Emergency Department Utilization and Capacity

Synthesizes research on who utilizes emergency departments, how often for non-urgent or preventable conditions and why, how cost-sharing affects utilization, and how utilization patterns affect hospital finances, overcrowding, and cost implications

Aiming Higher: Results From a State Scorecard on Health System Performance, 2009

Ranks states on thirty-eight indicators of healthcare access, prevention and treatment, avoidable hospital use and costs, equity, and healthy lives. Examines trends, including eroding adult insurance coverage, poor care coordination, and rising costs

Aiming Higher: Results From a State Scorecard on Health System Performance

Assesses state variation across key dimensions of health system performance -- access, quality, avoidable hospital use and costs, equity, and healthy lives -- and assigns overall state rankings as well as ranks on each dimension

The Impact of State Dependent Coverage Expansions on Young Adult Insurance Status: Further Analysis

Outlines how state initiatives to expand dependent coverage affected young adults' rates of uninsurance and of employer-sponsored coverage. Considers differential time effects and implications for national reform provisions to expand coverage to age 26

Dependent Coverage Expansions: Estimating the Impact of Current State Policies

Presents preliminary findings on common provisions in state regulations of dependent health coverage and discusses the analytic approach to estimating the impact of state policy changes on young adults

Recent trends in hospital market concentration and profitability: the case of New Jersey

Background: The United States (U.S.) and other countries rely on systems of private negotiations between insurance companies and hospitals to set hospital prices. To shed light on the implications of recent trends in hospital market consolidation in the U.S., particularly in New Jersey where not-for-profit hospitals dominate, we examined changes in hospital financial margins in New Jersey during a period of sustained consolidation activities. Methods: We documented trends in hospital market concentration and operating margins for the state overall as well as each of eight hospital market areas (HMAs) from 2010 to 2020 and examined the associations in trends between these measures. Market concentration was measured using the standard Herfindahl-Hirschman Index (HHI). We employed hospital-level ordinary least squares (OLS) regression to examine the relationship between market concentration and operating margins in quadratic models. For robustness, three alternative specifications were considered, controlling for observed hospital characteristics and hospital fixed effects. Sensitivity analyses were conducted to test the impacts of the pandemic, a time lag, and hospital size. Results: We found that hospital markets in New Jersey underwent increasing consolidation during our study period. By 2020, six HMAs, accounting for 71% of the total admissions in the state, were considered “highly concentrated” (HHI >0.25). On average, while there were some increases in operating margins in the earlier years, almost all HMAs exhibited relatively lower levels around 2020. Our regression model revealed that hospital market concentration was positively associated with hospital operating margins, but only at higher levels of concentration—above an HHI threshold level of 0.361. This finding is robust to controls for hospital characteristics, including hospital ownership status, and hospital fixed effects. As effect sizes from the lagged models did not differ much from our main results, it appears that the potential effect of increased concentration on margins occurred without much delay. Conclusions: Our findings demonstrate the need for continued scrutiny of proposed consolidation activity, rigorous enforcement of antitrust regulations, and development of policies by state and federal authorities to monitor and regulate prices and quality of care in markets that are already highly concentrated

Exploring HPV vaccination policy and payer strategies for opportunities to improve uptake in safety-net settings

IntroductionWe explored priorities and perspectives on health policy and payer strategies for improving HPV vaccination rates in safety-net settings in the United States.MethodsWe conducted qualitative interviews with policy and payer representatives in the greater Los Angeles region and state of New Jersey between December 2020 and January 2022. Practice Change Model domains guided data collection, thematic analysis, and interpretation.ResultsFive themes emerged from interviews with 11 policy and 8 payer participants, including: (1) payer representatives not prioritizing HPV vaccination specifically in incentive-driven clinic metrics; (2) policy representatives noting region-specific HPV vaccine policy options; (3) inconsistent motivation across policy/payer groups to improve HPV vaccination; (4) targeting of HPV vaccination in quality improvement initiatives suggested across policy/payer groups; and (5) COVID-19 pandemic viewed as both barrier and opportunity for HPV vaccination improvement across policy/payer groups.DiscussionOur findings indicate opportunities for incorporating policy and payer perspectives into HPV vaccine improvement processes. We identified a need to translate effective policy and payer strategies, such as pay-for-performance programs, to improve HPV vaccination within safety-net settings. COVID-19 vaccination strategies and community efforts create potential policy windows for expanding HPV vaccine awareness and access

Association of genetic variants in complement factor H and factor H-related genes with systemic lupus erythematosus susceptibility

Systemic lupus erythematosus (SLE), a complex polygenic autoimmune disease, is associated with increased complement activation. Variants of genes encoding complement regulator factor H (CFH) and five CFH-related proteins (CFHR1-CFHR5) within the chromosome 1q32 locus linked to SLE, have been associated with multiple human diseases and may contribute to dysregulated complement activation predisposing to SLE. We assessed 60 SNPs covering the CFH-CFHRs region for association with SLE in 15,864 case-control subjects derived from four ethnic groups. Significant allelic associations with SLE were detected in European Americans (EA) and African Americans (AA), which could be attributed to an intronic CFH SNP (rs6677604, in intron 11, Pmeta = 6.6×10-8, OR = 1.18) and an intergenic SNP between CFHR1 and CFHR4 (rs16840639, Pmeta = 2.9×10-7, OR = 1.17) rather than to previously identified disease-associated CFH exonic SNPs, including I62V, Y402H, A474A, and D936E. In addition, allelic association of rs6677604 with SLE was subsequently confirmed in Asians (AS). Haplotype analysis revealed that the underlying causal variant, tagged by rs6677604 and rs16840639, was localized to a ~146 kb block extending from intron 9 of CFH to downstream of CFHR1. Within this block, the deletion of CFHR3 and CFHR1 (CFHR3-1Δ), a likely causal variant measured using multiplex ligation-dependent probe amplification, was tagged by rs6677604 in EA and AS and rs16840639 in AA, respectively. Deduced from genotypic associations of tag SNPs in EA, AA, and AS, homozygous deletion of CFHR3-1Δ (Pmeta = 3.2×10-7, OR = 1.47) conferred a higher risk of SLE than heterozygous deletion (Pmeta = 3.5×10-4, OR = 1.14). These results suggested that the CFHR3-1Δ deletion within the SLE-associated block, but not the previously described exonic SNPs of CFH, might contribute to the development of SLE in EA, AA, and AS, providing new insights into the role of complement regulators in the pathogenesis of SLE

Contribution of copy number variants to schizophrenia from a genome-wide study of 41,321 subjects

Copy number variants (CNVs) have been strongly implicated in the genetic etiology of schizophrenia (SCZ). However, genome-wide investigation of the contribution of CNV to risk has been hampered by limited sample sizes. We sought to address this obstacle by applying a centralized analysis pipeline to a SCZ cohort of 21,094 cases and 20,227 controls. A global enrichment of CNV burden was observed in cases (OR=1.11, P=5.7×10−15), which persisted after excluding loci implicated in previous studies (OR=1.07, P=1.7 ×10−6). CNV burden was enriched for genes associated with synaptic function (OR = 1.68, P = 2.8 ×10−11) and neurobehavioral phenotypes in mouse (OR = 1.18, P= 7.3 ×10−5). Genome-wide significant evidence was obtained for eight loci, including 1q21.1, 2p16.3 (NRXN1), 3q29, 7q11.2, 15q13.3, distal 16p11.2, proximal 16p11.2 and 22q11.2. Suggestive support was found for eight additional candidate susceptibility and protective loci, which consisted predominantly of CNVs mediated by non-allelic homologous recombination