Jan Blustein

Professor of Health Policy and Medicine

The Puck Building
295 Lafayette Street
Room 3042
New York, NY 10012
12:00 - 12:45 PM Weds || or after EIPR || or by arrangement
Jan Blustein

Jan Blustein, Professor of Health Policy and Medicine, teaches courses in statistics, program evaluation, and research methods at the Wagner School. Health service equity and public health are some of her longstanding interests. Her work has been published in New England Journal of Medicine, JAMA, British Medical Journal, Health Affairs, and other leading journals.  

Professor Blustein’s newest research focuses on hearing loss and its consequences for health and quality of life for older Americans. That work spans clinical, epidemiologic, and policy dimensions.  She recently co-authored an article on policies and practices to lower the cost of hearing aids and increase hearing aid use that appeared in the American Journal of Public Health.  A companion piece on the topic appeared in The Washington Post.   Another line of work explores the impact of hearing loss on medical care, focussing on disruptions in doctor-patient communication.  Recent publications on this topic have appeared in the Journal of the American Geriatrics Society, the BMJ (British Medical Journal), and the Journal of the American Medical Directors Association (JAMDA) -- links to this work appear to the right.

Professor Blustein is involved in hearing loss advocacy, and serves on the board of the Hearing Loss Association of America.   She holds an MD degree from the Yale School of Medicine, and a Ph.D. from NYU Wagner.

This course introduces students to basic statistical methods and their application to management, policy, and financial decision-making. The course covers the essential elements of descriptive statistics, univariate and bivariate statistical inference, and introduces multivariate analysis. In addition to covering statistical theory the course emphasizes applied statistics and data analysis, using the software package, SPSS.

The course has several "audiences" and goals. For all Wagner students, the course develops basic skills and encourages a critical approach to reviewing statistical findings and using statistical reasoning in decision making. For those planning to continue studying statistics (often those in policy and finance concentrations) this course additionally provides the foundation for that further work.

Download Syllabus

This advanced course develops a set of analytic skills that are used by some policy analysts. It focuses on impact analysis. The goals of the course are to (a) extend familiarity with methodologic issues, including various study designs, measurement problems, and analytic approaches; (b) provide hands-on experience in management, analysis, and presentation of data; and (c) develop skills in reading, critiquing, and reporting on policy-relevant impact analyses written by others. The emphasis of the course is on learning by doing, through data analysis, data presentation, and study critiquing activities. Students work on developing the ability to convey findings in text and table format.

Download Syllabus

This course introduces students to basic statistical methods and their application to management, policy, and financial decision-making. The course covers the essential elements of descriptive statistics, univariate and bivariate statistical inference, and introduces multivariate analysis. In addition to covering statistical theory the course emphasizes applied statistics and data analysis, using the software package, SPSS.

The course has several "audiences" and goals. For all Wagner students, the course develops basic skills and encourages a critical approach to reviewing statistical findings and using statistical reasoning in decision making. For those planning to continue studying statistics (often those in policy and finance concentrations) this course additionally provides the foundation for that further work.

Download Syllabus

This advanced course develops a set of analytic skills that are used by some policy analysts. It focuses on impact analysis. The goals of the course are to (a) extend familiarity with methodologic issues, including various study designs, measurement problems, and analytic approaches; (b) provide hands-on experience in management, analysis, and presentation of data; and (c) develop skills in reading, critiquing, and reporting on policy-relevant impact analyses written by others. The emphasis of the course is on learning by doing, through data analysis, data presentation, and study critiquing activities. Students work on developing the ability to convey findings in text and table format.

Download Syllabus

This course introduces students to basic statistical methods and their application to management, policy, and financial decision-making. The course covers the essential elements of descriptive statistics, univariate and bivariate statistical inference, and introduces multivariate analysis. In addition to covering statistical theory the course emphasizes applied statistics and data analysis, using the software package, SPSS.

The course has several "audiences" and goals. For all Wagner students, the course develops basic skills and encourages a critical approach to reviewing statistical findings and using statistical reasoning in decision making. For those planning to continue studying statistics (often those in policy and finance concentrations) this course additionally provides the foundation for that further work.

Download Syllabus

This course introduces students to basic statistical methods and their application to management, policy, and financial decision-making. The course covers the essential elements of descriptive statistics, univariate and bivariate statistical inference, and introduces multivariate analysis. In addition to covering statistical theory the course emphasizes applied statistics and data analysis, using the software package, SPSS.

The course has several "audiences" and goals. For all Wagner students, the course develops basic skills and encourages a critical approach to reviewing statistical findings and using statistical reasoning in decision making. For those planning to continue studying statistics (often those in policy and finance concentrations) this course additionally provides the foundation for that further work.

Download Syllabus

This advanced course develops a set of analytic skills that are used by some policy analysts. It focuses on impact analysis. The goals of the course are to (a) extend familiarity with methodologic issues, including various study designs, measurement problems, and analytic approaches; (b) provide hands-on experience in management, analysis, and presentation of data; and (c) develop skills in reading, critiquing, and reporting on policy-relevant impact analyses written by others. The emphasis of the course is on learning by doing, through data analysis, data presentation, and study critiquing activities. Students work on developing the ability to convey findings in text and table format.

Download Syllabus

This course introduces students to basic statistical methods and their application to management, policy, and financial decision-making. The course covers the essential elements of descriptive statistics, univariate and bivariate statistical inference, and introduces multivariate analysis. In addition to covering statistical theory the course emphasizes applied statistics and data analysis, using the software package, SPSS.

The course has several "audiences" and goals. For all Wagner students, the course develops basic skills and encourages a critical approach to reviewing statistical findings and using statistical reasoning in decision making. For those planning to continue studying statistics (often those in policy and finance concentrations) this course additionally provides the foundation for that further work.

Download Syllabus

This advanced course develops a set of analytic skills that are used by some policy analysts. It focuses on impact analysis. The goals of the course are to (a) extend familiarity with methodologic issues, including various study designs, measurement problems, and analytic approaches; (b) provide hands-on experience in management, analysis, and presentation of data; and (c) develop skills in reading, critiquing, and reporting on policy-relevant impact analyses written by others. The emphasis of the course is on learning by doing, through data analysis, data presentation, and study critiquing activities. Students work on developing the ability to convey findings in text and table format.

Download Syllabus

2018

Abstract

Over the past decade, hearing loss has emerged as a key issue for aging and health. We describe why hearing loss may be especially disabling in nursing home settings and provide an estimate of prevalence using the Minimum Data Set (MDS v.3.0). We outline steps to mitigate hearing loss. Many solutions are inexpensive and low-tech, but require significant awareness and institutional commitment.

2017

Abstract

Background and objective

In utero exposure to perfluorooctanoic acid (PFOA) has been associated with decreases in birth weight. We aimed to estimate the proportion of PFOA-attributable low birth weight (LBW) births and associated costs in the US from 2003 to 2014, a period during which there were industry-initiated and regulatory activities aimed at reducing exposure.

Methods

Serum PFOA levels among women 18–49 years were obtained from the National Health and Nutrition Examination Survey (NHANES) for 2003–2014; birth weight distributions were obtained from the Vital Statistics Natality Birth Data. The exposure-response relationship identified in a previous meta-analysis (18.9 g decrease in birth weight per 1 ng/mL of PFOA) was applied to quantify PFOA-attributable LBW (reference level of 3.1 ng/mL for our base case, 1 and 3.9 ng/mL for sensitivity analyses). Hospitalization costs and lost economic productivity were also estimated.

Results

Serum PFOA levels remained approximately constant from 2003–2004 (median: 3.3 ng/mL) to 2007–2008 (3.5 ng/mL), and declined from 2009–2010 (2.8 ng/mL) to 2013–2014 (1.6 ng/mL). In 2003–2004, an estimated 12,764 LBW cases (4% of total for those years) were potentially preventable if PFOA exposure were reduced to the base case reference level (10,203 cases in 2009–2010 and 1,491 in 2013–2014). The total cost of PFOA-attributable LBW for 2003 through 2014 was estimated at $13.7 billion, with $2.97 billion in 2003–2004, $2.4 billion in 2009–2010 and $347 million in 2013–2014.

Conclusions

Serum PFOA levels began to decline in women of childbearing age in 2009–2010. Declines were of a magnitude expected to meaningfully reduce the estimated incidence of PFOA-attributable LBW and associated costs.

Abstract

Hearing loss is remarkably prevalent in the geriatric population: one-quarter of adults aged 60–69 and 80% of adults aged 80 years and older have bilateral disabling loss. Only about one in five adults with hearing loss wears a hearing aid, leaving many vulnerable to poor communication with healthcare providers. We quantified the extent to which hearing loss is mentioned in studies of physician-patient communication with older patients, and the degree to which hearing loss is incorporated into analyses and findings. We conducted a structured literature search within PubMed for original studies of physician-patient communication with older patients that were published since 2000, using the natural language phrase “older patient physician communication.” We identified 409 papers in the initial search, and included 67 in this systematic review. Of the 67 papers, only 16 studies (23.9%) included any mention of hearing loss. In six of the 16 studies, hearing loss was mentioned only; in four studies, hearing loss was used as an exclusion criterion; and in two studies, the extent of hearing loss was measured and reported for the sample, with no further analysis. Three studies examined or reported on an association between hearing loss and the quality of physician-patient communication. One study included an intervention to temporarily mitigate hearing loss to improve communication. Less than one-quarter of studies of physician-elderly patient communication even mention that hearing loss may affect communication. Methodologically, this means that many studies may have omitted an important potential confounder. Perhaps more importantly, research in this field has largely overlooked a highly prevalent, important, and remediable influence on the quality of communication.

Abstract

Importance  The increasing use of cesarean delivery is an emerging global health issue. Prior estimates of China’s cesarean rate have been based on surveys with limited geographic coverage.

Objective  To provide updated information about cesarean rates and geographic variation in cesarean use in China.

Design, Setting, and Data Sources  Descriptive study, covering every county (n = 2865) in mainland China’s 31 provinces, using county-level aggregated information on the number of live births, cesarean deliveries, maternal deaths, and perinatal deaths, collected by the Office for National Maternal & Child Health Statistics of China, from 2008 through 2014.

Exposures  Live births.

Main Outcomes and Measures  Annual rate of cesarean deliveries.

Results  Over the study period, there were 100 873 051 live births, of which 32 947 229 (32.7%) were by cesarean delivery. In 2008, there were 13 160 634 live births, of which 3 788 029 (28.8%) were by cesarean delivery and in 2014 there were 15 123 276 live births, of which 5 280 124 (34.9%) were by cesarean delivery. Rates varied markedly by province, from 4.0% to 62.5% in 2014. Despite the overall increase, by 2014 rates of cesarean delieries in 14 of the nation’s 17 “super cities” had declined by 4.1 to 17.5 percentage points from their earlier peak values (median, 11.4; interquartile range, 6.3-15.4). In 4 super cities with the largest decreases, there was no increase in maternal or perinatal mortality.

Conclusions and Relevance  Between 2008 and 2014, the overall annual rate of cesarean deliveries increased in China, reaching 34.9%. There was major geographic variation in rates and trends over time, with rates declining in some of the largest urban areas.


2016

Abstract

The surgical robot, a costly technology for treatment of prostate cancer with equivocal marginal benefit, rapidly diffused into clinical practice. We sought to evaluate the role of teaching in the early adoption phase of the surgical robot. Teaching hospitals were the primary early adopters: data from the Healthcare Cost and Utilization Project showed that surgical robots were acquired by 45.5% of major teaching, 18.0% of minor teaching and 8.0% of non-teaching hospitals during the early adoption phase. However, teaching hospital faculty produced little comparative effectiveness research: By 2008, only 24 published studies compared robotic prostatectomy outcomes to those of conventional techniques. Just ten of these studies (41.7%) were more than minimally powered, and only six (25%) involved cross-institutional collaborations. In adopting the surgical robot, teaching hospitals fulfilled their mission to innovate, but failed to generate corresponding scientific evidence.

Abstract

Hearing loss is a leading cause of disability among older people. Yet only one in seven US adults who could benefit from a hearing aid uses one. This fraction has not increased over the past 30 years, nor have hearing aid prices dropped, despite trends of steady improvements and price reductions in the consumer electronics industry.

The President’s Council on Science and Technology has proposed changes in the regulation of hearing aids, including the creation of a “basic” low-cost over-the-counter category of devices.

We discuss the potential to reduce disability as well as to improve public health, stakeholder responses to the president’s council’s proposal, and public health efforts to further mitigate the burden of disability stemming from age-related hearing loss.

Abstract

Objective

To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation.

Data Sources/Study Setting

Medicare cost reports for all Medicare-certified hospitals, 1987–2013, and Dartmouth Atlas geographic files.

Study Design

We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time.

Data Collection/Extraction Methods

Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas.

Principal Findings

In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time.

Conclusions

Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.

2015

Abstract

Abstract Background To quantify the association between maternal obesity and caesarean delivery, particularly caesarean delivery on maternal request (CDMR), a fast-growing component of caesarean delivery in many nations. Methods We followed 1 019 576 nulliparous women registered in the Perinatal Healthcare Surveillance System during 1993–2010. Maternal body mass index (BMI, kg/m2), before pregnancy or during early pregnancy, was classified as underweight (<18.5), normal (18.5 to <23; reference), overweight (23 to <27.5), or obese (≥27.5), consistent with World Health Organization guidelines for Asian people. The association between maternal obesity and overall caesarean and its subtypes was modelled using log-binomial regression. Results During the 18-year period, 404 971 (39.7%) caesareans and 93 927 (9.2%) CDMRs were identified. Maternal obesity was positively associated with overall caesarean and CDMR. Adjusted risk ratios for overall caesarean in the four ascending BMI categories were 0.96 [95% confidence interval (CI) 0.94, 0.97], 1.00 (Reference), 1.16 [95% CI 1.14, 1.18], 1.39 [95% CI 1.43, 1.54], and for CDMR were 0.95 [95% CI 0.94, 0.96], 1.00 (Reference), 1.20 [95% CI 1.18, 1.22], 1.48 [95% CI 1.433, 1.54]. Positive associations were consistently found in women residing in southern and northern provinces and in subgroups stratified by year of delivery, urban or rural residence, maternal age, education, level of delivering hospital, and birthweight. Conclusions In a large Chinese cohort study, maternal obesity was associated with an increased risk of caesarean delivery and its subtypes, including CDMR. Given the rising global prevalence of obesity, and in view of the growth of CDMR, it seems likely that caesarean births will increase, unless there are changes in obstetrical practice.

2013

H.T. Li, J.M.Liu, J. Blustein. Cesarean Delivery on Maternal Request. Journal of the American Medical Association, [JAMA] 2013;310(9):977-78 [letter]
Abstract

BACKGROUND: Di-2-ethylhexylphthalate (DEHP) is an environmental chemical commonly found in processed foods. Phthalate exposures, in particular to DEHP, have been associated with insulin resistance in adults, but have not been studied in adolescents.

METHODS:

Using cross-sectional data from 766 fasting 12- to 19-year-olds in the 2003-2008 NHANES, we examined associations of phthalate metabolites with continuous and categorical measures of homeostatic model assessment of insulin resistance (HOMA-IR).

RESULTS:

Controlling for demographic and behavioral factors, diet, continuous age, BMI category, and urinary creatinine, for each log (roughly threefold) increase in DEHP metabolites, a 0.27 increase (95% confidence interval 0.14-0.40; P < .001) in HOMA-IR was identified. Compared with the first tertile of DEHP metabolite in the study population (14.5% insulin resistant), the third tertile had 21.6% prevalence (95% confidence interval 17.2%-26.0%; P = .02). Associations persisted despite controlling for bisphenol A, another endocrine-disrupting chemical commonly found in foods, and HOMA-IR and insulin resistance were not significantly associated with metabolites of lower molecular weight phthalates commonly found in cosmetics and other personal care products.

CONCLUSIONS:

Urinary DEHP concentrations were associated with increased insulin resistance in this cross-sectional study of adolescents. This study cannot rule out the possibility that insulin-resistant children ingest food with higher phthalate content, or that insulin-resistant children excrete more DEHP.

Abstract

In January 1996, Congress passed an appropriations bill amendment prohibiting the US Centers for Disease Control and Prevention (CDC) from using “funds made available for injury prevention … to advocate or promote gun control.” This provision was triggered by evidence linking gun ownership to health harms, created uncertainty among CDC officials and researchers about what could be studied, and led to significant declines in funding. We evaluated the change in the number of publications on firearms in youth compared with research on other leading causes of death before and after the Congressional action. We focused on children and adolescents because they disproportionately experience gun violence and injury.

Abstract

OBJECTIVES: To assess associations of caesarean section with body mass from birth through adolescence.

DESIGN: Longitudinal birth cohort study, following subjects up to 15 years of age.

SETTING AND PARTICIPANTS: Children born in 1991-1992 in Avon, UK who participated in the Avon Longitudinal Study of Parents and Children (ALSPAC) (n=10 219).

OUTCOME MEASURES: Primary outcome: standardized measures of body mass (weight-for length z-scores at 6 weeks, 10 and 20 months; and body mass index (BMI) z-scores at 38 months, 7, 9, 11 and 15 years). Secondary outcome: categorical overweight or obese (BMI 85th percentile) for age and gender, at 38 months, 7, 9, 11 and 15 years.

RESULTS: Of the 10 219 children, 926 (9.06%) were delivered by caesarean section. Those born by caesarean had lower-birth weights than those born vaginally (-46.1 g, 95% confidence interval(CI): 14.6-77.6 g; P=0.004). In mixed multivariable models adjusting for birth weight, gender, parental body mass, family sociodemographics, gestational factors and infant feeding patterns, caesarean delivery was consistently associated with increased adiposity, starting at 6 weeks (+0.11 s.d. units, 95% CI: 0.03-0.18; P=0.005), through age 15 (BMI z-score increment+0.10 s.d. units, 95% CI: 0.001-0.198; P=0.042). By age 11 caesarean-delivered children had 1.83 times the odds of overweight or obesity (95% CI: 1.24-2.70; P=0.002). When the sample was stratified by maternal pre-pregnancy weight, the association among children born of overweight/obese mothers was strong and long-lasting. In contrast, evidence of an association among children born of normal-weight mothers was weak.

CONCLUSION: Caesarean delivery is associated with increased body mass in childhood and adolescence. Research is needed to further characterize the association in children of normal weight women. Additional work is also needed to understand the mechanism underlying the association, which may involve relatively enduring changes in the intestinal microbiome.

Abstract

Background: Phthalates have antiandrogenic effects and may disrupt lipid and carbohydrate metabolism. Racial/ethnic subpopulations have been documented to have varying urinary phthalate concentrations and prevalences of childhood obesity.

Objective: We examined associations between urinary phthalate metabolites and body mass outcomes in a nationally representative sample of U.S. children and adolescents.

Methods: We performed stratified and whole-sample cross-sectional analyses of 2,884 children 6–19 years of age who participated in the 2003–2008 National Health and Nutrition Examination Survey. Multivariable linear and logistic analyses of body mass index z-score, overweight, and obesity were performed against molar concentrations of low-molecular-weight (LMW), high-molecular-weight (HMW), and di-2-ethylhexylphthalate (DEHP) metabolites, controlling for sex, television watching, caregiver education, caloric intake, poverty–income ratio, race/ethnicity, serum cotinine, and age group. We used sensitivity analysis to examine robustness of results to removing sample weighting, normalizing phthalate concentrations for molecular weight, and examining different dietary intake covariates.

Results: In stratified, multivariable models, each log unit (roughly 3-fold) increase in LMW metabolites was associated with 21% and 22% increases in odds (95% CI: 1.05–1.39 and 1.07–1.39, respectively) of overweight and obesity, and a 0.090-SD unit increase in BMI z-score (95% CI: 0.003–0.18), among non-Hispanic blacks. Significant associations were not identified in any other racial/ethnic subgroup or in the study sample as a whole after controlling for potential confounders, associations were not significant for HMW or DEHP metabolites, and results did not change substantially with sensitivity analysis.

Conclusions: We identified a race/ethnicity–specific association of phthalates with childhood obesity in a nationally representative sample. Further study is needed to corroborate the association and evaluate genetic/epigenomic predisposition and/or increased phthalate exposure as possible explanations for differences among racial/ethnic subgroups.

2012

Abstract

Objectives:

To examine the associations of antibiotic exposures during the first 2 years of life and the development of body mass over the first 7 years of life.

Design:

Longitudinal birth cohort study.

Subjects:
A total of 11 532 children born at greater than or equal to2500 g in the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based study of children born in Avon, UK in 1991–1992.

Measurements:

Exposures to antibiotics during three different early-life time windows (

Results:

Antibiotic exposure during the earliest time window (

Conclusions:

Exposure to antibiotics during the first 6 months of life is associated with consistent increases in body mass from 10 to 38 months. Exposures later in infancy (6–14 months, 15–23 months) are not consistently associated with increased body mass. Although effects of early exposures are modest at the individual level, they could have substantial consequences for population health. Given the prevalence of antibiotic exposures in infants, and in light of the growing concerns about childhood obesity, further studies are needed to isolate effects and define life-course implications for body mass and cardiovascular risks.

Abstract

Background

Medicare will soon implement hospital value-based purchasing (VBP), using a scoring system that rewards both achievement (absolute performance) and improvement (performance increase over time).  However, improvement is defined so as to give less credit to initial low performers than initial high performers.  Since initial low performers are disproportionately hospitals in socioeconomically disadvantaged areas, these institutions stand to lose under Medicare’s VBP proposal. 

 

Methods

We developed an alternative improvement scale, and applied it to hospital performance throughout the US.   Using 2005-2008 Medicare process measures for acute myocardial infarction (AMI) and heart failure (HF), we calculated hospital scores using Medicare’s proposal and our alternative.  Hospital performance scores were compared across 5 locational dimensions of socioeconomic disadvantage: poverty, unemployment, physician shortage, high school and college graduation rates.

 

Results

Medicare’s proposed scoring system yielded higher overall scores for the most locationally advantaged hospitals for 4 out of 5 dimensions in AMI and 2 out of 5 for HF.  Using our alternative, differences in overall scores between hospitals in the most and least advantaged areas were attenuated, with locationally advantaged hospitals having higher overall scores for 3 out of 5 dimensions in AMI and 1 out of 5 dimensions for HF. 

 

Conclusions

Using an alternative VBP formula that reflects the principle of “equal credit for equal improvement,” resulted in a more equitable distribution of overall payment scores, which could allow hospitals in both socioeconomically advantaged and disadvantaged areas to succeed under VBP.

 

 

Abstract

Context  Bisphenol A (BPA), a manufactured chemical, is found in canned food, polycarbonate-bottled liquids, and other consumer products. In adults, elevated urinary BPA concentrations are associated with obesity and incident coronary artery disease. BPA exposure is plausibly linked to childhood obesity, but evidence is lacking to date.

Objective  To examine associations between urinary BPA concentration and body mass outcomes in children.

Design, Setting, and Participants  Cross-sectional analysis of a nationally representative subsample of 2838 participants aged 6 through 19 years randomly selected for measurement of urinary BPA concentration in the 2003-2008 National Health and Nutrition Examination Surveys.

Main Outcome Measures  Body mass index (BMI), converted to sex- and age-standardized z scores and used to classify participants as overweight (BMI ≥85th percentile for age/sex) or obese (BMI ≥95th percentile).

Results  Median urinary BPA concentration was 2.8 ng/mL (interquartile range, 1.5-5.6). Of the participants, 1047 (34.1% [SE, 1.5%]) were overweight and 590 (17.8% [SE, 1.3%]) were obese. Controlling for race/ethnicity, age, caregiver education, poverty to income ratio, sex, serum cotinine level, caloric intake, television watching, and urinary creatinine level, children in the lowest urinary BPA quartile had a lower estimated prevalence of obesity (10.3% [95% CI, 7.5%-13.1%]) than those in quartiles 2 (20.1% [95% CI, 14.5%-25.6%]), 3 (19.0% [95% CI, 13.7%-24.2%]), and 4 (22.3% [95% CI, 16.6%-27.9%]). Similar patterns of association were found in multivariable analyses examining the association between quartiled urinary BPA concentration and BMI z score and in analyses that examined the logarithm of urinary BPA concentration and the prevalence of obesity. Obesity was not associated with exposure to other environmental phenols commonly used in other consumer products, such as sunscreens and soaps. In stratified analysis, significant associations between urinary BPA concentrations and obesity were found among whites (P < .001) but not among blacks or Hispanics.

Conclusions  Urinary BPA concentration was significantly associated with obesity in this cross-sectional study of children and adolescents. Explanations of the association cannot rule out the possibility that obese children ingest food with higher BPA content or have greater adipose stores of BPA.

2011

Abstract

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.

Abstract

The Institute of Medicaid has identified equity as a key dimension of quality. Recently, Massachusetts’ Medicaid program (MassHealth) took the unusual step of linking pay-for-performance (P4P) to the reduction of racial/ethnic disparities for hospital care.  We report on early experience with the program, describing the challenges of implementing an ambitious program in a short time frame, with limited resources.  Our findings raise questions about whether P4P as currently constituted is a suitable tool for addressing disparities in hospital care.

Abstract

Objective. To test the effect of Massachusetts Medicaid's (MassHealth) hospital-based pay-for-performance (P4P) program, implemented in 2008, on quality of care for pneumonia and surgical infection prevention (SIP). Data. Hospital Compare process of care quality data from 2004 to 2009 for acute care hospitals in Massachusetts (N=62) and other states (N=3,676) and American Hospital Association data on hospital characteristics from 2005. Study Design. Panel data models with hospital fixed effects and hospital-specific trends are estimated to test the effect of P4P on composite quality for pneumonia and SIP. This base model is extended to control for the completeness of measure reporting. Further sensitivity checks include estimation with propensity-score matched control hospitals, excluding hospitals in other P4P programs, varying the time period during which the program was assumed to have an effect, and testing the program effect across hospital characteristics. Principal Findings. Estimates from our preferred specification, including hospital fixed effects, trends, and the control for measure completeness, indicate small and nonsignificant program effects for pneumonia (-0.67 percentage points, p>.10) and SIP (-0.12 percentage points, p>.10). Sensitivity checks indicate a similar pattern of findings across specifications. Conclusions. Despite offering substantial financial incentives, the MassHealth P4P program did not improve quality in the first years of implementation.

2010

Abstract

Abstract

Background: Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and

improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.

Methods and Findings: We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare’s ‘‘Value-Based Purchasing’’ program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p,0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p,0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.

Conclusions: Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare’s hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.

Please see later in the article for the Editors’ Summary.

Abstract

Objective
To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures, as measured by Medicare claims, and to assess the costs of developing and implementing the telemedicine intervention.
Design
We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine (IDEATel), a randomized controlled trial comparing telemedicine case management of diabetes to usual care. Participants were aged 55 years or older, and resided in federally designated medically underserved areas of New York State.
Measurements
We analyzed Medicare claims payments for each participant for up to 60 study months from date of randomization, until their death, or until December 31, 2006 (whichever happened first). We also analyzed study expenditures for the telemedicine intervention over six budget years (February 28, 2000- February 27, 2006).
Results
Mean annual Medicare payments (SE) were similar in the usual care and telemedicine groups, $9040 ($386) and $9669 ($443) per participant, respectively (p>0.05). Sensitivity analyses, including stratification by censored status, adjustment by enrollment site, and semi-parametric weighting by probability of dropping-out, rendered similar results. Over six budget years 28 821 participant/months of telemedicine intervention were delivered, at an estimated cost of $622 per participant/month.
Conclusion
Telemedicine case management was not associated with a reduction in Medicare claims in this medically underserved population. The cost of implementing the telemedicine intervention was high, largely representing special purpose hardware and software costs required at the time. Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used.

Abstract

Health care policymakers have cited transportation barriers as key obstacles to providing health care to low-income suburbanites, particularly because suburbs have become home to a growing number of recent immigrants who are less likely to own cars than their neighbors. In a suburb of New York City, we conducted a pilot survey of low income, largely immigrant clients in four public clinics, to find out how much transportation difficulties limit their access to primary care. Clients were receptive to the opportunity to participate in the survey (response rate = 94%). Nearly one-quarter reported having transportation problems that had caused them to miss or reschedule a clinic appointment in the past. Difficulties included limited and unreliable local bus service, and a tenuous connection to a car. Our pilot work suggests that this population is willing to participate in a survey on this topic. Further, since even among those attending clinic there was significant evidence of past transportation problems, it suggests that a population based survey would yield information about substantial transportation barriers to health care.

2008

Abstract

Background: Minority populations bear a disproportionate burden of chronic disease, due to higher disease prevalence and greater morbidity and mortality. Recent research has shown that several factors, including confidence to self-manage care, are associated with better health behaviors and outcomes among those with chronic disease.

Objective: To examine the association between minority status and confidence to self-manage cardiovascular disease (CVD).

Study Sample: Survey respondents admitted to 10 hospitals participating in the Expecting Success program, with a diagnosis of CVD, during January-September 2006 (n = 1107).

Results: Minority race/ethnicity was substantially associated with lower confidence to self-manage CVD, with 36.5% of Hispanic patients, 30.7% of Black patients, and 16.0% of white patients reporting low confidence (P < 0.001). However, in multivariate analysis controlling for socioeconomic status and clinical severity, minority status was not predictive of low confidence.

Conclusions: Although there is an association between race/ethnicity and confidence to self-manage care, that relationship is explained by the association of race/ethnicity with socioeconomic status and clinical severity.

2004

Abstract

Like many schools of public policy and management, New York University's Wagner School offers a capstone course in which teams of MPA students provide consultation to client organizations, This year, as the they began to assign students to teams, some members of the faculty sounded an alarm. Several of the projects might involve interviewing service recipients about sensitive issues. Other projects would give teams access to confidential information. Faculty members experience with their university human subjects review board knew that such projects, where they to be undertaken in a research context, would require lengthy and cumbersome review. Did the capstone projects need to go through the human subjects review process? If the answer was yes, the program would come to a grinding halt, given the open-endness of a capstone assignments and the bureaucratic nature of the committee application and approval process.

2000

Abstract

We compare the characteristics of enrollees in for-profit and nonprofit Medicare health plans using nationwide data from the 1996 Medicare Current Beneficiary Survey. We find few differences in overall health status, limitations in activities of daily living (ADLs), or history of chronic disease. However, older Americans enrolled in for-profit plans are substantially poorer and less educated than those enrolled in nonprofit plans, are more likely to have joined their plan recently, and are more likely to have joined a plan with the expectation of reducing their out-of-pocket health care costs.

1998

Abstract

"Preventable" hospitalizations have been proposed as indicators of poor health plan performance. In this study of elderly Medicare beneficiaries, however, we found that preventable hospitalizations are also more common among elders of lower socioeconomic status (SES). The relationship persisted even when an up-to-date severity-of-illness adjustment system was used. To the extent that indicators of health plan "performance" reflect enrollees' characteristics, plans will be rewarded for marketing their services to wealthier, healthier, and better-educated patients. Further work is needed to clarify issues of accountability for preventable hospitalizations and other putative indices of health plan performance.

1997

Abstract

OBJECTIVES: This research studied the relative contribution of diabetes mellitus to the increased prevalence of tuberculosis in Hispanics. METHODS: A case-control study was conducted involving all 5290 discharges from civilian hospitals in California during 1991 who had a diagnosis of tuberculosis, and 37,366 control subjects who had a primary discharge diagnosis of deep venous thrombosis, pulmonary embolism, or acute appendicitis. Risk of tuberculosis was estimated as the odds ratio (OR) across race/ethnicity, with adjustment for other factors. RESULTS: Diabetes mellitus was found to be an independent risk factor for tuberculosis. The association of diabetes and tuberculosis was higher among Hispanics (adjusted OR [ORadj] = 2.95: 95% confidence interval [CI] = 2.61, 3.33) than among non-Hispanic Whites (ORadj = 1.31: 95% CI = 1.19. 1.45): among non-Hispanic Blacks, diabetes was not found to be associated with tuberculosis (ORadj = 0.93: 95% CI = 0.78, 1.09). Among Hispanics aged 25 to 54, the estimated risk of tuberculosis attributable to diabetes (25.2%) was equivalent to that attributable to HIV infection (25.5%). CONCLUSIONS: Diabetes mellitus remains a significant risk factor for tuberculosis in the United States. The association is especially notable in middle-aged Hispanics.

1996

Abstract

To assess the validity of using hospital administrative data to measure variations in surgery for early-stage breast cancer, ICD-9-CM coded information was compared with corresponding tumor registry data for 1293 breast cancer patients undergoing lumpectomy or mastectomy at a tertiary referral center from January 1989 to October 1993. Relative to "gold standard" tumor registry data, the administrative data proved 83.4% sensitive and 80.4% specific in identifying women with localized disease who would be potential candidates for lumpectomy. The proportion of women with localized disease undergoing lumpectomy in groups defined by race and insurance status was nearly identical, whichever data were used. Administrative data, which is often readily and publicly available, may be useful in studying variations in breast cancer treatment in key demographic groups.

1995

Abstract

OBJECTIVES. Relatively few hospitals in the United States offer high-technology cardiac services (cardiac catheterization, bypass surgery, or angioplasty). This study examined the association between race and admission to a hospital offering those services. METHODS. Records of 11,410 patients admitted with acute myocardial infarction to hospitals in New York State in 1986 were analyzed. RESULTS. Approximately one third of both White and Black patients presented to hospitals offering high-technology cardiac services. However, in a multivariate model adjusting for home-to-hospital distance, the White-to-Black odds ratio for likelihood of presentation to such a hospital was 1.68 (95% confidence interval = 1.42, 1.98). This discrepancy between the observed and "distance-adjusted" probabilities reflected three phenomena: (1) patients presented to nearby hospitals; (2) Blacks were more likely to live near high-technology hospitals; and (3) there were racial differences in travel patterns. For example, when the nearest hospitals did not include a high-technology hospital, Whites were more likely than Blacks to travel beyond those nearest hospitals to a high-technology hospital. CONCLUSIONS. Whites and Blacks present equally to hospitals offering high-technology cardiac services at the time of acute myocardial infarction. However, there are important underlying racial differences in geographic proximity and tendencies to travel to those hospitals.