Large variation in radiation dose for routine abdomen CT: reasons for excess and easy tips for reduction.

OBJECTIVE: To characterize the use and impact of radiation dose reduction techniques in actual practice for routine abdomen CT. METHODS: We retrospectively analyzed consecutive routine abdomen CT scans in adults from a large dose registry, contributed by 95 hospitals and imaging facilities. Grouping exams into deciles by, first, patient size, and second, size-adjusted dose length product (DLP), we summarized dose and technical parameters and estimated which parameters contributed most to between-protocols dose variation. Lastly, we modeled the total population dose if all protocols with mean size-adjusted DLP above 433 or 645 mGy-cm were reduced to these thresholds. RESULTS: A total of 748,846 CTs were performed using 1033 unique protocols. When sorted by patient size, patients with larger abdominal diameters had increased dose and effective mAs (milliampere seconds), even after adjusting for patient size. When sorted by size-adjusted dose, patients in the highest versus the lowest decile in size-adjusted DLP received 6.4 times the average dose (1680 vs 265 mGy-cm) even though diameter was no different (312 vs 309 mm). Effective mAs was 2.1-fold higher, unadjusted CTDIvol 2.9-fold, and phase 2.5-fold for patients in the highest versus lowest size-adjusted DLP decile. There was virtually no change in kV (kilovolt). Automatic exposure control was widely used to modulate mAs, whereas kV modulation was rare. Phase was the strongest driver of between-protocols variation. Broad adoption of optimized protocols could result in total population dose reductions of 18.6-40%. CONCLUSION: There are large variations in radiation doses for routine abdomen CT unrelated to patient size. Modification of kV and single-phase scanning could result in substantial dose reduction. CLINICAL RELEVANCE: Radiation dose-optimization techniques for routine abdomen CT are routinely under-utilized leading to higher doses than needed. Greater modification of technical parameters and number of phases could result in substantial reduction in radiation exposure to patients. KEY POINTS: • Based on an analysis of 748,846 routine abdomen CT scans in adults, radiation doses varied tremendously across patients of the same size and optimization techniques were routinely under-utilized. • The difference in observed dose was due to variation in technical parameters and phase count. Automatic exposure control was commonly used to modify effective mAs, whereas kV was rarely adjusted for patient size. Routine abdomen CT should be performed using a single phase, yet multi-phase was common. • kV modulation by patient size and restriction to a single phase for routine abdomen indications could result in substantial reduction in radiation doses using well-established dose optimization approaches.

Changing home care aides: Differences between family and non-family care in California Medicaid home and community-based services.

In California Medicaid home-and-community-based services (HCBS), recipients' family members receive payment as home care aides (HCAs). We analyzed data on first-time HCBS recipients to examine factors associated with the likelihood of switching HCAs within the first year of services. Those with family HCAs were less than half as likely to change than those with non-family HCAs and racial/ethnic minorities with non-family HCAs had the highest switching rates. Lower wages and local unemployment were associated with switching of non-family HCAs but not family HCAs. Policymakers can foster continuity of home care by paying family members for home care and raising worker wages.

Predictors of Nursing Facility Entry by Medicaid-Only Older Adults and Persons With Disabilities in California.

Nearly one-third of adult Medicaid beneficiaries who receive long-term services and supports (LTSS) consist of older adults and persons with disabilities who are not eligible for Medicare. Beneficiaries, advocates, and policymakers have all sought to shift LTSS to home and community settings as an alternative to institutional care. We conducted a retrospective cohort study of Medicaid-only adults in California with new use of LTSS in 2006-2007 (N = 31 849) to identify unique predictors of entering nursing facilities versus receiving Medicaid home and community-based services (HCBS). Among new users, 18.3% entered into nursing facilities, whereas 81.7% initiated HCBS. In addition to chronic conditions, functional and cognitive limitations, substance abuse disorders (odds ratio [OR] 1.35; 95% confidence interval [CI]: 1.23, 1.48), and homelessness (OR: 4.35, 9% CI: 3.72, 5.08) were associated with higher odds of nursing facility entry. For older adults and persons with disabilities covered by Medicaid only, integration with housing and behavioral health services may be key to enabling beneficiaries to receive LTSS in noninstitutional settings.

Health Care Use Before and After Entering Long-Term Services and Supports.

OBJECTIVE: We examined the health care utilization patterns of Medicare and Medicaid enrollees (MMEs) before and after initiating long-term care in the community or after admission to a nursing facility (NF). METHOD: We used administrative data to compare hospitalizations, emergency department (ED) visits, and post-acute care use of MMEs receiving long-term care in California in 2006-2007. RESULTS: MMEs admitted to a NF for long-term care had much greater use of hospitalizations, ED visits, and post-acute care before initiating long-term care than those entering long-term care in the community. Post-entry, community service users had less than half the average monthly hospital and ED use compared with the NF cohort. CONCLUSION: Hospital and ED use prior to and following NF and personal care program entry suggest a need for reassessing the monitoring of these high-risk populations and the communication between health and community care providers.

Flexible Polymer/Metal/Polymer and Polymer/Metal/Inorganic Trilayer Transparent Conducting Thin Film Heaters with Highly Hydrophobic Surface.

Polymer/metal/polymer and polymer/metal/inorganic trilayer-structured transparent electrodes with fluorocarbon plasma polymer thin film heaters have been proposed. The polymer/metal/polymer and polymer/metal/inorganic transparent conducting thin films fabricated on a large-area flexible polymer substrate using a continuous roll-to-roll sputtering process show excellent electrical properties and visible-light transmittance. They also exhibit water-repelling surfaces to prevent wetting and to remove contamination. In addition, the adoption of a fluorocarbon/metal/fluorocarbon film permits an outer bending radius as small as 3 mm. These films have a sheet resistance of less than 5 Ω sq-1, sufficient to drive light-emitting diode circuits. The thin film heater with the fluorocarbon/Ag/SiNx structure exhibits excellent heating characteristics, with a temperature reaching 180 °C under the driving voltage of 13 V. Therefore, the proposed polymer/metal/polymer and polymer/metal/inorganic transparent conducting electrodes using polymer thin films can be applied in flexible and rollable displays as well as automobile window heaters and other devices.

Health Care Expenditures After Initiating Long-term Services and Supports in the Community Versus in a Nursing Facility.

BACKGROUND: Individuals who receive long-term services and supports (LTSS) are among the most costly participants in the Medicare and Medicaid programs. OBJECTIVES: To compare health care expenditures among users of Medicaid home and community-based services (HCBS) versus those using extended nursing facility care. RESEARCH DESIGN: Retrospective cohort analysis of California dually eligible adult Medicaid and Medicare beneficiaries who initiated Medicaid LTSS, identified as HCBS or extended nursing facility care, in 2006 or 2007. SUBJECTS: Propensity score matching for demographic, health, and functional characteristics resulted in a subsample of 34,660 users who initiated Medicaid HCBS versus extended nursing facility use. Those with developmental disabilities or in managed care plans were excluded. MEASURES: Average monthly adjusted acute, postacute, long-term, and total Medicare and Medicaid expenditures for the 12 months following initiation of either HCBS or extended nursing facility care. RESULTS: Those initiating extended nursing facility care had, on average, $2919 higher adjusted total health care expenditures per month compared with those who initiated HCBS. The difference was primarily attributable to spending on LTSS $2855. On average, the monthly LTSS expenditures were higher for Medicare $1501 and for Medicaid $1344 when LTSS was provided in a nursing facility rather than in the community. CONCLUSIONS: The higher cost of delivering LTSS in a nursing facility rather than in the community was not offset by lower acute and postacute spending. Medicare and Medicaid contribute similar amounts to the LTSS cost difference and both could benefit financially by redirecting care from institutions to the community.

Disparities in Service Use and Expenditures for People With Intellectual and Developmental Disabilities in California in 2005 and 2013.

This study examined service use and expenditures for people with intellectual and developmental disabilities (IDD) living at home and in the community in California in 2005 and 2013. The number of people assessed for IDD services increased, along with the percentage of individuals who did not receive any services between 2005 and 2013. Controlling for client needs, children age 3-21 were less likely than other age groups to receive any services using logistic regressions. All racial and ethnic minority groups were less likely to receive any services than were white populations. Females, younger people, and all racial and ethnic minority groups who received services had significantly lower expenditures, with wide geographic variations. The disparities by age, gender, race/ethnicity, and geography have persisted over time in California.

Hidden Owners, Hidden Profits, and Poor Nursing Home Care: A Case Study.

The study examined the ownership transparency, financial accountability, and quality indicators of a regional for-profit nursing home chain in California, using a case study methodology to analyze data on the chain's ownership and management structure, financial data, staffing levels, deficiencies and complaints, and litigation. Secondary data were obtained from regulatory and cost reports and litigation cases. Qualitative descriptions of ownership and management were presented and quantitative analyses were conducted by comparing financial and quality indicators with other California for-profit chains, for-profit non-chains, and nonprofit nursing home groups in 2011. The chain's complex, interlocking individual and corporate owners and property companies obscured its ownership structure and financial arrangements. Nursing and support services expenditures were lower than nonprofits and administrative costs were higher than for-profit non-chains. The chain's nurse staffing was lower than expected staffing levels; its deficiencies and citations were higher than in nonprofits; and a number of lawsuits resulted in bankruptcy. Profits were hidden in the chain's management fees, lease agreements, interest payments to owners, and purchases from related-party companies. Greater ownership transparency and financial accountability requirements are needed to ensure regulatory oversight and quality of care.

Payment rates for personal care assistants and the use of long-term services and supports among those dually eligible for Medicare and Medicaid.

OBJECTIVE: To examine the association between payment rates for personal care assistants and use of long-term services and supports (LTSS) following hospital discharge among dual eligible Medicare and Medicaid beneficiaries. DATA SOURCES: State hospital discharge, Medicaid and Medicare claims, and assessment data on California Medicaid LTSS users from 2006 to 2008. STUDY DESIGN: Cross-sectional study. We used multinomial logistic regression to analyze county personal care assistant payment rates and postdischarge LTSS use, and estimate marginal probabilities of each outcome across the range of rates paid in California. DATA EXTRACTION METHODS: We identified dual eligible Medicare and Medicaid adult beneficiaries discharged from an acute care hospital with no hospitalizations or LTSS use in the preceding 12 months. PRINCIPAL FINDINGS: Personal care assistant payment rates were modestly associated with home and community-based services (HCBS) use versus nursing facility entry following hospital discharge (RRR 1.2, 95 percent CI: 1.0-1.4). For a rate of $6.75 per hour, the probability of HCBS use was 5.6 percent (95 percent CI: 4.2-7.1); at $11.75 per hour, 18.0 percent (95 percent CI: 12.5-23.4). Payment rate was not associated with the probability of nursing facility entry. CONCLUSIONS: Higher payment rates for personal care assistants may increase utilization of HCBS, but with limited substitution for nursing facility care.

Personal service assistance: musculoskeletal disorders and injuries in consumer-directed home care.

BACKGROUND: Like other types of care for disabled or elderly adults, consumer-directed personal assistance services may present multi-factorial risks for work-related musculoskeletal disorders (WRMSDs). METHODS: Using survey data, we compared providers experiencing WRMSDs in the previous year to those who did not, seeking to identify functional, temporal, physical, and relationship risk factors for transient and chronic conditions. RESULTS: Longer work experience with the recipient and more frequent bending increased the risk of being in the most chronic group (≥12 painful episodes), whereas predictable work hours with rest breaks and greater social support from the recipient appeared protective. For transient conditions (one to two episodes), longer work experience with the recipient and predictable hours with rest breaks appeared protective. CONCLUSIONS: We offer recommendations to improve hazard assessment as well as training and information distribution related to home care programs. With the population aging, home care jobs require increasing oversight to prevent WRMSDs.

In-home supportive services for individuals with cerebral palsy in California.

INTRODUCTION: Individuals with cerebral palsy (CP) may require personal assistance services for optimal functioning. The primary goal of this project is to determine if differences in health services exist between individuals with CP with family versus non-family member paid personal assistance providers. The secondary goal is to describe the population of children and non-elderly adults with CP receiving in-home supportive services (IHSS) and determine their health care costs compared to other IHSS recipients. METHODS: Administrative data from the California Departments of Health and Human Services, Social Services and Developmental Services were linked and de-identified to provide information about individuals receiving IHSS in California in 2005. Recipients with CP were characterized and compared by age. Then to determine the factors associated with hospital use and emergency room (ER) use for IHSS recipients with CP adjusted odds were calculated. Monthly expenditures were calculated from claims data. RESULTS: 2.3% of all IHSS recipients in 2005 had CP of which 46% were children. 59% of recipients with CP have a parent as their paid provider. The presence of other medical diagnoses was the only factor associated with increased adjusted odds of hospital and ER use for both child-aged and non-elderly adult recipients with CP. Functional limitations and provider type were not associated with increased odds of health care utilization. Monthly health care expenditures for recipients with CP were ∼$1000 higher than for other IHSS recipients. CONCLUSIONS: Having a parent as the IHSS provider was not associated with difference in health service utilization. This finding supports the policy of allowing parents to be paid providers.

The relationship of California's Medicaid reimbursement system to nurse staffing levels.

BACKGROUND: Policy initiatives at the Federal and state level are aimed at increasing staffing in nursing homes. These include direct staffing standards, public reporting, and financial incentives. OBJECTIVE: To examine the impact of California's Medicaid reimbursement for nursing homes which includes incentives directed at staffing. RESEARCH DESIGN: Two-stage limited-information maximum-likelihood regressions were used to model the relationship between staffing [registered nurses (RNs), licensed practical nurses, and certified nursing assistants hours per resident day] and the Medicaid payment rate, accounting for the specific structure of the payment system, endogeneity of payment and case-mix, and controlling for facility and market characteristics. SAMPLE: A total of 927 California free-standing nursing homes in 2006. MEASURES: The model included facility characteristics (case-mix, size, ownership, and chain affiliation), market competition and excess demand, labor supply and wages, unemployment, and female employment. The instrumental variable for Medicaid reimbursement was the peer group payment rate for 7 geographical market areas, and the instrumental variables for resident case-mix were the average county revenues for professional therapy establishments and the percent of county population aged 65 and over. RESULTS: Consistent with the rate incentives and rational expectation behavior, expected nursing home reimbursement rates in 2008 were associated with increased RN staffing levels in 2006 but had no relationship with licensed practical nurse and certified nursing assistant staffing. The effect was estimated at 2 minutes per $10 increase in rate. CONCLUSIONS: The incentives in the Medicaid system impacted only RN staffing suggesting the need to improve the state's rate setting methodology.

Nurse staffing and deficiencies in the largest for-profit nursing home chains and chains owned by private equity companies.

OBJECTIVE: To compare staffing levels and deficiencies of the 10 largest U.S. for-profit nursing home chains with five other ownership groups and chain staffing and deficiencies before and after purchase by four private equity (PE) companies. DATA SOURCES: Facilities for the largest for-profit chains were identified through Internet searches and company reports and matched with federal secondary data for 2003-2008 for each ownership group. STUDY DESIGN: Descriptive statistics and generalized estimation equation panel regression models examined staffing and deficiencies by ownership groups in the 2003-2008 period, controlling for facility characteristics, resident acuity, and market factors with state fixed effects. PRINCIPAL FINDINGS: The top 10 for-profit chains had lower registered nurse and total nurse staffing hours than government facilities, controlling for other factors. The top 10 chains received 36 percent higher deficiencies and 41 percent higher serious deficiencies than government facilities. Other for-profit facilities also had lower staffing and higher deficiencies than government facilities. The chains purchased by PE companies showed little change in staffing levels, but the number of deficiencies and serious deficiencies increased in some postpurchase years compared with the prepurchase period. CONCLUSIONS: There is a need for greater study of large for-profit chains as well as those chains purchased by PE companies.

Allowing spouses to be paid personal care providers: spouse availability and effects on Medicaid-funded service use and expenditures.

PURPOSE OF THE STUDY: Medicaid service use and expenditure and quality of care outcomes in California's personal care program known as In-Home Supportive Service (IHSS) are described. Analyses investigated Medicaid expenditures, hospital use, and nursing home stays, comparing recipients who have paid spouse caregivers with those having other relatives or unrelated individuals as their caregivers. DESIGN AND METHODS: Medicaid claims and IHSS assessment data for calendar year 2005 were linked for IHSS recipients aged 18 years or older (n = 386,447) RESULTS: The rates of ambulatory care-sensitive hospital admissions and Medicaid-covered nursing home placements were at least comparable among IHSS recipients' with spouse, parent, other relative, or nonrelative caregivers. Statistically significant differences reflected more desirable outcomes for those with relatives as paid caregivers. In no comparisons did those with spouse providers have worse outcomes than those with nonrelative providers. Average monthly Medicaid expenditures for all services were also lower for IHSS recipients with family provider. IMPLICATIONS: There were no financial disadvantages and some advantages to Medicaid in terms of lower average Medicaid expenditures and fewer nursing home admissions when using spouses, parents, and other relatives as paid IHSS providers. This argues in favor of honoring the recipient's and family's preference for such providers.

Consumer-directed personal care: comparing aged and non-aged adult recipient health-related outcomes among those with paid family versus non-relative providers.

Risk factors associated with the incidence of recipient injuries, bedsores and contractures, and health care use (i.e., emergency department and hospital use) among aged and non-aged adult personal care recipients are investigated. Data are from a statewide survey of aged and non-aged adult personal assistance service (PAS) recipients (n = 913) in California's In-Home Supportive Services (IHSS) program. This is a consumer-directed PAS program. Outcomes among recipients using relatives (other than spouses or parents) as paid providers are compared with those of recipients having non-relatives as providers. No differences were found by provider-recipient relationships. Non-aged recipients, those in poorer health, those with more than three activities of daily living (ADL) limitations, and those changing providers during the year were all at greater risk for adverse health outcomes. African American, Hispanic, and Asian recipients were at lower risk for injuries and hospital stays than were White recipients.

Factors associated with living in developmental centers in California.

This study examined need, predisposing, market, and regional factors that predicted the likelihood of individuals with developmental disabilities living in state developmental centers (DCs) compared with living at home, in community care, or in intermediate care (ICFs) and other facilities. Secondary data analysis using logistic regression models was conducted for all individuals ages 21 years or older who had moderate, severe, or profound intellectual disability. Client needs were the most important factors associated with living arrangements, with those in DCs having more complex needs. Men had higher odds of living in DCs than in other settings, whereas older individuals had lower odds of living in DCs than in ICFs for persons with developmental disabilities and other facilities. Asians/Pacific Islanders, African Americans, and Hispanics were less likely to live in DCs than to live at home. The supply of residential care beds for the elderly reduced the likelihood of living in DCs, and the odds of living in a DC varied widely across regions. Controlling for need, many other factors predicted living arrangements. Policymakers need to ensure adequate resources and provider supply to reduce the need by individuals with intellectual disability to live in DCs and to transition individuals from DCs into other living arrangements.

Variation in types of service use and expenditures for individuals with developmental disabilities.

BACKGROUND: this study examined the types of services and expenditures for 8 service categories provided by regional centers to 138,336 individuals with developmental disabilities living at home and in the community in California in 2004-2005. METHODS: logistic regressions of secondary data were used to predict the types of services received, and ordinary least squares regressions were used to predict types of service expenditures. RESULTS: higher client needs generally were associated with higher odds of receiving services and with expenditures, although the types of services varied by client need. Controlling for client needs and other factors, males were more likely to receive out-of-home services. Individuals aged 3-21 years were generally less likely to receive many services but were more likely to receive in-home and out-of-home respite services than were those over age 62. All racial and ethnic minority groups were less likely to receive support and out-of-home services than were whites and had lower expenditures, although these varied by the types of services. The supply of nursing homes, community care facilities, area population characteristics, and regional centers also predicted variations in service use and expenditure patterns. CONCLUSION: studies of the underlying reasons for the variations are needed to ensure equity in access to all types of services and expenditures.

Disparities in service utilization and expenditures for individuals with developmental disabilities.

BACKGROUND: The factors that affect access to services for individuals with developmental disabilities (DD) have not received much attention. METHODS: This study examined service utilization and expenditures provided by regional centers to individuals with DD living at home and in residential settings in California in 2004-2005. Logistic regressions of secondary data were used to predict the receipt of services, and ordinary least squares regressions were used to examine the predictors of service expenditures. RESULTS: Of the 175,595 individuals assessed with DD, 21% did not receive any purchased services from regional centers in 2004-2005. Controlling for client needs, individuals aged 3-21 years were less likely than other age groups to receive services. All racial and ethnic minority groups were less likely to receive any services than were whites. The supply of intermediate care facilities for habilitation and residential care reduced the likelihood of receiving regional center services. Of those who received services, younger individuals and all racial and ethnic minority groups had significantly lower expenditures. Provider supply, area population characteristics, and regional centers also predicted variation in service use and expenditures. CONCLUSION: The disparities by age, race/ethnicity, and geographic area require further study, and specific approaches are needed to ensure equity in access to services.

Outcomes in a nursing home transition case-management program targeting new admissions.

PURPOSE: The Providing Assistance to Caregivers in Transition (PACT) program offers nursing home discharge planning and case management for individuals in the transitional period following a return to the community. The PACT program targeted individuals newly admitted to nursing homes and worked with a family caregiver to develop and implement a nursing home discharge plan. DESIGN AND METHOD: Reported are the results of a randomized control design evaluating the program's effectiveness. Those individuals randomly assigned to the intervention group (n = 33) received PACT case management in addition to their usual medical and nursing home care. The individuals in the control group (n = 29) continued their usual care. RESULT: There were no statistical differences in the discharge rate (84% treatment vs 76% controls) or in the median length of stay (42 days vs 55 days) between the two groups of individuals. IMPLICATIONS: Replications or extensions of a PACT-type intervention might consider a broader mix of nursing homes, working directly with the nursing home's admission Minimum Data Set coordinator in patient selection, or working with Medicare or Medicaid HMO plans.

Living quarters and unmet need for personal care assistance among adults with disabilities.

OBJECTIVES: This study used a person-environment (P-E) framework to examine individual capabilities and social and physical environmental attributes for their association with unmet assistance needs in activities of daily living (ADLs). Analyses were replicated among five ADLs (bathing, dressing, transferring, toileting, eating) and test the relative risk of apartment dwellers compared to those living in houses. METHODS: Data were obtained from the National Health Interview Survey, Supplement on Disability Followback Survey. Analyses consisted of a nationally representative sample of aged and nonaged adults with one or more ADL limitations. RESULTS: Slightly less than 1 in 5 subjects with a specific ADL limitation had unmet needs for that ADL. This was true across all ADLs. The likelihood of unmet ADL assistance increased with the number of ADL limitations and other health status indicators. It was at least 50% higher among those living in apartments than in houses and higher among Hispanics. There were no differences by age or gender. DISCUSSION: The P-E framework postulates that individuals seek settings matched to their capabilities, but findings suggest that many are at risk for adaptation at any one time. Specific risk factors are identified. Selection factors like preferences, expectations, and adaptation options available have not been directly measured.