Medicaid Benefit Generosity and Labor Market Outcomes: Evidence from Medicaid Adult Vision Benefits

Previous work suggests that Medicaid eligibility expansions may lead to declines in labor market activity. This paper explores the related, but novel question of whether variation in Medicaid benefit generosity alters employment outcomes. We consider adult vision benefits as a case study. Our findings suggest that vision benefits have a net positive effect on intensive margin measures including hours worked and occupational skill requirements, but no significant effect on the likelihood of being employed. These results indicate that Medicaid’s effect on labor market activity is sensitive to the set of covered services

Use of the integrated health interview series: trends in medical provider utilization (1972-2008)

The Integrated Health Interview Series (IHIS) is a public data repository that harmonizes four decades of the National Health Interview Survey (NHIS). The NHIS is the premier source of information on the health of the U.S. population. Since 1957 the survey has collected information on health behaviors, health conditions, and health care access. The long running time series of the NHIS is a powerful tool for health research. However, efforts to fully utilize its time span are obstructed by difficult documentation, unstable variable and coding definitions, and non-ignorable sample re-designs. To overcome these hurdles the IHIS, a freely available and web-accessible resource, provides harmonized NHIS data from 1969-2010. This paper describes the challenges of working with the NHIS and how the IHIS reduces such burdens. To demonstrate one potential use of the IHIS we examine utilization patterns in the U.S. from 1972-2008

Evaluation of emergency department performance:A systematic review on recommended performance and quality-in-care measures

BACKGROUND: Evaluation of emergency department (ED) performance remains a difficult task due to the lack of consensus on performance measures that reflects high quality, efficiency, and sustainability. AIM: To describe, map, and critically evaluate which performance measures that the published literature regard as being most relevant in assessing overall ED performance. METHODS: Following the PRISMA guidelines, a systematic literature review of review articles reporting accentuated ED performance measures was conducted in the databases of PubMed, Cochrane Library, and Web of Science. Study eligibility criteria includes: 1) the main purpose was to discuss, analyse, or promote performance measures best reflecting ED performance, 2) the article was a review article, and 3) the article reported macro-level performance measures, thus reflecting an overall departmental performance level. RESULTS: A number of articles addresses this study’s objective (n = 14 of 46 unique hits). Time intervals and patient-related measures were dominant in the identified performance measures in review articles from US, UK, Sweden and Canada. Length of stay (LOS), time between patient arrival to initial clinical assessment, and time between patient arrivals to admission were highlighted by the majority of articles. Concurrently, “patients left without being seen” (LWBS), unplanned re-attendance within a maximum of 72 hours, mortality/morbidity, and number of unintended incidents were the most highlighted performance measures that related directly to the patient. Performance measures related to employees were only stated in two of the 14 included articles. CONCLUSIONS: A total of 55 ED performance measures were identified. ED time intervals were the most recommended performance measures followed by patient centeredness and safety performance measures. ED employee related performance measures were rarely mentioned in the investigated literature. The study’s results allow for advancement towards improved performance measurement and standardised assessment across EDs

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.

The effect of contraceptive access reform on privately insured patients: Evidence from Delaware Contraceptive Access Now.

BackgroundMany states are implementing comprehensive programs aimed at reducing persistent barriers to contraceptive care. Evidence on the effectiveness of these programs is essential for practice improvement and policy development.ObjectiveTo evaluate changes in the probability of initiating a contraceptive method by women with employer sponsored insurance after implementation of Delaware Contraceptive Access Now (DelCAN), a statewide initiative that aimed to increase access to long-acting reversible contraceptives (LARCs).Design, setting, and participantsWe used a difference-in-differences design to examine contraceptive initiation rates. Data came from IBM Marketscan and covered women age 15-44 enrolled in employer sponsored insurance. The primary outcome was insertion of a LARC, both in the overall study population and in the immediate postpartum (IPP) setting. Secondary analysis examined changes to other contraceptive method types.ResultsThe cohort of 4,550,459 enrollees generated a sample of 11,888,837 person-years and 615,670 childbirth hospitalizations. Difference-in-differences estimates suggested that DelCAN was associated with a 0.3 percentage point (95% CI [0.2, 0.5], pConclusionsA comprehensive statewide program was associated with increased LARC insertion rates among enrollees with employer sponsored insurance. Understanding the effect of these programs is critical for on-going policy development for states engaged in contraceptive access reform

Association of Comorbid Substance Use Disorders and PTSD on Later Symptom Severity, Functioning, and Economic Outcomes among Veterans Applying for Department of Veterans Affairs PTSD Disability Benefits: A Retrospective Cohort Study

Background: Posttraumatic stress disorder (PTSD) that is comorbid with substance use disorders (SUDs) has been associated with poorer mental health outcomes compared to when SUD is not present. Objectives: To identify the prevalence of SUDs in Veterans who have applied for PTSD disability benefits and, within this subgroup, examine the effect of a SUD diagnosis on PTSD symptom severity, functioning, and economic outcomes approximately 2 years later. Method: Retrospective, gender-stratified cohort study of 4,918 representatively sampled Veterans who applied for Department of Veterans’ Affairs (VA) PTSD disability benefits between 1994 and 1998. We used medical administrative data to determine if a SUD diagnosis was present when Veterans’ disability claims were adjudicated. PTSD symptom severity; work, role, and social functioning; physical functioning; working for pay; and low income were assessed by mailed survey approximately 2 years later. Results: 3,337 (68%) Veterans returned surveys. Among respondents, men were more likely than women to have any SUD diagnosis at the time of their claims’ adjudication (25.6% v. 17.6%, p < 0.001). Regardless of gender, Veterans with a SUD diagnosis had clinically meaningful and statistically significantly severer PTSD symptoms and poorer functioning approximately 2 years after their claim was adjudicated than did Veterans without SUD (ps < 0.001). Work, role, and social functioning was also statistically significantly worse for men and women with a SUD diagnosis (ps < 0.001). In terms of economic outcomes, men and women with a SUD diagnosis at the time their claim was adjudicated were 50-60% less likely to report working for pay two years later and 40%-100% more likely to report low income compared to respondents without a SUD diagnosis (ps < 0.001). Conclusions: Although a substantial fraction of respondents were diagnosed with a SUD at the time their claim was adjudicated, the proportion of men with a SUD was similar to that reported for other clinical samples with PTSD; it was actually lower among the women compared to other clinical samples. A SUD diagnosis was a poor prognostic factor for the Veterans in this sample, associated with severer PTSD, poorer functioning, and poorer economic outcomes