Health Policy

The Influence of Primary Care and Hospital Supply on Ambulatory Care–Sensitive Hospitalizations Among Adults in Brazil, 1999–2007

The Influence of Primary Care and Hospital Supply on Ambulatory Care–Sensitive Hospitalizations Among Adults in Brazil, 1999–2007
American Journal of Public Health: October 2011, Vol. 101, No. 10, pp. 1963-1970. 10.2105/AJPH.2010.198887

Macinko, J., V.B. de Oliveira, M.A. Turci, F.C. Guanais, P.F. Bonolo, and M.F. Lima Costa
10/01/2011

Objectives. We assessed the influence of changes in primary care and hospital supply on rates of ambulatory care–sensitive (ACS) hospitalizations among adults in Brazil.

Methods. We aggregated data on nearly 60 million public sector hospitalizations between 1999 and 2007 to Brazil's 558 microregions. We modeled adult ACS hospitalization rates as a function of area-level socioeconomic factors, health services supply, Family Health Program (FHP) availability, and health needs by using dynamic panel estimation techniques to control for endogenous explanatory variables.

Results. The ACS hospitalization rates declined by more than 5% annually. When we controlled for other factors, FHP availability was associated with lower ACS hospitalization rates, whereas private or nonprofit hospital beds were associated with higher rates. Areas with highest predicted ACS hospitalization rates were those with the highest private or nonprofit hospital bed supply and with low (< 25%) FHP coverage. The lowest predicted rates were seen for areas with high (> 75%) FHP coverage and very few private or nonprofit hospital beds.

Conclusions. These results highlight the contribution of the FHP to improved health system performance and reflect the complexity of the health reform processes under way in Brazil.

Advancing Research Data Infrastructure for Patient-Centered Outcomes Research

Advancing Research Data Infrastructure for Patient-Centered Outcomes Research
JAMA: The Journal of the American Medical Association, 2011. Volume 306 / Issue 11 / September 2011, pp 1254-1255, Published online

Amol Navathe, Carolyn Clancy and Sherry Glied
09/21/2011

Patient-centered outcomes research, which aims to assist clinicians and patients in making informed decisions regarding prevention, diagnosis, and treatment, is essential for improving the delivery of quality health care. Much of patient-centered outcomes research relies on observational and quasi-experimental methods applied to data generated as a byproduct of providing care. While existing data sources have improved, there remain important data-related barriers to rapid, efficient research. Recent changes in the policy environment, coupled with significant technological progress, provide an opportunity to surmount some of these obstacles.

Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services Compared to Other Countries

Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services Compared to Other Countries
Health Affairs, 2011. Volume 30 / Issue 09 / September 2011, pp 1647-1656, Published online

Sherry Glied and Miriam Laugesen
09/08/2011

Higher health care prices in the United States are a key reason that the nation’s health spending is so much higher than that of other countries. Our study compared physicians’ fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. We also compared physicians’ incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of payments per physician and of physician supply in the countries’ national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more for private) than public and private payers paid these physicians’ counterparts in other countries. US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. We conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher US spending, particularly in orthopedics.

Geographic Variations in Health Care Workforce Training in the US: The Case of Registered Nurses (RNs)

Geographic Variations in Health Care Workforce Training in the US: The Case of Registered Nurses (RNs)
Med Care. 2011 Aug;49(8):769-74.

Blustein, Jan.
08/01/2011

Background: In the United States, registered nurses [RNs] are trained through one of three educational pathways: a diploma course; an associate's degree, or a baccalaureate degree in nursing (the BSN). A national consensus has emerged that the proportion of RNs that are baccalaureate-trained should be substantially increased. Yet achieving that goal may be difficult in areas where college graduates are unlikely to reside.


Objectives: To determine whether the level of training of the hospital registered nurse [RN] workforce varies geographically, along with the education of the local general workforce.


Research design: Cross sectional, ecological study.


Subjects: Hospital nurses who participated in the National Sample Survey of Registered Nurses [NSSRN] in 2004 (n = 16,567).


Measures. Registered Nurse training was measured as Diploma, Associates degree, or Baccalaureate degree or above. County-level general workforce quality was assessed as the adult college graduation rate. Counties were divided into US population quartiles, with the highest quartile (Q4) having more than 29.3% college graduates, and the lowest quartile (Q1) having fewer than 16.93% college graduates.


Results: Hospital RNs have a higher level of training in counties where the general population is better
educated. For example, in Q4, 55.2% of hospital RNs are baccalaureate-trained, in Q3, 50.2%; in Q2,45.2%; and in Q1, 34.9% (p < .001 for all pairwise comparisons). The association between RN training and general workforce education is found in cities, towns and rural areas.

Conclusions: Nationwide, there are substantial geographic variations in the training of hospital RNs. Educational segregation (the tendency for educated people to cluster geographically) may make it more difficult to achieve a BSN-rich nursing workforce in some areas of the US. Further work is needed to assess whether educational segregation similarly influences the distribution of other health care professionals, and whether it leads to variations in the local quality of care.

Resetting our priorities in environmental health: An example from the south-north partnership in Lake Chapala, Mexico

Resetting our priorities in environmental health: An example from the south-north partnership in Lake Chapala, Mexico
Environ Res. 2011 Aug;111(6):877-80.

Cifuentes E, Lozano Kasten F, Trasande L, Goldman RH.
08/01/2011

Lake Chapala is a major source of water for crop irrigation and subsistence fishing for a population of 300,000 people in central Mexico. Economic activities have created increasing pollution and pressure on the whole watershed resources. Previous reports of mercury concentrations detected in fish caught in Lake Chapala have raised concerns about health risks to local families who rely on fish for both their livelihood and traditional diet. Our own data has indicated that 27% of women of childbearing age have elevated hair mercury levels, and multivariable analysis indicated that frequent consumption of carp (i.e., once a week or more) was associated with significantly higher hair mercury concentrations. In this paper we describe a range of environmental health research projects. Our main priorities are to build the necessary capacities to identify sources of water pollution, enhance early detection of environmental hazardous exposures, and deliver feasible health protection measures targeting children and pregnant women. Our projects are led by the Children's Environmental Health Specialty Unit nested in the University of Guadalajara, in collaboration with the Department of Environmental Health of Harvard School of Public Health and Department of Pediatrics of the New York School of Medicine. Our partnership focuses on translation of knowledge, building capacity, advocacy and accountability. Communication will be enhanced among women's advocacy coalitions and the Ministries of Environment and Health. We see this initiative as an important pilot program with potential to be strengthened and replicated regionally and internationally.

We All Want It, but We Don't Know What It Is: Toward a Standard of Affordability for Health Insurance Premiums

We All Want It, but We Don't Know What It Is: Toward a Standard of Affordability for Health Insurance Premiums
Journal of Health Politics, Policy and Law, 2011. Volume 36 / Issue 05 / July 2011, pp 829-853, Published online

Peter Muennig, Bhaven Sampat, Nicholas Tilipman, Lawrence D. Brown and Sherry A. Glied
07/22/2011

The 2010 Patient Protection and Affordable Care Act (P.L. 111-148), or ACA, requires that U.S. citizens either purchase health insurance or pay a fine. To offset the financial burden for lower-income households, it also provides subsidies to ensure that health insurance premiums are affordable. However, relatively little work has been done on how such affordability standards should be set. The existing literature on affordability is not grounded in social norms and has methodological and theoretical flaws. To address these issues, we developed a series of hypothetical vignettes in which individual and household sociodemographic characteristics were varied. We then convened a panel of eighteen experts with extensive experience in affordability standards to evaluate the extent to which each vignette character could afford to pay for one of two health insurance plans. The panel varied with respect to political ideology and discipline. We find that there was considerable disagreement about how affordability is defined. There was also disagreement about what might be included in an affordability standard, with substantive debate surrounding whether savings, debt, education, or single parenthood is relevant. There was also substantial variation in experts' assessed affordability scores. Nevertheless, median expert affordability assessments were not far from those of ACA.

The Brazilian Health System: History, Advances, and Challenges

The Brazilian Health System: History, Advances, and Challenges
The Lancet, Vol. 377, no. 9779, pp. 1778-1797. 10.1016/S0140-6736(11)60054-8

Paim, J., C. Travassos, C. Almeida, L. Bahia, and J. Macinko
05/21/2011

Brazil is a country of continental dimensions with widespread regional and social inequalities. In this report, we examine the historical development and components of the Brazilian health system, focusing on the reform process during the past 40 years, including the creation of the Unified Health System. A defining characteristic of the contemporary health sector reform in Brazil is that it was driven by civil society rather than by governments, political parties, or international organisations. The advent of the Unified Health System increased access to health care for a substantial proportion of the Brazilian population, at a time when the system was becoming increasingly privatised. Much is still to be done if universal health care is to be achieved. Over the past 20 years, there have been other advances, including investments in human resources, science and technology, and primary care, and a substantial decentralisation process, widespread social participation, and growing public awareness of a right to health care. If the Brazilian health system is to overcome the challenges with which it is presently faced, strengthened political support is needed so that financing can be restructured and the roles of both the public and private sector can be redefined.

Robotic Surgery Claims on United States Hospital Websites

Robotic Surgery Claims on United States Hospital Websites
Journal for Healthcare Quality, Vol. 33, no. 6, pp. 48-52. DOI: 10.1111/j.1945-1474.2011.00148.x

Jin, L.X., A.M. Ibrahim, N.A. Newman, D.V. Makarov, P.J. Pronovost, and M.A. Makary
05/17/2011

To examine the prevalence and content of robotic surgery information presented on websites of U.S. hospitals. We completed a systematic analysis of 400 randomly selected U.S. hospital websites in June of 2010. Data were collected on the presence and location of robotic surgery information on a hospital's website; use of images or text provided by the manufacturer; use of direct link to manufacturer website; statements of clinical superiority; statements of improved cancer outcome; mention of a comparison group for a statement; citation of supporting data and mention of specific risks. Forty-one percent of hospital websites described robotic surgery. Among these, 37% percent presented robotic surgery on their homepage, 73% used manufacturer-provided stock images or text, and 33% linked to a manufacturer website. Statements of clinical superiority were made on 86% of websites, with 32% describing improved cancer control, and 2% described a reference group. No hospital website mentioned risks. Materials provided by hospitals regarding the surgical robot overestimate benefits, largely ignore risks and are strongly influenced by the manufacturer.

Prediction of patient-specific risk and percentile cohort risk of pathological stage outcome using continuous prostate-specific antigen measurement, clinical stage and biopsy Gleason score

Prediction of patient-specific risk and percentile cohort risk of pathological stage outcome using continuous prostate-specific antigen measurement, clinical stage and biopsy Gleason score
BJU International, Vol. 107, no. 10, pp. 1562-1569. DOI: 10.1111/j.1464-410X.2010.09692.x

Huang, Y., S. Isharwal, A. Haese, F.K.H. Chun,D.V. Makarov, Z. Feng, M. Han, E. Humphreys, J.I. Epstein, A.W. Partin, and R.W. Veltri
05/01/2011

Objectives: To develop a ‘2010 Partin Nomogram’ with total prostate-specific antigen (tPSA) as a continuous biomarker, in light of the fact that the current 2007 Partin Tables restrict the application of tPSA as a non-continuous biomarker by creating ‘groups’ for risk stratification with tPSA levels (ng/mL) of 0–2.5, 2.6–4.0, 4.1–6.0, 6.1–10.0 and >10.0. • To use a ‘predictiveness curve’ to calculate the percentile risk of a patient among the cohort.

Patients and Methods: In all, 5730 and 1646 patients were treated with radical prostatectomy (without neoadjuvant therapy) between 2000 and 2005 at the Johns Hopkins Hospital (JHH) and University Clinic Hamburg-Eppendorf (UCHE), respectively. • Multinomial logistic regression analysis was performed to create a model for predicting the risk of the four non-ordered pathological stages, i.e. organ-confined disease (OC), extraprostatic extension (EPE), and seminal vesicle (SV+) and lymph node (LN+) involvement. • Patient-specific risk was modelled as a function of the B-spline basis of tPSA (with knots at the first, second and third quartiles), clinical stage (T1c, T2a, and T2b/T2c) and biopsy Gleason score (5–6, 3 + 4 = 7, 4 + 3 = 7, 8–10).

Results: The ‘2010 Partin Nomogram’ calculates patient-specific absolute risk for all four pathological outcomes (OC, EPE, SV+, LN+) given a patient’s preoperative clinical stage, tPSA and biopsy Gleason score. • While having similar performance in terms of calibration and discriminatory power, this new model provides a more accurate prediction of patients’ pathological stage than the 2007 Partin Tables model. • The use of ‘predictiveness curves’ has also made it possible to obtain the percentile risk of a patient among the cohort and to gauge the impact of risk thresholds for making decisions regarding radical prostatectomy.

Conclusion: The ‘2010 Partin Nomogram’ using tPSA as a continuous biomarker together with the corresponding ‘predictiveness curve’ will help clinicians and patients to make improved treatment decisions.

A New Formula for Prostate Cancer Lymph Node Risk

A New Formula for Prostate Cancer Lymph Node Risk
International Journal of Radiation Oncology Biology Physics, Vol. 80, no. 1, pp. 69-75. DOI: 10.1016/j.ijrobp.2010.01.068

Yu, J.B. D.V. Makarov, and C. Gross
05/01/2011

Introduction: The successful treatment of prostate cancer depends on the accurate estimation of the risk of regional lymph node (LN) involvement. The Roach formula (RF) has been criticized as overestimating LN risk. A modification of the RF has been attempted by other investigators using simplified adjustment ratios: the Nguyen formula (NF).

Methods and Materials: The National Cancer Institute Surveillance, Epidemiology, and End Results database was investigated for patients treated in 2004 through 2006 for whom at least 10 LN were examined at radical prostatectomy, cT1c or cT2 disease, and prostate-specific antigen (PSA) <26 ng/ml (N = 2,930). The Yale formula (YF) was derived from half of the sample (n = 1,460), and validated in the other half (n = 1,470).

Results: We identified 2,930 patients. Only 4.6% of patients had LN+, and 72.6% had cT1c disease. Gleason (GS) 8–10 histology was found in 14.4% of patients. The YF for prediction of %LN+ risk is [GS – 5] × [PSA/3 + 1.5 × T], where T = 0, 1, and 2 for cT1c, cT2a, and cT2b/cT2c. Within each strata of predicted %LN+ risk, the actual %LN+ was closest to the YF. Using a >15% risk as an indicator of high-risk disease, the YF had increased sensitivity (39.0% vs. 13.6%) compared with the NF, without a significant reduction in specificity (94.9% vs. 98.8%). The NF was overly restrictive of the high-risk group, with only 2% of patients having a >15% risk of LN+ by that formula.

Conclusion: The YF performed better than the RF and NF and was best at differentiating patients at high risk for LN+ disease.

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