Preventing Malaria among Children in Zambia: The Role of Mother's Knowledge.

Malaria remains a devastating disease in Zambia, responsible for about 13% of deaths among children under age 5. Lack of malaria-specific knowledge has been commonly assumed to be an important barrier to engagement in behaviors that prevent malaria. To the best of our knowledge, this is the first study that accounts for the endogeneity of maternal knowledge in household's ownership of insecticide-treated nets (ITN), child's use of ITN, and household's protection against mosquitos (HSP). We account for the endogeneity of maternal knowledge through discrete factor and standard instrumental variable estimators. We find significant causal effects of maternal knowledge on the child's use of ITN and HSP but no significant effect on ownership of ITN. The causal effects of maternal knowledge on the use of ITN and HSP are strikingly larger in magnitude than the effects in the reduced form models.

Comparing and decomposing differences in preventive and hospital care: USA versus Taiwan.

As the USA expands health insurance coverage, comparing utilization of healthcare services with countries like Taiwan that already have universal coverage can highlight problematic areas of each system. The universal coverage plan of Taiwan is the newest among developed countries, and it is known for readily providing access to care at low costs. However, Taiwan experiences problems on the supply side, such as inadequate compensation for providers, especially in the area of preventive care. We compare the use of preventive, hospital, and emergency care between the USA and Taiwan. The rate of preventive care use is much higher in the USA than in Taiwan, whereas the use of hospital and emergency care is about the same. Results of our decomposition analysis suggest that higher levels of education and income, along with inferior health status in the USA, are significant factors, each explaining between 7% and 15% of the gap in preventive care use. Our analysis suggests that, in addition to universal coverage, proper remuneration schemes, education levels, and cultural attitudes towards health care are important factors that influence the use of preventive care.

New EHR certification requirements and their association with duplicate tests and images.

BACKGROUND: Certified electronic health record (EHR) technology has been adopted by most hospitals and health care providers. In 2015, the Office of the National Coordinator for Health Information Technology (ONC) published new EHR certification requirements, known as the 2015 Edition. To date, no research has examined the impact of hospitals' adoption of the 2015 Edition on health care delivery. METHODS: We analyzed aggregated, longitudinal data drawn from a repository of deidentified health insurance claims collected by FAIR Health, the repository was estimated to represent about 75% of the privately insured in the United States. These data were linked with the American Hospital Association (AHA) Information Technology Supplement Survey to obtain hospitals' health information technology characteristics. A fixed effects specification was used to assess the incidence of duplicate testing and imaging in both inpatient and outpatient settings before and after the hospitals' adoption of the 2015 Edition. RESULTS: Hospitals with the 2015 Edition were less likely to perform duplicate imaging for inpatients by 5 percentage points (or 50% from baseline). Hospitals that adopted the 2015 Edition and actively engaged in interoperable data exchange were even less likely to perform duplicate lab tests. CONCLUSIONS: Adoption of the 2015 Edition certified EHR was negatively associated with the incidence of lab and imaging test duplication in both the outpatient and inpatient settings. However, the results were not robust across specifications. Given that multiple factors influence care delivery decisions, improvements in certification standards alone are unlikely to eliminate unneeded duplicate lab and imaging tests.

The role of electronic health record developers in hospital patient sharing.

OBJECTIVE: To determine whether hospital adoption of a new electronic health record (EHR) developer increases patient sharing with hospitals using the same developer. MATERIALS AND METHODS: We extracted data on patients shared with other hospitals for 3076 US nonfederal acute care hospitals from the 2011 to 2016 Centers for Medicare & Medicaid Services Physician Shared Patient Patterns database. We calculated the ratio of patients shared with hospitals outside of the focal hospital's network that use the same EHR developer as the focal hospital, and estimated difference-in-differences models to compare same-developer patient sharing among hospitals that switched to a new developer with those that did not switch developer. RESULTS: Switching to a new EHR developer increased the ratio of patients shared with other hospitals having the same EHR developer by 4.1-19.3%, depending on model specification. The magnitude of this effect varied by EHR developer and was increasing in developer market share. DISCUSSION: Consolidation in the EHR industry has led to higher patient sharing among hospitals with the same EHR developer. Contributing factors could include the growth of developer-based health information exchanges, customizable referral management systems, and provider preferences for easy and reliable data exchange. However, hospital transfers that are significantly influenced by EHR developer could lead to poor patient-provider matches. CONCLUSION: Hospitals' choice of EHR developer impacts the flow of patients across hospitals, which could have both desirable and undesirable effects on patient care. Future research should investigate whether health outcomes decline with greater same-developer patient sharing.

Impact of Electronic Prescribing of Controlled Substances on Opioid Prescribing: Evidence From I-STOP Program in New York.

New York's Internet System for Tracking Over-Prescribing (I-STOP) Act, requires prescribers in the state to electronically prescribe controlled substances (EPCS). We examine the effects of this mandate on prescribing patterns of opioids for Medicare Part D beneficiaries. Using 2014-2017 CMS Medicare Part D Prescriber Data, we apply a lagged dependent variable regression approach to identify the impact of I-STOP on the prescription of opioids. In the first year of implementation, the number of opioid prescriptions per prescriber decreased by 5.7 per year. The policy had a larger effect on the prescription of short-acting opioids and on prescribers prescribing medication for predominantly younger beneficiaries. Overall, I-STOP resulted in a reduction in the number of beneficiaries being prescribed opioids and in the number of opioid claims in the state of New York, suggesting positive implications for other states intending to curtail opioid overprescribing and misuse through the use of EPCS.

Impact of the 2015 Health Information Technology Certification Edition on Interoperability among Hospitals.

OBJECTIVE: Most nonfederal acute care hospitals use electronic health records (EHRs) certified by the Office of the National Coordinator for Health Information Technology. In 2015, the Office of the National Coordinator for Health Information Technology finalized the 2015 Health IT Certification Edition and adoption by hospitals began in 2016. We examine the impact of the 2015 Edition on rates of interoperable exchange among nonfederal acute hospitals. MATERIALS AND METHODS: The study applies a standard difference-in-differences design and a recently developed fixed effects estimator that relaxes the assumption of treatment effects being constant across groups and time. In the analysis, we identify separate effects of the 2015 Edition for hospitals that switched EHR developers and forecast hospitals' interoperability over 2015 Edition adoption rates. RESULTS: The adoption of the 2015 Edition increased hospitals' rates of interoperable exchange and especially benefited hospitals that switched EHR developers in the post-implementation period. Forecasting results indicate that if all hospitals adopted the 2015 Edition, 53% to 61% of hospitals would engage in interoperable health information exchange compared with the current rate of 46%. DISCUSSION: Hospitals' levels of interoperability have been rising over the last few years. Adoption of newer technology improved hospitals' interoperability and accounts for up to 12% of the rise in interoperability. CONCLUSIONS: Certified technology is one mechanism to ensure providers use recent and safe technologies for interoperable exchange. Adoption of certified EHRs improves the nation's interoperable exchange; however, it has a clear limited effect. Other mechanisms are necessary for achieving comprehensive interoperable exchange.

Effects of immigration on the health insurance status of natives.

The objective of the paper is to estimate the effects of immigration on natives' probability of having private coverage and being uninsured. To examine whether immigrants affected employers' decisions to offer health benefits the study estimates immigration effects on natives' probability of being offered, eligible for, and a policy-holder of health insurance. Although in many cases the effects are statistically significant, most effects are very small. The increase in immigrant labor supply from 1995 to 2005 increases natives' uninsurance rates by about 0.7 percentage points and reduces the natives' probability of being offered and a holder of coverage by 0.8 and 1.9 percentage points, respectively. Immigrants' weaker preferences for coverage relative to natives' may be the key factor in this result.

Immigrants and the use of preventive care in the United States.

Using data from the Medical Expenditure Panel Survey, we compare immigrants' use of preventive care with that of natives. We employ a multinomial switching regression framework that accounts for non-random selection into continuous private insurance, temporary private insurance, public insurance, and no insurance. Our results indicate that among the populations with continuous private coverage and without coverage (uninsured), immigrants, especially non-citizens, are less likely to use preventive care than natives. We find that the longer immigrants stay in the US the more their use of care approximates to that of natives. However, for most types of care, immigrants' use of care never fully converges to that of natives. Among the publicly insured population, immigrants' use of care is similar to natives, but non-citizen immigrants are significantly less likely to use preventive measures. We find that the ability to speak English does not have a significant effect on the use of preventive care among publicly insured persons.

Uncovering differences in interoperability across hospital size.

BACKGROUND: Small hospitals significantly lag behind large hospitals in interoperable health information exchange. This analysis identifies factors that explain differences in interoperability between these hospital types. We place a particular emphasis on such factors as number of functionalities within electronic health record system (EHR), participation in regional and national networks, and adoption of a dominant EHR. METHODS: Using data from the 2017 American Hospital Association (AHA) Annual Survey Information Technology Supplement (n = 2789 hospitals), we applied a Blinder-Oaxaca decomposition technique to explain differences in each domain of interoperability. Interoperability is defined as a hospitals' ability to electronically send, receive, and integrate summary of care records into their EHR and electronically find patient health information from external sources. RESULTS: The percentage of small and large hospitals engaged in each interoperability domain increased between 2015 and 2017; however, the gap between these hospital types remained mostly the same. Differences in characteristics explained most of the gap in integrating, finding and receiving the data while differences in characteristics and returns to characteristics were significant in explaining the differences in sending the data. The number of EHR functionalities and participation in national and regional networks were among largest contributors to the gap. CONCLUSIONS: The lack of participation in multiple networks and the number of functionalities in EHRs among small hospitals are key factors that explain the difference in interoperability between small and large hospitals. Policies that incentivize these activities or simplify electronic exchange could reduce gaps in interoperability among hospitals of different sizes.

A discrete choice decomposition analysis of racial and ethnic differences in children's health insurance coverage.

This paper presents a multivariate decomposition analysis of racial and ethnic differences in children's health insurance using the 2004-2005 Medical Expenditure Panel Survey. We present two methodological contributions. First, we adapt a recently-developed matching decomposition method for use with sample-weighted data. Second, we develop a fully nonparametric approach that implements decomposition through weight adjustments. Accounting for the black-white wealth gap: a nonparametric approach. Journal of the American Statistical Association 97, 663-673]. Differences in observed characteristics explain large percentages of racial and ethnic coverage differences. Important contributors include poverty levels, parent education, family structure (for black children), and immigration-related factors (for Hispanic children). We also examine racial and ethnic differences in parent offers of employer-sponsored insurance and in children's coverage conditional on having a parent offer. Comparison of our linear, nonlinear, and nonparametric results suggests researchers may face a trade-off between robustness and precision when selecting among decomposition methodologies for discrete outcomes.

Comparison of health care utilization: United States versus Canada.

OBJECTIVE: To compare health care utilization between Canadian and U.S. residents. DATA SOURCES: Nationally representative 2007 surveys from the Medical Expenditure Panel Survey for the United States and the Canadian Community Health Survey for Canada. STUDY DESIGN: We use descriptive and multivariate methods to examine differences in health care utilization rates for visits to medical providers, nurses, chiropractors, specialists, dentists, and overnight hospital stays, usual source of care, Pap smear tests, and mammograms. PRINCIPAL FINDINGS: The poor and less educated were more likely to utilize health care in Canada than in the United States. The differences were especially pronounced for having a usual source of care and for visits to providers, specialists, and dentists. Health care use for residents with high incomes and higher levels of education were not markedly different between the two countries and often higher for U.S residents. Foreign-born residents were more likely to use health care in Canada than in the United States. The descriptive results were confirmed in multivariate regressions. CONCLUSIONS: Given the magnitude of our results, the health insurance structure in Canada might have played an important role in improving access to care for subpopulations examined in this study.

Adverse selection and the effect of health insurance on utilization of prescribed medicine among patients with chronic conditions.

PURPOSE: To examine the effects of health insurance types on the use of prescribed medication that treat patients with hypertension, diabetes, and asthma. The study distinguishes between individuals with private health maintenance organization (HMO) plans and private non-HMO plans. The study also distinguishes between people with health insurance and drug coverage and people with health insurance and no drug coverage. METHODS: Joint discrete factor models are estimated to control for endogeneity of each type of coverage. FINDINGS: The main findings suggest that the effect of health insurance varies across patients with different conditions. The strongest and most significant effect is evident among patients with hypertension while the weakest and least significant is among patients with asthma. These findings suggest that patients with asymptomatic conditions are more likely to exhibit moral hazard than patients with conditions that impose immediate impairment. Additional results suggest that, relative to the uninsured and people with health insurance but no drug coverage, patients with drug coverage are more likely to initiate drug therapy and to consume more medications. ORIGINALITY: The results of the study indicate that moral hazard of drug utilization is condition specific. The variation in "silence" of conditions' symptoms could be a key reason for difference in insurance effects among patients with hypertension, diabetes, and asthma.

Annual report on health care for children and youth in the United States: racial/ethnic and socioeconomic disparities in children's health care quality.

OBJECTIVE: The aim of this study was to explore the joint effect of race/ethnicity and insurance status/expected payer or income on children's health care quality. METHODS: The analyses are based on data from a nationally representative random sample of children in the United States in 2004 and 2005 from the Medical Expenditure Panel Survey (MEPS) and pediatric hospitalizations from a nationwide sample of hospitals in 2005 from the State Inpatient Databases disparities analysis file from the Healthcare Cost and Utilization Project (HCUP). We provide estimates of differences in race/ethnicity within income and insurance/expected payer categories on key pediatric quality indicators to provide a more nuanced understanding of disparities in care for children. Our indicators of quality cover several domains from the Institute of Medicine report, including effectiveness, patient centeredness, timeliness, and patient safety. RESULTS: Across a broad set of 23 quality indicators, findings indicate that racial/ethnic disparities vary by income levels and types of insurance. Key highlights include the finding that racial/ethnic differences within income or insurance/payer groups are more pronounced for some racial/ethnic groups than others. Hispanic children followed by Asian children had worse quality than whites as measured by the majority of quality indicators. Exceptions included rates of admissions for diabetes, admissions for gastroenteritis, accidental puncture during procedures, and decubitus ulcers. Many indicators showed less than ideal quality for all subgroups of children, even whites with private insurance. CONCLUSIONS: The extensive findings in this report make clear that patterns of racial/ethnic disparity vary by income and insurance/expected payer subgroup. However, disparities in quality are not similar across all measures of quality, and strategies to address these disparities need to be designed with these nuances in mind.

Reports of fewer activity limitations: recovery, survey fatigue, or switching respondent?

BACKGROUND: Very little is known about the validity and reliability of disability dynamics reported in household surveys, and some researchers argue that measurement error likely plays a large part in reported recovery from disability. OBJECTIVES: We assessed the reliability of reported recovery from activity limitations elicited from 2 types of questions. We assessed competing hypotheses explaining reported recoveries from disability: people are less likely to recover from more severe disabilities, switching between self- and proxy-response affects reported recovery, and survey fatigue reduces reported disability. METHODS: Using the second panel of the Medical Expenditure Panel Survey, we estimated kappas for 2 types of questions in the same interview about limitations in activities of daily living and instrumental activities of daily living. We estimated multinomial logit models of consistently reported recovery, consistently reported ongoing limitations, and inconsistent responses. Recovery is a function of severity, switching respondent, measures of survey burden (such as family size), age, and education. RESULTS: Within an interview, we found substantial reliability for both instrumental activities of daily living and activities of daily living limitations (kappa = 0.62 and 0.70, respectively). Sample members with more severe disabilities are less likely to report recovery, which is consistent with accurate reporting. Controlling for severity, the type of respondent affects reported recovery. Measures of survey burden did not affect reports. CONCLUSION: Researchers can be confident in reports of recovery in the Medical Expenditure Panel Survey, especially when disability status was self-reported in both interviews. Researchers may also want to control for proxy respondents and switching respondents in their analyses.