Using measures of race to make clinical predictions: Decision making, patient health, and fairness.

The use of race measures in clinical prediction models is contentious. We seek to inform the discourse by evaluating the inclusion of race in probabilistic predictions of illness that support clinical decision making. Adopting a static utilitarian framework to formalize social welfare, we show that patients of all races benefit when clinical decisions are jointly guided by patient race and other observable covariates. Similar conclusions emerge when the model is extended to a two-period setting where prevention activities target systemic drivers of disease. We also discuss non-utilitarian concepts that have been proposed to guide allocation of health care resources.

Embracing Uncertainty: The Value of Partial Identification in Public Health and Clinical Research.

INTRODUCTION: This paper describes the methodology of partial identification and its applicability to empirical research in preventive medicine and public health. METHODS: The authors summarize findings from the methodologic literature on partial identification. The analysis was conducted in 2020-2021. RESULTS: The applicability of partial identification methods is demonstrated using 3 empirical examples drawn from published literature. CONCLUSIONS: Partial identification methods are likely to be of considerable interest to clinicians and others engaged in preventive medicine and public health research.

Likelihood of hospital readmission in Medicare Advantage and Fee-For-Service within same hospital.

OBJECTIVE: To assess the extent to which all-cause 30-day readmission rate varies by Medicare program within the same hospitals. STUDY DESIGN: We used conditional logistic regression clustered by hospital and generalized estimating equations to compare the odds of unplanned all-cause 30-day readmission between Medicare Fee-for-Service (FFS) and Medicare Advantage (MA). DATA COLLECTION: Wisconsin Health Information Organization collects claims data from various payers including private insurance, Medicare, and Medicaid, twice a year. PRINCIPAL FINDINGS: For 62 of 66 hospitals, hospital-level readmission rates for MA were lower than those for Medicare FFS. The odds of 30-day readmission in MA were 0.92 times lower than Medicare FFS within the same hospital (odds ratio, 0.93; 95 percent confidence interval, 0.89-0.98). The adjusted overall readmission rates of Medicare FFS and MA were 14.9 percent and 11.9 percent, respectively. CONCLUSION: These findings provide additional evidence of potential variations in readmission risk by payer and support the need for improved monitoring systems in hospitals that incorporate payer-specific data. Further research is needed to delineate specific care delivery factors that contribute to differential readmission risk by payer source.

Individual results may vary: Inequality-probability bounds for some health-outcome treatment effects.

While many results from the treatment-effect and related literatures are familiar and have been applied productively in health economics evaluations, other potentially useful results from those literatures have had little influence on health economics practice. With the intent of demonstrating the value and use of some of these results in health economics applications, this paper focuses on one particular class of parameters that describe probabilities that one outcome is larger or smaller than other outcomes ("inequality probabilities"). While the properties of such parameters have been exposited in the technical literature, they have scarcely been considered in informing practical questions in health evaluations. This paper shows how such probabilities can be used informatively, and describes how they might be identified or bounded informatively given standard sampling assumptions and information only on marginal distributions of outcomes. The logic of these results and the empirical implementation thereof-sampling, estimation, and inference-are straightforward. Derivations are provided and several health-related applications are presented.

Considering mean and inequality health outcomes together: the population health performance index.

BACKGROUND: The purpose was to develop and test a population health measure that combines mean health outcomes and inequalities into a single GDP-like metric to help policymakers measure population health performance on both dimensions in one metric. METHODS: The Population Health Performance Index is a weighted average of a mean index and an inequality index according to the user's inequality aversion. We deploy this methodology for two combinations of health outcome and disparity domain: infant mortality by race and unhealthy days by education. RESULTS: The PHPI is bounded between 0 and 1, and is comprised of a weighted average of two separate indices: a mean index and an inequality index, with 1 representing the ideal state of no ill health and no inequality and 0 representing the worst state in the U.S. PHPI values across states (neutral 50:50 weighting) vary between 0.60 (Massachusetts) to 0.17 (Delaware) for infant mortality by race and between 0.65 (North Dakota) to 0.00 (West Virginia) for unhealthy days by education. For some states, the choice of inequality aversion significantly impacts their PHPI value and state rank. CONCLUSIONS: Mean and inequality health outcomes can be combined into a single Population Health Performance Index for use by public and private policy makers, like the GDP is used as a summary metric to measure economic output. The index can allow for varying degrees of inequality aversion, an individual's or jurisdiction's value choice that can substantially impact the value of this new summary population health metric.

Substance Use Screening, Brief Intervention, and Referral to Treatment Among Medicaid Patients in Wisconsin: Impacts on Healthcare Utilization and Costs.

Unhealthy substance use in the USA results in significant mortality and morbidity. This study measured the effectiveness of paraprofessional-administered substance use screening, brief intervention, and referral to treatment (SBIRT) services on subsequent healthcare utilization and costs. The pre-post with comparison group study design used a population-based sample of Medicaid patients 18-64 years receiving healthcare services from 33 clinics in Wisconsin. Substance use screens were completed by 7367 Medicaid beneficiaries, who were compared to 6751 randomly selected treatment-as-usual Medicaid patients. Compared to unscreened patients, those screened changed their utilization over the 24-month follow-up period by 0.143 outpatient days per member per month (PMPM) (p < 0.001), -0.036 inpatient days PMPM (p < 0.05), -0.001 inpatient admissions PMPM (non-significant), and -0.004 emergency department days PMPM (non-significant). The best estimate of net annual savings is $391 per Medicaid adult beneficiary (2014 dollars). SBIRT was associated with significantly greater outpatient visits and significant reductions in inpatient days among working-age Medicaid beneficiaries in Wisconsin.

MULTIVARIATE FRACTIONAL REGRESSION ESTIMATION OF ECONOMETRIC SHARE MODELS.

This paper describes and applies econometric strategies for estimating regression models of economic share data outcomes where the shares may take boundary values (zero and one) with nontrivial probability. The main focus of the paper is on the conditional mean structures of such data. The paper proposes an extension of the fractional regression methodology proposed by Papke and Wooldridge, 1996, 2008, in univariate cross-sectional and panel contexts. The paper discusses the stochastic aspects of share definition and measurement, and summarizes important features of the existing literature on econometric strategies for share model estimation. The paper then goes on to discuss the univariate fractional regression estimation strategies proposed by Papke and Wooldridge and to extend the fractional regression approach to estimation of and inference about regression models describing the multivariate share data. Some issues involving outcome aggregation/disaggregation are considered, as is a full likelihood estimation approach based on Dirichlet-multinomial models. The paper demonstrates the workings of these various empirical strategies by estimating models of financial asset portfolio shares using data from the 2001, 2004, and 2007 U.S. Surveys of Consumer Finances.

Development of a novel, objective measure of health care-related financial burden for U.S. families with children.

OBJECTIVE: To develop and validate a theoretically based and empirically driven objective measure of financial burden for U.S. families with children. DATA SOURCES: The measure was developed using 149,021 families with children from the National Health Interview Survey, and it was validated using 18,488 families with children from the Medical Expenditure Panel Survey. STUDY DESIGN: We estimated the marginal probability of unmet health care need due to cost using a bivariate tensor product spline for family income and out-of-pocket health care costs (OOPC; e.g., deductibles, copayments), while adjusting for confounders. Recursive partitioning was performed on these probabilities, as a function of income and OOPC, to establish thresholds demarcating levels of predicted risk. PRINCIPAL FINDINGS: We successfully generated a novel measure of financial burden with four categories that were associated with unmet need (vs. low burden: midlow OR: 1.93, 95 percent CI: 1.78-2.09; midhigh OR: 2.78, 95 percent CI: 2.49-3.10; high OR: 4.38, 95 percent CI: 3.99-4.80). The novel burden measure demonstrated significantly better model fit and less underestimation of financial burden compared to an existing measure (OOPC/income ≥ 10 percent). CONCLUSION: The newly developed measure of financial burden establishes thresholds based on different combinations of family income and OOPC that can be applied in future studies of health care utilization and expenditures and in policy development and evaluation.

Sleep behavior and unemployment conditions.

Recent research has reported that habitually short sleep duration is a risk factor for declining health, including increased risk of obesity, diabetes and coronary heart disease. In this study we investigate whether macroeconomic conditions are associated with variation in mean sleep time in the United States, and if so, whether the effect is procyclical or countercyclical. We merge state unemployment rates from 2003 through 2012 with the American Time Use Survey, a nationally representative sample of adults with 24h time diaries. We find that higher aggregate unemployment is associated with longer mean sleep duration, with each additional point of state unemployment associated with an additional average 0.83 min of sleep (p<0.001), after adjusting for a secular trend of increasing sleep over the time period. Despite a national poll in 2009 that found one-third of Americans reporting losing sleep over the economy, we do not find that higher state unemployment is associated with more sleeplessness. Instead, we find that higher state unemployment is associated with less frequent time use described as "sleeplessness" (marginal effect=0.05 at 4% unemployment and 0.034 at 14% unemployment, p<0.001), after controlling for a secular trend.

The association between motor vehicle injuries and health-related quality of life: a longitudinal study of a population-based sample in the United States.

PURPOSE: As many as 3 million US residents are injured in traffic-related incidents every year leaving many victims with disabling conditions. To date, limited numbers of studies have examined the effects of traffic-related injuries on self-reported health. This study aims to examine the association between health-related quality of life (HRQOL) and traffic-related injuries longitudinally in a nationally representative sample of US adult population. METHODS/APPROACH: This is a longitudinal study of adult participants (age ≥18) from seven panels (2000-2007) of the Medical Expenditure Panel Survey. The dependent variables included the physical and mental components of the SF-12, a measure of self-reported health. The outcome was assessed twice during the follow-up period: round 2 (~4-5 months into the study) and round 4 (~18 months into the study) for 62,298 individuals. Two methods estimate the association between traffic-related injuries and HRQOL: a within person change using paired tests and a between person change using multivariable regression adjusting for age, sex, income and educational level. RESULTS: Nine hundred and ninety-three participants reported traffic-related injuries during the follow-up period. Compared to their pre-crash HRQOL, these participants lost 2.7 of the physical component score while their mental component did not change. Adjusted results showed significant deficits in the physical component (-2.84, p value = <.001) but not the mental component (-0.07, p value = .83) of HRQOL after controlling for potential confounders. CONCLUSION: Traffic injuries were significantly associated with the physical component of HRQOL. These findings highlight the individual and societal burden associated with motor vehicle crash-related disability in the United States.

Understanding socioeconomic and racial differences in adult lung function.

RATIONALE: The contribution of socioeconomic factors to racial differences in the distribution of lung function is not well understood. OBJECTIVES: We investigated the contribution of socioeconomic factors to racial differences in FEV1 using statistical tools that allow for examination across the population distribution of FEV1. METHODS: We compared FEV1 for white and African-American participants (aged 20-80 yr) in NHANES III with greater than or equal to two acceptable maneuvers to a restricted sample following the routine exclusion criteria used to derive population reference equations. Ordinary least squares and quantile regression analyses using spirometric, anthropometric, and socioeconomic data (high school completion) were performed separately by sex for both data sets. MEASUREMENTS AND MAIN RESULTS: In the entire sample with acceptable spirometry (n » 9,658), high school completion was associated with a mean 69.13-ml increase in FEV1 for males (P , 0.05) and a mean 50.75-ml increase in FEV1 for females (P , 0.01). In quantile regression analysis, we observed a significant racial difference in the association of high school completion with FEV1 among both sexes that varied across the distribution; college completion was associated with an additional increase in FEV1 for white males (70.36-250.76 ml) and white females (57.87-317.77 ml). Routine exclusion criteria differentially excluded individuals by age, race, and education. In the restricted sample (n » 2,638), the association with high school completion was not significant. CONCLUSIONS: High school completion is associated with racially patterned improvements in the FEV1 of adults in the general population. The application of routine exclusion criteria leads to underestimates of the role of high school completion on FEV1.

Race and preference-based health-related quality of life measures in the United States.

BACKGROUND: Health-related quality of life instruments (HRQoL) are widely used to produce measures that summarize population health and to inform decision-making and health policy. Although the literature about the relationship between health and race in the United States is quite extensive, there is a lack of studies that comprehensively examine the relationship between race and preference-based HRQoL. Given the widespread use of these measures, it becomes important to understand the extent of the race differences in HRQoL scores and factors associated with any such differences. METHODS: We examined the differences in HRQoL, between blacks and whites and associated factors, using the summary scores of the SF-6D, EQ-5D, QWB-SA, HUI2, HUI3, administered by telephone to a nationally representative sample of 3,578 black and white US adults between the ages of 35 and 89 in the National Health Measurement Study (NHMS). RESULTS: Black women had substantially lower HRQoL than white women. The difference was largely explained by sociodemographic and socioeconomic variables. Black men did not differ significantly from white men, except for the EQ-5D. HRQoL among black men was higher at higher income levels, while the HRQoL of black women was especially low compared to other groups at high income levels.

For-profit hospital status and rehospitalizations at different hospitals: an analysis of Medicare data.

BACKGROUND: About one quarter of rehospitalized Medicare patients are admitted to hospitals different from their original hospital. The extent to which this practice is related to for-profit hospital status and affects payments and mortality is unknown. OBJECTIVE: To describe and examine predictors of and payments for rehospitalization at a different hospital among Medicare patients rehospitalized within 30 days at for-profit and nonprofit or public hospitals. DESIGN: Cohort study of patients discharged and rehospitalized from January 2005 to November 2006. SETTING: Medicare fee-for-service hospitals throughout the United States. PARTICIPANTS: A 5% random national sample of Medicare patients with acute care rehospitalizations within 30 days of discharge (n = 74,564). MEASUREMENTS: 30-day rehospitalizations at different hospitals and total payments or mortality over the subsequent 30 days. Multivariate logistic and quantile regression models included index hospital for-profit status, discharge counts, geographic region, rural-urban commuting area, and teaching status; patient sociodemographic characteristics, disability status, and comorbid conditions; and a measure of risk adjustment. RESULTS: 16 622 patients (22%) in the sample were rehospitalized at a different hospital. Factors associated with increased risk for rehospitalization at a different hospital included index hospitalization at a for-profit, major medical school-affiliated, or low-volume hospital and having a Medicare-defined disability. Compared with patients rehospitalized at the same hospital, patients rehospitalized at different hospitals had higher adjusted 30-day total payments (median additional cost, $1308 per patient; P < 0.001) but no statistically significant differences in 30-day mortality, regardless of index hospital for-profit status. LIMITATION: The database lacked detailed clinical information about patients and did not include information about specific provider practice motivations or the role of patient choice in hospitalization venues. CONCLUSION: Rehospitalizations at different hospitals are common among Medicare patients, are more likely among those initially hospitalized at a for-profit hospital, and are related to increased overall payments without improved mortality. PRIMARY FUNDING SOURCE: University of Wisconsin Hartford Center of Excellence in Geriatrics, National Institutes of Health.

Health domains and race in generic preference-based health-related quality of life instruments in the United States literature / Domínios de saúde e raça nas medidas genéricas de qualidade de vida associada à saúde na literatura dos Estados Unidos / Dominios de salud y raza en las medidas genéricas de calidad de vida, asociada a la salud, en la literatura de los Estados Unidos

Race differences in health have been extensively analyzed and documented in the literature, especially between African Americans or blacks and whites in the United States. Despite the vast literature in the area, the majority of studies that explore the relationship between race and health use outcomes such as self-rated health, mortality or morbidity, and disability, but very few use Health-Related Quality of Life (HRQoL) measures and their domains or dimensions. This narrative review aims to provide a better understanding of the relationship between race and health domains that are commonly used in preference-based HRQoL measures. We investigated the literature on race, physical health, mental health, pain and discomfort, cognition, neurologic spectrum domains, dexterity, ambulation, vitality and social functioning domains. We conducted a literature search and review using the key words race and the health domain of interest, using medical and social sciences databases, such as MEDLINE/Pubmed, Web of Science, and the Google Scholar portal.The majority of the studies identified in the literature show that African Americans or blacks in the United States tend to have lower scores than whites throughout a variety of health domains found in preference-based HRQoL measures. This review also emphasizes the scarcity of studies that investigate some health domains, such as social functioning, dexterity, vitality and neurologic spectrum domains, and therefore we identify the need for more studies focusing on race and measures that address such domains.

A literatura sobre raça nos Estados Unidos está repleta de estudos que documentam diferenças na saúde entre negros e brancos. Entretanto, a maioria dos trabalhos que exploram a relação entre raça e saúde utiliza medidas com saúde autorrelatada, mortalidade e morbidade, mas poucos empregam medidas de qualidade de vida relacionada à saúde e seus domínios específicos. Este artigo revisa a literatura sobre raça e qualidade de vida relacionada à saúde, especificamente examinando os domínios que constituem as principais medidas baseadas na teoria da utilidade: saúde física; saúde mental; dor e desconforto; cognição; domínios neurológicos; destreza; locomoção; vitalidade; e funcionamento social. Conduziu-se uma revisão da literatura usando as palavras-chave raça e o domínio da qualidade de vida de interesse nos Estados Unidos. Foram consultadas as bases de dados Medline/Pubmed, Web of Science e o portal Google Scholar. A maioria dos estudos sobre diversos domínios das medidas de qualidade de vida investigados sugere que negros têm pior qualidade de vida do que brancos nos Estados Unidos. A revisão salienta a escassez de estudos que exploram a relação entre raça e alguns domínios, como, por exemplo, funcionamento social, destreza, vitalidade e domínios de escopo neurológico, e, portanto, mostra a necessidade de que futuros estudos examinem a relação entre raça e estes domínios.

La literatura sobre raza en los Estados Unidos está repleta de estudios que documentan diferencias en la salud entre negros y blancos. No obstante, la mayoría de los trabajos que explotan la relación entre raza y salud utiliza medidas con salud autorrelatada, mortalidad y morbilidad, pero pocos emplean medidas de calidad de vida relacionada con la salud y sus dominios específicos. Este artículo revisa la literatura sobre raza y calidad de vida relacionada con la salud, específicamente, examinando los dominios que constituyen las principales medidas basadas en la teoría de la utilidad: salud física; salud mental; dolor y molestias; cognición; dominios neurológicos; agilidad; locomoción; vitalidad; y funcionamiento social. Se realizó una revisión de la literatura usando las palabras-clave raza y el dominio de la calidad de vida de interés en los Estados Unidos. Se consultaron las bases de datos Medline/Pubmed, Web of Science y el portal Google Scholar. La mayoría de los estudios sobre diversos dominios de las medidas de calidad de vida investigados sugiere que los negros tienen peor calidad de vida que los blancos en los Estados Unidos. La revisión resalta la escasez de estudios que explotan la relación entre raza y algunos dominios, como, por ejemplo, funcionamiento social, agilidad, vitalidad y dominios de objetivo neurológico, y, por tanto, muestra la necesidad de que futuros estudios examinen la relación entre raza y estos dominios.