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PubMed2006

How did welfare reform affect the health insurance coverage of women and children?

OBJECTIVE: To measure the change in U.S. women and children's health insurance coverage as a result of welfare reform (i.e. the creation of Temporary Assistance for Needy Families or TANF) in 1996. DATA SOURCE: 1992-1999 longitudinal data from the Survey of Income and Program Participation (SIPP) merged with data on the timing of state implementation of welfare reform after 1996. Two key advantages of the SIPP data are that they permit matching type of insurance coverage to the welfare policy environment in each state in each month, and permit controlling for individual-level fixed effects. STUDY DESIGN: We measure how much insurance coverage changed after welfare reform using a difference in differences method that eliminates the influence of time-invariant unobserved individual heterogeneity and of statewide trends in insurance coverage. Models also control for individual, state, and year fixed effects, individual-level characteristics such as education, age, and number of children, plus state-level variables such as real per capita income, real minimum wage, and Medicaid eligibility. DATA COLLECTION/EXTRACTION METHODS: We limit our analysis to the SIPP data specific to the month just completed prior to the interview; as a result, we have up to twelve observations for each individual in the SIPP. This paper uses pooled data from the 1992-1996 panels of the SIPP covering the period 1992-1999. Publicly available state identifiers permit the merger of state policies and macroeconomic variables with the SIPP. PRINCIPAL FINDINGS: TANF implementation is associated with an 8.1 percent increase in the probability that a welfare-eligible woman was uninsured. Welfare reform had less of an impact on the health insurance coverage of children. For example, TANF implementation was associated with a 3.0 percent increase in the probability that a welfare-eligible child lacked health insurance. CONCLUSIONS: An unintended consequence of welfare reform was to adversely impact the health insurance coverage of economically vulnerable women and children, and that this impact was several times larger than the previous literature implies.

Adolescent↗
PubMed1994

Mapping the human genome--friend or foe?

The Human Genome Project represents one of science's most significant advances. It offers to individuals and communities the capacity to make informed and autonomous decisions. However, it also poses fundamental questions which, it is argued, should be in contemplation now. If mechanisms for the resolution of these issues are not in place before the conclusion of the project, and are not available to guide and control its progress, individual privacy may be seriously affected. Employers, insurers and many other groups may seek access to information which would otherwise be confidential to the individual; families may be torn apart by the information held by one member in respect of the collective gene pool of the family unit. The law has a key role to play in encouraging the sensible use of this information, whilst at the same time protecting individuals and their rights.

Confidentiality↗
PubMed2006

The contribution of Medicaid managed care to the increasing undercount of Medicaid beneficiaries in the Current Population Survey.

BACKGROUND: The Current Population Survey (CPS) is an important source of data for comparing beneficiaries across insurance groups. However, the CPS routinely underestimates the Medicaid population, and for unexplained reasons these underestimates have been increasing over time. OBJECTIVE: We sought to determine whether the penetration of Medicaid managed care is associated with the magnitude of the underestimate of Medicaid beneficiaries in the CPS using a pooled cross-sectional comparison of survey and administrative databases on all California Medicaid beneficiaries younger than 65 years of age. MEASURES: We compared the CPS estimates of Medicaid beneficiaries in California from 1995 to 1999 with the gold-standard number derived from the Medicaid eligibility file for the same time period and examined the association between the CPS underestimate and penetration of managed care in the beneficiary's county. RESULTS: The CPS underestimated the Medicaid population by approximately a third. At the county level, errors in estimated numbers of Medicaid beneficiaries in the CPS increased in association with the penetration of Medicaid managed care. Each percentage point increase in the penetration of managed care was associated with an underestimate in the CPS of 0.4 percentage points. CONCLUSION: A substantial portion of the increase in the underestimates of the number of Medicaid beneficiaries in the CPS can be explained by the growth of Medicaid managed care. Steps must be taken to improve the CPS if this survey is to remain useful for making accurate estimates of Americans' health insurance status.

Cross-Sectional Studies↗
PubMed2006

Racial and socioeconomic disparity in perforated appendicitis among children: where is the problem?

OBJECTIVE: Significant racial, ethnic, and socioeconomic disparities have been observed in the rates of perforated appendicitis among children, by using large administrative databases. This study evaluated whether these factors had an impact on the care of patients with appendicitis at a major children's hospital with a well-established, comprehensive, primary referral system. METHODS: A retrospective analysis was performed for all children between the ages of 2 and 20 years who were treated for appendicitis between January 1, 2001, and December 31, 2003. Demographic variables included patient age, gender, race, insurance status, parental educational status, and income level. Coding data were used to identify patients with perforated appendicitis. The use of radiologic imaging was also analyzed. RESULTS: During the 3-year period, 788 patients were treated for appendicitis. The racial distribution (white: 81%; black: 12%; other: 7%) was consistent with the demographic composition of the local population. The overall perforation rate was 25%, and the rate was significantly greater in the age group of <6 years, compared with older children. However, there were no significant differences in the perforation rate with respect to race, insurance status, educational level, or income status. Rates of radiologic imaging use were similar among all racial and socioeconomic groups. CONCLUSIONS: Although racial and socioeconomic disparities in the rates of perforated appendicitis among children have been reported, we found no significant evidence for such inequality at our institution. This may reflect improved access, early diagnosis, and referral by primary care physicians in the community. Pooled national and multiple-state administrative databases have been used to highlight persistent disparities in health care. This study illustrates how single-institution data sources can be used to test a local hypothesis generated by national data, with surprisingly different results.

Acute Disease↗
PubMed2004

[Quality control in coprology].

Quality control in medical laboratories was defined in guidelines for good execution of laboratory analyses issued by the French health authorities in 1994. Application of these guidelines is difficult in coprology because the sample is a complex heterogeneous matrix which varies with disease, surgery, food intake, and treatment. In addition, commercial quality control kits are not available for stool biochemical analyses and a national quality control program has not been established. We thus developed our own fecal quality control technique using pooling lyophylized stool samples. Manual or partially automated methods are used in coprology, leading to a long pre-analysis phase which is not always taken into account in quality control. This implies the need for complementary tools to insure the quality of coprology analyses. For example, semi-quantitative microscopic lipid analysis can be used as an internal standard for a given specimen. Quality assurance also involves a post-analytical phase where results obtained for a given specimen are compared with other available data and interpreted in light of the patient's clinical and therapeutic status. This quality assurance strategy enables accurate reliable results useful for long-term patient management.

Animals↗
PubMed1990

[Study on the vertical transmission of the dengue virus in the South Pacific].

In the course of a dengue outbreak, 765 larvae and 20 pupae were collected in Noumea and in Wallis island around patients premises, to investigate a possible natural infection. On 15 pools made of 335 Aedes aegypti larvae and pupae, 3 appeared to be infected. Dengue virus type 1 was the only serotype identified. Minimum infection rate reached 1: 112. In New Caledonia, the local strains of Aedes aegypti can insure the survival of dengue 1 virus between outbreaks, due to a vertical infection of their progeny.

Aedes↗
PubMed2005

Aortoiliac occlusive disease in patients with known or suspected peripheral vascular disease: safety and efficacy of gadofosveset-enhanced MR angiography--multicenter comparative phase III study.

PURPOSE: To prospectively determine the safety and efficacy of the gadolinium-based blood pool magnetic resonance (MR) imaging contrast agent gadofosveset in patients known to have or suspected of having peripheral vascular disease. MATERIALS AND METHODS: Ethical committee approval and patient written informed consent were obtained. This study was compliant with the Health Insurance Portability and Accountability Act. Adults known or suspected to have peripheral vascular disease received gadofosveset (0.03 mmol per kilogram of body weight) for MR angiography of the aortoiliac region. Gadofosveset-enhanced MR angiography and unenhanced two-dimensional time-of-flight MR angiography were compared with the reference standard, conventional angiography, for the presence of vascular stenosis. All patients were monitored for adverse events with hematologic analysis, analysis of blood chemistry, urinalysis, and electrocardiographic parameters; these methods were analyzed to determine safety. RESULTS: A total of 274 patients were enrolled at 37 centers. Gadofosveset-enhanced MR angiography showed significant improvement (P < .001) compared with unenhanced MR angiography for each of the readers for diagnosis of clinically significant (> or = 50%) stenosis. Specificity and accuracy were significantly greater for three readers, and sensitivity increased significantly for two readers. For all readers, the area under the receiver operator characteristic curve for both quantitative and qualitative measures of significant disease increased (P < .001) for gadofosveset-enhanced MR angiography versus two-dimensional time-of-flight MR angiography. All readers also expressed more confidence in diagnosis (P < .001) and found fewer images to be uninterpretable (0.5% vs 11.0%). The most common adverse events were as follows: feeling hot, 12 (4.4%) patients; nausea, 10 (3.6%) patients; headache, nine (3.3%) patients; and burning sensation, eight (2.9%) patients. Only four serious adverse events were reported, in three patients, and all events were rated as unlikely related to the drug. No patients were excluded because of adverse events or laboratory abnormalities. There were no clinically important trends in the findings of hematologic analysis, blood chemistry, urinalysis, electrocardiography, or physical examination. CONCLUSION: On the basis of substantial improvements over non-contrast MR angiography in efficacy and a minimal and transient side-effect profile, gadofosveset was found to be safe and effective for MR angiography in patients known or suspected to have peripheral vascular disease.

Aged↗
PubMed2005

Household out-of-pocket medical expenditures and National Health Insurance in Taiwan: income and regional inequality.

BACKGROUND: Unequal geographical distribution of medical care resources and insufficient healthcare coverage have been two long-standing problems with Taiwan's public health system. The implementation of National Health Insurance (NHI) attempted to mitigate the inequality in health care use. This study examines the degree to which Taiwan's National Health Insurance (NHI) has reduced out-of-pocket medical expenditures in households in different regions and varying levels of income. METHODS: Data used in this study were drawn from the 1994 and 1996 Surveys of Family Income and Expenditure. We pooled the data from 1994 and 1996 and included a year dummy variable (NHI), equal to 1 if the household data came from 1996 in order to assess the impact of NHI on household out-of-pocket medical care expenditures shortly after its implementation in 1995. RESULTS: An individual who was older, female, married, unemployed, better educated, richer, head of a larger family household, or living in the central and eastern areas was more likely to have greater household out-of-pocket medical expenditures. NHI was found to have effectively reduced household out-of-pocket medical expenditures by 23.08%, particularly for more affluent households. With the implementation of NHI, lower and middle income quintiles had smaller decreases in out-of-pocket medical expenditure. NHI was also found to have reduced household out-of-pocket medical expenditures more for households in eastern Taiwan. CONCLUSION: Although NHI was established to create free medical care for all, further effort is needed to reduce the medical costs for certain disadvantaged groups, particularly the poor and aborigines, if equality is to be achieved.

Adult↗
PubMed1993

Health care coverage and costs in small business: an exploratory study.

Health coverage and health care costs continue to frustrate employers, employees, and public policy makers. Controlling escalating health costs, improving coverage for the uninsured, and providing retiree health care are all important to the small employer. This study was undertaken to investigate the availability and extent of health care coverage and to assess the effects of health care costs on small firms. The results revealed that the percentage of small firms offering health benefits totaled 58 percent. The availability of group health insurance increases as firm size increases. Small employers cited insufficient profits, high insurance costs, and unavailable group coverage as the primary reasons for not offering health benefits. The results also indicated that the vast majority of small firms opposed a mandated employer-provided health coverage and suggested that small businesses should pool together to form groups to reduce the cost of health care coverage for small firms.

Administrative Personnel↗
PubMed1997

Access to Care for Elderly Persons.

Access to appropriate care for elderly persons for cardiovascular diseases is still a major problem for some segments of the population and some geographic regions. The problem of access can be defined in terms of three principle components: 1) lack of personal resources (insurance); 2) inadequate facilities (hospitals, clinics and medical personnel; and 3) inappropriate withholding of care (principally due to ethnic or culturally-based biases). Solutions to these defined problem components can be planned along the same lines and will require pooling of federal, state, and local government resources; education of the lay public; improved professional education; and raising the level of tolerance for substandard practices based upon peer review and the promulgation of standards of practice via guidelines.

Journal Article↗
PubMed1993

Options for long-term care financing reform: a view from the inside out.

The goals for any proposal for long-term care financing reform must include the development of a deliberative, organized and coordinated structure of consistent benefits and service capacity that is accessible to individuals with administrative simplicity and operating certainty for providers. The best way to achieve these program goals is to foster a radical new system that relies on the maximum use of private long-term care insurance. Elimination of the Medicaid program as the primary funding vehicle for long-term care and federalization of all nursing home and home care services will serve as an interim measure until private options are developed and in place. A continued federal role will be needed for maximum risk pooling, standard setting and acting as the stop-loss reinsurer and ultimate safety net for those outside the reach of the private market. Certain interest groups, including the state governors and the advocacy groups on women's issues have unique roles to play in shaping the coming debate. The shifts in thinking and in behavior change needed to commit to such a vision will not be easily achieved. Long-term care is as much about roles, relationships and responsibilities as it is about health, illness, rules or regulations. These inherent and intimate characteristics of long-term care mandate a clear vision of what the system should look like and very deliberate steps to devise and to enact the progressive reforms necessary to meet the coming demand. Reasonable people will differ about the appropriate mix of public and private responsibilities in any system to provide long-term care.(ABSTRACT TRUNCATED AT 250 WORDS)

Female↗
PubMed2005

Performance benchmarks for diagnostic mammography.

PURPOSE: To evaluate a range of performance parameters pertinent to the comprehensive auditing of diagnostic mammography examinations, and to derive performance benchmarks therefrom, by pooling data collected from large numbers of patients and radiologists that are likely to be representative of mammography practice in the United States. MATERIALS AND METHODS: Institutional review board approval was met, informed consent was not required, and this study was Health Insurance Portability and Accountability Act compliant. Six mammography registries contributed data to the Breast Cancer Surveillance Consortium (BCSC), providing patient demographic and clinical information, mammogram interpretation data, and biopsy results from defined population-based catchment areas. The study involved 151 mammography facilities and 646 interpreting radiologists. The study population included women 18 years of age or older who underwent at least one diagnostic mammography examination between 1996 and 2001. Collected data were used to derive mean performance parameter values, including abnormal interpretation rate, positive predictive value (for abnormal interpretation, biopsy recommended, and biopsy performed), cancer diagnosis rate, invasive cancer size, and the percentages of minimal cancers, axillary node-negative invasive cancers, and stage 0 and I cancers. Additional benchmarks were derived for these performance parameters, including 10th, 25th, 50th (median), 75th, and 90th percentile values. RESULTS: The study involved 332,926 diagnostic mammography examinations. Mean performance parameter values were abnormal interpretation rate, 8.0%; positive predictive value for abnormal interpretation, 31.4%; positive predictive value for biopsy recommended, 31.5%; positive predictive value for biopsy performed, 39.5%; cancer diagnosis rate, 25.3 per 1000 examinations; invasive cancer size, 20.2 mm; percentage of minimal cancers, 42.0%; percentage of axillary node-negative invasive cancers, 73.6%; and percentage of stage 0 and I cancers, 62.4%. CONCLUSION: The presented BCSC outcomes data and performance benchmarks may be used by mammography facilities and individual radiologists to evaluate their own performance for diagnostic mammography as determined by means of periodic comprehensive audits.

Adult↗
PubMed2006

The comparative safety of rosuvastatin: a retrospective matched cohort study in over 48,000 initiators of statin therapy.

PURPOSE: The purpose of this study was to compare incidence rates of hospitalization associated with rhabdomyolysis, myopathy, renal, or hepatic dysfunction, and of in-hospital death, between initiators of rosuvastatin and other statins. METHODS: This was a matched cohort study of statin initiators from the administrative database of a large health insurer in the US, during the first 6 months of rosuvastatin availability with up to 18 months of follow-up. All outcome events were verified by medical record review. Incidence rates, risk ratios, and associated 95% confidence intervals were estimated. RESULTS: From an initial pool of 12,217, 11,249 eligible rosuvastatin initiators were matched to 37,282 initiators of other statins. The incidence rate (IR) per 1000 person-years for rhabdomyolysis was 0.10 [0.00, 0.55] for rosuvastatin initiators (n = 1) and 0.06 [0.01, 0.22] for other statin initiators (n = 2), for a hazard ratio (HR) of 1.98 [0.18, 21.90]. The IR for myopathy was 0.20 [0.02, 0.71] for rosuvastatin initiators (n = 2) and 0.00 [0.00, 0.09] for other statin initiators (n = 0). The IR for renal dysfunction was 1.18 [0.61, 2.06] for rosuvastatin initiators (n = 12) and 1.26 [0.91, 1.71] for other statin initiators (n = 42), for a HR of 0.90 [0.47, 1.73]. The IR for hepatic dysfunction was 0.20 (0.02, 0.71) for rosuvastatin initiators (n = 2) and 0.24 (0.10, 0.47) for other statin initiators (n = 8), for a HR of 0.87 (0.18, 4.14). CONCLUSIONS: This study found no difference between rosuvastatin and the other statins in the incidence of hospitalizations associated with renal or hepatic events, or death. The absolute incidence rates of rhabdomyolysis and myopathy were reassuringly low among all statin initiators but remain too small for firm conclusions to be drawn on any difference between the statins.

Adolescent↗
PubMed1993

Nursing home care in 2001.

As we move toward the 21st century, nursing home care will become an increasingly important part of family practice. The number of nursing home residents will grow, their illnesses will become more acute, and the types of medical services provided by nursing homes will broaden. The fiscal difficulty of providing nursing home care will intensify, and a variety of innovative payment programs will be introduced in an attempt to control costs. The only way these will succeed is by a partial reallocation of health care dollars from expensive high-technology hospital care to less expensive low-technology care in nursing homes. As a result of these changes, hospitals will become more involved in the provision of what were traditionally nursing home services. Nursing homes will be used to a larger extent for medical education, and, under congressional pressure, a shrinking pool of federal research dollars will be more fairly allocated to clinical investigation in this setting.

Aged↗
PubMed1997

Is health care really a luxury?

Much of the work which has led to a widely held view that the income elasticity of health care spending exceeds one has been based on international cross-section data, or on pooled cross-sections and time series. In this paper we re-examine this view in the context of long-run equilibrium relationships between non-stationary time series, possibly including autonomous trends. Our results cast doubt upon the usefulness of pooling and upon the notion of an elasticity above one.

Canada↗
PubMed2006

A review of malignancies observed during efalizumab (Raptiva) clinical trials for plaque psoriasis.

BACKGROUND: Psoriasis is a chronic, incurable immune-mediated disease. Most therapies used for moderate to severe psoriasis are immunosuppressive. Agents that depress immune function, including traditional psoriasis therapies, have been associated with an increased incidence of malignancies. Efalizumab is a recombinant monoclonal immunoglobulin G1 (IgG1) antibody approved for use in psoriasis patients. OBJECTIVES: To evaluate the incidence of malignancy in patients receiving efalizumab during clinical trials compared with placebo-treated patients, psoriasis patients from external cohorts and the general US population. METHODS: Patient data were pooled from multiple phase III placebo-controlled, open-label efalizumab clinical trials, and the incidence rate of reported malignancies was calculated as a function of patient years of observation. The results for the efalizumab-treated patients were compared with the data on psoriasis patients from insurance claims databases and a registry of events in the general population. RESULTS: The efalizumab- and placebo-treated patients had similar incidence rates of malignancy, including lymphoproliferative disease, solid tumor, malignant melanoma and nonmelanoma skin cancer. The incidence of nonmelanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma, in patients receiving efalizumab or placebo was elevated relative to the external databases. CONCLUSIONS: These results suggest that efalizumab treatment does not increase a patient's risk for malignancy. The difference observed with nonmelanoma skin cancer may be due to biases introduced by the clinical trial methodology. Additional patient observation is necessary to ascertain whether a link exists between efalizumab therapy and nonmelanoma skin cancer above that normally observed in psoriasis patients.

Antibodies, Monoclonal↗
PubMed1999

Use of cancer screening practices by Hispanic women: analyses by subgroup.

OBJECTIVES: This study compares the use of three cancer screening practices (Pap smear, mammogram, and clinical breast examination) 3 years prior to interview among five subgroups of Hispanic women, and examines whether sociodemographic; access; health behavior, perception, and knowledge; and acculturation factors predict screening practices for any subgroup. METHODS: Descriptive and multiple logistic regression analyses were conducted with data pooled from the 1990 and 1992 National Health Interview Surveys on women who reported that they were Hispanic. The study sample includes 2,391 respondents: 668 Mexican-American, 537 Mexican, 332 Puerto Rican, 143 Cuban, and 711 other Hispanic women. RESULTS: Subgroup profiles reveal differences in education, health insurance, use of English language, and screening use. Mexican women were the least likely to be screened with any procedure. Logistic regression results for each screening practice show that having a usual source of care was a positive predictor for obtaining each of the three screening practices within the last 3 years. Being married, being more than 50 years of age, and having knowledge of breast self-examination were all predictors of having a Pap smear. Having health insurance and ever having had a clinical breast examination and Pap smear were predictors of having a mammography, while age, knowledge of breast self-examination, ever having had a Pap smear and mammogram, and being a nonsmoker all predicted having a clinical breast examination. CONCLUSIONS: We conclude that access factors and prior screening are more strongly associated with current screening than are language and ethnic factors. Our data confirm that a disproportionate percentage of Hispanic women are low income and at risk of being underscreened. Our findings from a nationally representative sample of Hispanics have implications for provider practices, ethnic-specific community interventions, and future development of measures and data collection approaches.

Acculturation↗