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Biomedical subjects

José J Escarce

Publications and source records attributed to José J Escarce.

At least 19 recordsLinked to original sources
PubMed2007

Did the Medicare inpatient rehabilitation facility prospective payment system result in changes in relative patient severity and relative resource use?

BACKGROUND: The Centers for Medicare and Medicaid Services implemented a prospective payment system (PPS) in 2002 for care provided by inpatient rehabilitation facilities (IRFs) to Medicare beneficiaries. OBJECTIVE: We sought to examine changes in the composition of Medicare beneficiaries in IRFs by examining the percentages of patients having worse functional or health status than the average for their payment groups (relative severity) and of patients having greater cost or longer length of stay than the average for their payment groups (relative resource use) before versus after IRF PPS; to examine whether observed changes in relative resource use were expected given predicted changes; and to explore whether these effects varied by IRF Medicare volume. METHODS: In an observational study of indicators of Medicare beneficiary relative severity and relative resource use, we studied cases paid for by Medicare during 1999 and 2002 having an acute care stay preceding their IRF stay (n = 363,542 in 1999 and 446,002 in 2002). RESULTS: Similar percentages of cases had longer than expected lengths of stay, greater-than-expected costs per case, and worse-than-expected functional status pre- versus post-IRF PPS. Cases under the IRF PPS had lower predicted probabilities of death 150 days after admission. Although predicted relative resource use remained steady, observed relative resource use decreased after IRF PPS. CONCLUSIONS: IRF patient composition has not changed meaningfully for Medicare beneficiaries, but patients within payment groups are being provided less care, which could be attributable to the IRF PPS, existing trends in decreasing length of stay, or both.

Aged↗
PubMed2006

Consumer decision making in the individual health insurance market.

This paper summarizes the results from a study of consumer decision making in California's individual health insurance market. We conclude that price subsidies will have only modest effects on participation and that efforts to reduce nonprice barriers might be just as effective. We also find that there is substantial pooling in the individual market and that it increases over time because people who become sick can continue coverage without new underwriting. Finally, we show that people prefer more-generous benefits and that it is difficult to induce people in poor health to enroll in high-deductible health plans.

California↗
PubMed2006

Effects of family structure on children's use of ambulatory visits and prescription medications.

OBJECTIVE: To examine the effects of family structure, including number of parents, number of other children, and number and type of other adults, on office visits, emergency room visits, and use of prescription medications by children. DATA SOURCE: The Household Component of the 1996-2001 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: The study consisted of a nationally representative sample of children 0-17 years of age living in single-mother or two-parent families. We used negative binomial regression to model office visits and emergency room visits and logistic regression to model the likelihood of prescription medication use. Our analyses adjusted for demographic and socioeconomic characteristics as well as measures of children's health and parental education and child-rearing experience. DATA COLLECTION/EXTRACTION METHOD: We combined 1996-2001 MEPS Full Year Consolidated Files and Medical Conditions Files. PRINCIPAL FINDINGS: Descriptive data showed that children in single-mother families had fewer office visits than children in two-parent families; however, the effect of number of parents in the family on children's office visits or use of prescription medications was completely explained by other explanatory variables. By contrast, children living in families with many other children had fewer total and physician office visits and a lower likelihood of using a prescription medication than children living in families with no other children even after adjusting for other explanatory variables. Children who lived with other adults in addition to their parents also had fewer office visits and a lower likelihood of using a prescription medication than children who lived only with their parents. CONCLUSIONS: Children living in families with many other children or with other adults use less ambulatory care and prescription medications than their peers. Additional research is needed to determine whether these differences in utilization affect children's health.

Adolescent↗
PubMed2006

Impact of instructional practices on student satisfaction with attendings' teaching in the inpatient component of internal medicine clerkships.

OBJECTIVE: To determine the prevalence and influence of specific attending teaching practices on student evaluations of the quality of attendings' teaching in the inpatient component of Internal Medicine clerkships. DESIGN: Nationwide survey using a simple random sample. SETTING: One hundred and twenty-one allopathic 4-year medical schools in the United States. PARTICIPANTS: A total of 2,250 fourth-year medical students. MEASUREMENTS AND MAIN RESULTS: In the spring of 2002, student satisfaction with the overall quality of teaching by attendings in the inpatient component of Internal Medicine clerkships was measured on a 5-point scale from very satisfied to very dissatisfied (survey response rate, 68.3%). Logistic regression was used to determine the association of specific teaching practices with student evaluations of the quality of their attendings' teaching. Attending physicians' teaching practices such as engaging students in substantive discussions (odds ratio (OR)=3.0), giving spontaneous talks and prepared presentations (OR=1.6 and 1.8), and seeing new patients with the team (OR=1.2) were strongly associated with higher student satisfaction, whereas seeming rushed and eager to finish rounds was associated with lower satisfaction (OR=0.6). CONCLUSION: Findings suggest that student satisfaction with attendings' teaching is high overall but there is room for improvement. Specific teaching behaviors used by attendings affect student satisfaction. These specific behaviors could be taught and modified for use by attendings and clerkship directors to enhance student experiences during clerkships.

Adult↗
PubMed2006

Hospital competition, managed care, and mortality after hospitalization for medical conditions: evidence from three states.

This study assessed the effect of hospital competition and HMO penetration on mortality after hospitalization for six medical conditions in California, New York, and Wisconsin. We used linked hospital-discharge and vital-statistics data to study adults hospitalized for myocardial infarction, hip fracture, stroke, gastrointestinal hemorrhage, congestive heart failure, or diabetes. We estimated logistic regression models with death within 30 days of admission as the dependent variable and hospital competition, HMO penetration, and hospital and patient characteristics as explanatory variables. Higher hospital competition was associated with lower mortality in California and New York but not Wisconsin. Higher HMO penetration was associated with lower mortality in California but higher mortality in New York. These findings suggest that hospitals in highly competitive markets compete on quality even in the absence of mature managed-care markets. The findings also underscore the need to consider geographic effects in studies of market structure and hospital quality.

Economic Competition↗
PubMed2006

Dimensions of the local health care environment and use of care by uninsured children in rural and urban areas.

OBJECTIVE: Despite concerted policy efforts, a sizeable percentage of children lack health insurance coverage. This article examines the impact of the health care safety net and health care market structure on the use of health care by uninsured children. METHODS: We used the Medical Expenditure Panel Survey linked with data from multiple sources to analyze health care utilization among uninsured children. We ran analyses separately for children who lived in rural and urban areas and assessed the effects on utilization of the availability of safety net providers, safety net funding, supply of primary care physicians, health maintenance organization penetration, and the percentage of people who are uninsured, controlling for other factors that influence use. RESULTS: Fewer than half of uninsured children had office-based visits to health care providers during the year, 8% of rural and 10% of urban children visited the emergency department at least once, and just over half of children had medical expenditures or charges during the year. Among uninsured children in rural areas, living closer to a safety net provider and living in an area with a higher supply of primary care physicians were positively associated with higher use and medical expenditures. In urban areas, the supply of primary care physicians and the level of safety net funding were positively associated with uninsured children's medical expenditures, whereas the percentage of the population that was uninsured was negatively associated with use of the emergency department. CONCLUSIONS: Uninsured children had low levels of utilization over a range of different health care provider types and settings. The availability of safety net providers in the local area and the safety net's capacity to serve the uninsured influence access to care among children. Possible measures for ensuring access to health care among uninsured children include increasing the density of safety net providers in rural areas, enhancing funding for the safety net, and policies to increase primary care physician supply.

Adolescent↗
PubMed2005

Predictors of surgery resident satisfaction with teaching by attendings: a national survey.

OBJECTIVE: To identify factors that predict fourth- and fifth-year surgical resident satisfaction of attending teaching quality. SUMMARY BACKGROUND DATA: With the training of surgical residents undergoing major changes, a key issue facing surgical educators is whether high-quality surgeons can still be produced. Innovative techniques (eg, computer simulation surgery) are being developed to substitute partially for conventional teaching methods. However, an aspect of training that cannot be so easily replaced is the faculty-resident interaction. This study investigates resident perceptions of attending teaching quality and the factors associated with this faculty-resident interaction to identify predictors of resident educational satisfaction. METHODS: A national survey of clinical fourth- and fifth-year surgery residents in 125 academically affiliated general surgery training programs was performed. The survey contained 67 questions and addressed demographics, hospital, and service characteristics, as well as surgery, education, and clinical care-related factors. Univariate analyses were performed to describe the characteristics of the sample; multivariate analyses were performed to evaluate the factors associated with resident educational satisfaction. RESULTS: The response rate was 61.5% (n = 756). Average age was 32 years; most were male (79%), white (72%), and married (69%); 42% had children. Ninety-five percent of respondents graduated from U.S. medical schools, and the average debt was $80,307. Of 20 potentially mutable factors, 6 variables had positive associations with resident education satisfaction and 7 had negative associations. Positive factors included the resident being the operating surgeon in major surgeries, substantial citing of evidence-based literature by the attending, attending physicians giving spontaneous or unplanned presentations, increasing the continuity of care, clinical teaching aimed at the chief resident level, and having clinical decisions made together by both the attending and resident. There were 7 negative factors such as overly supervising in surgery, being interrupted so much that teaching was ineffective, and attending physicians being rushed and/or eager to finish rounds. CONCLUSION: This study identifies several factors that were associated with resident educational satisfaction. It offers the perspective of the learners (ie, residents) and, importantly, highlights mutable factors that surgery faculty (and departments) may consider changing to improve surgery resident education and satisfaction. Improving such satisfaction may help to produce a better product.

Adult↗
PubMed2005

How much is postacute care use affected by its availability?

OBJECTIVE: To assess the relative impact of clinical factors versus nonclinical factors-such as postacute care (PAC) supply-in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care. DATA SOURCES AND STUDY SETTING: Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data. STUDY DESIGN: We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements. DATA COLLECTION/EXTRACTION METHODS: A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999. PRINCIPAL FINDINGS: PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there. CONCLUSIONS: We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes-or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes.

Aftercare↗
PubMed2005

Residency work-hours reform. A cost analysis including preventable adverse events.

BACKGROUND: In response to proposed federal legislation, the Accreditation Council for Graduate Medical Education limited resident work-hours in July 2003. The cost may be substantial but, if successful, the reform might lower preventable adverse event costs in hospital and after discharge. OBJECTIVES: This study sought to estimate the reform's net cost in 2001 dollars, and to determine the reduction in preventable adverse events needed to make reform cost neutral from teaching hospital and societal perspectives. DESIGN: Cost analysis using published literature and data. Net costs were determined for 4 reform strategies and over a range of potential effects on preventable adverse events. RESULTS: Nationwide, transferring excess work to task-tailored substitutes (the lowest-level providers appropriate for noneducational tasks) would cost 673 million dollars; mid-level providers would cost 1.1 billion dollars. Reform strategies promoting adverse events would increase net teaching hospital and societal costs as well as mortality. If task-tailored substitutes decrease events by 5.1% or mid-level providers decrease them by 8.5%, reform would be cost neutral for society. Events must fall by 18.5% and 30.9%, respectively, to be cost neutral for teaching hospitals. CONCLUSIONS: Because most preventable adverse event costs occur after discharge, a modest decline (5.1% to 8.5%) in them might make residency work-hours reform cost neutral for society but only a much larger drop (18.5% to 30.9%) would make it cost neutral for teaching hospitals, unless additional funds are allocated. Future research should evaluate which reform approaches prevent adverse events and at what cost.

Health Care Reform↗
PubMed2004

Predictors for medical students entering a general surgery residency: National survey results.

BACKGROUND: The number of general surgery (GS) residency applicants had been decreasing before 2003. This national survey of fourth-year medical students elucidates factors related to the basic surgery clerkship that are associated with the decision to enter a GS residency. METHODS: A national sample of 2250 fourth-year medical students from all 4-year allopathic US medical schools was surveyed in spring 2002. Multivariate analyses were performed to identify mutable predictors for students entering GS. RESULTS: Data from 1531 fourth-year medical students from 121 different medical schools (response rate=68%) showed that 5.6% planned to enter GS. In multivariate analyses, the strongest predictor of entering GS was satisfaction with the quality of attending teaching (odds ratio 2.14, P <.01) in surgery clerkships. Several clerkship factors, such as frequency of call nights and total hours worked., were not as strongly associated with entering GS residency, Subsequent analyses showed that predictors of satisfaction with the quality of attending teaching included intraoperative activities (ie, suturing, cutting, and stapling), having attending-led rounds, and performing a history and physical with an attending. Significant negative predictors of satisfaction included observing or retracting only in surgery. CONCLUSIONS: In this national survey, factors are identified that are significantly associated with students entering a GS residency. Some of these mutable factors may increase the pool of GS residency applicants.

Adult↗
PubMed2004

Sociodemographic differences in use of preventive services by women enrolled in Medicare+Choice plans.

BACKGROUND: We examined the effect of sociodemographic factors on the receipt of mammography, colorectal cancer screening, and influenza vaccinations by women enrolled in two Medicare+Choice health plans. METHODS: Administrative and survey data for 2,698 female health plan members was analyzed using multivariate logistic and ordinal logistic regression to assess the effects of enrollee characteristics on use of preventive services. RESULTS: Age, race and wealth were associated with the receipt of one or more preventive services. Older women were less likely to receive mammograms, wealthier women were more likely to receive mammograms and CRC screening, and Black women were more likely to receive CRC screening but less likely to receive influenza vaccinations. Wealthier women received a greater number of preventive services, other things equal, while older women received fewer preventive services. CONCLUSIONS: Race and wealth continue to be important factors in the receipt of preventive services by elderly women, though not always consistent with historical trends. Medicare+Choice plans should consider strategies to further reduce racial and wealth disparities in the use of preventive services.

Aged↗
PubMed2004

Quantifying income-related inequality in healthcare delivery in the United States.

BACKGROUND: Numerous studies have found that high-income Americans use more medical care than their low-income counterparts, irrespective of medical "need." The methods employed in these studies, however, make it difficult to evaluate differences in the degree of income-related inequality in utilization across population subgroups. In this study, we derive a summary index to quantify income-related inequality in need-adjusted medical care expenditures and report values of the index for adults and children in the United States. METHODS: We used the summary index of income-related inequality in expenditures developed by Wagstaff et al. 1 The source of data for the study was the Household Component of the 1996-1998 Medical Expenditure Panel Survey, which contains person-level data on medical care expenditures, demographic characteristics, household income, and a wide array of health status measures. We used multivariate regression analysis to predict need-adjusted annual medical care expenditures per person by income level and used the predictions to calculate the indices of inequality. Separate indices were calculated for all adults, working-age adults, seniors, and children ages 5 to 17. RESULTS: For all age groups, predicted expenditures per person, adjusted for medical need, generally increased as income rose. The index of inequality for all adults was +0.087 (95% confidence interval, +0.035, +0.139); for working-age adults, +0.099 (+0.046, +0.152); for seniors, +0.147 (+0.059, +0.235); and for children, +0.067 (+0.006, +0.128). CONCLUSIONS: There exists income-related inequality in medical care expenditures in the United States, and it favors the wealthy. The inequality is highest among seniors despite Medicare, intermediate among working-age adults, and lowest among children.

Adolescent↗
PubMed2004

Recent trends and geographic variation in the safety net.

BACKGROUND: Policymakers and researchers are concerned that changes in the healthcare market have stressed and weakened the safety net nationwide. OBJECTIVES: The objectives of this study were to investigate variations in the safety net across communities and over time and to explore the effect of market changes on the safety net. MATERIALS AND METHODS: We examined the safety net in all large urban communities from 1993 to 1998. Data from a variety of sources measure uncompensated hospital care, local government spending for health, admissions to safety net hospitals, visits to outpatient departments of safety net hospitals, visits to community health centers, and demographic and market characteristics of the communities. Descriptive analyses examine trends and community variations. Multivariate methods are used to estimate the effect of market structure and of economic factors on the safety net. RESULTS: The safety net did not erode in urban areas over the study period. There was substantial variation across communities, but the disparity did not increase over time. HMO penetration and hospital competition are not significantly related to variations in the safety net, although demographic and economic factors are. CONCLUSIONS: Local financing capacity is a factor in variations across communities in the safety net. The economic downturn and pressures on state budgets could lead to future problems.

Community Health Planning↗
PubMed2004

Impact of managed care on the treatment, costs, and outcomes of fee-for-service Medicare patients with acute myocardial infarction.

OBJECTIVE: To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients. DATA SOURCES/STUDY SETTING: Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996. STUDY DESIGN: We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics. DATA COLLECTION/EXTRACTION METHODS: We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital. PRINCIPAL FINDINGS: Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets. CONCLUSIONS: The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.

Aged↗
PubMed2004

Updated variable-radius measures of hospital competition.

OBJECTIVE: To calculate variable-radius measures of hospital market size and create measures of competition for hospitals' markets. DATA SOURCES: Discharge abstracts from the 1997 State Inpatient Databases of the Healthcare Cost and Utilization Project (HCUP) linked with the American Hospital Association (AHA) Annual Survey, Area Resource File (ARF), InterStudy Regional Market Analysis database, and Medicare's Prospective Payment System Impact Files. STUDY DESIGN: Hospital radii capturing 75 and 90 percent of hospital admissions regressed against hospital and health care market characteristics and other local area characteristics, where the specification was designed to maximize predictive ability. The number of competing hospitals and the Herfindahl-Hirschman index (HHI) of competition were calculated for each hospital's market. DATA COLLECTION METHODS: Discharge abstracts were used to create actual radii for hospitals in nine states. These data were linked with other data describing hospital, health care market, and other characteristics. PRINCIPAL FINDINGS: We explained 44.7 and 9.6 percent of the variation among urban and rural hospitals, respectively, in radii that capture 90 percent of patients, and slightly less of the variation in radii that capture 75 percent of patients. Population density; number of other hospitals in the local area; and hospital characteristics such as medical school affiliation, percentage of admissions that are Medicaid, case mix, and service offerings are important correlates of a hospital's market size. CONCLUSIONS: Predicted radii and associated competition measures were created (matched to AHA hospital identifiers) for all nonfederal, short-term, general medical/surgical hospitals in the continental United States for which complete data were available in 1997 (N=4,806) and are available from the authors.

Catchment Area, Health↗