a commonly used algorithm, we found that ED patients were more likely to die (risk-adjusted odds ratio=2.75; 95% confidence interval, 2.56-2.96) or be hospitalized (odds ratio=1.97; 95% confidence interval, 1.95-2.00) after discharge than clinic patients. Differences in short-term outcomes were observed even when comparing patients with the same discharge diagnoses after risk adjustment. CONCLUSIONS: Patients presenting to EDs have worse risk-adjusted short-term outcomes than those presenting to outpatient clinics, even after controlling for acuity level of visit or discharge diagnosis. Existing measures of acuity using administrative data may not adequately capture severity of illness, making judgments of the appropriate setting for care difficult.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Mortalidade , Idoso , Algoritmos , Estudos Transversais , Feminino , Humanos , Masculino , Medicare/estatística & dados numéricos , Razão de Chances , Gravidade do Paciente , Índice de Gravidade de Doença , Estados Unidos
13.
N Engl J Med ; 367(19): 1773-5, 2012 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-23113834

RESUMO

Medicare should provide access to care and protection from catastrophic spending while not being so generous that beneficiaries overconsume low-value care, thus driving up costs. Setting cost sharing is a balancing act that the Medicare program doesn't perform very well.


Assuntos
Reforma dos Serviços de Saúde/legislação & jurisprudência , Benefícios do Seguro/economia , Medicare/economia , Acessibilidade aos Serviços de Saúde/economia , Humanos , Medicare/legislação & jurisprudência , Estados Unidos
16.
N Engl J Med ; 367(11): 1025-34, 2012 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-22830435

RESUMO

BACKGROUND: Several states have expanded Medicaid eligibility for adults in the past decade, and the Affordable Care Act allows states to expand Medicaid dramatically in 2014. Yet the effect of such changes on adults' health remains unclear. We examined whether Medicaid expansions were associated with changes in mortality and other health-related measures. METHODS: We compared three states that substantially expanded adult Medicaid eligibility since 2000 (New York, Maine, and Arizona) with neighboring states without expansions. The sample consisted of adults between the ages of 20 and 64 years who were observed 5 years before and after the expansions, from 1997 through 2007. The primary outcome was all-cause county-level mortality among 68,012 year- and county-specific observations in the Compressed Mortality File of the Centers for Disease Control and Prevention. Secondary outcomes were rates of insurance coverage, delayed care because of costs, and self-reported health among 169,124 persons in the Current Population Survey and 192,148 persons in the Behavioral Risk Factor Surveillance System. RESULTS: Medicaid expansions were associated with a significant reduction in adjusted all-cause mortality (by 19.6 deaths per 100,000 adults, for a relative reduction of 6.1%; P=0.001). Mortality reductions were greatest among older adults, nonwhites, and residents of poorer counties. Expansions increased Medicaid coverage (by 2.2 percentage points, for a relative increase of 24.7%; P=0.01), decreased rates of uninsurance (by 3.2 percentage points, for a relative reduction of 14.7%; P<0.001), decreased rates of delayed care because of costs (by 2.9 percentage points, for a relative reduction of 21.3%; P=0.002), and increased rates of self-reported health status of "excellent" or "very good" (by 2.2 percentage points, for a relative increase of 3.4%; P=0.04). CONCLUSIONS: State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health.


Assuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Medicaid , Mortalidade/tendências , Planos Governamentais de Saúde , Adulto , Definição da Elegibilidade , Humanos , Cobertura do Seguro/tendências , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Adulto Jovem
17.
N Engl J Med ; 367(18): 1724-31, 2012 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-23113483

RESUMO

BACKGROUND: Wide geographic variation in health care spending has generated both concern about inefficiency and policy debate about geographic-based payment reform. Evidence regarding variation has focused on hospital referral regions (HRRs), which incorporate numerous local hospital service areas (HSAs). If there is substantial variation across local areas within HRRs, then policies focusing on HRRs may be poorly targeted. METHODS: Using prescription drug and medical claims data from a 5% random sample of Medicare beneficiaries from 2006 through 2009, we compared variation in health care spending and utilization among 306 HRRs and 3436 HSAs. We adjusted for beneficiary-level demographic characteristics, insurance status, and clinical characteristics. RESULTS: There was substantial local variation in health care (drug and nondrug) utilization and spending. Furthermore, many of the low-spending HSAs were located in high-spending HRRs, and many of the high-spending HSAs were in low-spending HRRs. For drug spending, only 50.7% of the HSAs located within the borders of the highest-spending quintile of HRRs were in the highest-spending quintile of HSAs; conversely, only 51.5% of the highest-spending HSAs were located within the borders of the highest-spending HRRs. Similar patterns were observed for nondrug spending. CONCLUSIONS: The effectiveness of payment reforms in reducing overutilization while maintaining access to high-quality care depends on the effectiveness of targeting. Our analysis suggests that HRR-based policies may be too crudely targeted to promote the best use of health care resources. (Funded by the Institute of Medicine and others.).


Assuntos
Gastos em Saúde/estatística & dados numéricos , Serviços de Saúde/estatística & dados numéricos , Programas Médicos Regionais/economia , Idoso , Atenção à Saúde/economia , Uso de Medicamentos/economia , Serviços de Saúde/economia , Humanos , Padrões de Prática Médica/estatística & dados numéricos , Programas Médicos Regionais/estatística & dados numéricos , Estados Unidos
18.
Ann Intern Med ; 160(9): 585-93, 2014 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-24798521

RESUMO

BACKGROUND: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear. OBJECTIVE: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care. DESIGN: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions. SETTING: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score-defined control group of counties in other states. PARTICIPANTS: Adults aged 20 to 64 years in Massachusetts and control group counties. MEASUREMENTS: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146,825) from the Centers for Disease Control and Prevention's Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health. RESULTS: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (-2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100,000 adults). Deaths from causes amenable to health care also significantly decreased (-4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year. LIMITATIONS: Nonrandomized design subject to unmeasured confounders. Massachusetts results may not generalize to other states. CONCLUSION: Health reform in Massachusetts was associated with significant reductions in all-cause mortality and deaths from causes amenable to health care. PRIMARY FUNDING SOURCE: None.


Assuntos
Reforma dos Serviços de Saúde/legislação & jurisprudência , Mortalidade , Cobertura Universal do Seguro de Saúde/legislação & jurisprudência , Adulto , Fatores de Confusão Epidemiológicos , Acessibilidade aos Serviços de Saúde , Nível de Saúde , Humanos , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Fatores Socioeconômicos , Adulto Jovem
19.
J Health Polit Policy Law ; 40(6): 1157-77, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26447025

RESUMO

There is ongoing policy debate about the potential for malpractice liability reform to reduce the use of defensive medicine and slow the growth of health care spending. The effectiveness of such policy levers hinges on the degree to which physicians respond to liability pressures by prescribing medically unnecessary care. Many estimates of this relationship are based on physician reports. We present new survey evidence on physician assessment of their own use of medically unnecessary care in response to medical liability and other pressures, including a randomized evaluation of the sensitivity of those responses to survey framing. We find that while use of such care is potentially quite prevalent, responses vary substantially based on survey framing, with the way the question is phrased driving differences in responses that are often as great as those driven by physician specialty or whether the physician has personally been named in a lawsuit. These results suggest that self-reported use of medically unnecessary care ought to be used with caution in the formulation of malpractice liability system reform.


Assuntos
Medicina Defensiva , Médicos/psicologia , Feminino , Reforma dos Serviços de Saúde , Humanos , Responsabilidade Legal , Masculino , Imperícia , Inquéritos e Questionários , Procedimentos Desnecessários
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