Adoption of Health System Innovations: Evidence of Urban-Rural Disparities from the Ohio Primary Care Marketplace.

BACKGROUND: Accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and the meaningful use of electronic health records (EHRs) generated particular attention during the last decade. Translating these reforms into meaningful increases in population health depends on improving the quality and clinical integration of primary care providers (PCPs). However, if these innovations spread more quickly among PCPs in urban and wealthier areas, then they could potentially worsen existing geographic disparities in health outcomes. OBJECTIVE: To determine the market penetration of Medicare Shared Savings Program (MSSP) ACOs, PCMHs, and the meaningful use of EHRs among PCPs across urban and rural counties in Ohio. DESIGN: Retrospective, observational study of the percent of PCPs in a county who are affiliated with PCMH, ACO, and meaningful use (MU) of EHR. PARTICIPANTS: PCPs in all of Ohio's 88 counties from 2011 to 2015. MAIN MEASURES: Primary care market penetration of ACO, PCMH, and meaningful use of EHR KEY RESULTS: In 2015, the Ohio primary care market penetration of PCMH was 23.4%, ACO was 27.7%, MU stage 1 was 55.8%, and MU stage 2 was 26.6%. During the study period, PCMH and ACO market penetration increased faster in urban counties relative to rural counties, and market penetration of meaningful use of EHR increased faster in rural counties. CONCLUSIONS: Market penetration of PCMH and ACOs increased faster in urban markets compared to rural markets. However, the adoption of EHRs increased faster in rural markets. The results are a cause for optimism as well as a call to action: although recent efforts to increase PCMH and ACO adoption were less effective among the rural population in Ohio, federal programs to accelerate adoption of EHRs were overwhelmingly successful in rural areas.

Optimal Omeprazole Dosing and Symptom Control: A Randomized Controlled Trial (OSCAR Trial).

BACKGROUND: Proton pump inhibitors (PPIs) are potent inhibitors of acid secretion and are the mainstay of therapy for gastroesophageal reflux disease (GERD). Initially designed to be taken 30 min before the first daily meal, these agents are commonly used suboptimally, which adversely affects symptom relief. No study to date has assessed whether correcting dosing regimens would improve symptom control. The objective of this study was to determine whether patients with persistent GERD symptoms on suboptimal omeprazole dosing experience symptomatic improvement when randomized to commonly recommended dosing regimen and to evaluate the economic impact of suboptimal PPI dosing in GERD patients. METHODS: Patients with persistent heartburn symptoms ≥ 3 times per week treated with omeprazole 20 mg daily were enrolled and randomized to commonly recommended dosing or continued suboptimal dosing of omeprazole. The primary outcomes were changes in symptom, frequency, and severity, as determined using the Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) 4 weeks after the intervention was administered. In secondary analysis, an alternative measure of symptom load was used to infer potential costs. RESULTS: Sixty-four patients were enrolled. GSAS symptom, frequency, and severity scores were significantly better when dosing was optimized for overall and heartburn-specific symptoms (P < 0.01 for all parameters). Cost savings resulting from reduced medical care and workplace absenteeism were estimated to be $159.60 per treated patient, with cost savings potentially exceeding $4 billion annually in the USA. DISCUSSION: Low-cost efforts to promote commonly recommended PPI dosing can dramatically reduce GERD symptoms and related economic costs. ClinicalTrials.gov, number: NCT02623816.

Effects of neighborhood characteristics on the mortality of black male youth: evidence from Gautreaux, Chicago.

We estimate the effect of neighborhood characteristics on the mortality of poor black male youth in families relocated through the Gautreaux Assisted Housing Program, a residential mobility program implemented in Chicago, USA in 1976. Within our sample (N=2850), 52 post-placement deaths were observed, the majority of which (30) were homicides. All-cause and homicide mortality rates were substantially lower among those relocating to Census tracts with higher fractions of residents with college degrees, which suggests that relocating to more-advantaged neighborhoods can ameliorate the mortality risks faced by this population. The estimated effect declines over the post-placement period, a result consistent with evidence that Gautreaux families routinely relocated following their initial placement. A causal interpretation of these findings is undermined somewhat by evidence of neighborhood selection, though the mortality effect estimate is very robust to inclusion of covariates predictive of placement tract characteristics. Mortality effect estimates relating to Census tract measures of socioeconomic deprivation other than education were weaker in magnitude and generally insignificant, suggesting that neighborhood levels of human capital more strongly affect the mortality risks faced by this population than racial composition or neighborhood poverty.

Association Of A Regional Health Improvement Collaborative With Ambulatory Care-Sensitive Hospitalizations.

Although regional health improvement collaboratives have been adopted nationwide to improve primary care quality, their effects on avoidable hospitalizations and costs remain unclear. We quantified the association of the Better Health Partnership, a primary care-led regional health improvement collaborative operating in Cuyahoga County, Ohio (Cleveland and surrounding suburbs), with hospitalization rates for ambulatory care-sensitive conditions. The partnership uses a positive deviance approach to identify, disseminate publicly, and accelerate adoption of best practices for care of patients with diabetes, heart failure, and hypertension. Using a difference-in-differences approach, we compared rates of hospitalizations for ambulatory care-sensitive conditions in six Ohio counties before (2003-08) and after (2009-14) the establishment of the partnership. Age- and sex-adjusted hospitalization rates for targeted ambulatory care-sensitive conditions in Cuyahoga County declined significantly more than the rates in the comparator counties in 2009-11 (106 fewer hospitalizations per 100,000 adult residents) and 2012-14 (91 fewer hospitalizations). We estimated that 5,746 hospitalizations for ambulatory care-sensitive conditions were averted in 2009-14, leading to cost savings of nearly $40 million.

Medical cost savings associated with 17 alpha-hydroxyprogesterone caproate.

OBJECTIVE: This study was undertaken to assess the impact of 17 alpha hydroxyprogesterone caproate treatment on future medical costs for expectant mothers with a prior spontaneous preterm birth. STUDY DESIGN: Data on the costs of preterm birth were combined with published data on the effectiveness of 17 alpha hydroxyprogesterone caproate to produce estimates of the effect of treatment on expected future direct medical costs. These estimates were compared with an estimate of the cost of a typical 17 alpha hydroxyprogesterone caproate treatment regimen to estimate the net savings per treated woman. RESULTS: Treatment is estimated to reduce initial neonatal hospitalization costs by 3800 dollars per woman treated with 17 alpha hydroxyprogesterone caproate. Expected lifetime medical costs (discounted) of treated infants are estimated to decline 15,900 dollars. CONCLUSIONS: Treating expectant mothers with a prior spontaneous preterm birth with 17 alpha hydroxyprogesterone caproate generates future medical cost savings that substantially exceed the cost of treatment. If this population were universally treated with 17 alpha hydroxyprogesterone caproate, discounted lifetime medical costs of their offspring could be reduced by more than 2.0 billion dollars annually.

Overcoming bias in estimating the volume-outcome relationship.

OBJECTIVE: To examine the effect of hospital volume on 30-day mortality for patients with congestive heart failure (CHF) using administrative and clinical data in conventional regression and instrumental variables (IV) estimation models. DATA SOURCES: The primary data consisted of longitudinal information on comorbid conditions, vital signs, clinical status, and laboratory test results for 21,555 Medicare-insured patients aged 65 years and older hospitalized for CHF in northeast Ohio in 1991-1997. STUDY DESIGN: The patient was the primary unit of analysis. We fit a linear probability model to the data to assess the effects of hospital volume on patient mortality within 30 days of admission. Both administrative and clinical data elements were included for risk adjustment. Linear distances between patients and hospitals were used to construct the instrument, which was then used to assess the endogeneity of hospital volume. PRINCIPAL FINDINGS: When only administrative data elements were included in the risk adjustment model, the estimated volume-outcome effect was statistically significant (p=.029) but small in magnitude. The estimate was markedly attenuated in magnitude and statistical significance when clinical data were added to the model as risk adjusters (p=.39). IV estimation shifted the estimate in a direction consistent with selective referral, but we were unable to reject the consistency of the linear probability estimates. CONCLUSIONS: Use of only administrative data for volume-outcomes research may generate spurious findings. The IV analysis further suggests that conventional estimates of the volume-outcome relationship may be contaminated by selective referral effects. Taken together, our results suggest that efforts to concentrate hospital-based CHF care in high-volume hospitals may not reduce mortality among elderly patients.

Divorced fathers' proximity and children's long-run outcomes: evidence from Norwegian registry data.

This study examines the link between divorced nonresident fathers' proximity and children's long-run outcomes, using high-quality data from Norwegian population registers. We follow (from birth to young adulthood) each of 15,992 children born into married households in Norway in the years 1975-1979 whose parents divorced during his or her childhood. We observe the proximity of the child to his or her father in each year following the divorce and link proximity to educational and economic outcomes for the child in young adulthood, controlling for a wide range of observable characteristics of the parents and the child. Our results show that closer proximity to the father following a divorce has, on average, a modest negative association with offspring's outcomes in young adulthood. The negative associations are stronger among children of highly educated fathers. Complementary Norwegian survey data show that highly educated fathers report more post-divorce conflict with their ex-wives as well as more contact with their children (measured in terms of the number of nights that the child spends at the father's house). Consequently, the father's relocation to a more distant location following the divorce may shelter the child from disruptions in the structure of the child's life as they split time between households and/or from post-divorce interparental conflict.

Redirecting patients to improve stroke outcomes: implications of a volume-based approach in one urban market.

BACKGROUND: The designation of primary stroke centers may result in patients being redirected from their usual source of care, although there is little evidence that these centers would result in better outcomes or lower costs. An alternative approach could direct patients to hospitals treating greater volumes of stroke patients. OBJECTIVES: We sought to estimate the effect of hospital stroke volume on patient mortality and costs in a regional hospital market and to analyze the implications of hypothetical volume-based referral policies in that market, including the effects of patient-hospital distance. METHODS: Using a retrospective cohort, we studied 12,150 Medicare patients admitted for acute stroke to 1 of 29 hospitals in Greater Cleveland during a 7-year period. The primary outcome was risk-adjusted 30-day mortality. Secondary outcomes included log hospital costs and discharge destination. The primary measure of volume was average annual number of stroke patients; patient distance to the nearest hospital was approximated using patient zip code and hospital address data. RESULTS: Overall 30-day mortality was 14.9%. For each 100-patient increase in hospitals' annual stroke volume, risk-adjusted mortality declined 0.9 percentage points (odds ratio = 0.90; 95% confidence interval = 0.82-0.98; P < 0.02) with no significant difference in hospital costs. For each 1-mile increase in patient distance to nearest hospital, mortality increased 0.6 percentage points (odds ratio = 1.07; 95% confidence interval = 1.03-1.11; P < 0.01). Only 3 of 29 hospitals (10.3%) exceeded the highest plausible threshold (250 strokes/year), redirecting 81.4% of patients for a net reduction in mortality of 0.4%; lower thresholds would redirect fewer patients but have negligible effects on mortality. CONCLUSIONS: Our findings fail to support redirecting acute stroke patients based on hospital stroke volume.