The Cumulative Effect of Expanding the Breadth and Scope of Coverage for Substance Use Disorder Treatment on Behavioral Health Acute Inpatient Admissions: Evidence from Virginia Medicaid.

We evaluated the impact of Medicaid policies in Virginia (VA), namely the Addiction and Recovery Treatment Services (ARTS) program and Medicaid expansion, on the number of behavioral health acute inpatient admissions from 2016 to 2019. We used Poisson fixed-effect event study regression and compared average proportional differences in admissions over three time periods: (1) prior to ARTS; (2) following ARTS but before Medicaid expansion; (3) post-Medicaid expansion. The number of behavioral health acute inpatient admissions decreased by 2.6% (95% CI [-5.1, -0.2]) in the first quarter of 2018 and this decrease gradually intensified by 4.9% (95% CI [-7.5, -2.4]) in the fourth quarter of 2018 compared to the second quarter of 2017 (beginning of ARTS) in VA relative to North Carolina (NC). Following the first quarter of 2019 (beginning of Medicaid expansion), decreases in VA admissions became larger relative to NC. The average proportional difference in admissions estimated a decrease of 2.7% (95% CI, [-4.1, -0.8]) after ARTS but before Medicaid expansion and a decrease of 2.9% (95% CI, [-6.1, 0.4]) post-Medicaid expansion compared to pre-ARTS in VA compared to NC. Behavioral health acute inpatient admissions in VA decreased following ARTS implementation, and the decrease became larger after Medicaid expansion.

Health literacy competency requirements for health professionals: a Delphi consensus study in Taiwan.

BACKGROUND: Cumulative evidence supports the importance of health literacy in determining the quality of healthcare delivery and outcomes. To enhance health literacy competencies among professionals and alleviate healthcare barriers owing to patients' inadequate health literacy, evidence-based health literacy competency guidelines are needed for the development of health professionals' training curricula. The aim of this study was to validate and refine a set of health literacy competencies, including knowledge, attitude, and skills of health professionals, and to prioritize the importance of health literacy practices among healthcare professionals. METHODS: We employed a consensus-building approach that utilized a modified three-round Delphi process conducted in 2017. An online Delphi panel was assembled, comprising 20 Taiwanese health literacy experts from diverse fields such as medicine, nursing, public health, language, and communication. A set of health literacy competencies previously identified and validated by an international panel of health literacy experts was cross-culturally translated. RESULTS: After three rounds of ratings and modifications, a consensus agreement was reached on 42 of 62 health literacy competencies, including 12 of 24 knowledge items, 9 of 11 attitude items, and 21 of 27 skill items. Of the 32 health literacy practices, "avoidance using medical jargon," "speaking slowly and clearly with patients," and "using analogies and examples" were deemed most important by the panelists. CONCLUSIONS: The Delphi panel's consensus helped to identify a set of core health literacy competencies that could serve as measurable learning objectives to guide the development of a health literacy curriculum for health professionals. The prioritized health literacy practices can be employed as indicators of health literacy competencies that health professionals should learn and routinely use in clinical settings.

Hospital Finances During the First Two Years of the COVID-19 Pandemic: Evidence From Washington State Hospitals.

The COVID-19 pandemic created a broad array of challenges for hospitals. These challenges included restrictions on admissions and procedures, patient surges, rising costs of labor and supplies, and a disparate impact on already disadvantaged populations. Many of these intersecting challenges put pressure on hospitals' finances. There was concern that financial pressure would be particularly acute for hospitals serving vulnerable populations, including safety-net (SN) hospitals and critical access hospitals (CAHs). Using data from hospitals in Washington State, we examined changes in operating margins for SN hospitals, CAHs, and other acute care hospitals in 2020 and 2021. We found that the operating margins for all three categories of hospitals fell from 2019 to 2020, with SNs and CAHs sustaining the largest declines. During 2021, operating margins improved for all three hospital categories but SN operating margins still remained negative. Both changes in revenue and changes in expenses contributed to observed changes in operating margins. Our study is one of the first to describe how the financial effects of COVID-19 differed for SNs, CAHs, and other acute care hospitals over the first two years of the pandemic. Our results highlight the continuing financial vulnerability of SNs and demonstrate how the factors that contribute to profitability can shift over time.

Validation of the Measurement Approaches to Partnership Success (MAPS) Questionnaire.

Conceptualizing and testing factors that contribute to the success of community-academic partnerships are critical to understanding their contributions to the health and well-being of communities. Most measures to date focus on factors that contribute to the development of new partnerships, and only a few have been adequately tested and validated. Methods. The Measurement Approaches to Partnership Success (MAPS) study followed a community-based participatory research (CBPR) approach and a multiphase process that included the construction and pilot testing of a questionnaire, and a national survey to validate the psychometric properties of the questionnaire in long-standing CBPR partnerships (existing ≥ six years). All members within partnerships were recruited to complete the survey (55 partnerships with 563 partners). We used confirmatory factor analysis (CFA), Cronbach's alpha statistics, and a pairwise correlations approach to assess discriminant and convergent validity, and assessed internal consistency, and test-retest reliability. Results. All MAPS Questionnaire dimensions demonstrated strong validity and reliability and demonstrated agreement over time. Conclusion. The MAPS Questionnaire includes seven dimensions and 81 items related to the MAPS conceptual model and provides a scientific, in-depth measurement tool that allows long-standing CBPR partnerships to evaluate their work toward achieving health equity.

Using a CBPR Approach to Guide Successful Recruitment for an Online Questionnaire: The Measurement Approaches to Partnership Success (MAPS) Case Study.

The Measurement Approaches to Partnership Success (MAPS) study team effectively used a community-based participatory research (CBPR) approach to recruit 55 long-standing CBPR partnerships to participate in an online questionnaire to assess factors associated with partnership success. Our recruitment was guided by interconnected values of collaboration, transparency, and relationship-building to maintain fidelity to CBPR principles throughout the process. We operationalized these values into a series of strategies to recruit partnerships and sustain their involvement, including establishing primary points of contact, offering incentives for completion, personalizing recruitment materials, and practicing flexibility in our approach. We aim to inform public health researchers on the strategies that enabled our team to achieve 100% of our study recruitment goal, with the intent that our recommendations can be applied by others to enhance their recruitment efforts and reach their data collection goals for future public health research.

The Measurement Approaches to Partnership Success (MAPS) Questionnaire and Facilitation Guide: A Validated Measure of CBPR Partnership Success.

Partnerships that effectively engage in certain key structural and process functions are more likely to meet their research goals and contribute to longer-term health equity outcomes. Ongoing evaluation of partnerships' level of achievement of these key functions, along with their fidelity to the guiding principles of community-based participatory research (CBPR), is therefore essential to understand how they can achieve desired partnership outcomes. This article describes the validated Measurement Approaches to Partnership Success (MAPS) Questionnaire and the use of an accompanying Facilitation Guide in helping members of CBPR partnerships evaluate their partnership's state of development and interpret findings to improve its structure, processes, and outcomes. We describe the conceptual framework guiding the development of the MAPS Questionnaire and its 81-item across seven key outcome dimensions, along with 28 items measuring precursor characteristics of CBPR partnership outcomes. The Facilitation Guide provides general guidelines for sharing, interpreting, and applying results within partnerships using a participatory process, definitions and items for each dimension, an example of presenting summary means, and dimension-specific reflective questions for discussion. We offer recommendations for practical uses of the MAPS Questionnaire and Facilitation Guide. Whether used as a comprehensive tool or by dimension, the MAPS Questionnaire is conceptually sound and empirically validated for evaluating how CBPR partnerships can achieve long-standing success. CBPR partnerships at any stage of development will find the MAPS Questionnaire and Facilitation Guide useful in measuring and interpreting indicators of partnership success, sharing results, and improving their ability to contribute to achieving health equity goals.

Provision of chaplaincy services in U.S. hospitals: A strategic conformity perspective.

BACKGROUND: Increasingly, hospitals are expected to provide patient-centered care that attends to patients' health needs, including spiritual care needs. Chaplaincy services help to meet patients' spiritual care needs, which have been shown to have a positive impact on health outcomes. Variation in the provision of chaplaincy services suggests hospitals do not uniformly conform to the expectation of making chaplaincy services available. PURPOSE: The aim of this study was to examine the availability and factors that influence hospitals' provision of chaplaincy services. METHODOLOGY: Data were combined from the American Hospital Association annual surveys with the Area Health Resource File at the county level from 2010 to 2019. Observations on general, acute-care community hospitals were analyzed (45,384 hospital-year observations) using logistic regression that clustered standard errors at the hospital level. RESULTS: Hospitals with Joint Commission accreditation, more staffed beds, nonprofit and government ownership, teaching status, one or more intensive care units, a higher percentage of Medicare inpatient days, church affiliation, and system membership were more likely to provide chaplaincy services than their counterparts. Certification as a trauma hospital and market competition showed no influence on the provision of chaplaincy services. CONCLUSION: The lack of chaplaincy services in many hospitals may be due to limited resources, workforce shortage, or a lack of consensus on scope and nature of chaplaincy services. PRACTICE IMPLICATIONS: Chaplaincy services are an underutilized resource that influences patient experience, clinician burnout and turnover, and the goal of ensuring care is patient-centered. Administrators should consider stronger partnerships where services are provided; researchers and policymakers should consider how the lack of these services in some hospitals may reinforce existing health disparities.

Understanding the Benefit-Cost Relationship in Long-standing Community-based Participatory Research (CBPR) Partnerships: Findings from the Measurement Approaches to Partnership Success (MAPS) Study.

As part of the Measurement Approaches to Partnership Success (MAPS) study, we investigated the relationship between benefits and costs of participation in long-standing community-based participatory research (CBPR) partnerships using social exchange theory as a theoretical framework. Three major findings were identified: (1) the concept of benefits and costs operating as a ratio, where individual benefits must outweigh costs for participation, applies to early stages of CBPR partnership formation; (2) as CBPR partnerships develop, the benefits and costs of participation include each other's needs and the needs of the group as a whole; and (3) there is a shift in the relationship of benefits and costs over time in long-standing CBPR partnerships, in which partners no longer think in terms of costs but rather investments that contribute to mutual benefits.

A CBPR-Enhanced Delphi Method: The Measurement Approaches to Partnership Success Case Study.

As part of a 5-year study to develop and validate an instrument for measuring success in long-standing community-based participatory research (CBPR) partnerships, we utilized the Delphi method with a panel of 16 community and academic CBPR experts to assess face and content validity of the instrument's broad concepts of success and measurement items. In addition to incorporating quantitative and qualitative feedback from two online surveys, we included a 2-day face-to-face meeting with the Expert Panel to invite open discussion and diversity of opinion in line with the CBPR principles framing and guiding the study. The face-to-face meeting allowed experts to review the survey data (with maintained anonymity), convey their perspectives, and offer interpretations that were untapped in the online surveys. Using a CBPR approach facilitated a synergistic process that moved above and beyond the consensus achieved in the initial Delphi rounds, to enhance the Delphi technique and the development of items in the instrument.

Dispersion in the hospital network of shared patients is associated with less efficient care.

BACKGROUND: There is growing recognition that health care providers are embedded in networks formed by the movement of patients between providers. However, the structure of such networks and its impact on health care are poorly understood. PURPOSE: We examined the level of dispersion of patient-sharing networks across U.S. hospitals and its association with three measures of care delivered by hospitals that were likely to relate to coordination. METHODOLOGY/APPROACH: We used data derived from 2016 Medicare Fee-for-Service claims to measure the volume of patients that hospitals treated in common. We then calculated a measure of dispersion for each hospital based on how those patients were concentrated in outside hospitals. Using this measure, we created multivariate regression models to estimate the relationship between network dispersion, Medicare spending per beneficiary, readmission rates, and emergency department (ED) throughput rates. RESULTS: In multivariate analysis, we found that hospitals with more dispersed networks (those with many low-volume patient-sharing relationships) had higher spending but not greater readmission rates or slower ED throughput. Among hospitals with fewer resources, greater dispersion related to greater readmission rates and slower ED throughput. Holding an individual hospital's dispersion constant, the level of dispersion of other hospitals in the hospital's network was also related to these outcomes. CONCLUSION: Dispersed interhospital networks pose a challenge to coordination for patients who are treated at multiple hospitals. These findings indicate that the patient-sharing network structure may be an overlooked factor that shapes how health care organizations deliver care. PRACTICE IMPLICATIONS: Hospital leaders and hospital-based clinicians should consider how the structure of relationships with other hospitals influences the coordination of patient care. Effective management of this broad network may lead to important strategic partnerships.

Application of Mixed Methods in Health Services Management Research: A Systematic Review.

Mixed methods research (MMR) is versatile, pragmatic, and adaptable to constraints and opportunities during a research process. Although MMR has gain popularity in health services management research, little is known about how the research approach has been used and the quality of research. We conducted a systematic review of 198 MMR articles published in selected U.S.-based and international health services management journals from 2000 through 2018 to examine the extent of MMR application and scientific rigor. Results showed limited, yet increasing, use of MMR and a high degree of correspondence between MMR designs and study purposes. However, most articles did not clearly justify using MMR designs and the reporting of method details and research integration were inadequate in a significant portion of publications. We propose a checklist to assist the preparation and review of MMR manuscripts. Additional implications and recommendations to improve transparency, rigor, and quality in MMR are discussed.

The Impact of Choosing Wisely Interventions on Low-Value Medical Services: A Systematic Review.

Policy Points Dissemination of Choosing Wisely guidelines alone is unlikely to reduce the use of low-value health services. Interventions by health systems to implement Choosing Wisely guidelines can reduce the use of low-value services. Multicomponent interventions targeting clinicians are currently the most effective types of interventions. CONTEXT: Choosing Wisely aims to reduce the use of unnecessary, low-value medical services through development of recommendations related to service utilization. Despite the creation and dissemination of these recommendations, evidence shows low-value services are still prevalent. This paper synthesizes literature on interventions designed to reduce medical care identified as low value by Choosing Wisely and evaluates which intervention characteristics are most effective. METHODS: We searched peer-reviewed and gray literature from the inception of Choosing Wisely in 2012 through June 2019 to identify interventions in the United States motivated by or using Choosing Wisely recommendations. We also included studies measuring the impact of Choosing Wisely on its own, without interventions. We developed a coding guide and established coding agreement. We coded all included articles for types of services targeted, components of each intervention, results of the intervention, study type, and, where applicable, study quality. We measured the success rate of interventions, using chi-squared tests or Wald tests to compare across interventions. FINDINGS: We reviewed 131 articles. Eighty-eight percent of interventions focused on clinicians only; 48% included multiple components. Compared with dissemination of Choosing Wisely recommendations only, active interventions were more likely to generate intended results (65% vs 13%, p < 0.001) and, among those, interventions with multiple components were more successful than those with one component (77% vs 47%, p = 0.002). The type of services targeted did not matter for success. Clinician-based interventions were more effective than consumer-based, though there is a dearth of studies on consumer-based interventions. Only 17% of studies included a control arm. CONCLUSIONS: Interventions built on the Choosing Wisely recommendations can be effective at changing practice patterns to reduce the use of low-value care. Interventions are more effective when targeting clinicians and using more than one component. There is a need for high-quality studies that include active controls.

What Does "Patient-Centered" Mean? Qualitative Perspectives from Older Adults and Family Caregivers.

This study aimed to (1) examine what patient-centeredness means for older adults and family caregivers, and (2) assess circumstances underlying their preference for geriatric care. We conducted separate focus groups with older adults and family caregivers of older adults about health care experiences and expectations and conducted a vignette-based experiment to assess preference for geriatric care. Participants expressed a need for greater skill and empathy and integration of caregivers. They preferred geriatric care to usual primary care with increasing social, health, and healthcare complexity. Distinct needs of older adults should be considered in referral practices to geriatric medicine.

A retrospective comparison of guidelines to assess hospital-diagnosed urinary tract infection in nursing home residents.

BACKGROUND: Inappropriate antibiotic treatments for urinary tract infection (UTI) in nursing home (NH) residents are common and contribute to antibiotic resistance. Published guidelines aim to improve accurate assessment, diagnosis, and treatment of UTIs. This study assessed whether records from hospitalized NH residents diagnosed with UTI, while comparing the Cooper Tool and Stone criteria, supported appropriate treatment. METHODS: A retrospective chart review was conducted using electronic medical record (EMR) data from residents of 3 NHs who were diagnosed with UTI when hospitalized over a 3-year period. The Cooper Tool and Stone criteria were used to assess treatment appropriateness. RESULTS: Of 79 hospitalized residents treated for UTI, 11 (13.9%) were appropriately treated according to the Cooper Tool and 9 (11.4%) according to Stone. The 2 criteria agreed in 9 of the cases including 100% of those with catheters. Urinalysis was documented in 72% of residents and 24% had documentation of culture and sensitivity. CONCLUSIONS: Appropriate UTI treatment rates using both tools were low but much higher in those with catheters. Future research is necessary to validate the use of these tools in the hospital setting which have the potential to improve treatment accuracy and reduce unnecessary antibiotics use.

Can Collaboration Between Nonprofit Hospitals and Local Health Departments Influence Population Health Investments by Nonprofit Hospitals?

BACKGROUND: The patient protection and Affordable Care Act (ACA) sought to improve population health by requiring nonprofit hospitals (NFPs) to conduct triennial community health needs assessments and address the identified needs. In this context, some states have encouraged collaboration between hospitals and local health department (LHD) to increase the focus of community benefit spending onto population health. OBJECTIVES: The aim was to examine whether a 2012 state law that required NFPs to collaborate with LHDs in local health planning influenced hospital population health improvement spending. RESEARCH DESIGN: We merged Internal Revenue Service data on NFP community benefit spending with data on hospital, county and state-level characteristics and estimated a difference-in-differences specification of hospital population health spending in 2009-2016 that compared the difference between hospitals that were required to collaborate with LHDs to those that were not, before and after the requirement. MEASURES: The primary outcome was population health spending divided by operating expenses. RESULTS: We found that the requirement for hospital-LHD collaboration was associated with increased mean population health spending of ∼$393,000-$786,000 (P=0.03). This association was significant in 2015-2016, perhaps reflecting the lag between assessments and implementation. Urban hospitals were responsible for most of the increased spending. CONCLUSIONS: Policymakers have sought to encourage hospitals to increase their investment in population health; however, overall community benefit spending on population health has remained flat. We found that requiring hospital-LHD collaboration was associated with increased hospital investment in population health. It may be that hospitals increase population health spending because collaboration improves expected effectiveness or increases hospital accountability.

Trends in Regional Supply of Peritoneal Dialysis in an Era of Health Reform, 2006 to 2013.

Peritoneal dialysis (PD), a home-based treatment for kidney failure, is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis. Yet <10% of patients receive PD. Access to this alternative treatment, vis-à-vis providers' supply of PD services, may be an important factor but has been sparsely studied in the current era of national payment reform for dialysis care. We describe temporal and regional variation in PD supply among Medicare-certified dialysis facilities from 2006 to 2013. The average proportion of facilities offering PD per hospital referral region increased from 40% (2006) to 43% (2013). PD supply was highest in hospital referral regions with higher percentage of facilities in urban areas (p = .004), prevalence of PD use (p < .0001), percentage of White end-stage renal disease patients (p = .02), and per capita income (p = .02). Disparities in PD access persist in rural, non-White, and low-income regions. Policy efforts to further increase regional PD supply should focus on these underserved communities.

Targeting Patient and Health System Barriers To Improve Rates of Hemodialysis Initiation with an Arteriovenous Access.

Background: Guidelines recommend pre-emptive creation of arteriovenous (AV) access. However, <20% of US patients initiate hemodialysis (HD) with a functional AV access. We implemented a quality improvement (QI) program to improve pre-HD vascular access care. Methods: After conducting qualitative research with key informants, we implemented a 7-month vascular access support QI program at Geisinger Health. The program targeted patient and health system barriers to AV access through education, needs assessment, peer support, care navigation, and electronic supports. We performed pre-, intra-, and postprogram stakeholder interviews to identify program barriers and facilitators and to assess acceptability. In a research substudy, we compared pre- and postprogram self-efficacy, knowledge, and confidence navigating vascular access care. Results: There were 37 patient and 32 clinician/personnel participants. Of the 37 patients, 34 (92%) completed vascular access-specific education, 33 (89%) underwent needs assessment, eight (22%) engaged with peer mentors, 21 (57%) had vein mapping, 18 (49%) had an initial surgical appointment, 15 (40%) underwent AV access surgery, and six (16%) started HD during the 7-month program. Qualitative findings demonstrated program acceptability to participants and suggested that education provision and emotional barrier identification were important to engaging patients in vascular access care. Research findings showed pre- to postprogram improvements in patient self-efficacy (28.1-30.8, P=0.05) and knowledge (4.9-6.9, P=0.004), and trends toward improvements in confidence among patients (8.0-8.7, P=0.2) and providers (7.5-7.8, P=0.1). Conclusions: Our intervention targeting patient and health system barriers improved patient vascular access knowledge and self-efficacy. Clinical Trial registry name and registration number: Breaking Down Care Process and Patient-level Barriers to Arteriovenous Access Creation Prior to Hemodialysis Initiation, NCT04032613.

Comparing Mortality of Peritoneal and Hemodialysis Patients in an Era of Medicare Payment Reform.

BACKGROUND: Prior studies have shown peritoneal dialysis (PD) patients to have lower or equivalent mortality to patients who receive in-center hemodialysis (HD). Medicare's 2011 bundled dialysis prospective payment system encouraged expansion of home-based PD with unclear impacts on patient outcomes. This paper revisits the comparative risk of mortality between HD and PD among patients with incident end-stage kidney disease initiating dialysis in 2006-2013. RESEARCH DESIGN: We conducted a retrospective cohort study comparing 2-year all-cause mortality among patients with incident end-stage kidney disease initiating dialysis via HD and PD in 2006-2013, using data from the US Renal Data System and Medicare. Analysis was conducted using Cox proportional hazards models fit with inverse probability of treatment weighting that adjusted for measured patient demographic and clinical characteristics and dialysis market characteristics. RESULTS: Of the 449,652 patients starting dialysis between 2006 and 2013, the rate of PD use in the first 90 days increased from 9.3% of incident patients in 2006 to 14.2% in 2013. Crude 2-year mortality was 27.6% for patients dialyzing via HD and 16.7% for patients on PD. In adjusted models, there was no evidence of mortality differences between PD and HD before and after bundled payment (hazard ratio, 0.96; 95% confidence interval, 0.89-1.04; P=0.33). CONCLUSIONS: Overall mortality for HD and PD use was similar and mortality differences between modalities did not change before versus after the 2011 Medicare dialysis bundled payment, suggesting that increased use of home-based PD did not adversely impact patient outcomes.

Exploring How Personal, Social, and Institutional Characteristics Contribute to Geriatric Medicine Subspecialty Decisions: A Qualitative Study of Trainees' Perceptions.

PURPOSE: To explore internal medicine residents' and geriatrics fellows' perceptions of how personal, social, and institutional characteristics contribute to their professional identity and subspecialty decisions related to geriatric medicine. METHOD: The authors conducted 23 in-depth, semistructured interviews with internal medicine residents, with and without an interest in geriatrics, and geriatrics fellows across 3 academic medical centers in the United States from October 2018 through June 2019. They then used a qualitative narrative approach to analyze the interview data. RESULTS: Trainees related personal experiences, such as exposure to physicians and experiences with grandparents, to their interest in medicine. Trainees with an interest in geriatrics at 2 institutions did not feel supported, or understood, by peers and mentors in their respective institutions but maintained their interest in the field. The following variations between institutions that are supportive and those that are not were noted: the number of geriatricians, the proximity of the institution to geriatrics clinics, and the ways in which institutional leaders portrayed the prestige of geriatric medicine. Institutional characteristics influenced trainees' understanding of what it meant to be a doctor, what meaning they garnered from work as a physician, and their comfort with different types of complexity, such as those presented when providing care to older adults. CONCLUSIONS: Institutional characteristics may be particularly important in shaping trainee interest in geriatric medicine. Institutions should encourage leadership training and opportunities for geriatricians so they can serve as role models and as hands-on mentors for trainees beginning in medical school. Increasing the number of geriatricians requires institutions to increase the value they place on geriatrics to generate a positive interest in this field among trainees. Institutions facilitating formation of professional identity and sense of purpose in work may consider engaging geriatricians in leadership and mentoring roles as well as curriculum development.