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BACKGROUND: Little is known as to whether the effects of physician sex on patients' clinical outcomes vary by patient sex. OBJECTIVE: To examine whether the association between physician sex and hospital outcomes varied between female and male patients hospitalized with medical conditions. DESIGN: Retrospective observational study. SETTING: Medicare claims data. PATIENTS: 20% random sample of Medicare fee-for-service beneficiaries hospitalized with medical conditions during 2016 to 2019 and treated by hospitalists. MEASUREMENTS: The primary outcomes were patients' 30-day mortality and readmission rates, adjusted for patient and physician characteristics and hospital-level averages of exposures (effectively comparing physicians within the same hospital). RESULTS: Of 458 108 female and 318 819 male patients, 142 465 (31.1%) and 97 500 (30.6%) were treated by female physicians, respectively. Both female and male patients had a lower patient mortality when treated by female physicians; however, the benefit of receiving care from female physicians was larger for female patients than for male patients (difference-in-differences, -0.16 percentage points [pp] [95% CI, -0.42 to 0.10 pp]). For female patients, the difference between female and male physicians was large and clinically meaningful (adjusted mortality rates, 8.15% vs. 8.38%; average marginal effect [AME], -0.24 pp [CI, -0.41 to -0.07 pp]). For male patients, an important difference between female and male physicians could be ruled out (10.15% vs. 10.23%; AME, -0.08 pp [CI, -0.29 to 0.14 pp]). The pattern was similar for patients' readmission rates. LIMITATION: The findings may not be generalizable to younger populations. CONCLUSION: The findings indicate that patients have lower mortality and readmission rates when treated by female physicians, and the benefit of receiving treatments from female physicians is larger for female patients than for male patients. PRIMARY FUNDING SOURCE: Gregory Annenberg Weingarten, GRoW @ Annenberg.
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Mortalidade Hospitalar , Medicare , Readmissão do Paciente , Humanos , Readmissão do Paciente/estatística & dados numéricos , Masculino , Feminino , Estudos Retrospectivos , Estados Unidos/epidemiologia , Fatores Sexuais , Idoso , Médicas/estatística & dados numéricos , Médicos Hospitalares , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço PrestadoRESUMO
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.
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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 JovemRESUMO
OBJECTIVE: To compare clinical outcomes of patients treated by female surgeons versus those treated by male surgeons. SUMMARY BACKGROUND DATA: It remains unclear as to whether surgical performance and outcomes differ between female and male surgeons. METHODS: We conducted a meta-analysis to compare patients' clinical outcomes-including patients' postoperative mortality, readmission, and complication rates-between female versus male surgeons. MEDLINE, Embase, CENTRAL, ICTRP, and ClinicalTrials.gov were searched from inception to September 8, 2022. The update search was conducted on July 19, 2023. We used random-effects models to synthesize data and GRADE to evaluate the certainty. RESULTS: A total of 15 retrospective cohort studies provided data on 5,448,121 participants. We found that patients treated by female surgeons experienced a lower post-operative mortality compared with patients treated by male surgeons (8 studies; adjusted odds ratio [aOR], 0.93; 95%CI, 0.88 - 0.97; I2=27%; moderate certainty of the evidence). We found a similar pattern for both elective and non-elective (emergent or urgent) surgeries, although the difference was larger for elective surgeries (test for subgroup difference P=0.003). We found no evidence that female and male surgeons differed for patient readmission (3 studies; aOR, 1.20; 95%CI, 0.83 - 1.74; I2=92%; very low certainty of the evidence) or complication rates (8 studies; aOR, 0.94; 95%CI, 0.88 - 1.01: I2=38%; very low certainty of the evidence). CONCLUSIONS: This systematic review and meta-analysis suggests that patients treated by female surgeons have a lower mortality compared with those treated by male surgeons.
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BACKGROUND: Understanding how the coronavirus disease 2019 (COVID-19) pandemic affected site of death-an important patient-centered outcome related to end-of-life care-would inform healthcare system resiliency in future public health emergencies. OBJECTIVE: To evaluate the changes in site of death during the COVID-19 pandemic among older adults without a COVID-19 diagnosis. DESIGN: Using a quasi-experimental difference-in-differences method, we estimated net changes in site of death during the pandemic period (March-December 2020) from the pre-pandemic period (January-February 2020), using data on the same months in prior years (2016-2019) as the control. PARTICIPANTS: A 20% sample of Medicare Fee-for-Service beneficiaries aged 66 years and older who died in 2016-2020. We excluded beneficiaries with a hospital diagnosis of COVID-19. MAIN MEASURES: We assessed each of the following sites of death separately: (1) home or community; (2) acute care hospital; and (3) nursing home. KEY RESULTS: We included 1,133,273 beneficiaries without a hospital diagnosis of COVID-19. We found that the proportion of Medicare beneficiaries who died at home or in the community setting increased (difference-in-differences [DID] estimate, + 3.1 percentage points [pp]; 95% CI, + 2.6 to + 3.6 pp; P < 0.001) and the proportion of beneficiaries who died (without COVID-19 diagnosis) in an acute care hospital decreased (- 0.8 pp; 95% CI, - 1.2 to - 0.4 pp; P < 0.001) during the pandemic. We found no evidence that the proportion of deaths in nursing homes changed during the pandemic. CONCLUSIONS: Using national data on older adults without a COVID-19 diagnosis, we found that site of death shifted toward home or community settings during the COVID-19 pandemic. Our findings may inform clinicians and policymakers in supporting end-of-life care during future public health emergencies.
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COVID-19 , Medicare , Idoso , Humanos , Estados Unidos , Pandemias , Teste para COVID-19 , EmergênciasRESUMO
BACKGROUND: Many persons living with dementias (PLWD) prefer to remain at home as long as possible, and days spent at home (DAH)-defined as the time an individual spends outside of healthcare facilities-has emerged as a person-centred outcome measure in this population. We examined the association between DAH and functional status and health among PLWD. METHODS: Utilizing a nationally representative cohort of individuals age 65 and older in the United States with dementia from the 2010-2018 Health and Retirement Study (HRS), we assessed the relationship between an ordinal categorical DAH variable and number of activities of daily living (ADLs) (range 0-10; 10 being independent), mobility (0-5; 5 being mobile), and self-rated health (SRH) (0-4; 4 being excellent), controlling for patient characteristics. DAH was defined as the number of self-reported days spent outside a hospital or nursing home in the time between survey waves, typically 730 days. RESULTS: We identified 3002 participants (4192 observations, average 1.4 observations per participant). The mean DAH was 704.4 days (SD 10.8 days) and 64.9% spent all days at home (i.e. 730 days). A 2-week decrease in DAH was associated with a lower ADL score by 0.32 points (95% confidence internal [CI]: 0.24-0.40, P-for-trend<0.001), a lower mobility score by 0.18 points (95% CI: 0.13-0.22, P-for-trend<0.001), and a lower SRH by 0.05 points (95% CI: 0.02-0.08, P-for-trend<0.001). CONCLUSION: We demonstrate that DAH is positively associated with important patient-reported outcomes among the dementia population, strengthening the argument for considering DAH as a meaningful outcome measure for PLWD.
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Atividades Cotidianas , Demência , Estado Funcional , Humanos , Masculino , Feminino , Demência/psicologia , Demência/epidemiologia , Demência/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Estados Unidos/epidemiologia , Fatores de Tempo , Nível de SaúdeRESUMO
BACKGROUND: The United States has 2 types of degree programs that educate physicians: allopathic and osteopathic medical schools. OBJECTIVE: To determine whether quality and costs of care differ between hospitalized Medicare patients treated by allopathic or osteopathic physicians. DESIGN: Retrospective observational study. SETTING: Medicare claims data. PATIENTS: 20% random sample of Medicare fee-for-service beneficiaries hospitalized with a medical condition during 2016 to 2019 and treated by hospitalists. MEASUREMENTS: The primary outcome was 30-day patient mortality. The secondary outcomes were 30-day readmission, length of stay (LOS), and health care spending (Part B spending). Multivariable regression models adjusted for patient and physician characteristics and their hospital-level averages (to effectively estimate differences within hospitals) were estimated. RESULTS: Of 329 510 Medicare admissions, 253 670 (77.0%) and 75 840 (23.0%) received care from allopathic and osteopathic physicians, respectively. The results can rule out important differences in quality and costs of care between allopathic versus osteopathic physicians for patient mortality (adjusted mortality, 9.4% for allopathic physicians vs. 9.5% [reference] for osteopathic hospitalists; average marginal effect [AME], -0.1 percentage point [95% CI, -0.4 to 0.1 percentage point]; P = 0.36), readmission (15.7% vs. 15.6%; AME, 0.1 percentage point [CI, -0.4 to 0.3 percentage point; P = 0.72), LOS (4.5 vs. 4.5 days; adjusted difference, -0.001 day [CI, -0.04 to 0.04 day]; P = 0.96), and health care spending ($1004 vs. $1003; adjusted difference, $1 [CI, -$8 to $10]; P = 0.85). LIMITATION: Data were limited to elderly Medicare patients hospitalized with medical conditions. CONCLUSION: The quality and costs of care were similar between allopathic and osteopathic hospitalists when they cared for elderly patients and worked as the principal physician in a team of health care professionals that often included other allopathic and osteopathic physicians. PRIMARY FUNDING SOURCE: National Institutes of Health/National Institute on Aging.
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Médicos Hospitalares , Médicos Osteopáticos , Humanos , Idoso , Estados Unidos , Medicare , Hospitalização , HospitaisRESUMO
BACKGROUND: Heart failure (HF) admission is used as a study endpoint in clinical trials. However, it remains unclear whether it can be a valid surrogate endpoint for mortality. OBJECTIVES: To validate whether HF admission is a valid surrogate for mortality. METHODS: In PubMed and EMBASE, randomized controlled trials (RCTs) of interventions to treat patients with heart failure at the enrolment were searched on 13 April 2022. We extracted RCTs in which event numbers of both HF admission and all-cause mortality were reported as either primary or secondary outcomes. Trial-level correlations (R-squared) between HF admission and mortality were assessed. We performed subgroup analyses by study year, follow-up duration, baseline HF with reduced ejection fraction (HFrEF) or HF with preserved ejection fraction (HFpEF), and whether the intervention was pharmacological. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. RESULTS: A total of 117 RCTs met the criteria for inclusion. Overall, the trial-level R-squared between HF admission and all-cause mortality was 0.39 (95% confidence interval (CI), 0.26 to 0.53). However, in the subgroup analyses, the trial-level R-squared was increased when the follow-up duration was ≥24 months (0.70 [95% CI: 0.55, 0.85]), when intervention was pharmacological (0.51 [95% CI: 0.34, 0.68]) and when the baseline HF type was HFrEF (0.57 [95% CI: 0.42, 0.73]). CONCLUSIONS: Our findings indicate that HF admission may not always be a valid surrogate for mortality in patients with HF. Rather, the surrogacy of HF admission may be dependent on clinical background and interventions.
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Insuficiência Cardíaca , Disfunção Ventricular Esquerda , Humanos , Insuficiência Cardíaca/tratamento farmacológico , Hospitalização , Volume SistólicoRESUMO
STUDY OBJECTIVE: To determine the association between emergency physicians' ages and patient mortality after emergency department visits. METHODS: This observational study used a 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 89 years treated by emergency physicians at EDs from 2016 to 2017. We investigated whether 7-day mortality after ED visits differed by the age of the emergency physician, adjusting for patient and physician characteristics and hospital fixed effects. RESULTS: We observed 2,629,464 ED visits treated by 32,570 emergency physicians (mean age 43.5). We found that patients treated by younger emergency physicians had lower mortality rates compared with those treated by older physicians. Adjusted 7-day mortality was 1.33% for patients treated by emergency physicians aged less than 40 years, 1.36% (adjusted difference, 0.03%; 95% confidence interval [CI], -0.001% to 0.06%) for physicians ages 40 to 49, 1.40% (0.08%; 95% CI 0.04% to 0.12%) for physicians ages 50 to 59, and 1.43% (0.11%; 95% CI 0.06% to 0.16%) for those with a physician age of 60 years and more. Similar patterns were observed when stratified by the patient's disposition (discharged vs admitted), and the association was more pronounced for patients with higher severity of illness. CONCLUSIONS: Medicare patients aged 65 to 89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians aged 50 to 59 years and 60 years or older within the same hospital. Potential mechanisms explaining the association between emergency physician age and patient mortality (eg, differences in training received and other unobservable patient/physician characteristics) are uncertain and require further study.
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Medicare , Médicos , Humanos , Idoso , Estados Unidos/epidemiologia , Adulto , Pessoa de Meia-Idade , Hospitalização , Hospitais , Serviço Hospitalar de EmergênciaRESUMO
Sustaining economic activities while curbing the number of new coronavirus disease 2019 (COVID-19) cases until effective vaccines or treatments become available is a major public health and policy challenge. In this paper, we use agent-based simulations of a network-based susceptible-exposed-infectious-recovered (SEIR) model to investigate two network intervention strategies for mitigating the spread of transmission while maintaining economic activities. In the simulations, we assume that people engage in group activities in multiple sectors (e.g., going to work, going to a local grocery store), where they interact with others in the same group and potentially become infected. In the first strategy, each group is divided into two subgroups (e.g., a group of customers can only go to the grocery store in the morning, while another separate group of customers can only go in the afternoon). In the second strategy, we balance the number of group members across different groups within the same sector (e.g., every grocery store has the same number of customers). The simulation results show that the dividing groups strategy substantially reduces transmission, and the joint implementation of the two strategies could effectively bring the spread of transmission under control (i.e., effective reproduction number ≈ 1.0).
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COVID-19/economia , COVID-19/prevenção & controle , Pandemias/economia , Pandemias/prevenção & controle , Rede Social , Simulação por Computador , Humanos , Análise de SistemasRESUMO
BACKGROUND: Although CKD screening programs have been provided in many settings, little is known as to how we can effectively translate those screening programs into improved health. METHODS: We conducted a randomized clinical trial on national health screening for CKD in Japan between April 2018 and March 2019. A total of 4011 participants in CKD screening programs aged 40-63 years were randomly assigned to two interventions or the control, with a ratio of 2:2:1, respectively: (1) the nudge-based letter that contained a message on the basis of behavioral economics, (2) the clinical letter including general information about CKD risks, and (3) the control (informed only of the screening results). The main outcome was adherence to a recommended physician visit within 6 months of the intervention. The secondary outcomes were eGFR, proteinuria, and BP 1 year after the intervention. RESULTS: Compared with the control group, the probability of undergoing a recommended physician visit was higher among participants who received the nudge-based letter (19.7% for the intervention group versus 15.8% for the control; difference, +3.9 percentage points [pp]; 95% CI, +0.8 to +7.0; P=0.02) and the clinical letter (19.7% versus 15.8%; difference, +3.9 pp; 95% CI, +0.8 to +7.0; P=0.02). We found no evidence that interventions were associated with improved early health outcomes. CONCLUSIONS: The behavioral economics intervention tested in this large RCT had limited effect on changing behavior or improving health outcomes. Although the approach has promise, this study demonstrates the challenge of developing behavioral interventions that improve the effectiveness of CKD screening programs.Clinical Trial registry name and registration number: University Hospital Medical Information Network Clinical Trial Registry, UMIN000035230.
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Economia Comportamental , Visita a Consultório Médico , Cooperação do Paciente , Sistemas de Alerta , Insuficiência Renal Crônica/psicologia , Adulto , Pressão Sanguínea , Correspondência como Assunto , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Avaliação de Resultados em Cuidados de Saúde , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/terapia , Fatores de TempoRESUMO
BACKGROUND: While advanced care planning (ACP) is recommended in dementia and cancer care, there are unique challenges in ACP for individuals with dementia, such as the insidious onset and progression of cognitive impairment, potentially leading to high-intensity care at the end of life (EOL) for this population. OBJECTIVE: To compare ACP completion and receipt of high-intensity care at the EOL between decedents with dementia versus cancer. DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: Participants of the U.S. Health and Retirement Study who died between 2000 and 2014 with dementia (n = 2099) and cancer (n = 1137). MAIN MEASURES: Completion of three types of ACP (living will, durable power of attorney for healthcare [DPOAH], discussions of preferences for EOL care) and three measures of EOL care intensity (in-hospital death, intensive care unit [ICU] care in the last 2 years of life, life support use in the last 2 years of life). KEY RESULTS: Use of living will was lower in dementia than in cancer (adjusted proportion, 49.9% vs. 56.9%; difference, - 7.0 percentage points [pp, 95% CI, - 13.3 to - 0.7]; p = 0.03). Use of DPOAH was similar between the two groups, but a lower proportion of decedents with dementia had discussed preferences compared to decedents with cancer (53.0% vs. 68.1%; - 15.1 pp [95% CI, - 19.3 to - 10.9]; p < 0.001). In-hospital death was higher in dementia than in cancer (29.5% vs. 19.8%; + 9.7 pp [95% CI, + 5.9 to + 13.5]; p < 0.001), although use of ICU care was lower (20.9% vs. 26.1%; - 5.2 pp [95% CI, - 9.8 to - 0.7]; p = 0.03). Use of life support was similar between the two groups. CONCLUSIONS: Individuals with dementia complete ACP less frequently and might be receiving higher-intensity EOL care than those with cancer. Interventions targeting individuals with dementia may be necessary to further improve EOL care for this population.
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Planejamento Antecipado de Cuidados , Demência , Neoplasias , Assistência Terminal , Demência/epidemiologia , Demência/terapia , Mortalidade Hospitalar , Humanos , Estudos Longitudinais , Neoplasias/epidemiologia , Neoplasias/psicologia , Neoplasias/terapia , Estudos Retrospectivos , Assistência Terminal/psicologiaRESUMO
BACKGROUND: A study has shown that industry payments to physicians for drugs are associated not only with higher drug prescriptions but also with higher non-drug costs due to additional utilization of healthcare services. However, the association between industry payments to cardiologists for antiplatelet drugs and the costs and number of percutaneous coronary interventions they perform has not been investigated. OBJECTIVE: To examine the association between industry payments to cardiologists for antiplatelet drugs and the costs and number of percutaneous coronary interventions they perform. DESIGN: Using the 2016 Open Payments Database linked to the 2017 Medicare Provider Utilization and Payment Data, we examined the association between the value of industry payments related to the antiplatelet drugs prasugrel and ticagrelor and healthcare spending and volume for cardiovascular procedures, adjusted for potential cofounders. SUBJECTS: A total of 7456 cardiologists who performed diagnostic cardiac catheterizations on Medicare beneficiaries in 2017. MAIN MEASURES: Primary outcomes included (1) healthcare spending on cardiac procedures, (2) diagnostic cardiac catheterization volumes, and (3) rates of coronary stenting. Secondary outcomes were total expenditures for all drugs and for antiplatelet drugs. KEY RESULTS: Industry payments for antiplatelet drugs were associated with higher healthcare spending on cardiac procedures (adjusted difference, +$50.9 for additional $100 industry payments; 95% CI, +$25.5 to +$76.2; P < 0.001), diagnostic cardiac catheterizations (+0.1 procedures per cardiologist; 95% CI, +0.03 to +0.1; P=0.001), and stent use (+0.5 per 1000 diagnostic cardiac catheterizations per cardiologist; 95% CI, +0.2 to +0.9; P=0.002). Industry payments for antiplatelet drugs were associated with higher total costs for all drugs and antiplatelet drugs. CONCLUSIONS: Industry payments to cardiologists for antiplatelet drugs were associated with both prescribing of antiplatelet drugs and the use of cardiac procedures and stents. Further research is warranted to understand whether the observed associations are causal or reflect a greater propensity for higher volume proceduralists to have relationships with industry.
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Medicare Part D , Médicos , Medicamentos sob Prescrição , Idoso , Indústria Farmacêutica , Humanos , Inibidores da Agregação Plaquetária/uso terapêutico , Padrões de Prática Médica , Stents , Estados UnidosRESUMO
BACKGROUND: The global burden of influenza is substantial. It is a major disease that causes annual epidemics and occasionally, pandemics. Given that influenza primarily infects the upper respiratory system, it may be possible to diagnose influenza infection by applying deep learning to pharyngeal images. OBJECTIVE: We aimed to develop a deep learning model to diagnose influenza infection using pharyngeal images and clinical information. METHODS: We recruited patients who visited clinics and hospitals because of influenza-like symptoms. In the training stage, we developed a diagnostic prediction artificial intelligence (AI) model based on deep learning to predict polymerase chain reaction (PCR)-confirmed influenza from pharyngeal images and clinical information. In the validation stage, we assessed the diagnostic performance of the AI model. In additional analysis, we compared the diagnostic performance of the AI model with that of 3 physicians and interpreted the AI model using importance heat maps. RESULTS: We enrolled a total of 7831 patients at 64 hospitals between November 1, 2019, and January 21, 2020, in the training stage and 659 patients (including 196 patients with PCR-confirmed influenza) at 11 hospitals between January 25, 2020, and March 13, 2020, in the validation stage. The area under the receiver operating characteristic curve for the AI model was 0.90 (95% CI 0.87-0.93), and its sensitivity and specificity were 76% (70%-82%) and 88% (85%-91%), respectively, outperforming 3 physicians. In the importance heat maps, the AI model often focused on follicles on the posterior pharyngeal wall. CONCLUSIONS: We developed the first AI model that can accurately diagnose influenza from pharyngeal images, which has the potential to help physicians to make a timely diagnosis.
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Aprendizado Profundo , Influenza Humana , Humanos , Inteligência Artificial , Influenza Humana/diagnóstico , Curva ROC , Sensibilidade e Especificidade , Estudos RetrospectivosRESUMO
BACKGROUND: The rapidly increased spending on insulin is a major public health issue in the United States. Industry marketing might be one of the upstream determinants of physicians' prescription of long-acting insulin-the most commonly used and costly type of insulin, but the evidence is lacking. We therefore aimed to investigate the association between industry payments to physicians and subsequent prescriptions of long-acting insulin. METHODS AND FINDINGS: Using the databases of Open Payments and Medicare Part D, we examined the association between the receipt of industry payments for long-acting insulin in 2016 and (1) the number of claims; (2) the costs paid for all claims; and (3) the costs per claim of long-acting insulin in 2017. We also examined the association between the receipt of payments and the change in these outcomes from 2016 to 2017. We employed propensity score matching to adjust for the physician-level characteristics (sex, years in practice, specialty, and medical school attended). Among 145,587 eligible physicians treating Medicare beneficiaries, 51,851 physicians received industry payments for long-acting insulin worth $22.3 million. In the propensity score-matched analysis including 102,590 physicians, we found that physicians who received the payments prescribed a higher number of claims (adjusted difference, 57.8; 95% CI, 55.8 to 59.7), higher costs for total claims (adjusted difference, +$22,111; 95% CI, $21,387 to $22,836), and higher costs per claim (adjusted difference, +$71.1; 95% CI, $69.0 to $73.2) of long-acting insulin, compared with physicians who did not receive the payments. The association was also found for changes in these outcomes from 2016 to 2017. Limitations to our study include limited generalizability, confounding, and possible reverse causation. CONCLUSIONS: Industry marketing payments to physicians for long-acting insulin were associated with the physicians' prescriptions and costs of long-acting insulin in the subsequent year. Future research is needed to assess whether policy interventions on physician-industry financial relationships will help to ensure appropriate prescriptions and limit overall costs of this essential drug for diabetes care.
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Compensação e Reparação , Conflito de Interesses/economia , Indústria Farmacêutica/economia , Hipoglicemiantes/uso terapêutico , Insulina de Ação Prolongada/uso terapêutico , Padrões de Prática Médica/economia , Atitude do Pessoal de Saúde , Bases de Dados Factuais , Prescrições de Medicamentos/economia , Uso de Medicamentos/economia , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Medicare Part D , Pontuação de Propensão , Estados UnidosRESUMO
OBJECTIVE: To evaluate the association between the introduction of the Affordable Care Act (ACA) Health Insurance Marketplaces ("Marketplaces") and financial protection for patients undergoing surgery. BACKGROUND: The ACA established Marketplaces through which individuals could purchase subsidized insurance coverage. However, the effect of these Marketplaces on surgical patients' healthcare spending remains largely unknown. METHODS: We analyzed a nationally representative sample of adults aged 19-64 who underwent surgery in 2010-2017, using the Medical Expenditure Panel Survey. Low-income patients eligible for cost-sharing and premium subsidies in the Marketplaces [income 139%-250% federal poverty level (FPL)] and middle-income patients eligible only for premium subsidies (251%-400% FPL) were compared to high-income controls ineligible for subsidies (>400% FPL) using a quasi-experimental difference-in-differences approach. We evaluated 3 main outcomes: (1) out-of-pocket spending, (2) premium contributions, and (3) likelihood of experiencing catastrophic expenditures, defined as out-of-pocket plus premium spending exceeding 19.5% of family income. RESULTS: Our sample included 5450 patients undergoing surgery, representing approximately 69 million US adults. Among low-income patients, Marketplace implementation was associated with $601 lower [95% confidence interval (CI): -$1169 to -$33; P = 0.04) out-of-pocket spending; $968 lower (95% CI: -$1652 to -$285; P = 0.006) premium spending; and 34.6% lower probability (absolute change: -8.3 percentage points; 95% CI: -14.9 to -1.7; P = 0.01) of catastrophic expenditures. We found no evidence that health expenditures changed for middle-income surgical patients. CONCLUSIONS: The ACA's insurance Marketplaces were associated with improved financial protection among low-income surgical patients eligible for both cost-sharing and premium subsidies, but not in middle-income patients eligible for only premium subsidies.
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Gastos em Saúde , Trocas de Seguro de Saúde/economia , Procedimentos Cirúrgicos Operatórios/economia , Adulto , Custo Compartilhado de Seguro/economia , Humanos , Cobertura do Seguro/economia , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/economia , Fatores Socioeconômicos , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: The aim of this study was to compare patient outcomes between International Medical Graduate (IMG) versus US medical graduate (USMG) surgeons. SUMMARY BACKGROUND DATA: One in 7 surgeons practicing in the US graduated from a foreign medical school. However, it remains unknown whether patient outcomes differ between IMG versus USMG surgeons. METHODS: Using 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 99 years who underwent 1 of 13 common nonelective surgical procedures (as a "natural experiment" as surgeons are less likely to select patients in this context) in 2011 to 2014 (638,973 patients treated by 37,221 surgeons for the mortality analysis), we compared operative mortality, complications, and length of stay (LOS) between IMG and USMG surgeons, adjusting for patient and surgeon characteristics and hospital-specific fixed effects (effectively comparing IMG and USMG surgeons within the same hospital). We also conducted stratified analyses by patients' severity of illness and procedure type. RESULTS: We found no evidence that patient outcomes differ between IMG and USMG surgeons for operative mortality [adjusted mortality, 7.3% for IMGs vs 7.3% for USMGs; adjusted odds ratio (aOR), 1.01; 95% confidence interval (CI), 0.96-1.05; P = 0.79], complication rate (adjusted complication rate, 0.6% vs 0.6%; aOR, 0.95; 95% CI, 0.85-1.06; P = 0.43), and LOS (adjusted LOS, 6.6 days vs 6.6 days; adjusted difference, +0.02 days; 95% CI, -0.05 to +0.08; P = 0.54). We also found no difference when we stratified by severity of illness and procedures. CONCLUSION: Using national data of Medicare beneficiaries who underwent common surgical procedures, we found no evidence that outcomes differ between IMG and USMG surgeons.
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Competência Clínica , Médicos Graduados Estrangeiros , Avaliação de Resultados em Cuidados de Saúde , Padrões de Prática Médica/estatística & dados numéricos , Cirurgiões/normas , Procedimentos Cirúrgicos Operatórios , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Medicare , Estados UnidosRESUMO
BACKGROUND: Research suggests that preventive measures are critical to reducing the spread of coronavirus disease 2019 (COVID-19), but evidence regarding the association between trust in government and the practice of preventive measures is limited. OBJECTIVE: To examine whether the practice of preventive measures against COVID-19 differs by one's level of trust in government. DESIGN: A cross-sectional analysis using the Japan COVID-19 and Society Internet Survey (JACSIS) conducted in August and September 2020. PARTICIPANTS: A nationally representative sample of Japanese individuals aged 15 through 79 years. MAIN MEASURES: The primary outcome was the composite score for COVID-19 preventive measures, defined as the percentage of preventive measures an individual reported to be practicing (out of nine measures: social distancing, wearing masks, avoiding closed spaces, avoiding crowded spaces, avoiding close contact settings, hand washing, avoiding touching one's face, respiratory hygiene, and surface disinfection). The secondary outcomes were (1) support for stay-at-home requests, (2) use of a contact-tracing app, and (3) receipt of the influenza vaccine in the previous season. KEY RESULTS: Our analysis included a total of 25,482 individuals. After adjusting for potential confounders, we found that individuals with high trust in government were likely to practice preventive measures more frequently compared to those with low trust (adjusted composite scores, 83.8% for high- vs. 79.5% for low-trust individuals; adjusted difference, +4.3 percentage points [pp]; 95% CI, +2.4 to +6.2pp; P<0.001). We also found that high trust in government was associated with higher likelihoods of support for stay-at-home requests, use of a contact-tracing app, and receipt of the influenza vaccine in the previous season. CONCLUSIONS: High trust in government was associated with a higher intensity of practicing COVID-19 preventive measures among Japanese individuals at the national level. Our findings may provide useful information to develop and design effective public health interventions.
Assuntos
COVID-19 , Pandemias , Estudos Transversais , Governo , Humanos , Japão/epidemiologia , SARS-CoV-2 , Inquéritos e Questionários , ConfiançaRESUMO
BACKGROUND: Evidence is limited as to whether the introduction of the Affordable Care Act (ACA)'s Medicaid expansions was associated with improvements in cardiovascular risk factors at the population level. OBJECTIVE: To examine the association between the ACA Medicaid expansions and changes in cardiovascular risk factors among low-income individuals during the first 3 years of the implementation of the ACA Medicaid expansions at the national level. DESIGN: A quasi-experimental difference-in-differences (DID) analysis to compare outcomes before (2005-2012) and after (2015-2016) the implementation of the ACA Medicaid expansions between individuals in states that expanded Medicaid and individuals in non-expansion states. PARTICIPANTS: A nationally representative sample of individuals aged 19-64 years with family incomes below 138% of the federal poverty level from the 2005-2016 National Health and Nutrition Examination Survey (NHANES). INTERVENTION: ACA Medicaid expansions. MAIN MEASURES: Cardiovascular risk factors included (1) systolic and diastolic blood pressure, (2) hemoglobin A1c (HbA1c) level, and (3) cholesterol levels (low-density lipoprotein cholesterol, triglyceride, and high-density lipoprotein cholesterol). KEY RESULTS: A total of 9177 low-income individuals were included in our analysis. We found that the ACA Medicaid expansions were associated with a lower systolic blood pressure (DID estimate, - 3.03 mmHg; 95% CI, - 5.33 mmHg to - 0.73 mmHg; P = 0.01; P = 0.03 after adjustment for multiple comparisons) and lower HbA1c level (DID estimate, - 0.14 percentage points [pp]; 95% CI, - 0.24 pp to - 0.03 pp; P = 0.01; P = 0.03 after adjustment for multiple comparisons). We found no evidence that diastolic blood pressure and cholesterol levels changed following the ACA Medicaid expansions. CONCLUSION: Using the nationally representative data of individuals who were affected by the ACA, we found that the ACA Medicaid expansions were associated with a modest improvement in cardiovascular risk factors related to hypertension and diabetes during the first 3 years of implementation.
Assuntos
Doenças Cardiovasculares , Medicaid , Doenças Cardiovasculares/epidemiologia , Acessibilidade aos Serviços de Saúde , Fatores de Risco de Doenças Cardíacas , Humanos , Cobertura do Seguro , Inquéritos Nutricionais , Patient Protection and Affordable Care Act , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The extent to which a surgeon's risk aversion influences their clinical decisions remains unknown. We assessed whether a surgeon's attitude toward risk ("risk aversion") influences their surgical decisions and whether the relationship can be explained by differences in surgeons' perception of treatment risks and benefits. MATERIALS AND METHODS: We presented a series of detailed clinical vignettes to a national sample of surgeons (n = 1,769; 13.4% adjusted response rate) and asked them to complete an instrument that measured how risk averse they are within their clinical practice (scale 6-36; higher number indicates greater risk aversion). For each vignette, participants rated their likelihood of recommending an operation and judged the likelihood of complications or full recovery. We examined whether differences in perceived likelihood of complications versus recovery could explain why risk-averse surgeons may be less likely to recommend an operation. RESULTS: Surgeons varied in their self-reported risk aversion score (median = 25, interquartile range[22,28]). Scores did not differ by level of surgeon experience or gender. Risk-averse surgeons were significantly less likely to recommend an operation for patients with exactly the same condition (65.5% for surgeons in highest quartile of risk aversion versus 62.3% for lowest quartile; P = 0.02). However, after controlling for surgeons' perception of the likelihood of complications versus recovery, there was no longer a significant association between surgeons' risk aversion and the decision to recommend an operation (64.7% versus 64.8%; P = 0.96). CONCLUSIONS: Surgeons vary widely in their self-reported risk aversion. Risk-averse surgeons were significantly less likely to recommend an operation, a finding that was explained by a higher perceived probability of post-operative complications than their colleagues.
Assuntos
Cirurgiões , Tomada de Decisão Clínica , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Fatores de RiscoRESUMO
BACKGROUND: The use of telemedicine outpatient visits has increased dramatically during the COVID-19 pandemic in many countries. Although disparities in access to telemedicine by age and socioeconomic status (SES) have been well-documented, evidence is limited as to how these disparities changed during the COVID-19 pandemic. Moreover, the equity of patient access to telemedicine has been scarcely reported in Japan, despite the huge potential for telemedicine expansion. OBJECTIVE: We aimed to investigate changes due to age and SES disparities in telemedicine use during the COVID-19 pandemic in Japan. METHODS: Using data from a large internet survey conducted between August 25 and September 30, 2020, in Japan, we examined the associations of participant age and SES (educational attainment, urbanicity of residence, and income level) with their telemedicine use in the following two time periods during the pandemic: April 2020 and August-September 2020. RESULTS: Of the 24,526 participants aged 18 to 79 years (50.8% [n=12,446] women), the proportion of individuals who reported using telemedicine increased from 2.0% (n=497) in April 2020 to 4.7% (n=1159) in August-September 2020. After adjusting for potential confounders, younger individuals were more likely to use telemedicine than older individuals in April 2020. Although this pattern persisted in August-September 2020, we also observed a substantial increase in telemedicine use among individuals aged 70 to 79 years (adjusted rates, 0.2% in April 2020 vs 3.8% in August-September 2020; P<.001 after multiple comparisons). We found disparities in telemedicine use by SES in August-September 2020 that did not exist in April 2020. In August-September 2020, individuals with a university degree were more likely to use telemedicine than those with a high school diploma or less (adjusted rates, 6.6% vs 3.5%; P<.001). Individuals living in urban areas exhibited higher rates of telemedicine use than those living in rural areas only in August-September 2020 (adjusted rates, 5.2% vs 3.8%; P<.001). Disparities in telemedicine use by income level were not observed in either time period. CONCLUSIONS: In general, younger individuals increased their use of telemedicine compared to older individuals during the pandemic, although individuals in their 70s also increased their use of telemedicine. Disparities in telemedicine use by educational attainment and urbanicity of residence widened during the COVID-19 pandemic.