One-Year Costs Associated With the Veterans Affairs National TeleStroke Program.

OBJECTIVES: Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP). METHODS: We identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect. RESULTS: NTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P < .0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care. CONCLUSIONS: Telestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.

Expansion of the Veterans Health Administration Network and Surgical Outcomes.

Importance: The US Department of Veterans Affairs (VA) Veterans Choice Program (VCP) expanded health care access to community settings outside the VA for eligible patients. Little is known about the effect of VCP on access to surgery and postoperative outcomes. Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported. Research findings on the association of VCP and postoperative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding. Objective: To investigate the association of the VCP with access to surgery and postoperative outcomes using a nonrandomized controlled regression discontinuity design (RDD) to reduce the impact of unmeasured confounders. Design, Setting, and Participants: This was a nonrandomized RDD study of the Veterans Health Administration (VHA). Participants included veterans enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019. Interventions: The VCP, which expanded access to VA-paid community care for eligible veterans living 40 miles or more from their closest VA hospital. Main Outcomes and Measures: Postoperative emergency department visits, inpatient readmissions, and mortality at 30 and 90 days. Results: A total of 615 473 unique surgical procedures among 498 427 patients (mean [SD] age, 63.0 [12.9] years; 450 366 male [90.4%]) were identified. Overall, 94 783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type. Patients who underwent VA-paid procedures were more likely to be women (9209 [12.7%] vs men, 38 771 [9.1%]), White race (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and younger than 65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided), with a significantly lower comorbidity burden (mean [SD], 1.8 [2.2] vs 2.6 [2.7]). The nonrandomized RDD revealed that VCP was associated with a slight increase of 0.03 in the proportion of VA-paid surgical procedures among eligible veterans (95% CI, 0.01-0.05; P = .01). However, there was no difference in postoperative mortality, readmissions, or emergency department visits. Conclusions and Relevance: Expanded access to health care in the VHA was associated with a shift in the performance of surgical procedures in the private sector but had no measurable association with surgical outcomes. These findings may assuage concerns of worsened patient outcomes resulting from care coordination issues when care is expanded outside of a single health care system, although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.

Association of Expanded Health Care Networks With Utilization Among Veterans Affairs Enrollees.

Importance: Health insurers alter the size of their networks, offering lower premiums in exchange for a more limited set of care choices. However, little is known about the association of network size with health care utilization and outcomes, particularly outside of the context of private insurance plans. Objective: To evaluate changes in health care utilization after an expansion in the Veterans Affairs Health Care System (VA) health care network. Design, Setting, and Participants: This cross-sectional study included individuals enrolled in the VA from 2015 to 2018. Considering that the health care network expansion only affected a portion of enrollees, only those who lived between 20 and 60 miles from a VA facility were included. Data analysis was conducted from September 2020 to February 2021. Exposures: Individuals who lived 40 or more miles away from a VA facility were automatically eligible for an expanded health care network through non-VA practitioners (VA community care); those living less than 40 miles away from a VA facility were not automatically eligible. Main Outcomes and Measures: A regression discontinuity analysis of individuals who became eligible for an expanded network based on geographic residence was performed. Inpatient and outpatient utilization rates per VA enrollee during the study period, with utilization differentiated by whether services were provided by a VA or non-VA practitioner, were calculated. Results: The study included more than 2.7 million unique individuals whose characteristics largely reflected the demographic characteristics of the VA system (mean [SD] age, 62 [17] years; 2 589 252 [90%] men; 282 168 [10%] Black; 2 203 352 [77%] White). Patient characteristics (age, race, and comorbidities) did not vary significantly by eligibility status. Outpatient utilization was 3.2% higher (95% CI, 1.0% to 5.3%) among those with access to an expanded network. Increased utilization was most pronounced among those with a higher VA disability rating (3.1%; 95% CI, 0.5% to 5.7%) and among younger individuals without service-connected disabilities (7.0%, 95% CI, 1.7% to 12.3%). There was no evidence of changes to inpatient utilization (1.2%; 95% CI. -2.5% to 4.9%; P = .37) for those with access to the expanded network. Conclusions and Relevance: In this study, expanded network access was associated with increased total health care utilization among affected enrollees in the VA. Understanding how network size affects utilization is immediately informative for the VA, but it can also help to guide policies for insurance markets.

Comparing demographic and health characteristics of new and existing SNAP recipients: application of a machine learning algorithm.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) expanded significantly after the Great Recession of 2008-2009, but no studies have characterized this new group of recipients. Few data sets provide details on whether an individual is a new or established recipient of SNAP. OBJECTIVE: We sought to identify new and existing SNAP recipients, and to examine differences in sociodemographic characteristics, health, nutritional status, and food purchasing behavior between new and existing recipients of SNAP after the recession. METHODS: We created a probabilistic algorithm to identify new and existing SNAP recipients using the 1999-2013 waves of the Panel Study of Income Dynamics. We applied this algorithm to the National Household Food Acquisition and Purchase Survey (FoodAPS), fielded during 2012-2013, to predict which individuals were likely to be new SNAP recipients. We then compared health and nutrition characteristics between new, existing, and never recipients of SNAP in FoodAPS. RESULTS: New adult SNAP recipients had higher socioeconomic status, better self-reported health, and greater food security relative to existing recipients, and were more likely to smoke relative to never recipients. New child SNAP recipients were less likely to eat all meals and had lower BMI relative to existing recipients. New SNAP households exhibited differences in food access and expenditures, although dietary quality was similar to that of existing SNAP households. CONCLUSION: We developed a novel algorithm for predicting new and existing SNAP recipiency that can be applied to other data sets, and subsequently demonstrated differences in health characteristics between new and existing recipients. The expansion of SNAP since the Great Recession enrolled a population that differed from the existing SNAP population and that may benefit from different types of nutritional and health services than those traditionally offered.

Forecasting Trends in Disability in a Super-Aging Society: Adapting the Future Elderly Model to Japan.

Japan has experienced pronounced population aging, and now has the highest proportion of elderly adults in the world. Yet few projections of Japan's future demography go beyond estimating population by age and sex to forecast the complex evolution of the health and functioning of the future elderly. This study estimates a new state-transition microsimulation model - the Japanese Future Elderly Model (FEM) - for Japan. We use the model to forecast disability and health for Japan's future elderly. Our simulation suggests that by 2040, over 27 percent of Japan's elderly will exhibit 3 or more limitations in IADLs and social functioning; almost one in 4 will experience difficulties with 3 or more ADLs; and approximately one in 5 will suffer limitations in cognitive or intellectual functioning. Since the majority of the increase in disability arises from the aging of the Japanese population, prevention efforts that reduce age-specific morbidity can help reduce the burden of disability but may have only a limited impact on reducing the overall prevalence of disability among Japanese elderly. While both age and morbidity contribute to a predicted increase in disability burden among elderly Japanese in the future, our simulation results suggest that the impact of population aging exceeds the effect of age-specific morbidity on increasing disability in Japan's future.

Geographic variation in surgical outcomes and cost between the United States and Japan.

OBJECTIVES: Unwarranted geographic variation in spending has received intense scrutiny in the United States. However, few studies have compared variation in spending and surgical outcomes between the United States healthcare system and those of other nations. In this study, we compare the geographic variation in postsurgical outcomes and cost between the United States and Japan. STUDY DESIGN: This retrospective cohort study uses Medicare Part A data from the United States (2010-2011) and similar inpatient data from Japan (2012). Patients 65 years or older undergoing 1 of 5 surgeries (coronary artery bypass graft, abdominal aortic aneurysm repair, colectomy, pancreatectomy, or gastrectomy) were selected in the United States and Japan. METHODS: Reliability- and case-mix-adjusted coefficient of variation (COV) values were calculated using hierarchical modeling and empirical Bayes techniques for the following 5 outcomes: postoperative mortality, the development of a complication, death after complication (failure to rescue), length of stay, and the cost of the hospitalization. Sensitivity analyses were also performed by calculating patient demographic-and case-mix-adjusted COV values for each outcome using weighted age- and sex-standardized values. RESULTS: The variability of the postsurgical outcomes was uniformly lower in the United States compared with Japan. Cost variation was consistently higher in the United States for all surgeries. CONCLUSIONS: Although the US healthcare system may be more inefficient regarding costs, the presence of higher geographic variation in postoperative care in Japan, relative to the United States, suggests that the observed geographic variation in the United States-both for health expenditures and outcomes-is not a unique manifestation of its structural shortcomings.

Physician spending and subsequent risk of malpractice claims: observational study.

STUDY QUESTION: Is a higher use of resources by physicians associated with a reduced risk of malpractice claims? METHODS: Using data on nearly all admissions to acute care hospitals in Florida during 2000-09 linked to malpractice history of the attending physician, this study investigated whether physicians in seven specialties with higher average hospital charges in a year were less likely to face an allegation of malpractice in the following year, adjusting for patient characteristics, comorbidities, and diagnosis. To provide clinical context, the study focused on obstetrics, where the choice of caesarean deliveries are suggested to be influenced by defensive medicine, and whether obstetricians with higher adjusted caesarean rates in a year had fewer alleged malpractice incidents the following year. STUDY ANSWER AND LIMITATIONS: The data included 24,637 physicians, 154,725 physician years, and 18,352,391 hospital admissions; 4342 malpractice claims were made against physicians (2.8% per physician year). Across specialties, greater average spending by physicians was associated with reduced risk of incurring a malpractice claim. For example, among internists, the probability of experiencing an alleged malpractice incident in the following year ranged from 1.5% (95% confidence interval 1.2% to 1.7%) in the bottom spending fifth ($19,725 (£12,800; €17,400) per hospital admission) to 0.3% (0.2% to 0.5%) in the top fifth ($39,379 per hospital admission). In six of the specialties, a greater use of resources was associated with statistically significantly lower subsequent rates of alleged malpractice incidents. A principal limitation of this study is that information on illness severity was lacking. It is also uncertain whether higher spending is defensively motivated. WHAT THIS STUDY ADDS: Within specialty and after adjustment for patient characteristics, higher resource use by physicians is associated with fewer malpractice claims. FUNDING, COMPETING INTERESTS, DATA SHARING: This study was supported by the Office of the Director, National Institutes of Health (grant 1DP5OD017897-01 to ABJ) and National Institute of Aging (R37 AG036791 to JB). The authors have no competing interests or additional data to share.

Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: an economic analysis.

INTRODUCTION: The decreasing effectiveness of antimicrobial agents is a growing global public health concern. Low-income and middle-income countries are vulnerable to the loss of antimicrobial efficacy because of their high burden of infectious disease and the cost of treating resistant organisms. We aimed to assess if copayments in the public sector promoted the development of antibiotic resistance by inducing patients to purchase treatment from less well regulated private providers. METHODS: We analysed data from the WHO 2014 Antibacterial Resistance Global Surveillance report. We assessed the importance of out-of-pocket spending and copayment requirements for public sector drugs on the level of bacterial resistance in low-income and middle-income countries, using linear regression to adjust for environmental factors purported to be predictors of resistance, such as sanitation, animal husbandry, and poverty, and other structural components of the health sector. Our outcome variable of interest was the proportion of bacterial isolates tested that showed resistance to a class of antimicrobial agents. In particular, we computed the average proportion of isolates that showed antibiotic resistance for a given bacteria-antibacterial combination in a given country. FINDINGS: Our sample included 47 countries (23 in Africa, eight in the Americas, three in Europe, eight in the Middle East, three in southeast Asia, and two in the western Pacific). Out-of-pocket health expenditures were the only factor significantly associated with antimicrobial resistance. A ten point increase in the percentage of health expenditures that were out-of-pocket was associated with a 3·2 percentage point increase in resistant isolates (95% CI 1·17-5·15; p=0·002). This association was driven by countries requiring copayments for drugs in the public health sector. Of these countries, moving from the 20th to 80th percentile of out-of-pocket health expenditures was associated with an increase in resistant bacterial isolates from 17·76% (95% CI 12·54-22·97) to 36·27% (31·16-41·38). INTERPRETATION: Out-of-pocket health expenditures were strongly correlated with antimicrobial resistance in low-income and middle-income countries. This relation was driven by countries that require copayments on drugs in the public sector. Our data suggest cost-sharing of antimicrobials in the public sector might drive demand to the private sector in which supply-side incentives to overprescribe are probably heightened and quality assurance less standardised. FUNDING: National Institutes of Health.

Exposing physicians to reduced residency work hours did not adversely affect patient outcomes after residency.

In 2003, work hours for physicians-in-training (residents) were capped by regulation at eighty hours per week, leading to the hotly debated but unexplored issue of whether physicians today are less well trained as a result of these work-hour reforms. Using a unique database of nearly all hospitalizations in Florida during 2000-09 that were linked to detailed information on the medical training history of the physician of record for each hospitalization, we studied whether hospital mortality and patients' length-of-stay varied according to the number of years a physician was exposed to the 2003 duty-hour regulations during his or her residency. We examined this database of practicing Florida physicians, using a difference-in-differences analysis that compared trends in outcomes of junior physicians (those with one-year post-residency experience) pre- and post-2003 to a control group of senior physicians (those with ten or more years of post-residency experience) who were not exposed to these reforms during their residency. We found that the duty-hour reforms did not adversely affect hospital mortality and length-of-stay of patients cared for by new attending physicians who were partly or fully exposed to reduced duty hours during their own residency. However, assessment of the impact of the duty-hour reforms on other clinical outcomes is needed.