Andrew W. Dick

Reduction in Racial and Ethnic Disparities After Enrollment in the State Children's Health Insurance Program

Background. Racial/ethnic disparities are associated with lack of health insurance. Although the State Childrens Health Insurance Program (SCHIP) provides health insurance to low-income children, many of whom are members of racial/ethnic minority groups, little is known about whether SCHIP affects racial/ethnic disparities among children who enroll. Objectives. The objectives of this study were to (1) describe demographic characteristics and previous health insurance experiences of SCHIP enrollees by race, (2) compare racial/ethnic disparities in medical care access, continuity, and quality before and during SCHIP, and (3) determine whether disparities before or during SCHIP are explained by sociodemographic and health system factors. Methods. Pre/post–parent telephone survey was conducted just after SCHIP enrollment and 1 year after enrollment of 2290 children who had an enrollment start date in New York States SCHIP between November 2000 and March 2001, stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The main outcome measures were usual source of care (USC), preventive care use, unmet needs, patterns of USC use, and parent-rated quality of care before versus during SCHIP. Results. Children were white (25%), black (31%), or Hispanic (44%); 62% were uninsured ≥12 months before SCHIP. Before SCHIP, a greater proportion of white children had a USC compared with black or Hispanic children (95%, 86%, and 81%, respectively). Nearly all children had a USC during SCHIP (98%, 95%, and 98%, respectively). Before SCHIP, black children had significantly greater levels of unmet need relative to white children (38% vs 27%), whereas white and Hispanic children did not differ significantly (27% vs 29%). During SCHIP, racial/ethnic disparities in unmet need were eliminated, with unmet need at 19% for all 3 racial/ethnic groups. Before SCHIP, more white children made all/most visits to their USC relative to black or Hispanic children (61%, 54%, and 34%, respectively); all improved during SCHIP with no remaining disparities (87%, 86%, and 92%, respectively). Parent-rated visit quality improved for all groups, but preexisting racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. Sociodemographic and health system factors did not explain disparities in either period. Conclusions. Enrollment in SCHIP was associated with (1) improvement in access, continuity, and quality of care for all racial/ethnic groups and (2) reduction in preexisting racial/ethnic disparities in access, unmet need, and continuity of care. Racial/ethnic disparities in quality of care remained, despite improvements for all racial groups. Sociodemographic and health system factors did not add to the understanding of racial/ethnic disparities. SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care.

Economic burden associated with Parkinson's disease on elderly Medicare beneficiaries.

We evaluated medical utilization and economic burden of self‐reported Parkinsons disease (PD) on patients and society. Using the 1992–2000 Medicare Current Beneficiary Survey, we compared health care utilization and expenditures (in 2002 U.S. dollars) of Medicare subscribers with and without PD, adjusting for sociodemographic characteristics and comorbidities. PD patients used significantly more health care services of all categories and paid significantly more out of pocket for their medical services than other elderly (mean ± SE,

Improved Asthma Care After Enrollment in the State Children's Health Insurance Program in New York

5,532 ±

Is the hospital volume-mortality relationship in coronary artery bypass surgery the same for low-risk versus high-risk patients?

329 vs.

Are High-Quality Cardiac Surgeons Less Likely to Operate on High-Risk Patients Compared to Low-Quality Surgeons? Evidence from New York State

2,187 ±

Impact of the State Children's Health Insurance Program on Adolescents in New York

38; P < 0.001). After adjusting for other factors, PD patients had higher annual health care expenses than beneficiaries without PD (

Misspecification issues in risk adjustment and construction of outcome-based quality indicators

18,528 vs.

The Savings Impact of College Financial Aid

10,818; P < 0.001). PD patients were more likely to use medical care (OR = 3.77; 95% CI = 1.44–9.88), in particular for long‐term care (OR = 3.80; 95% CI = 3.02–4.79) and home health care (OR = 2.08; 95% CI = 1.76–2.46). PD is associated with a significant economic burden to patients and society. Although more research is needed to understand the relationship between PD and medical expenditures and utilization, these findings have important implications for health care providers and payers that serve PD populations.

Editorial Comment—Stroke Cost-Effectiveness Research: Are Acceptability Curves Acceptable?

BACKGROUND. Uninsured children with asthma are known to face barriers to asthma care, but little is known about the impact of health insurance on asthma care. OBJECTIVES. We sought to assess the impact of New Yorks State Childrens Health Insurance Program (SCHIP) on health care for children with asthma. DESIGN. Parents of a stratified random sample of new enrollees in New Yorks SCHIP were interviewed by telephone shortly after enrollment (baseline, n = 2644 [74% of eligible children]) and 1 year later (follow-up, n = 2310 [87%]). Asthma was defined by parent report using questions based on National Heart, Lung, and Blood Institute criteria. A comparison group (n = 401) who enrolled in SCHIP 1 year later was interviewed as a test for secular trends. MAIN OUTCOME MEASURES. Access (having a usual source of care [USC], unmet health needs, problems receiving acute asthma care), asthma-related medical visits, quality (continuity of care at the USC, problems receiving chronic asthma care, use of antiinflammatory medications), and asthma outcomes (change in asthma care or severity) were the main outcome measures used. Bivariate and multivariate analyses compared measures at baseline (year before SCHIP) versus follow-up (year during SCHIP). RESULTS. Three-hundred eighty-three children (14%) had asthma at baseline, and 364 had asthma at follow-up (16%). No secular trends were detected between the baseline study group and the comparison group. After enrollment in SCHIP, improvements were noted in access: lacking a USC (decrease from 5% to 1%), unmet health needs (48% to 21%), and problems getting to the USC for asthma (13 to 4%). Children had fewer asthma-related attacks and medical visits after SCHIP (mean number of attacks: 9.5 to 3.8: mean number of asthma visits: 3.0 to 1.5; hospitalizations: 11% to 3%). Quality of asthma care improved for general measures (most/all visits to USC: 53% to 94%; mean rating of provider: 7.9 to 8.8 of 10) and asthma-specific measures (problems getting to the USC for asthma care when child was well: 13% to 1%). More than two thirds of the parents at follow-up reported that both quality of asthma care and asthma severity were “better or much better” than at baseline, generally because of insurance coverage or lower costs of medications and medical care. CONCLUSIONS. Enrollment in New Yorks SCHIP was associated with improvements in access to asthma care, quality of asthma care, and asthma-specific outcomes. These findings suggest that health insurance improves the health of children with asthma.

The Cost Effectiveness of Implantable Cardioverter-Defibrillators: Results From the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II

BACKGROUND There is evidence to support the existence of an inverse relation between mortality after coronary artery bypass graft (CABG) surgery and procedure volume. It is unclear whether all patients benefit equally from having CABG surgery performed at high-volume centers. The objective of this study was to determine whether the volume-outcome association for CABG surgery is modified by patient risk. METHODS This retrospective cohort analysis was conducted using data from the Cardiac Surgery Reporting System database on all patients (20,078) undergoing CABG surgery in New York State who were discharged in 1996. The main outcome measure was in-hospital mortality as a function of procedure volume after adjusting for severity of disease. Logistic regression modeling was used to explore the interaction between patient risk and procedure volume. RESULTS There is a significant interaction between procedure volume and patient risk (p = 0.01). The final model exhibits excellent discrimination (C statistic = 0.818) and goodness-of-fit (Hosmer-Lemeshow statistic = 6.02; p = 0.645). Very low (<0.5%) and low-risk (0.5%-2.0%) patients exhibit a greater reduction in CABG mortality than high (5.0%-10.0%) and very high risk (>10%) patients at high-volume centers relative to low-volume centers. Among the highest risk patients (>25% risk of mortality), higher risk patients have better outcomes at higher volume centers. CONCLUSIONS For the vast majority of patients, low-risk patients benefit significantly more than high-risk patients from undergoing CABG surgery at high-volume centers instead of at low-volume centers. Low-risk patients benefit significantly more than high-risk patients from undergoing CABG surgery at high-volume centers instead of at low-volume centers. However, before generalizing these findings to other states, this study should be repeated using other regional population-based clinical databases.