Marketplace Plans With Narrow Physician Networks Feature Lower Monthly Premiums Than Plans With Larger Networks

Key Findings: Narrow network plans on the health insurance marketplaces allow consumers to trade-off lower premiums for a more restricted choice of providers. This study finds that, all else being equal, an individual consumer is saving 6.7 percent of premiums, or between $212 and$339 a year, on a typical plan

Eliminating Monitor Overuse (EMO) Type III Effectiveness-Deimplementation Cluster-Randomized Trial: Statistical Analysis Plan

Background: Deimplementing overused health interventions is essential to maximizing quality and value while minimizing harm, waste, and inefficiencies. Three national guidelines discourage continuous pulse oximetry (SpO2) monitoring in children who are not receiving supplemental oxygen, but the guideline-discordant practice remains prevalent, making it a prime target for deimplementation. This paper details the statistical analysis plan for the Eliminating Monitor Overuse (EMO) SpO2 trial, which compares the effect of two competing deimplementation strategies (unlearning only vs. unlearning plus substitution) on the sustainment of deimplementation of SpO2 monitoring in children with bronchiolitis who are in room air. Methods: The EMO Trial is a hybrid type 3 effectiveness-deimplementation trial with a longitudinal cluster-randomized design, conducted in Pediatric Research in Inpatient Settings Network hospitals. The primary outcome is deimplementation sustainment, analyzed as a longitudinal difference-in-differences comparison between study arms. This analysis will use generalized hierarchical mixed-effects models for longitudinal clustering outcomes. Secondary outcomes include the length of hospital stay and oxygen supplementation duration, modeled using linear mixed-effects regressions. Using the well-established counterfactual approach, we will also perform a mediation analysis of hospital-level mechanistic measures on the association between the deimplementation strategy and the sustainment outcome. Discussion: We anticipate that the EMO Trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, and likelihood of sustained practice change using rigorously designed deimplementation strategies. This pre-specified statistical analysis plan will mitigate reporting bias and support data-driven approaches

Empirical essays on health care for children and families

textThis dissertation consists of three empirical essays investigating different aspects of health care for children and families. The first essay examines the effectiveness of adherence to American Academy of Pediatrics guidelines for preventive pediatric health care. Using a national longitudinal sample of children age two years and younger, we investigate whether compliance with prescribed periodic well-child care visits has beneficial effects on child health. We find that increased compliance improves child health. In particular, higher compliance lowers future risks of fair or poor health, of some history of a serious illness and of having a health limitation. The second essay examines child health care utilization in relation to maternal labor supply. We test the hypothesis that working-mothers trade off the advantages of greater income against the disadvantages of less time for other valuable tasks, such as seeking health care for their children. This tradeoff may result in positive, negative, or no net impacts on child health investment. We estimate health care demand regressions that include separate variables for mother’s labor supply and her labor income. Our results indicate that higher maternal work hours reduce child health care visits; higher maternal earnings increase them. In addition, wage-employment, as opposed to self-employment, is detrimental to child health investment. A further finding is that preventive care demand for younger children is less sensitive to maternal time and income changes. We also find that detrimental time effects dominate beneficial income effects. The third essay studies intra-household resource allocation as it pertains to its demand for preventive medical care. We test the income-pooling hypothesis of the common preference model by using individual specific medical care consumption data and present evidence on the allocation of household resources to the medical needs of the child, husband and wife. Our results are in line with the findings of previous studies that emphasize the ongoing importance of the traditional gender role of woman as the primary caregiver. We find that the resources of the wife have a greater positive impact on child’s and her own preventive care demand than does the resources of the husband. In contrast to most studies from developing countries, we find that US families do not exhibit differential health care demand based on child gender. It is also noteworthy that the wife’s education level has a greater positive impact than that of her husband does on both the husband’s and her own preventive care utilization.Economic

Costs of autism spectrum disorders in the United Kingdom and the United States

Importance: The economic effect of autism spectrum disorders (ASDs) on individuals with the disorder, their families, and society as a whole is poorly understood and has not been updated in light of recent findings. Objective: To update estimates of age-specific, direct, indirect, and lifetime societal economic costs, including new findings on indirect costs, such as individual and parental productivity costs, associated with ASDs. Design, Setting, and Participants: A literature review was conducted of US and UK studies on individuals with ASDs and their families in October 2013 using the following keywords: age, autism spectrum disorder, prevalence, accommodation, special education, productivity loss, employment, costs, and economics. Current data on prevalence, level of functioning, and place of residence were combined with mean annual costs of services and support, opportunity costs, and productivity losses of individuals with ASDs with or without intellectual disability. Exposure: Presence of ASDs. Main Outcomes and Measures: Mean annual medical, nonmedical, and indirect economic costs and lifetime costs were measured for individuals with ASDs separately for individuals with and without intellectual disability in the United States and the United Kingdom. Results: The cost of supporting an individual with an ASD and intellectual disability during his or her lifespan was $2.4 million in the United States and £1.5 million (US$2.2 million) in the United Kingdom. The cost of supporting an individual with an ASD without intellectual disability was $1.4 million in the United States and £0.92 million (US$1.4 million) in the United Kingdom. The largest cost components for children were special education services and parental productivity loss. During adulthood, residential care or supportive living accommodation and individual productivity loss contributed the highest costs. Medical costs were much higher for adults than for children. Conclusions and Relevance: The substantial direct and indirect economic effect of ASDs emphasizes the need to continue to search for effective interventions that make best use of scarce societal resources. The distribution of economic effect across many different service systems raises questions about coordination of services and sectors. The enormous effect on families also warrants policy attention

Validation of the Developmental Check-In Tool for Low-Literacy Autism Screening.

BACKGROUND: Persistent disparities exist in early identification of autism spectrum disorder (ASD) among children from low-income families who are racial and/or ethnic minorities and where English is not the primary language. Parental literacy and level of maternal education may contribute to disparities. The Developmental Check-In (DCI) is a visually based ASD screening tool created to reduce literacy demands and to be easily administered and scored across settings. In a previous study, the DCI showed acceptable discriminative ability between ASD versus non-ASD in a young, underserved sample at high-risk for ASD. In this study, we tested the DCI among an unselected, general sample of young underserved children. METHODS: Six hundred twenty-four children ages 24 to 60 months were recruited through Head Start and Early Head Start. Parents completed the DCI, Modified Checklist for Autism in Toddlers, Revised with Follow-Up, and Social Communication Questionnaire. Children scoring positive on any measure received evaluation for ASD. Those screening negative on both Modified Checklist for Autism in Toddlers, Revised with Follow-Up and Social Communication Questionnaire were considered non-ASD. RESULTS: Parents were primarily Hispanic, reported high school education or less, and had public or no insurance. The DCI demonstrated good discriminative power (area under the curve = 0.80), performing well across all age groups, genders, levels of maternal education, primary language, and included ethnic and racial groups. Item-level analyses indicated that 24 of 26 DCI items discriminated ASD from non-ASD. CONCLUSIONS: The DCI is a promising ASD screening tool for young, underserved children and may be of particular value in screening for ASD for those with low literacy levels or with limited English proficiency

Cost Offset Associated With Early Start Denver Model for Children With Autism

ObjectiveTo determine the effect of the Early Start Denver Model (ESDM) for treatment of young children with autism on health care service use and costs.MethodWe used data from a randomized trial that tested the efficacy of the ESDM, which is based on developmental and applied behavioral analytic principles and delivered by trained therapists and parents, for 2 years. Parents were interviewed about their children's service use every 6 months from the onset of the intervention to follow-up (age 6 years). The sample for this study consisted of 39 children with autism who participated in the original randomized trial at age 18 to 30 months, and were also assessed at age 6 years. Of this sample, 21 children were in the ESDM group, and 18 children were in the community care (COM) group. Reported services were categorized and costed by applying unit hourly costs. Annualized service use and costs during the intervention and post intervention for the two study arms were compared.ResultsDuring the intervention, children who received the ESDM had average annualized total health-related costs that were higher by about $14,000 than those of children who received community-based treatment. The higher cost of ESDM was partially offset during the intervention period because children in the ESDM group used less applied behavior analysis (ABA)/early intensive behavioral intervention (EIBI) and speech therapy services than children in the comparison group. In the postintervention period, compared with children who had earlier received treatment as usual in community settings, children in the ESDM group used less ABA/EIBI, occupational/physical therapy, and speech therapy services, resulting in significant cost savings in the amount of about$19,000 per year per child.ConclusionCosts associated with ESDM treatment were fully offset within a few years after the intervention because of reductions in other service use and associated costs.Clinical trial registration informationEarly Characteristics of Autism; http://clinicaltrials.gov/; NCT0009415