Reports of insurance-based discrimination in health care and its association with access to care.

OBJECTIVES: We examined reports of insurance-based discrimination and its association with insurance type and access to care in the early years of the Patient Protection and Affordable Care Act. METHODS: We used data from the 2013 Minnesota Health Access Survey to identify 4123 Minnesota adults aged 18 to 64 years who reported about their experiences of insurance-based discrimination. We modeled the association between discrimination and insurance type and predicted odds of having reduced access to care among those reporting discrimination, controlling for sociodemographic factors. Data were weighted to represent the state's population. RESULTS: Reports of insurance-based discrimination were higher among uninsured (25%) and publicly insured (21%) adults than among privately insured adults (3%), which held in the regression analysis. Those reporting discrimination had higher odds of lacking a usual source of care, lacking confidence in getting care, forgoing care because of cost, and experiencing provider-level barriers than those who did not. CONCLUSIONS: Further research and policy interventions are needed to address insurance-based discrimination in health care settings.

Impact of different privacy conditions and incentives on survey response rate, participant representativeness, and disclosure of sensitive information: a randomized controlled trial.

BACKGROUND: Anonymous survey methods appear to promote greater disclosure of sensitive or stigmatizing information compared to non-anonymous methods. Higher disclosure rates have traditionally been interpreted as being more accurate than lower rates. We examined the impact of 3 increasingly private mailed survey conditions-ranging from potentially identifiable to completely anonymous-on survey response and on respondents' representativeness of the underlying sampling frame, completeness in answering sensitive survey items, and disclosure of sensitive information. We also examined the impact of 2 incentives ($10 versus $20) on these outcomes. METHODS: A 3X2 factorial, randomized controlled trial of 324 representatively selected, male Gulf War I era veterans who had applied for United States Department of Veterans Affairs (VA) disability benefits. Men were asked about past sexual assault experiences, childhood abuse, combat, other traumas, mental health symptoms, and sexual orientation. We used a novel technique, the pre-merged questionnaire, to link anonymous responses to administrative data. RESULTS: Response rates ranged from 56.0% to 63.3% across privacy conditions (p = 0.49) and from 52.8% to 68.1% across incentives (p = 0.007). Respondents' characteristics differed by privacy and by incentive assignments, with completely anonymous respondents and $20 respondents appearing least different from their non-respondent counterparts. Survey completeness did not differ by privacy or by incentive. No clear pattern of disclosing sensitive information by privacy condition or by incentive emerged. For example, although all respondents came from the same sampling frame, estimates of sexual abuse ranged from 13.6% to 33.3% across privacy conditions, with the highest estimate coming from the intermediate privacy condition (p = 0.007). CONCLUSION: Greater privacy and larger incentives do not necessarily result in higher disclosure rates of sensitive information than lesser privacy and lower incentives. Furthermore, disclosure of sensitive or stigmatizing information under differing privacy conditions may have less to do with promoting or impeding participants' "honesty" or "accuracy" than with selectively recruiting or attracting subpopulations that are higher or lower in such experiences. Pre-merged questionnaires bypassed many historical limitations of anonymous surveys and hold promise for exploring non-response issues in future research.

Adaptive COVID-19 Mitigation Strategies: Tradeoffs between Trigger Thresholds, Response Timing, and Effectiveness.

Background. To support proactive decision making during the COVID-19 pandemic, mathematical models have been leveraged to identify surveillance indicator thresholds at which strengthening nonpharmaceutical interventions (NPIs) is necessary to protect health care capacity. Understanding tradeoffs between different adaptive COVID-19 response components is important when designing strategies that balance public preference and public health goals. Methods. We considered 3 components of an adaptive COVID-19 response: 1) the threshold at which to implement the NPI, 2) the time needed to implement the NPI, and 3) the effectiveness of the NPI. Using a compartmental model of SARS-CoV-2 transmission calibrated to Minnesota state data, we evaluated different adaptive policies in terms of the peak number of hospitalizations and the time spent with the NPI in force. Scenarios were compared with a reference strategy, in which an NPI with an 80% contact reduction was triggered when new weekly hospitalizations surpassed 8 per 100,000 population, with a 7-day implementation period. Assumptions were varied in sensitivity analysis. Results. All adaptive response scenarios substantially reduced peak hospitalizations relative to no response. Among adaptive response scenarios, slower NPI implementation resulted in somewhat higher peak hospitalization and a longer time spent under the NPIs than the reference scenario. A stronger NPI response resulted in slightly less time with the NPIs in place and smaller hospitalization peak. A higher trigger threshold resulted in greater peak hospitalizations with little reduction in the length of time under the NPIs. Conclusions. An adaptive NPI response can substantially reduce infection circulation and prevent health care capacity from being exceeded. However, population preferences as well as the feasibility and timeliness of compliance with reenacting NPIs should inform response design. Highlights: This study uses a mathematical model to compare different adaptive nonpharmaceutical intervention (NPI) strategies for COVID-19 management across 3 dimensions: threshold when the NPI should be implemented, time it takes to implement the NPI, and the effectiveness of the NPI.All adaptive NPI response scenarios considered substantially reduced peak hospitalizations compared with no response.Slower NPI implementation results in a somewhat higher peak hospitalization and longer time spent with the NPI in place but may make an adaptive strategy more feasible by allowing the population sufficient time to prepare for changing restrictions.A stronger, more effective NPI response results in a modest reduction in the time spent under the NPIs and slightly lower peak hospitalizations.A higher threshold for triggering the NPI delays the time at which the NPI starts but results in a higher peak hospitalization and does not substantially reduce the time the NPI remains in force.

Caregiver reports of subsequent injuries among veterans with traumatic brain injury after discharge from inpatient polytrauma rehabilitation programs.

OBJECTIVE: : We examined prevalence of, and potential risk factors for, nonfatal injuries among Veterans with traumatic brain injury (TBI) postdischarge from Veterans Affairs inpatient polytrauma rehabilitation programs. METHODS: : We surveyed caregivers of patients who had military service anytime from 2001 to 2009, sustained polytrauma including TBI, received Veterans Affairs inpatient care from 2001 to 2009, were discharged at least 3 months before the study, and were alive when the study was fielded about caregiver and patient health, including patients' medically treated "accidents/new injuries" since discharge. We examined prevalence and source(s) of subsequent injuries and estimated patients' injury risk in reference to hypothesized risk factors. Odds ratios and 95% confidence intervals were calculated using multivariate logistic regression. RESULTS: : Caregivers reported that nearly one-third (32%) of patients incurred medically treated injuries after discharge; most were associated with falls (49%) and motor vehicles (37%). Odds of subsequent injury were associated with select demographics, initial injury characteristics, and postdischarge health and functioning. Characteristics of caregivers, including physical and mental health, were also associated with patients' odds of subsequent injury. CONCLUSIONS: : A significant number of caregivers reported subsequent nonfatal injuries among patients treated for TBI/polytrauma in inpatient rehabilitation settings. Enhanced injury prevention efforts may be beneficial for this population.

The invisible side of war: families caring for US service members with traumatic brain injuries and polytrauma.

OBJECTIVES: : To (1) identify informal caregivers to injured US service members following acute rehabilitation for polytraumatic injuries, principally traumatic brain injury (TBI), and (2) describe the prevalence and variation of care recipient and caregiver experiences. DESIGN: : Cross-sectional survey of caregivers. PARTICIPANTS: : Caregivers (N = 564) of service members with TBI who received inpatient rehabilitation care in a Veterans Affairs' Polytrauma Rehabilitation Center between 2001 and 2009. MAIN OUTCOME MEASURES: : Questions about caregiver and patient characteristics, type, and quantity of care currently being provided. RESULTS: : Caregiving responsibilities fall primarily on women (79%), typically a parent (62%) or spouse (32%). After a median 4 years since injury, 22% of patients still required assistance with activities of daily living and instrumental activities of daily living. An additional 48% required assistance with only instrumental activities of daily living. Nearly 25% of caregivers reported more than 40 h/wk of care and another 20% reported 5 to 40 h/wk of care. Of caregivers providing assistance with activities of daily living, 49% provided care ≥ 80 h/wk. Nearly 60% of caregivers were solely responsible for the caregiving. Most caregivers also reported providing other help, including managing emotions and navigating health and legal systems. CONCLUSIONS: : Caregivers who provide assistance with either activities of daily living or instrumental activities of daily living may need additional resources to meet the long-term needs of their injured family member.

A comparison of small monetary incentives to convert survey non-respondents: a randomized control trial.

BACKGROUND: Maximizing response rates is critically important in order to provide the most generalizable and unbiased research results. High response rates reduce the chance of respondents being systematically different from non-respondents, and thus, reduce the risk of results not truly reflecting the study population. Monetary incentives are often used to improve response rates, but little is known about whether larger incentives improve response rates in those who previously have been unenthusiastic about participating in research. In this study we compared the response rates and cost-effectiveness of a $5 versus $2 monetary incentive accompanying a short survey mailed to patients who did not respond or refused to participate in research study with a face-to-face survey. METHODS: 1,328 non-responders were randomly assigned to receive $5 or $2 and a short, 10-question survey by mail. Reminder postcards were sent to everyone; those not returning the survey were sent a second survey without incentive. Overall response rates, response rates by incentive condition, and odds of responding to the larger incentive were calculated. Total costs (materials, postage, and labor) and incremental cost-effectiveness ratios were also calculated and compared by incentive condition. RESULTS: After the first mailing, the response rate within the $5 group was significantly higher (57.8% vs. 47.7%, p<.001); after the second mailing, the difference narrowed by 80%, resulting in a non-significant difference in cumulative rates between the $5 and $2 groups (67.3% vs. 65.4%, respectively, p=.47). Regardless of incentive or number of contacts, respondents were significantly more likely to be male, white, married, and 50-75 years old. Total costs were higher with the larger versus smaller incentive ($13.77 versus $9.95 per completed survey). CONCLUSIONS: A $5 incentive provides a significantly higher response rate than a $2 incentive if only one survey mailing is used but not if two survey mailings are used.

Post-deployment injury among new combat veterans enrolled in Veterans Affairs (VA) healthcare.

The purpose of this study was to examine prevalence and potential risk factors for post-deployment injury among Iraq and Afghanistan combat veterans enrolled in Veterans Affairs (VA) healthcare. A national, stratified sample of Iraq/Afghanistan combat Veteran VA users was surveyed in 2008. Mental and physical health, including medically-treated injuries sustained since deployment, were self-reported. Injury risk was estimated using survey logistic regression. Stratified ORs and 95% CIs were adjusted for potential confounders and non-response bias and weighted to represent the target population. Nearly half the population reported post-deployment injuries. In multivariate models, veterans with probable post-traumatic stress disorder (OR=2.1; 95% CI 1.3 to 3.5), self-reported diagnosed depression (OR=3.6; 95% CI 1.8 to 7.0) and anger problems (OR=2.4; 95% CI 1.4 to 4.2) had greater odds of post-deployment injury. Deployment-related injuries were also strongly associated with odds of post-deployment injury. Results suggest that mental health disorders increase the odds of post-deployment injury among combat veteran VA users. Longitudinal research examining these associations is warranted.

Health insurance literacy: How best to measure and does it matter to health care access and affordability?

BACKGROUND: Health insurance is complex, cost are continuously rising, and people are assuming more of these costs. Health insurance literacy (HIL) is related to healthcare access, yet there is no agreement about how best to measure HIL. OBJECTIVES: Contrast two HIL measures. First, evaluating their association with demographic characteristics, insurance type, and health status. Second, comparing how these distinct measures relate to access, forgone care, and financial burden of health care. METHODS: Data are from a 2017 telephone survey focused on health insurance coverage and access. Participants were randomly assigned either the 4-item likelihood of proactive use scale or a 4-item measure of confidence in use of insurance. Logistic regressions assess correlates of each HIL measure and their association with a range of access measures. RESULTS: For both measures, 25% of insured adults report high HIL. Few demographic and health status measures are associated with high HIL and they are different for each measure. For both measures, high HIL translates into reports of having a usual source of care and confidence in getting care when needed. The HIL measures behave in opposite ways for forgone care due to costs and problems paying medical bills. Adults scoring high on the likelihood measure are more likely to forgo care and report financial burden. By contrast, adults scoring high on the confidence measure are less likely to forgo care and report burdensome medical bills. CONCLUSIONS: The two measures capture different concepts and raise the question of whether reporting a likely behavior or being confident of that behavior are predictive when it is time to use health insurance. Because HIL is measured at the same time as the outcomes, we reason that the likelihood measure is capturing peoples' past experience using insurance and may result in more proactive use of insurance in the future.

Rewarding early abstinence in Veterans Health Administration addiction clinics.

This study investigates the addition of a contingency management (CM) intervention to Veterans Health Administration substance use disorders treatment on during- and post-treatment outcomes for Veterans diagnosed with alcohol dependence only (n=191) or stimulant dependence (n=139). Participants were randomly assigned to 8weeks of usual care or usual care plus CM. Follow-up assessments occurred at 2, 6 and 12months. In the alcohol dependent subgroup, CM participants submitted significantly more negative samples (13 versus 11 samples, Cohen's d=0.54), were retained significantly longer (7 versus 6weeks, d=0.47), achieved significantly longer median durations of abstinence (16 versus 9 consecutive visits; median difference=7, 95% CI=4-8), and submitted significantly more negative samples at follow-ups (unstandardized effect size=0.669, se=0.2483) compared to usual care participants. Intervention effects were non-significant for the stimulant dependent subgroup. The study provides support for the effectiveness of CM interventions for alcohol dependent patients.