Hospital Capital Assets, Community Health, and the Utilization and Cost of Inpatient Care: A Population-Based Study of US Counties.

BACKGROUND: The provision of high-quality hospital care requires adequate space, buildings, and equipment, although redundant infrastructure could also drive service overprovision. OBJECTIVE: To explore the distribution of physical hospital resources-that is, capital assets-in the United States; its correlation with indicators of community health and nonhealth factors; and the association between hospital capital density and regional hospital utilization and costs. RESEARCH DESIGN: We created a dataset of n=1733 US counties by analyzing the 2019 Medicare Cost Reports; 2019 State Inpatient Database Community Inpatient Statistics; 2020-2021 Area Health Resource File; 2016-2020 American Community Survey; 2022 PLACES; and 2019 CDC WONDER. We first calculated aggregate hospital capital assets and investment at the county level. Next, we examined the correlation between community's medical need (eg, chronic disease prevalence), ability to pay (eg, insurance), and supply factors with 4 metrics of capital availability. Finally, we examined the association between capital assets and hospital utilization/costs, adjusted for confounders. RESULTS: Counties with older and sicker populations generally had less aggregate hospital capital per capita, per hospital day, and per hospital discharge, while counties with higher income or insurance coverage had more hospital capital. In linear regressions controlling for medical need and ability to pay, capital assets were associated with greater hospital utilization and costs, for example, an additional $1000 in capital assets per capita was associated with 73 additional discharges per 100,000 population (95% CI: 45-102) and $19 in spending per bed day (95% CI: 12-26). CONCLUSIONS: The level of investment in hospitals is linked to community wealth but not population health needs, and may drive use and costs.

Specialty Care Utilization Among Adults with Limited English Proficiency.

BACKGROUND: People with limited English proficiency (LEP) face greater barriers to accessing medical care than those who are English proficient (EP). Language-related differences in the use of outpatient care across the full spectrum of physician specialties have not been studied. OBJECTIVE: To compare outpatient visit rates to physicians in 28 specialties by people with LEP vs EP. DESIGN: Multivariable negative binomial regression analysis of nationally representative data from the Medical Expenditure Panel Survey (pooled 2013-2018) with adjustment for age, sex, and self-reported health status. PARTICIPANTS: 149,611 survey respondents aged 18 and older. EXPOSURE: LEP, defined as taking the survey in a language other than English. MAIN MEASURES: Annual per capita adjusted visit rate ratios (ARRs) comparing visit rates by LEP and EP persons to individual specialties, and to three categories of specialties: (1) primary care (internal or family medicine, geriatrics, general practice, or obstetrics/gynecology), (2) medical-subspecialties, or (3) surgical specialties. KEY RESULTS: Patients with LEP were underrepresented in 26 of 28 specialties. Disparities were particularly large for the following: pulmonology (ARR, 0.26; 95% CI, 0.20-0.35), orthopedics (ARR, 0.35; 95% CI, 0.30-0.40), otolaryngology (ARR, 0.40; 95% CI, 0.27-0.59), and psychiatry (ARR, 0.43; 95% CI, 0.32-0.58). Among individuals with several specific common chronic conditions, LEP-EP disparities in visits to specialties in those conditions generally persisted. Disparities were larger for medical subspecialties (ARR, 0.41; 95% CI, 0.36-0.46) and surgical specialties (ARR, 0.46; 95% CI, 0.42-0.50) than for primary care (ARR, 0.76; 95% CI, 0.72 to 0.79). CONCLUSIONS: Patients with LEP are underrepresented in most outpatient specialty practices, particularly medical subspecialties and surgical specialties. Our findings highlight the need to remove language barriers to physician services in order to ensure access to the full spectrum of outpatient specialty care for people with LEP.

Health Status and Health Care Utilization of US Adults Under Probation: 2015-2018.

Objectives. To compare the health and health care utilization of persons on and not on probation nationally.Methods. Using the National Survey of Drug Use and Health, a population-based sample of US adults, we compared physical, mental, and substance use disorders and the use of health services of persons (aged 18-49 years) on and not on probation using logistic regression models controlling for age, race/ethnicity, gender, poverty, and insurance status.Results. Those on probation were more likely to have a physical condition (adjusted odds ratio [AOR] = 1.3; 95% confidence interval [CI] = 1.2, 1.4), mental illness (AOR = 2.4; 95% CI = 2.1, 2.8), or substance use disorder (AOR = 4.2; 95% CI = 3.8, 4.5). They were less likely to attend an outpatient visit (AOR = 0.8; 95% CI = 0.7, 0.9) but more likely to have an emergency department visit (AOR = 1.8; 95% CI = 1.6, 2.0) or hospitalization (AOR = 1.7; 95% CI = 1.5, 1.9).Conclusions. Persons on probation have an increased burden of disease and receive less outpatient care but more acute services than persons not on probation.Public Health Implications. Efforts to address the health needs of those with criminal justice involvement should include those on probation.

Inter-clinician eConsults without programmatic incentives or requirements: a qualitative study of primary care provider perspectives.

BACKGROUND: Inter-clinician electronic consultation (eConsult) programmes are becoming more widespread in the USA as health care systems seek innovative ways of improving specialty access. Existing studies examine models with programmatic incentives or requirements for primary care providers (PCPs) to participate. OBJECTIVE: We aimed to examine PCP perspectives on eConsults in a system with no programmatic incentive or requirement for PCPs to use eConsults. METHODS: We conducted seven focus groups with 41 PCPs at a safety-net community teaching health care system in Eastern Massachusetts, USA. RESULTS: Focus groups revealed that eConsults improved PCP experience by enabling patient-centred care and enhanced PCP education. However, increased workload and variations in communication patterns added challenges for PCPs. Patients were perceived as receiving timelier and more convenient care. Timelier care combined with direct documentation in the patient record was perceived as improving patient safety. Although cost implications were less clear, PCPs perceived costs as being lowered through fewer unnecessary visits and laboratories. CONCLUSIONS: Our findings suggest that eConsult systems with no programmatic incentives or requirements for PCPs have the potential to improve care.

The Effects on Hospital Utilization of the 1966 and 2014 Health Insurance Coverage Expansions in the United States.

Background: Persons with comprehensive health insurance use more hospital care than those who are uninsured or have high-deductible plans. Consequently, analysts generally assume that expanding coverage will increase society-wide use of inpatient services. However, a limited supply of beds might constrain this growth. Objective: To determine how the implementations of Medicare and Medicaid (1966) and the Patient Protection and Affordable Care Act (ACA) (2014) affected hospital use. Design: Repeated cross-sectional study. Setting: Nationally representative surveys. Participants: Respondents to the National Health Interview Survey (1962 to 1970) and Medical Expenditure Panel Survey (2008 to 2015). Measurements: Mean hospital discharges and days were measured, both society-wide and among subgroups defined by income, age, and health status. Changes between preexpansion and postexpansion periods were analyzed using multivariable negative binomial regression. Results: Overall hospital discharges averaged 12.8 per 100 persons in the 3 years before implementation of Medicare and Medicaid and 12.7 per 100 persons in the 4 years after (adjusted difference, 0.2 discharges [95% CI, -0.1 to 0.4 discharges] per 100 persons; P = 0.26). Hospital days did not change in the first 2 years after implementation but increased later. Effects differed by subpopulation: Adjusted discharges increased by 2.4 (CI, 1.7 to 3.1) per 100 persons among elderly compared with nonelderly persons (P < 0.001) and also increased among those with low incomes compared with high-income populations. For younger and higher-income persons, use decreased. Similarly, after the ACA's implementation, overall hospital use did not change: Society-wide rates of discharge were 9.4 per 100 persons before the ACA and 9.0 per 100 persons after the ACA (adjusted difference, -0.6 discharges [CI, -1.3 to 0.2 discharges] per 100 persons; P = 0.133), and hospital days were also stable. Trends differed for some subgroups, and rates decreased significantly in unadjusted (but not adjusted) analyses among persons reporting good or better health status and increased nonsignificantly among those in worse health. Limitation: Data sources relied on participant recall, surveys excluded institutionalized persons, and follow-up after the ACA was limited. Conclusion: Past coverage expansions were associated with little or no change in society-wide hospital use; increases in groups who gained coverage were offset by reductions among others, suggesting that bed supply limited increases in use. Reducing coverage may merely shift care toward wealthier and healthier persons. Conversely, universal coverage is unlikely to cause a surge in hospital use if growth in hospital capacity is carefully constrained. Primary Funding Source: None.

The Incidence of Diabetic Ketoacidosis During "Emerging Adulthood" in the USA and Canada: a Population-Based Study.

BACKGROUND: As children with diabetes transition to adulthood, they may be especially vulnerable to diabetic ketoacidosis (DKA). Cross-national comparisons may inform efforts to avoid this complication. OBJECTIVE: To compare DKA hospitalization rates in the USA and Manitoba, Canada, during the vulnerable years known as "emerging adulthood." DESIGN: Cross-sectional study using inpatient administrative databases in the USA (years 1998-2014) and Manitoba, Canada (years 2003-2013). PARTICIPANTS: Individuals aged 12-30 years hospitalized with DKA, identified using ICD-9 (USA) or ICD-10 codes (Manitoba). MAIN MEASURES: DKA hospitalization rates per 10,000 population by age (with a focus on those aged 15-17 vs. 19-21). Admissions were characterized by gender, socioeconomic status, year of hospitalization, and mortality during hospitalization. KEY RESULTS: The DKA rate was slightly higher in the USA among those aged 15-17: 4.8 hospitalizations/10,000 population vs. 3.7/10,000 in Manitoba. Among those aged 19-21, the DKA hospitalization rate rose 90% in the USA to 9.2/10,000, vs. 23% in Manitoba, to 4.5/10,000. In both the USA and Manitoba, rates were higher among those from poorer areas, and among adolescent girls compared with adolescent boys. DKA admissions rose gradually during the period under study in the USA, but not in Manitoba. CONCLUSIONS: In years of "emerging adulthood," the Canadian healthcare system appears to perform better than that of the USA in preventing hospitalizations for DKA. Although many factors likely contribute to this difference, universal and seamless coverage over the lifespan in Canada may contribute.

Coverage Expansions and Utilization of Physician Care: Evidence From the 2014 Affordable Care Act and 1966 Medicare/Medicaid Expansions.

Objectives. To evaluate the effects of the 2 major coverage expansions in US history-Medicare/Medicaid in 1966 and the Affordable Care Act (ACA) in 2014-on the utilization of physician care.Methods. Using the National Health Interview Survey (1963-1969; 2011-2016), we analyzed trends in utilization of physician services society-wide and by targeted subgroups.Results. Following Medicare/Medicaid's implementation, society-wide utilization remained unchanged. While visits by low-income persons increased 6.2% (P < .01) and surgical procedures among the elderly increased 14.7% (P < .01), decreases among nontargeted groups offset these increases. After the ACA, society-wide utilization again remained unchanged. Increased utilization among targeted low-income groups (e.g., a 3.5-percentage-point increase in the proportion of persons earning less than or equal to 138% of the federal poverty level with at least 1 office visit [P < .001]) was offset by small, nonsignificant reductions among the nontargeted population.Conclusions. Past coverage expansions in the United States have redistributed physician care, but have not increased society-wide utilization in the short term, possibly because of the limited supply of physicians.Public Health Implications. These findings suggest that future expansions may not cause unaffordable surges in utilization.

In Pursuit of Educational Integrity: Professional Identity Formation in the Harvard Medical School Cambridge Integrated Clerkship.

Graduates of Harvard Medical School's Cambridge Integrated Clerkship (CIC) describe several core processes that may underlie professional identity formation (PIF): encouragement to integrate pre-professional and professional identities; support for learner autonomy in discovering meaningful roles and responsibilities; learning through caring relationships; and a curriculum and an institutional culture that make values explicit. The authors suggest that the benefits of educational integrity accrue when idealistic learners inhabit an educational model that aligns with their own core values, and when professional development occurs in the context of an institutional home that upholds these values. Medical educators should clarify and animate principles within curricula and learning environments explicitly in order to support the professional identity formation of their learners.

Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured.

OBJECTIVES: We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care. METHODS: Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485). RESULTS: Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia. CONCLUSIONS: Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.

Support for National Health Insurance Seven Years Into Massachusetts Healthcare Reform: Views of Populations Targeted by the Reform.

Before the Affordable Care Act (ACA), many surveys showed majority support for national health insurance (NHI), also known as single payer; however, little is currently known about views of the ACA's targeted population. Massachusetts residents have had seven years of experience with state health care reform that became the model for the ACA. We surveyed 1,151 adults visiting safety-net emergency departments in Massachusetts in late 2013 on their preference for NHI or the Massachusetts reform and on their experiences with insurance. Most of the patients surveyed were low-income and non-white. The majority of patients (72.0%) preferred NHI to the Massachusetts reform. Support for NHI among those with public insurance, commercial insurance, and no insurance was 68.9%, 70.3%, and 86.3%, respectively (p < .001). Support for NHI was higher among patients dissatisfied with their insurance plan (83.3% vs. 68.9%, p = .014), who delayed medical care (81.2% vs. 69.6%, p < .001) or avoided purchasing medications due to cost (87.3% vs. 71.4%; p = .01). Majority support for NHI was observed in every demographic subgroup. Given the strong support for NHI among disadvantaged Massachusetts patients seven years after state health reform, a reappraisal of the ACA's ability to meet the needs of underserved patients is warranted.

Into the future: patient-centredness endures in longitudinal integrated clerkship graduates.

OBJECTIVES: This study was intended to determine if previously identified educational benefits of the Harvard Medical School (HMS) Cambridge Integrated Clerkship (CIC) endure over time. METHODS: The authors' earlier work compared the 27 graduates in the first three cohorts of students undertaking the CIC with a comparison group of 45 traditionally trained HMS students; CIC graduates emerged from their clerkship year with a higher degree of patient-centredness and felt more prepared to deal with numerous domains of patient care. Between April and July 2011, at 4-6 years post-clerkship, the authors asked these original study cohorts to complete an electronic survey which included measures used in the original study. The authors also reviewed data from the National Residency Match Program to compare career paths in the two groups. RESULTS: The response rate was 62% (42/68). The immediate post-clerkship finding that CIC students held more patient-centred attitudes was sustained over time (p < 0.035). Reflecting retrospectively on their clerkship experiences, CIC graduates continued to report that their clerkship year had better prepared them in a wide variety of domains. Graduates of the CIC attained awards and published papers at the same rates as peers, and were more likely to engage in health advocacy work. Both groups chose a wide range of residency programmes. Among those expressing a preference, no CIC graduates said they would choose a traditional clerkship, but 6 (27%) of the traditionally trained graduates said they would choose a longitudinal integrated clerkship. CONCLUSIONS: This paper indicates that benefits of longitudinal integrated clerkship training are sustained over time across multiple domains.

Geographically skewed recruitment and COVID-19 seroprevalence estimates: a cross-sectional serosurveillance study and mathematical modelling analysis.

OBJECTIVES: Convenience sampling is an imperfect but important tool for seroprevalence studies. For COVID-19, local geographic variation in cases or vaccination can confound studies that rely on the geographically skewed recruitment inherent to convenience sampling. The objectives of this study were: (1) quantifying how geographically skewed recruitment influences SARS-CoV-2 seroprevalence estimates obtained via convenience sampling and (2) developing new methods that employ Global Positioning System (GPS)-derived foot traffic data to measure and minimise bias and uncertainty due to geographically skewed recruitment. DESIGN: We used data from a local convenience-sampled seroprevalence study to map the geographic distribution of study participants' reported home locations and compared this to the geographic distribution of reported COVID-19 cases across the study catchment area. Using a numerical simulation, we quantified bias and uncertainty in SARS-CoV-2 seroprevalence estimates obtained using different geographically skewed recruitment scenarios. We employed GPS-derived foot traffic data to estimate the geographic distribution of participants for different recruitment locations and used this data to identify recruitment locations that minimise bias and uncertainty in resulting seroprevalence estimates. RESULTS: The geographic distribution of participants in convenience-sampled seroprevalence surveys can be strongly skewed towards individuals living near the study recruitment location. Uncertainty in seroprevalence estimates increased when neighbourhoods with higher disease burden or larger populations were undersampled. Failure to account for undersampling or oversampling across neighbourhoods also resulted in biased seroprevalence estimates. GPS-derived foot traffic data correlated with the geographic distribution of serosurveillance study participants. CONCLUSIONS: Local geographic variation in seropositivity is an important concern in SARS-CoV-2 serosurveillance studies that rely on geographically skewed recruitment strategies. Using GPS-derived foot traffic data to select recruitment sites and recording participants' home locations can improve study design and interpretation.