Better performance for right-skewed data using an alternative gamma model.

BACKGROUND: The Maximum Likelihood Estimator (MLE) for parameters of the gamma distribution is commonly used to estimate models of right-skewed variables such as costs, hospital length of stay, and appointment wait times in Economics and Healthcare research. The common specification for this estimator assumes the variance is proportional to the square of the mean, which underlies estimation and specification tests. We present a specification in which the variance is directly proportional to the mean. METHODS: We used simulation experiments to investigate finite sample results, and we used United States Department of Veterans Affairs (VA) healthcare cost data as an empirical example comparing the fit and predictive ability of the models. RESULTS: Simulation showed the MLE based on a correctly specified alternative has less parameter bias, lower standard errors, and less skewness in distribution than a misspecified standard model. The application to VA healthcare cost data showed the alternative specification can have better R square, smaller root mean squared error, and smaller mean residuals within deciles of predicted values. CONCLUSIONS: The alternative gamma specification can be a useful alternative to the standard specification for estimating models of right-skewed continuous variables.

Perinatal Health Outcomes Following a Community Health Worker-Supported Home-Visiting Program in Rochester, New York, 2015-2018.

We evaluated the effectiveness of a community health worker-supported home visitor program on perinatal outcomes of 455 at-risk pregnant women with program data merged with electronic medical records from July 2015 through October 2017 in Rochester, New York. Program participants had fewer adverse outcomes than did nonparticipants, including lower rates of preterm birth (12% vs 20%; χ2, P = .05) and low birth weight (14% vs 22%; χ2, P = .05). This program was effective at achieving improved perinatal outcomes.

Mobility Improvements are Found in Older Veterans After 6-Months of Gerofit Regardless of BMI Classification.

Veterans represent a unique population of older adults as they are more likely to self-report disability and be overweight or obese compared to the general population. We sought to compare changes in mobility function across the obesity spectrum in older Veterans participating in six-months of Gerofit, a clinical exercise program. 270 Veterans completed baseline, three, and six-month functional assessment and were divided post-hoc into groups: normal weight, overweight, and obese. Physical function assessment included: ten-meter walk time, six-minute walk distance, 30-second chair stands, and eight-foot up-and-go time. No significant weight x time interactions were found for any measure. However, significant (P<0.02) improvements were found for all mobility measures from baseline to three-months and maintained at six-months. Six-months of participation in Gerofit, if enacted nationwide, appears to be one way to improve mobility and function in older Veterans at high risk for disability regardless of weight status.

Political orientation, political environment, and health behaviors in the United States.

Political orientation (Republican/Democrat and conservative/liberal) and political environment (geo-spatial political party affiliated voting patterns) are both associated with various health outcomes, including mortality. Modern disease etiology in the U.S. suggests that many of our health outcomes derive from behaviors and lifestyle choices. Thus, we examine the associations of political orientation and political environment with health behaviors. We used the Annenberg National Health Communication Survey (ANHCS) data, which is a nationally representative U.S. survey fielded continuously from 2005 through 2012. The health behaviors studied include health information search, flu vaccination, excessive alcohol consumption, tobacco consumption, exercise, and dietary patterns. Democrats/liberals had higher odds of cigarette smoking and excessive drinking compared to Republicans/conservatives. Whereas, Republicans/conservatives ate fewer servings and fewer varieties of fruit and vegetables; ate more high fat and processed foods; and engaged in less in-depth health information searches compared to Democrats/liberals. Also, conservatives had lower odds of exercise participation than liberals; whereas Republicans had lower odds of flu vaccination. Greater Republican vote share in the 2008 and 2012 presidential elections at the state and/or county levels was associated with higher odds of flu vaccination and smoking cigarettes and lower odds of avoiding fat/calories, avoiding fast/processed food, eating a variety of fruits and vegetables, and eating more servings of fruit. We use the distinct cognitive-motivational styles attributed to political orientation in discussing the findings. Health communication strategies could leverage these relationships to produce tailored and targeted messages as well as to develop and advocate for policy.

Effects of implantable cardioverter/defibrillator shock and antitachycardia pacing on anxiety and quality of life: A MADIT-RIT substudy.

Effects of implantable cardioverter/defibrillator (ICD) shocks and antitachycardia pacing (ATP) on anxiety and quality of life (QoL) in ICD patients are poorly understood. METHODS: We evaluated changes in QoL from baseline to 9-month follow-up using the EQ-5D questionnaire in patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT) (n=1,268). We assessed anxiety levels using the Florida Shock Anxiety Scale (1-10 score) in patients with appropriate or inappropriate shocks or ATP compared to those with no ICD therapy during the first 9 months postimplant. The analysis was stratified by number of ATP or shocks (0-1 vs ≥2) and adjusted for covariates. RESULTS: In MADIT-RIT, 15 patients (1%) had ≥2 appropriate shocks, 38 (3%) had ≥2 appropriate ATPs. Two or more inappropriate shocks were delivered in 16 patients (1%); ≥2 inappropriate ATPs, in 70. In multivariable analysis, patients with ≥2 appropriate shocks had higher levels of shock-related anxiety than those with ≤1 appropriate shock (P<.01). Furthermore, ≥2 inappropriate shocks produced more anxiety than ≤1 inappropriate shock (P=.005). Consistently, ≥2 appropriate ATPs resulted in more anxiety than ≤1 (P=.028), whereas the number of inappropriate ATPs showed no association with anxiety levels (P=.997). However, there was no association between QoL and appropriate or inappropriate ATP/shock (all P values > .05). CONCLUSIONS: In MADIT-RIT, ≥2 appropriate or inappropriate ICD shocks and ≥2 appropriate ATPs are associated with more anxiety at 9-month follow-up despite no significant changes in the assessment of global QoL by the EQ-5D questionnaire. Innovative ICD programming reducing inappropriate therapies may help deal with patient concerns about the device.

HCBS Spending and Nursing Home Admissions for 1915(c) Waiver Enrollees.

Medicaid waiver programs for home- and community-based services (HCBS) have grown rapidly and serve a population at high risk for nursing home (NH) admission. This study utilized the Medicaid Analytic Extract Personal Summary File and the NH Minimum Data Set and tested whether higher levels of per-beneficiary HCBS spending were associated with (1) lower risk of long-term (90+ days) NH admission and (2) higher functional/cognitive impairment at admission for new enrollees in 1915(c) aged or aged and disabled waiver programs. Waiver enrollees in states and counties with higher HCBS spending were found to have lower risk of long-term NH admission and greater functional impairment at NH admission compared to waiver enrollees in states and counties with lower spending. This indicates that higher per-enrollee HCBS spending may enable waiver enrollees to remain in the community until their functional impairment becomes more severe.

Fluoride Varnish: Knowledge, Preferences and Practices of General and Pediatric Dentists.

To determine the use of fluoride varnish (FV) to prevent dental caries and explore related factors, a survey was mailed to all 540 licensed general and pediatric dentists in eight Western New York counties. Of 193 surveys analyzed, 47.5% of dentists used FV in children. Only 44% accurately assessed high-risk cases for caries. Dentists serving children under age 2 and those correctly assessing high-risk children for caries were more likely to use FV in children under 7. Only 28% correctly recommended the first visit at 6/12 months; 38.7% recommended age 3. The authors concluded that FV was underutilized, suggesting a need for guide-line based strategies.

Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital.

We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.

Does patient time spent viewing computer-tailored colorectal cancer screening materials predict patient-reported discussion of screening with providers?

The main aim is to examine whether patients' viewing time on information about colorectal cancer (CRC) screening before a primary care physician (PCP) visit is associated with discussion of screening options during the visit. We analyzed data from a multi-center randomized controlled trial of a tailored interactive multimedia computer program (IMCP) to activate patients to undergo CRC screening, deployed in primary care offices immediately before a visit. We employed usage time information stored in the IMCP to examine the association of patient time spent using the program with patient-reported discussion of screening during the visit, adjusting for previous CRC screening recommendation and reading speed.On average, patients spent 33 minutes on the program. In adjusted analyses, 30 minutes spent using the program was associated with a 41% increase in the odds of the patient having a discussion with their PCP (1.04, 1.59, 95% CI). In a separate analysis of the tailoring modules; the modules encouraging adherence to the tailored screening recommendation and discussion with the patient's PCP yielded significant results. Other predictors of screening discussion included better self-reported physical health and increased patient activation. Time spent on the program predicted greater patient-physician discussion of screening during a linked visit.Usage time information gathered automatically by IMCPs offers promise for objectively assessing patient engagement around a topic and predicting likelihood of discussion between patients and their clinician.

Preoperative brain natriuretic peptide and atrial arrhythmias after coronary artery bypass graft surgery.

OBJECTIVE: To assess the association of preoperative brain natriuretic peptide with atrial arrhythmias and length of stay after cardiac surgery. DESIGN: A retrospective data analysis. SETTING: All data were collected from patients who underwent cardiac surgery at a single institution, an academic hospital, between 2005 and 2010. PARTICIPANTS: Patient data were collected from the authors' institution's Perioperative Health Documentation System of cardiac surgeries. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The major findings were that individuals with a 10-pg/mL increase in brain natriuretic peptide were 1.005 (95% CI: 1.002, 1.009) times more likely to have an atrial arrhythmia than those with no increase in brain natriuretic peptide. A brain natriuretic peptide value ≥306 pg/mL was calculated to best predict an atrial arrhythmia. Those above the threshold were 1.455 (95% CI: 1.087, 1.947) times more likely to have an atrial arrhythmia than those below the threshold. Individuals above the threshold had a median of 3 days in the intensive care unit compared to 1 day for those below the threshold, as well as median hospital stays of 11 days for those below the threshold. CONCLUSIONS: The results indicated that elevated brain natriuretic peptide was associated with increased risk of atrial arrhythmias and prolonged length of hospital stay after cardiac surgery. Identifying at-risk patients is important to guide preventative strategies for postoperative atrial arrhythmias.

Who avoids going to the doctor and why? Audience segmentation analysis for application of message development.

This exploratory study examines the prevalent and detrimental health care phenomenon of patient delay in order to inform formative research leading to the design of communication strategies. Delayed medical care diminishes optimal treatment choices, negatively impacts prognosis, and increases medical costs. Various communication strategies have been employed to combat patient delay, with limited success. This study fills a gap in research informing those interventions by focusing on the portion of patient delay occurring after symptoms have been assessed as a sign of illness and the need for medical care has been determined. We used CHAID segmentation analysis to produce homogeneous segments from the sample according to the propensity to avoid medical care. CHAID is a criterion-based predictive cluster analysis technique. CHAID examines a variety of characteristics to find the one most strongly associated with avoiding doctor visits through a chi-squared test and assessment of statistical significance. The characteristics identified then define the segments. Fourteen segments were produced. Age was the first delineating characteristic, with younger age groups comprising a greater proportion of avoiders. Other segments containing a comparatively larger percent of avoiders were characterized by lower income, lower education, being uninsured, and being male. Each segment was assessed for psychographic properties associated with avoiding care, reasons for avoiding care, and trust in health information sources. While the segments display distinct profiles, having had positive provider experiences, having high health self-efficacy, and having an internal rather than external or chance locus of control were associated with low avoidance among several segments. Several segments were either more or less likely to cite time or money as the reason for avoiding care. And several older aged segments were less likely than the remaining sample to trust the government as a source for health information. Implications for future research are discussed.

Predictors of avoiding medical care and reasons for avoidance behavior.

BACKGROUND: Delayed medical care has negative health and economic consequences; interventions have focused on appraising symptoms, with limited success in reducing delay. OBJECTIVE: To identify predictors of care avoidance and reasons for avoiding care. METHODS: Using the Health Information National Trends Survey (2007), we conducted logistic regressions to identify predictors of avoiding medical visits deemed necessary by the respondents; and, we then conducted similar analyses on reasons given for avoidance behavior. Independent variables included geographic, demographic, socioeconomic, personal health, health behavior, health care system, and cognitive characteristics. RESULTS: Approximately one third of adults avoided doctor visits they had deemed necessary. Although unadjusted associations existed, avoiding needed care was not independently associated with geographic, demographic, and socioeconomic characteristics. Avoidance behavior is characterized by low health self-efficacy, less experience with both quality care and getting help with uncertainty about health, having your feelings attended to by your provider, no usual source of care, negative affect, smoking daily, and fatalistic attitude toward cancer. Reasons elicited for avoidance include preference for self-care or alternative care, dislike or distrust of doctors, fear or dislike of medical treatments, time, and money; respondents also endorsed discomfort with body examinations, fear of having a serious illness, and thoughts of dying. Distinct predictors distinguish each of these reasons. CONCLUSIONS: Interventions to reduce patient delay could be improved by addressing the health-related behavioral, belief, experiential, and emotional traits associated with delay. Attention should also be directed toward the interpersonal communications between patients and providers.

Telemedicine and Disparities in Mental Health Service Use Among Community-Dwelling Older Adults With Alzheimer Disease and Related Dementias.

OBJECTIVE: To examine disparities in mental health (MH) service utilization, via in-person and telemedicine (ie, tele-MH), by individuals' race, ethnicity, and community socioeconomic status, among community-dwelling older adults with Alzheimer disease and related dementias (ADRD) before and after the expansion of the Centers for Medicare and Medicaid Services' (CMS's) telemedicine policy. DESIGN: Observational study. SETTING AND PARTICIPANTS: A total of 3,003,571 community-dwelling Medicare beneficiaries with ADRD between 2019 and 2021 were included in the study. METHODS: Multiple national data were linked. The unit of analysis was individual-quarter. Three outcomes were defined: any MH visits (in-person or tele-MH), in-person MH visits, and tele-MH visits per quarter. Key independent variables included individual race and ethnicity, the socioeconomic status of the community, and an indicator for the implementation of the telemedicine policy. Regression analyses with individual random effects were used. RESULTS: In general, Black and Hispanic older adults with ADRD and those in socioeconomically deprived communities were less likely to have MH visits than white adults and those from less-deprived communities. In-person and tele-MH visits varied throughout the pandemic and across subpopulations. For instance, at the beginning of the pandemic, white, Black, and Hispanic older adults experienced 5.05, 3.03, and 2.87 percentage point reductions in in-person MH visits, and 3.53, 1.26, and 0.32 percentage point increases in tele-MH visits (with P < .01 for racial/ethnic differences), respectively. During the pandemic, the increasing trend in in-person MH visits and the decreasing trend in tele-MH visits varied across different subgroups. Overall, racial and ethnic differences in any MH visits were reduced, but the gap in any MH visits between deprived and less-deprived communities doubled during the pandemic (P < .01). CONCLUSIONS AND IMPLICATIONS: Telemedicine may have provided an opportunity to improve access to MH services among underserved populations. However, although some disparities in MH care were reduced, others widened, underscoring the importance of equitable health care access strategies to address the unique needs of different populations.

Racial and ethnic differences in telemedicine use among community-dwelling older adults with dementia.

BACKGROUND: Routine ambulatory care is essential for older adults with Alzheimer's disease and related dementias (ADRD) to manage their health conditions. The federal government expanded telemedicine coverage to mitigate the impact of the COVID-19 pandemic on ambulatory services, which may provide an opportunity to improve access to care. This study aims to examine differences in telemedicine use for ambulatory services by race, ethnicity, and community-level socioeconomic status among community-dwelling older adults with ADRD. METHODS: This retrospective cohort study used Medicare claims data between April 01, 2020 and December 31, 2021. We included community-dwelling Medicare fee-for-service beneficiaries aged 65 years and older with ADRD. The outcome variable is individual's use (yes/no) of telemedicine evaluation and management (tele-EM) visits in each quarter. The key independent variables are race, ethnicity, and community-level socioeconomic status. RESULTS: The analytical sample size of the study was 2,068,937, including 9.9% Black, 82.7% White, and 7.4% Hispanic individuals. In general, we observed a decreasing trend of tele-EM use, and the average rate of quarterly tele-EM use was 23.0%. Tele-EM utilization varied by individual race, ethnicity, and community-level socioeconomic status. On average, White and Black individuals in deprived communities were 3.5 and 2.4 percentage-points less likely to use tele-EM compared with their counterparts in less-deprived communities (p < 0.001). However, Hispanic individuals in deprived communities were 2.4 percentage-points more likely to utilize tele-EM compared with those in less-deprived communities (p < 0.001). Additionally, we observed various racial and ethnic differences in telemedicine use in deprived communities versus less-deprived communities. CONCLUSIONS: We observed various racial and ethnic differences in telemedicine use, both within and between communities by socioeconomic status. Telemedicine is a viable healthcare delivery option that may influence healthcare access for racial and ethnic minorities and for individuals in socioeconomically deprived communities. Further policies or interventions may be needed to ensure all individuals have equal access to newly available care delivery models.

Home Health Quality among Hospitalized Older Adults with Alzheimer's Disease and Related Dementia: Association with Race/Ethnicity and Dual Eligibility before and during the COVID Pandemic.

OBJECTIVES: During the COVID-19 pandemic, home health agencies (HHAs) discharges following acute hospitalizations increased. This study examined whether racial and ethnic minoritized and socioeconomically disadvantaged patients (ie, Medicare-Medicaid dual-eligible) were differentially discharged to below-average quality HHAs before and during the COVID-19 pandemic. We focused on post-acute patients with Alzheimer's disease and related dementias (ADRD), who are generally frail and have high care needs. DESIGN: Cohort study. SETTING AND PARTICIPANTS: We linked 2019 to 2021 Medicare data with Area Deprivation Index (ADI), Home Health Compare, and COVID-19 infection data. We included Medicare beneficiaries with ADRD who were hospitalized for non-COVID-19 conditions and discharged to HHAs between January 2019 and November 2021. The final analytical sample included 426,766 qualified hospitalization events. METHODS: The outcome variable was whether a patient received care from a below-average quality HHA, defined by an average Quality of Patient Care Star Rating lower than 3.0. Key independent variables included individual race, ethnicity, and Medicare-Medicaid dual status. Linear probability models with county fixed effects were estimated, sequentially adjusting for the individual- and community-level covariates. Sensitivity analysis using various definitions of below-average quality HHAs was conducted. RESULTS: Before the pandemic, Black and Hispanic individuals had significantly higher probabilities of discharge to below-average quality HHAs compared with white individuals (3.4 and 3.9 percentage points, respectively). Dual-eligible individuals were also 2.5 percentage points more likely to be discharged to below-average quality HHAs. During the pandemic, disparities in being discharged to below-average quality HHAs persisted among racial and ethnic minoritized patients and increased among duals. Findings were consistent with and without adjusting for individual covariates and across different definitions of below-average quality HHA. CONCLUSIONS AND IMPLICATIONS: Persistent disparities were observed in being discharged to below-average quality HHAs by race, ethnicity, and dual status. Further research is needed to identify factors contributing to these ongoing inequalities.

Post-acute care transitions during COVID-19: Racial, ethnic, and socioeconomic differences in older adults with Alzheimer's disease and related dementia.

BACKGROUND: Differences in the post-acute care (PAC) destinations among racial, ethnic, and socioeconomic groups have been documented before the COVID-19 pandemic. Yet, the pandemic's impact on these differences remains unknown. We examined the impact of the COVID-19 pandemic on PAC destinations and its variation by individual race, ethnicity, and socioeconomic status among community-dwelling older adults with Alzheimer's disease and related dementia (ADRD). METHODS: We linked 2019-2021 national data (Medicare claims, Minimum Data Set, Master Beneficiary Summary File) and several publicly available datasets, including Provider of Services File, Area Deprivation Index, Area Health Resource File, and COVID-19 infection data. PAC discharge destinations included skilled nursing facilities (SNFs), home health agencies (HHA), and homes without services. Key variables of interest included individual race, ethnicity, and Medicare-Medicaid dual status. The analytic cohort included 830,656 community-dwelling Medicare fee-for-service beneficiaries with ADRD who were hospitalized between 2019 and 2021. Regression models with hospital random effects and state-fixed effects were estimated, stratified by the time periods, and adjusted for the individual, hospital, and county-level covariates. RESULTS: SNF discharges decreased while home and HHA discharges increased during the pandemic. The trend was more prominent among racial and ethnic minoritized groups and even more so among dual-eligible beneficiaries. For instance, the reduction in the probabilities of SNF admissions between the pre-pandemic period and the 2nd year of COVID was 4.6 (White non-duals), 18.5 (White duals), 8.7 (Black non-duals), and 20.1 (Black duals) percentage-point, respectively. We also found that non-duals were more likely to replace SNF with HHA services, while duals were more likely to be discharged home without HHA. CONCLUSIONS: The COVID-19 pandemic significantly impacted PAC destinations for individuals with ADRD, especially among socioeconomically disadvantaged and racial and ethnic minoritized populations. Future research is needed to understand if and how these transitions may have affected health outcomes.

Is the emergency department used as a substitute or a complement to primary care in Medicaid?

Policies to decrease low-acuity emergency department (ED) use have traditionally assumed that EDs are a substitute for unavailable primary care (PC). However, such policies can exacerbate ED overcrowding, rather than ameliorate it, if patients use EDs to complement, rather than substitute, their PC use. We tested whether Medicaid managed care enrolees visit the ED for nonemergent and PC treatable conditions to substitute for or to complement PC. Based on consumer choice theory, we modelled county-level monthly ED visit rate as a function of PC supply and used 2012-2015 New York Statewide Planning and Research Cooperative System (SPARCS) outpatient data and non-linear least squares method to test substitution vs complementarity. In the post-Medicaid expansion period (2014-2015), ED and PC are substitutes state-wide, but are complements in highly urban and poorer counties during nights and weekends. There is no evidence of complementarity before the expansion (2012-2013). Analyses by PC provider demonstrate that the relationship between ED and PC differs depending on whether PC is provided by physicians or advanced practice providers. Policies to reduce low-acuity ED use via improved PC access in Medicaid are likely to be most effective if they focus on increasing actual appointment availability, ideally by physicians, in areas with low PC provider supply. Different aspects of PC access may be differently related to low-acuity ED use.

Cost-effectiveness of cardiac resynchronization therapy in the MADIT-CRT trial.

BACKGROUND: The Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) trial demonstrated that cardiac resynchronization therapy (CRT) when added to the implantable cardiac defibrillator (ICD) reduces risk of heart failure or death in minimally symptomatic patients with reduced cardiac ejection fraction and wide QRS complex. OBJECTIVES: To evaluate 4-year cost-effectiveness of CRT-ICD compared to ICD alone using MADIT-CRT data. RESEARCH DESIGN: Patients enrolled in the trial were randomized to implantation of either ICD or CRT-ICD in a 2:3 ratio, with up to 4-year follow-up period. Cost-effectiveness analyses were conducted, and sensitivity analyses by age, gender, and left bundle branch block (LBBB) conduction pattern were performed. SUBJECTS: A total of 1,271 patients with ICD or CRT-ICD (US centers only) who reported healthcare utilization and health-related quality of life data. MEASURES: We used the EQ-5D (US weights) to assess patient HRQOL and translated utilization data to costs using national Medicare reimbursement rates. RESULTS: Average 4-year healthcare expenditures in CRT-ICD patients were higher than costs of ICD patients ($62,600 vs 57,050, P = 0.015), mainly due to the device and implant-related costs. The incremental cost-effectiveness ratio of CRT-ICD compared to ICD was $58,330/quality-adjusted life years (QALY) saved. The cost effectiveness improved with longer time horizon and for the LBBB subgroup ($7,320/QALY), with no cost-effectiveness benefit being evident in the non-LBBB group. CONCLUSIONS: In minimally symptomatic patients with low ejection fraction and LBBB, CRT-ICD is cost effective within 4-year horizon when compared to ICD-only.

Is personality associated with health care use by older adults?

CONTEXT: The patterns of health care utilization in the United States pose well-established challenges for public policy. Although economic and sociological research has resulted in considerable knowledge about what influences the use of health services, the psychological literature in this area is underdeveloped. Importantly, it is not known whether personality traits are associated with older adults' use of acute and long-term care services. METHODS: Data were collected from 1,074 community-dwelling seniors participating in a Medicare demonstration. First they completed a self-report questionnaire measuring the "Big Five" personality traits: Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness. During the next two years, the participants maintained daily journals of their use of health care services. We used regression models based on the Andersen behavioral model of health care utilization to test for associations. FINDINGS: Our hypothesis that higher Neuroticism would be associated with greater health care use was confirmed for three services-probability of any emergency department (ED) use, likelihood of any custodial nursing home use, and more skilled nursing facility (SNF) days for SNF users-but was disconfirmed for hospital days for those hospitalized. Higher Openness to Experience was associated with a greater likelihood of custodial home care use, and higher Agreeableness and lower Conscientiousness with a higher probability of custodial nursing home use. For users, lower Openness was associated with more ED visits and SNF days, and lower Conscientiousness with more ED visits. For many traits with significant associations, the predicted use was 16 to 30 percent greater for people high (low) versus low (high) in specific traits. CONCLUSIONS: Personality traits are associated with Medicare beneficiaries' use of many expensive health care services, findings that have implications for health services research and policy. Accordingly, person-centered interventions, population-based translational effectiveness programs, and other personalized approaches that leverage the profound advances in personality psychology in recent decades should be considered.

Making difficult decisions: the role of quality of care in choosing a nursing home.

OBJECTIVES: We investigated how quality of care affects choosing a nursing home. METHODS: We examined nursing home choice in California, Ohio, New York, and Texas in 2001, a period before the federal Nursing Home Compare report card was published. Thus, consumers were less able to observe clinical quality or clinical quality was masked. We modeled nursing home choice by estimating a conditional multinomial logit model. RESULTS: In all states, consumers were more likely to choose nursing homes of high hotel services quality but not clinical care quality. Nursing home choice was also significantly associated with shorter distance from prior residence, not-for-profit status, and larger facility size. CONCLUSIONS: In the absence of quality report cards, consumers choose a nursing home on the basis of the quality dimensions that are easy for them to observe, evaluate, and apply to their situation. Future research should focus on identifying the quality information that offers the most value added to consumers.