The Relationship Between Regional Growth in Neonatal Intensive Care Capacity and Perinatal Risk.

BACKGROUND: The supply of US neonatal intensive care unit (NICU) beds and neonatologists is known to vary markedly across regions, but there have been no investigation of patterns of recent growth (1991-2017) in NICUs in relation to newborn need. OBJECTIVE: The objective of this study was to test the hypothesis that greater growth in NICU capacity occurred in neonatal intensive care regions with higher perinatal risk. RESEARCH DESIGN: A longitudinal ecological analysis with neonatal intensive care regions (n=246) as the units of analysis. Associations were tested using linear regression. SUBJECTS: All US live births ≥400 g in 1991 (n=4,103,528) and 2017 (n=3,849,644). MEASURES: Primary measures of risk were the proportions of low-birth weight and very low-birth weight newborns and mothers who were Black or had low educational attainment. RESULTS: Over 26 years, the numbers of NICU beds and neonatologists per live birth increased 42% and 200%, respectively, with marked variation in growth across regions (interquartile range: 0.3-4.1, beds; neonatologists, 0.4-1.0 per 1000 live births). A weak association of capacity with perinatal risk in 1991 was absent in 2017. There was no meaningful (ie, clinical or policy relevant) association between regional changes in capacity and regions with higher perinatal risk or lower capacity in 1991; higher increases in perinatal risk were not associated with higher capacity growth. CONCLUSION: The lack of association between newborn medical needs and the supply of NICU resources raises questions about the current effectiveness of newborn care at a population level.

Regional Differences in Procedural Care of Hemorrhoid Management in Medicare Patients; Unwarranted Variation in Clinical Practice for a Medical-First Problem.

INTRODUCTION: Hemorrhoid disease is very common problem in the Medicare population. Prior work has shown significant variation in county-level practices of hemorrhoidectomy; however, regional variation of rubber band ligation (RBL) has yet to be assessed. This is important as many different practitioners from different specialties can perform this procedure repeatedly in an office-based setting. We aim to evaluate the variation of RBL and hemorrhoidectomy over a 7-y period. METHODS: Using Medicare part B claims data, we identified all beneficiaries >65 y seen for hemorrhoid disease between 2006 and 2013. Current Procedural Terminology (CPT) codes were used to identify all events for hemorrhoidectomy (46083, 46250, 46255, 46257, 46260, and 46261) or RBL (46221) by hospital referral region (HRR). We determined HRR-level rates of hemorrhoidectomy and RBL per 1000 beneficiaries adjusted for age, sex, and race. We calculated annual coefficients of variation (SD × 100/mean) for hemorrhoidectomy and RBL. RESULTS: 1.2 to 1.3 million fee-for-service Medicare beneficiaries were seen annually for evaluation of hemorrhoid disease. Mean-adjusted annual rates for hemorrhoidectomy by HRRs varied from 4.34 to 63.03 per 1000 beneficiaries. Mean-adjusted rates of RBL by HRRs varied from 7.06 to 163 per 1000 beneficiaries. Annual procedural coefficients of variation over the study period were 41-48 (high) for hemorrhoidectomy and 69-74 (very high) for RBL. CONCLUSIONS: While continued high variation exists for hemorrhoidectomy, there is very high variation for RBL between HRRs in treating hemorrhoid disease among Medicare beneficiaries. There are substantial Medicare expenditures in this high-volume population that are likely unwarranted.

Unwarranted geographic variation in paediatric health care in the United States and Norway.

AIM: We present the four US and Norwegian paediatric and neonatal health atlases and discuss the concept and causes of unwarranted geographic variation in paediatric health care. METHODS: The four atlases analyse data from both publicly owned health registers, registers of insurance claims and quality registers. Healthcare utilisation is counted per recipient in predefined hospital service areas, adjusted for relevant confounders and presented as extremal ratios between the highest and lowest rate. RESULTS: The atlases describe geographic variation in rates for primary health care, hospital admissions, outpatient visits, treatment procedures and diagnostic testing. A difference in extremal ratios from 2 to 4 between health service areas are common, and for some procedures extremal ratios is even higher. CONCLUSION: Variation in healthcare utilisation of the magnitude described in these four atlases cannot be explained by differences in population morbidity or patient preferences and are therefore characterised as unwarranted variation. Individual provider preferences or supply of resources such as hospital beds may explain the observed variation.

Neonatal Intensive Care Utilization and Postdischarge Newborn Outcomes: A Population-based Study of Texas Medicaid Insured Infants.

OBJECTIVE: To test the hypothesis that newborn infants cared for in hospitals with greater utilization of neonatal intensive care experienced fewer postdischarge adverse events. STUDY DESIGN: We developed 3 retrospective population-based cohorts of Texas Medicaid insured singletons born in 2010-2014 (very low birth weight [VLBW n = 11 139], late preterm [n = 57 509], and non-preterm [n = 664 447]) who received care in higher volume hospitals with level III/IV neonatal intensive care units (NICUs). Measures of NICU care were hospital-level risk adjusted NICU admission rates, special care days (days of nonroutine care) per infant, and the percent of intensive (highest billable care code) special care days. The units of analysis were hospitals (n = 80) and the primary outcome was an adverse event, (defined as admission, emergency department visit, or death) within 30 days postdischarge. RESULTS: Higher use of NICU care at a hospital level was not associated with lower postdischarge 30-day adverse event. Infants cared for in hospitals with above vs below median special care day rates experienced slightly higher postdischarge adverse event per 100 infants (VLBW: 14.01 [95% CI 12.74-15.27] vs 11.84 [10.52-13.16], P < .05; late preterm: 7.33 [6.68-7.97] vs 6.28 [5.87-6.69], P < .01; non-preterm: 4.47 [4.17-4.76] vs 3.97 [3.75-4.18], P < .01). Weak positive associations (Pearson correlations of 0.31-0.37, P < .01) were observed for adverse event with special care days; in no instance was a negative association observed between NICU utilization and adverse event. CONCLUSION: Higher utilization of NICU care was not associated with lower rates of short-term events suggesting that there may be opportunities to safely decrease admission rates and length of NICU stays.

Epidemiology of Surgical Procedures, Anesthesia, and Imaging Studies by Gestational Age during the First Year of Life in Medicaid-Insured Infants.

OBJECTIVES: To evaluate the rate of surgical procedures, anesthetic use, and imaging studies by prematurity status for the first year of life we analyzed data for Texas Medicaid-insured newborns. STUDY DESIGN: We developed a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 4 subcohorts: extremely premature, very premature, moderate/late premature, and term. RESULTS: In 1 102 958 infants, surgical procedures per 100 infants were 135.9 for extremely premature, 35.4 for very premature, 15.5 for moderate/late premature, and 6.5 for term. Anesthetic use was 62.0 for extremely premature, 20.8 for very premature, 11.1 for moderate/late premature, and 5.6 for the term subcohort. The most common procedures in the extremely premature were neurosurgery, intubations, and procedures that facilitated caloric intake (gastrostomy tubes and fundoplications). The annual rates for the first year of life for chest radiograph ranged from 15.0 per year for the extremely premature cohort to 0.6 for term infants and for magnetic resonance imaging (MRI) from 0.3 to 0.01. MRI was the most common imaging study with anesthesia support in all maturity levels. MRIs were done in extremely premature without anesthesia in over 90% and in term infants in 57.2%. CONCLUSIONS: Surgical procedures, anesthetic use, and imaging studies in infants are common and more frequent with higher a degree of prematurity while the use of anesthesia is lower in more premature newborns. These findings can provide direction for outcome studies of surgery and anesthesia exposure.

Geographical variation in palliative cancer care in a tax-based healthcare system: drug reimbursement in Denmark.

BACKGROUND: In Denmark, a tax-based universal healthcare setting, drug reimbursement for terminal illness (DRTI) should be equally accessible for all terminally ill patients. Examining DRTI status by regions provides new knowledge on inequality in palliative care provision and associated factors. This study aims to investigate geographical variation in DRTI among terminally ill cancer patients. METHODS: We linked socioeconomic and medical data from 135 819 Danish cancer decedents in the period 2007-15 to regional healthcare characteristics. We analyzed associations between region of residence and DRTI. Prevalence ratios (PR) for DRTI were estimated using generalized linear models adjusted for patient factors (age, gender, comorbidity and socioeconomic profile) and multilevel models adjusted for both patient factors and regional healthcare capacity (patients per general practitioner, numbers of hospital and hospice beds). RESULTS: DRTI allocation differed substantially across Danish regions. Healthcare capacity was associated with DRTI with a higher probability of DRTI among patients living in regions with high compared with low hospice bed supply (PR 1.13, 95% CI 1.10-1.17). Also, the fully adjusted PR of DRTI was 0.94 (95% CI 0.91-0.96) when comparing high with low number of hospital beds. When controlled for both patient and regional healthcare characteristics, the PR for DRTI was 1.17 (95% CI 1.14-1.21) for patients living in the Central Denmark Region compared with the Capital Region. CONCLUSION: DRTI status varied across regions in Denmark. The variation was associated with the distribution of healthcare resources. These findings highlight difficulties in ensuring equal access to palliative care even in a universal healthcare system.

Neonatal Intensive Care Variation in Medicaid-Insured Newborns: A Population-Based Study.

OBJECTIVE: To assess the contribution of maternal and newborn characteristics to variation in neonatal intensive care use across regions and hospitals. STUDY DESIGN: This was a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 2 subcohorts: very low birth weight (VLBW) singletons and late preterm singletons. Crude and risk-adjusted neonatal intensive care unit (NICU) admission rates, intensive and intermediate special care days, and imaging procedures were calculated across Neonatal Intensive Care Regions (n = 21) and hospitals (n = 100). Total Medicaid payments were calculated. RESULTS: Overall, 11.5% of live born, 91.7% of VLBW, and 37.6% of infants born late preterm were admitted to a NICU, receiving an average of 2 days, 58 days, and 5 days of special care with payments per newborn inpatient episode of $5231, $128 075, and $10 837, respectively. There was little variation across regions and hospitals in VLBW NICU admissions but marked variation for NICU admissions in late preterm newborn infants and for special care days and imaging rates in all cohorts. The variation decreased slightly after health risk adjustment. There was moderate substitution of intermediate for intensive care days across hospitals (Pearson r VLBW -0.63 P < .001; late preterm newborn -0.53 P < .001). CONCLUSIONS: Across all risk groups, the variation in NICU use was poorly explained by differences in newborn illness levels and is likely to indicate varying practice styles. Although the "right" rates are uncertain, it is unlikely that all of these use patterns represent effective and efficient care.

Role of Prices, Utilization, and Health in Explaining Texas Medicaid Newborn Care Spending Variation.

BACKGROUND: Newborn care is one of the most frequent types of hospitalization and Medicaid covers over 50% of all births nationwide. However, little is known about regional variation in Medicaid newborn care spending and its drivers. OBJECTIVES: To measure the contribution of market-level prices, utilization, and health risk on regional variation in spending among newborn Medicaid population in Texas. RESEARCH DESIGN AND METHODS: The study used 2014 Texas Medicaid newborn claims and encounters linked to birth and death certificate data. Newborn care spending was defined as Medicaid payments per newborn hospital stay, including hospital transfers, from birth through discharge home or death. Spending was further categorized into inpatient facility and related professional spending. Variation in spending across neonatal intensive care regions was decomposed into price and utilization, accounting for input price and health risk differences. RESULTS: Newborn care spending across Texas regions varied significantly (coefficient of variation, 0.31), with most of the variation attributed to spending on inpatient facility services (91%). Both price (41%) and utilization (27%) played a role in explaining this variation, after adjusting for health status (29%) and input price (4%). Though most regions with the highest spending indexes had high price and utilization indexes, some had high spending driven mostly by high prices and others by high utilization. CONCLUSIONS: Significant regional variations in price, utilization, and health status exist in Medicaid newborn care across Texas in 2014. Disentangling the effect of each driver is important to address spending variation and improve efficiency in newborn care.

Regional Variation in Neonatal Intensive Care Admissions and the Relationship to Bed Supply.

OBJECTIVE: To characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates. STUDY DESIGN: This was a population-based, cross-sectional study. 2013 US birth certificate and 2012 American Hospital Association data were used to assign newborns and NICU beds to neonatal intensive care regions. Descriptive statistics of admission rates were calculated across neonatal intensive care regions. Multilevel logistic regression was used to examine the relationship between bed supply and individual odds of admission, with adjustment for maternal and newborn characteristics. RESULTS: Among 3 304 364 study newborns, the NICU admission rate was 7.2 per 100 births and varied across regions for all birth weight categories. IQRs in admission rates were 84.5-93.2 per 100 births for 500-1499 g, 35.3-46.1 for 1500-2499 g, and 3.5-5.5 for ≥2500 g. Adjusted odds of admission for newborns of very low birth weight were unrelated to regional bed supply; however, newborns ≥2500 g in regions with the highest NICU bed supply were significantly more likely to be admitted to a NICU than those in regions with the lowest (aOR 1.20 [1.03-1.40]). CONCLUSIONS: There is persistent underuse of NICU care for newborns of very low birth weight that is not associated with regional bed supply. Among larger newborns, we find evidence of supply-sensitive care, raising concerns about the potential overuse of expensive and unnecessary care. Rather than improving access to needed care, NICU expansion may instead further deregionalize neonatal care, exacerbating underuse.

Death at no cost? Persons with no health insurance claims in the last year of life in Switzerland.

BACKGROUND: Lack of health insurance claims (HIC) in the last year of life might indicate suboptimal end-of-life care, but reasons for no HIC are not fully understood because information on causes of death is often missing. We investigated association of no HIC with characteristics of individuals and their place of residence. METHODS: We analysed HIC of persons who died between 2008 and 2010, which were obtained from six providers of mandatory Swiss health insurance. We probabilistically linked these persons to death certificates to get cause of death information and analysed data using sex-stratified, multivariable logistic regression. Supplementary analyses looked at selected subgroups of persons according to the primary cause of death. RESULTS: The study population included 113,277 persons (46% males). Among these persons, 1199 (proportion 0.022, 95% CI: 0.021-0.024) males and 803 (0.013, 95% CI: 0.012-0.014) females had no HIC during the last year of life. We found sociodemographic and health differentials in the lack of HIC at the last year of life among these 2002 persons. The likelihood of having no HIC decreased steeply with older age. Those who died of cancer were more likely to have HIC (adjusted odds ratio for males 0.17, 95% CI: 0.13-0.22; females 0.19, 95% CI: 0.12-0.28) whereas those dying of mental and behavioural disorders (AOR males 1.83, 95% CI:1.42-2.37; females 1.65, 95% CI: 1.27-2.14), and males dying of suicide (AOR 2.15, 95% CI: 1.72-2.69) and accidents (AOR 2.41, 95% CI: 1.96-2.97) were more likely to have none. Single, widowed, and divorced persons also were more likely to have no HIC (AORs in range of 1.29-1.80). There was little or no association between the lack of HIC and characteristics of region of residence. Patterns of no HIC differed across main causes of death. Associations with age and civil status differed in particular for persons who died of cancer, suicide, accidents and assaults, and mental and behavioural disorders. CONCLUSIONS: Particular groups might be more likely to not seek care or not report health insurance costs to insurers. Researchers should be aware of this aspect of health insurance data and account for persons who lack HIC.

Medical practice variation: public reporting a first necessary step to spark change.

From previous work, we know that medical practice varies widely, and that unwarranted variation signals low value for patients and society. We also know that public reporting helps to create awareness of the need for quality improvement. Despite the availability of rich data, most Western countries have no routine surveillance of the geographic distribution of utilization, costs, and outcomes of healthcare, including trends in variation over time. This paper highlights the role of transparent public reporting as a necessary first step to spark change and reduce unwarranted variation. Two recent examples of public reporting are presented to illustrate possible ways to reduce unwarranted variation and improve care. We conclude by introducing the Value Improvement Cycle, which underscores that reporting is only a necessary first step, and suggests a path toward developing a multi-stakeholder approach to change.

Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data.

BACKGROUND: Health care spending increases sharply at the end of life. Little is known about variation of cost of end of life care between regions and the drivers of such variation. We studied small-area patterns of cost of care in the last year of life in Switzerland. METHODS: We used mandatory health insurance claims data of individuals who died between 2008 and 2010 to derive cost of care. We used multilevel regression models to estimate differences in costs across 564 regions of place of residence, nested within 71 hospital service areas. We examined to what extent variation was explained by characteristics of individuals and regions, including measures of health care supply. RESULTS: The study population consisted of 113,277 individuals. The mean cost of care during last year of life was 32.5k (thousand) Swiss Francs per person (SD=33.2k). Cost differed substantially between regions after adjustment for patient age, sex, and cause of death. Variance was reduced by 52%-95% when we added individual and regional characteristics, with a strong effect of language region. Measures of supply of care did not show associations with costs. Remaining between and within hospital service area variations were most pronounced for older females and least for younger individuals. CONCLUSIONS: In Switzerland, small-area analysis revealed variation of cost of care during the last year of life according to linguistic regions and unexplained regional differences for older women. Cultural factors contribute to the delivery and utilization of health care during the last months of life and should be considered by policy makers.

Prescription Use among Children with Autism Spectrum Disorders in Northern New England: Intensity and Small Area Variation.

OBJECTIVE: To measure prescription use intensity and regional variation of psychotropic and 2 important nonpsychotropic drug groups among children with autism spectrum disorders (ASDs) compared with children in the general population. STUDY DESIGN: Cross-sectional study of ambulatory prescription fills from Maine, Vermont, and New Hampshire all-payer administrative data, 2007-2010. RESULTS: Overall there were 13,100 children diagnosed with ASD (34,584 person years [PYs]) and 936,721 (1.7 million PYs) without ASD diagnosis. The overall prescription fill rate was 16.6 per PY in children with ASD and 4.1 per PY in the general population. Psychotropic use among children with ASDs was 9-fold the general population rate (7.80 vs 0.85 fills per PY); these children comprised 2.0% of the pediatric population but received 15.6% of psychotropics. Nonpsychotropic drug use was also higher in the population with ASD, particularly the youngest: among those under age 3 years, antibiotic use was 2-fold and antacid use nearly 5-fold the general population rate (3.2 vs 1.4 and 1.0 vs 0.2 per PY, respectively). Among children with ASDs, prescription use varied substantially across hospital service areas, as much as 3-fold for antacids and alpha agonists, more than 4-fold for benzodiazepines (5th to 95th percentile). CONCLUSIONS: The overall psychotropic and nonpsychotropic prescription intensity among children with ASDs is characterized by broad regional variation, suggesting diverse provider responses to pharmacotherapeutic uncertainty. This variation highlights a need for more research, practice-based learning, and shared decision making with caregivers surrounding therapy for children with ASDs.

Variation in Utilization and Need for Tympanostomy Tubes across England and New England.

OBJECTIVES: To compare rates of typmanostomy tube insertions for otitis media with effusion with estimates of need in 2 countries. STUDY DESIGN: This cross-sectional analysis used all-payer claims to calculate rates of tympanostomy tube insertions for insured children ages 2-8 years (2007-2010) across pediatric surgical areas (PSA) for Northern New England (NNE; Maine, Vermont, and New Hampshire) and the English National Health Service Primary Care Trusts (PCT). Rates were compared with expected rates estimated using a Monte Carlo simulation model that integrates clinical guidelines and published probabilities of the incidence and course of otitis media with effusion. RESULTS: Observed rates of tympanostomy tube placement varied >30-fold across English PCT (N = 150) and >3-fold across NNE PSA (N = 30). At a 25 dB hearing threshold, the overall difference in observed to expected tympanostomy tubes provided was -3.41 per 1000 child-years in England and -0.01 per 1000 child-years in NNE. Observed incidence of insertion was less than expected in 143 of 151 PCT, and was higher than expected in one-half of the PSA. Using a 20 dB hearing threshold, there were fewer tube insertions than expected in all but 2 England and 7 NNE areas. There was an inverse relationship between estimated need and observed tube insertion rates. CONCLUSIONS: Regional variations in observed tympanostomy tube insertion rates are unlikely to be due to differences in need and suggest overall underuse in England and both overuse and underuse in NNE.

Amputation Rates for Patients with Diabetes and Peripheral Arterial Disease: The Effects of Race and Region.

BACKGROUND: It remains unknown whether care of high-risk vascular patients with both diabetes and peripheral arterial disease (PAD) is improving. We examined national trends in care of patients with both PAD and diabetes. METHODS: A cohort of patients diagnosed with PAD and diabetes between 2007 and 2011 undergoing open or endovascular diagnostic or revascularization procedures was analyzed using Medicare claims data. Main outcome measure was amputation-free survival measured from time of initial revascularization procedure to 24 months, stratified by race and hospital referral region (HRR). RESULTS: From 2007 to 2011, 2.3 per 1,000 patients underwent a major amputation with the higher rate among black patients (5.5 per 1,000 vs. 1.9 per 1,000; P < 0.001) compared with nonblack. The rate varied widely by HRR (1.2 per 1,000-6.2 per 1,000), with higher variation in amputation rates in black patients (2.1-16.1 per 1,000). Overall, amputation-free survival was approximately 74.6% at 2 years, 68.4% among black patients, and 75.4% among nonblack patients, with the disparity between the 2 groups increasing over time. CONCLUSIONS: Prevalence of concurrent PAD and diabetes is increasing, but amputation rates and amputation-free survival vary significantly by both race and HRR. Prevention and care coordination effort should aim to limit racial disparities in the treatment and outcomes of these high-risk patients.

Dying among older adults in Switzerland: who dies in hospital, who dies in a nursing home?

BACKGROUND: Institutional deaths (hospitals and nursing homes) are an important issue because they are often at odds with patient preference and associated with high healthcare costs. The aim of this study was to examine deaths in institutions and the role of individual, regional, and healthcare supply characteristics in explaining variation across Swiss Hospital Service Areas (HSAs). METHODS: Retrospective study of individuals ≥66 years old who died in a Swiss institution (hospital or nursing homes) in 2010. Using a two-level logistic regression analysis we examined the amount of variation across HSAs adjusting for individual, regional and healthcare supply measures. The outcome was place of death, defined as death in hospital or nursing homes. RESULTS: In 2010, 41,275 individuals ≥66 years old died in a Swiss institution; 54 % in nursing homes and 46 % in hospitals. The probability of dying in hospital decreased with increasing age. The OR was 0.07 (95 % CI: 0.05-0.07) for age 91+ years compared to those 66-70 years. Living in peri-urban areas (OR = 1.06 95 % CI: 1.00-1.11) and French speaking region (OR = 1.43 95 % CI: 1.22-1.65) was associated with higher probability of hospital death. Females had lower probability of death in hospital (OR = 0.54 95 % CI: 0.51-0.56). The density of ambulatory care physicians (OR = 0.81 95 % CI: 0.67-0.97) and nursing homes beds (OR = 0.67 95 % CI: 0.56-0.79) was negatively associated with hospital death. The proportion of dying in hospital varied from 38 % in HSAs with lowest proportion of hospital deaths to 60 % in HSAs with highest proportion of hospital deaths (1.6-fold variation). CONCLUSIONS: We found evidence for variation across regions in Switzerland in dying in hospital versus nursing homes, indicating possible overuse and underuse of end of life (EOL) services.

Improving outcomes for diabetic patients undergoing revascularization for critical limb ischemia: does the quality of outpatient diabetic care matter?

BACKGROUND: Diabetic patients who undergo lower extremity surgical revascularization for critical limb ischemia (CLI) are at high risk for amputation or death, even when their inpatient procedures are successful. We hypothesized that postoperative outcomes might be improved in regions where diabetics with CLI receive more frequent high-quality outpatient care. METHODS: A retrospective cohort study was performed among 172,134 patients with CLI (52% male, 15% black, mean age 76 years) who underwent open and endovascular lower extremity revascularization procedures using Medicare claims (2004-2007), which included 84,653 (49%) beneficiaries who were diabetic. Regional utilization of annual serum cholesterol and hemoglobin A1c testing were used to assess the quality of outpatient diabetic care. We examined relationships between frequency of diabetic testing with amputation-free survival (AFS), major adverse limb events (MALE), and rates of readmission across all US hospital referral regions. RESULTS: There was significant regional variation in annual serum cholesterol and hemoglobin A1c testing across the United States (87% highest quartile vs. 59% lowest quartile, P < 0.01). Compared with the lowest quartile of diabetic testing, diabetic patients undergoing lower extremity revascularization in regions with the highest quartile of diabetic testing had significantly improved AFS (hazards ratio [HR]: 0.94, 95% confidence interval [CI]: 0.90-0.97; P < 0.01) and MALE (HR: 0.92, 95% CI: 0.89-0.96; P < 0.01) persisting up to 2 years after lower extremity revascularization, even after adjusting for procedure type, gender, age, race, and comorbidities. Moreover, the risk of 30-day readmission was significantly reduced in regions with the highest versus lowest quartile of diabetic testing (odds ratio: 0.91, 95% CI: 0.85-0.97; P < 0.01). Nondiabetic patients with CLI, in comparison, did not benefit to the same extent from undergoing revascularization in regions with high-quality outpatient diabetic care. CONCLUSIONS: Diabetic patients undergoing lower extremity revascularization in regions with higher utilization of diabetic care quality measures have significantly better long-term limb salvage and readmission outcomes. Our study underscores the importance of providing optimal outpatient care to diabetics following vascular surgery and outlines a potential strategy for quality improvement in these high-risk patients.

Maternal satisfaction with group care: a systematic review.

OBJECTIVE: This review examined the quantitative relationship between group care and overall maternal satisfaction compared with standard individual care. DATA SOURCES: We searched CINAHL, Clinical Trials, The Cochrane Library, PubMed, Scopus, and Web of Science databases from the beginning of 2003 through June 2023. STUDY ELIGIBILITY CRITERIA: We included studies that reported the association between overall maternal satisfaction and centering-based perinatal care where the control group was standard individual care. We included randomized and observational designs. METHODS: Screening and independent data extraction were carried out by 4 researchers. We extracted data on study characteristics, population, design, intervention characteristics, satisfaction measurement, and outcome. Quality assessment was performed using the Cochrane tools for Clinical Trials (RoB2) and observational studies (ROBINS-I). We summarized the study, intervention, and satisfaction measurement characteristics. We presented the effect estimates of each study descriptively using a forest plot without performing an overall meta-analysis. Meta-analysis could not be performed because of variations in study designs and methods used to measure satisfaction. We presented studies reporting mean values and odds ratios in 2 separate plots. The presentation of studies in forest plots was organized by type of study design. RESULTS: A total of 7685 women participated in the studies included in the review. We found that most studies (ie, 17/20) report higher satisfaction with group care than standard individual care. Some of the noted results are lower satisfaction with group care in both studies in Sweden and 1 of the 2 studies from Canada. Higher satisfaction was present in 14 of 15 studies reporting CenteringPregnancy, Group Antenatal Care (1 study), and Adapted CenteringPregnancy (1 study). Although indicative of higher maternal satisfaction, the results are often based on statistically insignificant effect estimates with wide confidence intervals derived from small sample sizes. CONCLUSION: The evidence confirms higher maternal satisfaction with group care than with standard care. This likely reflects group care methodology, which combines clinical assessment, facilitated health promotion discussion, and community-building opportunities. This evidence will be helpful for the implementation of group care globally.

Rural-urban disparities in health care delivery for children with medical complexity and moderating effects of payer, disability, and community poverty.

PURPOSE: Children with medical complexity (CMC) may be at increased risk of rural-urban disparities in health care delivery given their multifaceted health care needs, but these disparities are poorly understood. This study evaluated rural-urban disparities in health care delivery to CMC and determined whether Medicaid coverage, co-occurring disability, and community poverty modified the effects of rurality on care delivery. METHODS: This retrospective cohort study of 2012-2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire included CMC <18 years. Health care delivery measures (ambulatory clinic visits, emergency department visits, acute care hospitalizations, total hospital days, and receipt of post-acute care) were compared for rural- versus urban-residing CMC in multivariable regression models, following established methods to evaluate effect modification. FINDINGS: Of 112,475 CMC, 7307 (6.5%) were rural residing and 105,168 (93.5%) were urban residing. A total of 68.9% had Medicaid coverage, 33.9% had a disability, and 39.7% lived in communities with >20% child poverty. In adjusted analyses, rural-residing CMC received significantly fewer ambulatory visits (risk ratio [RR] = 0.95, 95% confidence interval [CI]: 0.94-0.96), more emergency visits (RR = 1.12, 95% CI: 1.08-1.16), and fewer hospitalization days (RR = 0.90, 95% CI = 0.85-0.96). The estimated modification effects of rural residence by Medicaid coverage, disability, and community poverty were each statistically significant. Differences in the odds of having a hospitalization and receiving post-acute care did not persist after incorporating sociodemographic and clinical characteristics and interaction effects. CONCLUSIONS: Rural- and urban-residing CMC differed in their receipt of health care, and Medicaid coverage, co-occurring disabilities, and community poverty modified several of these effects. These modifying effects should be considered in clinical and policy initiatives to ensure that such initiatives do not widen rural-urban disparities.

Hospital-Level NICU Capacity, Utilization, and 30-Day Outcomes in Texas.

Importance: Risk-adjusted neonatal intensive care unit (NICU) utilization and outcomes vary markedly across regions and hospitals. The causes of this variation are poorly understood. Objective: To assess the association of hospital-level NICU bed capacity with utilization and outcomes in newborn cohorts with differing levels of health risk. Design, Setting, and Participants: This population-based retrospective cohort study included all Medicaid-insured live births in Texas from 2010 to 2014 using linked vital records and maternal and newborn claims data. Participants were Medicaid-insured singleton live births (LBs) with birth weights of at least 400 g and gestational ages between 22 and 44 weeks. Newborns were grouped into 3 cohorts: very low birth weight (VLBW; <1500 g), late preterm (LPT; 34-36 weeks' gestation), and nonpreterm newborns (NPT; ≥37 weeks' gestation). Data analysis was conducted from January 2022 to October 2023. Exposure: Hospital NICU capacity measured as reported NICU beds/100 LBs, adjusted (ie, allocated) for transfers. Main Outcomes and Measures: NICU admissions and special care days; inpatient mortality and 30-day postdischarge adverse events (ie, mortality, emergency department visit, admission, observation stay). Results: The overall cohort of 874 280 single LBs included 9938 VLBW (5054 [50.9%] female; mean [SD] birth weight, 1028.9 [289.6] g; mean [SD] gestational age, 27.6 [2.6] wk), 63 160 LPT (33 684 [53.3%] female; mean [SD] birth weight, 2664.0 [409.4] g; mean [SD] gestational age, 35.4 [0.8] wk), and 801 182 NPT (407 977 [50.9%] female; mean [SD] birth weight, 3318.7 [383.4] g; mean [SD] gestational age, 38.9 [1.0] wk) LBs. Median (IQR) NICU capacity was 0.84 (0.57-1.30) allocated beds/100 LB/year. For VLBW newborns, NICU capacity was not associated with the risk of NICU admission or number of special care days. For LPT newborns, birth in hospitals with the highest compared with the lowest category of capacity was associated with a 17% higher risk of NICU admission (adjusted risk ratio [aRR], 1.17; 95% CI, 1.01-1.33). For NPT newborns, risk of NICU admission was 55% higher (aRR, 1.55; 95% CI, 1.22-1.97) in the highest- vs the lowest-capacity hospitals. The number of special care days for LPT and NPT newborns was 21% (aRR, 1.21; 95% CI,1.08-1.36) and 37% (aRR, 1.37; 95% CI, 1.08-1.74) higher in the highest vs lowest capacity hospitals, respectively. Among LPT and NPT newborns, NICU capacity was associated with higher inpatient mortality and 30-day postdischarge adverse events. Conclusions and Relevance: In this cohort study of Medicaid-insured newborns in Texas, greater hospital NICU bed supply was associated with increased NICU utilization in newborns born LPT and NPT. Higher capacity was not associated with lower risk of adverse events. These findings raise important questions about how the NICU is used for newborns with lower risk.