Effects of rural hospital closures on nurse staffing levels and health care utilization at nearby hospitals.

Our study examines the causal effect of rural hospital closures on nearby hospitals' nurse staffing levels and health care utilization. We use data from the 2014-2019 American Hospital Association Survey on nurse staffing level outcomes including licensed practical or vocational nurses (LPNs), registered nurses (RNs), and advanced practice nurses (APNs); and health care utilization outcomes, including inpatient and outpatient surgical operations and emergency department (ED) visits. Using propensity score matching and difference-in-differences (DID) methods, we find that rural hospital closures lead to an average increase of 37.3% in the number of nurses in nearby rural hospitals during the 4 years following the closure. This increase is found across all categories of nurses, including LPNs, RNs, and APNs. We also find a substantial increase in the provision of inpatient and outpatient surgical operations but there is no change in ED visits. We do not find any effects for nearby urban hospitals. Our study suggests that a large proportion of the nursing workforce relocates to nearby hospitals after a rural hospital closure, which mitigates the negative consequences of such closures and allows these nearby hospitals to provide a larger volume of highly profitable services.

Regional and temporal effects of naloxone access laws on opioid overdose mortality.

BACKGROUND: Naloxone is a drug that reverses opioid overdose. Naloxone Access Laws (NALs) increase public access to naloxone and have been considered as one promising solution to reducing opioid-related harm. However, previous studies on whether NALs are effective in reducing opioid overdose mortality found somewhat contradictory results. Our study attempts to provide a more definitive answer to this question by utilizing an approach that matches NAL vs non-NAL states and stratifies by US region and years of implementation. Methods: We assess the causal impact of NALs on state-level opioid-related mortality rate by constructing a comparison group using matching to produce a valid counterfactual scenario, and estimating the effects of NAL using a semi-dynamic staggered difference in differences (DID) model that allows heterogeneous effects across regions and years of implementation. State-level opioid-related mortality data from CDC's WONDER database and NALs effective from 1999 to 2014 were utilized. Results: We find that NAL effects have reduced fatal opioid-related overdose in western states and have produced minimal or no effects for other regions. Conclusions: The effects of NALs vary across regions and years of implementation. It is important to study the successful experience of the western states.

Blood use and transfusion needs at a large health care system in Washington state during the SARS-CoV-2 pandemic.

BACKGROUND: This report evaluates hospital blood use trends during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, and identifies factors associated with the need for transfusion and risk of death in patients with coronavirus 2019 (COVID-19). METHODS: Overall hospital blood use and medical records of adult patients with COVID-19 were extracted for two institutions. Multivariate logistic regression models were conducted to estimate associations between the outcomes transfusion and mortality and patient factors. RESULTS: Daily blood use decreased compared to pre-COVID-19 levels; the effect was more significant for platelets (29% and 34%) compared to red blood cells (25% and 20%) at the two institutions, respectively. Surgical and oncologic services had a decrease in average daily use of platelets of 52% and 30%, and red blood cells of 39% and 25%, respectively. A total of 128 patients with COVID-19 were hospitalized, and 13 (10%) received at least one transfusion due to anemia secondary to chronic illness (n = 7), recent surgery (n = 3), and extracorporeal membrane oxygenation (n = 3). Lower baseline platelet count and admission to the intensive care unit were associated with increased risk of transfusion. The blood group distribution in patients with COVID-19 was 37% group O, 40% group A, 18% group B, and 5% group AB. Non-type O was not associated with increased risk of mortality. CONCLUSION: The response to the SARS-CoV-2 pandemic included changes in routine hospital operations that allowed for the provision of a sufficient level of care for patients with and without COVID-19. Although blood type may play a role in COVID-19 susceptibility, it did not seem to be associated with patient mortality.

Use of hydroxyethyl starch in leukocytapheresis procedures does not increase renal toxicity.

BACKGROUND: Hydroxyethyl starch (HES) is reportedly associated with an increased risk of renal failure and death when used for fluid resuscitation in critically ill patients. HES can be used during therapeutic leukocytapheresis (TL) procedures to enhance cell separation. The purpose of this study was to evaluate the occurrence of adverse events associated with HES during TL procedures. STUDY DESIGN AND METHODS: We performed a retrospective review of patients who underwent TL with and without HES in the period 2009 to 2013 at six academic medical institutions. RESULTS: A difference-in-difference regression analysis was used to estimate the mean change before and after TL in selected outcomes in the HES group relative to the average change in the non-HES group. Selected outcomes included serum creatinine, estimated glomerular filtration rate (eGFR), and white blood cell (WBC) count. A total of 195 patients who underwent 278 TL procedures were studied. We found no significant differences in serum creatinine levels and eGFR on Days 1 and 7 after TL procedure between patients who received and those who did not receive HES. The rate of adverse events and overall and early mortality were similar in both groups. Patients with acute myeloid leukemia who received HES had greater WBC reduction when HES was used. Additionally, patients who received HES had improvement in pulmonary leukostasis symptoms. CONCLUSION: HES, used at low doses during TL procedures, was not associated with adverse events previously ascribed to its use as a volume expander.

The effect of Surgical Care Improvement Project (SCIP) compliance on surgical site infections (SSI).

BACKGROUND: The Surgical Care Improvement Project (SCIP) has developed a set of process compliance measures in an attempt to reduce the incidence of surgical site infections (SSIs). Previous research has been inconclusive on whether compliance with these measures is associated with lower SSI rates. OBJECTIVES: To determine whether hospitals with higher levels of compliance with SCIP measures have lower incidence of SSIs and to identify the measures that are most likely to drive this association. DATA AND METHODS: Analysis of linked SCIP compliance rates and SSIs on 295 hospital groups observed annually over the study period 2007-2010. A hospital group comprises all hospitals sharing identical categories for location by state, teaching status, bed size, and urban/rural location. We used a generalized linear model regression with logistic link and binomial family to estimate the association between 3 SCIP measures and SSI rates. RESULTS: Hospital groups with higher compliance rates had significantly lower SSI rates for 2 SCIP measures: antibiotic timing and appropriate antibiotic selection. For a hospital group of median characteristics, a 10% improvement in the measure provision of antibiotic 1 hour before intervention led to a 5.3% decrease in the SSI rates (P<0.05). Rural hospitals had effect sizes several times larger than urban hospitals (P<0.05). A third-core measure, Timely Antibiotic Stop, showed no robust association. CONCLUSIONS: This analysis supports a clinically and statistically meaningful relationship between adherence to 2 SCIP measures and SSI rates, supporting the validity of the 2 publicly available healthcare-associated infection metrics.

Telehealth Expansion and Medicare Beneficiaries' Care Quality and Access.

Importance: Understanding the association of telehealth use with health care outcomes is fundamental to determining whether telehealth waivers implemented during the COVID-19 public health emergency should be made permanent. The current literature has yielded inconclusive findings owing to its focus on select states, practices, or health care systems. Objective: To estimate the association of telehealth use with outcomes for all Medicare fee-for-service (FFS) beneficiaries by comparing hospital service areas (HSAs) with different levels of telehealth use. Design, Setting, and Participants: This US population-based, retrospective cohort study was conducted from July 2022 to April 2023. Participants included Medicare claims of beneficiaries attributed to HSAs with FFS enrollment in Parts A and B. Exposures: Low, medium, or high tercile of telehealth use created by ranking HSAs according to the number of telehealth visits per 1000 beneficiaries. Main Outcomes and Measures: The primary outcomes were quality (ambulatory care-sensitive [ACS] hospitalizations and emergency department [ED] visits per 1000 FFS beneficiaries), access to care (clinician encounters per FFS beneficiary), and cost (total cost of care for Part A and/or B services per FFS Medicare beneficiary) determined with a difference-in-difference analysis. Results: In this cohort study of claims from approximately 30 million Medicare beneficiaries (mean [SD] age in 2019, 71.04 [1.67] years; mean [SD] percentage female in 2019, 53.83% [2.14%]) within 3436 HSAs, between the second half of 2019 and the second half of 2021, mean ACS hospitalizations and ED visits declined sharply, mean clinician encounters per beneficiary declined slightly, and mean total cost of care per beneficiary per semester increased slightly. Compared with the low group, the high group had more ACS hospitalizations (1.63 additional hospitalizations per 1000 beneficiaries; 95% CI, 1.03-2.22 hospitalizations), more clinician encounters (0.30 additional encounters per beneficiary per semester; 95% CI, 0.23-0.38 encounters), and higher total cost of care ($164.99 higher cost per beneficiary per semester; 95% CI, $101.03-$228.96). There was no statistically significant difference in ACS ED visits between the low and high groups. Conclusions and Relevance: In this cohort study of Medicare beneficiaries across all 3436 HSAs, high levels of telehealth use were associated with more clinician encounters, more ACS hospitalizations, and higher total health care costs. COVID-19 cases were still high during the period of study, which suggests that these findings partially reflect a higher capacity for providing health services in HSAs with higher telehealth intensity than other HSAs.

Racial and Ethnic Differences in Antipsychotic Medication Use Among Children Enrolled in Medicaid.

OBJECTIVE: The objective of this study was to detect and measure differences in antipsychotic drug use across racial-ethnic groups of children enrolled in Medicaid. METHODS: The main data sources were the Medicaid MAX Person Summary and the MAX Prescription Drug files for calendar years 2005-2009 and the Environmental Scanning and Program Characteristics Database. The analyses were based on the entire population (5.8 million) of Medicaid-enrolled children and adolescents, ages two to 20, from eight states. Proportional hazard and ordinary least-squares multivariate regressions were used to assess the effect of race-ethnicity on the likelihood of antipsychotic prescription fills and the use of any psychiatric services. RESULTS: The study found robust and statistically significant evidence of higher antipsychotic drug use among white children, especially relative to Hispanic and Asian children. When analyses held all variables constant, the probability of having an antipsychotic fill was lower compared with whites by 1.8 percentage points for African Americans, by 2.0 percentage points for Asians, and by 1.8 percentage points for Hispanics. These effects are large in light of the finding that the probability of an antipsychotic prescription fill across child-years was only 2.4%. Children from these minority groups were also less likely to receive psychiatric services. CONCLUSIONS: Substantial racial-ethnic differences were found in antipsychotic use. Explanations based on greater aversion to pharmacological treatment among minority groups are insufficient to explain the phenomenon.

Small area estimation of obesity prevalence and dietary patterns: a model applied to Rio de Janeiro city, Brazil.

We propose the use of previously developed small area estimation techniques to monitor obesity and dietary habits in developing countries and apply the model to Rio de Janeiro city. We estimate obesity prevalence rates at the Census Tract through a combinatorial optimization spatial microsimulation model that matches body mass index and socio-demographic data in Brazil's 2008-9 family expenditure survey with Census 2010 socio-demographic data. Obesity ranges from 8% to 25% in most areas and affects the poor almost as much as the rich. Male and female obesity rates are uncorrelated at the small area level. The model is an effective tool to understand the complexity of the problem and to aid in policy design.

Income-based disparities in health care utilisation under universal health coverage in Brazil, 2002-2003.

Since Brazil's adoption of universal health care in 1988, the country's health care system has consisted of a mix of private providers and free public providers. We test whether income-based disparities in medical visits and medications remain in Brazil despite universal coverage using a nationally representative sample of over 48,000 households. Additional income is associated with less public sector utilisation and more private sector utilisation, both using simple correlations and regressions controlling for household characteristics and local area fixed effects. Importantly, the increase in private care use is greater than the drop in public care use. Also, income and unmet medical needs are negatively associated. These results suggest that access limitations remain for low-income households despite the availability of free public care.

Public versus private treatment of chronic diseases in seniors: Argentina, Brazil, Chile and Uruguay.

This article measures differences in the likelihood of treatment of chronic diseases in elders across types of coverage (private, public and social security) in four major Latin American cities: Buenos Aires (Argentina), Sao Paulo (Brazil), Santiago (Chile) and Montevideo (Uruguay). We used a logistic regression to estimate the odds ratio for treatment of chronic diseases carried by individuals with public, private and social security coverage. The data were from the Survey on health, well-being and aging in Latin America and the Caribbean (SABE) conducted in 1999 and 2000. We find a strong association between possession of public coverage only and treatment failure of chronic diseases in elders in Argentina. We find no significant association for Brazil, Chile and Uruguay. In Buenos Aires, access to private or social security coverage is a necessity for elders because the public sector fails to provide proper treatment. In the remaining cities, private or social security coverage provides similar coverage for chronic diseases in elders compared with the public sector. For this group of countries, the main difference between the former and the latter seems to be in terms of 'luxurious' characteristics, such as the quality of the facilities and waiting times.