Gestur Davidson

Substitution of formal and informal care for the community-based elderly.

The Minnesota Pre-Admission Screening/Alternative Care Grants Program screens those at risk of nursing home placement and funds services that will allow the elderly to be cared for at home. Information was collected for a 1-year period on client placement, health and functional status, informal support, use of health and formal services, and care-giver characteristics for 214 clients screened during the last quarter of 1984. A two-equation model was hypothesized to examine the formal service decisions of case managers and the amount of informal care provided for elderly clients at risk of institutionalization. A system of two simultaneous equations was estimated using a two-stage leastsquares approach. The findings suggest that case managers allocate formal services based primarily on client need. The amount of informal care provided to clients did not affect significantly the decisions of case managers and is not determined significantly by the amount of formal services received by the elderly in the community. The lack of substitution between formal services and informal care reinforces the findings of previous research

Physician Smoking-Cessation Actions Are They Dependent on Insurance Coverage or on Patients?

BACKGROUND Despite good evidence that their smoking-cessation actions can be very effective, physicians have not consistently used the 5A actions (being asked, advised, assessed, assisted, and arranged) recommended in the U.S. Public Health Service tobacco guidelines. We tested the hypothesis that the introduction of coverage for smoking-cessation pharmacotherapy by the health plans covering most of the population in one region would increase physician use of 5As. METHODS A cohort of smoking members of two health plans was surveyed before and after the introduction of coverage for smoking cessation. A total of 1560 current smokers with a physician visit in the last year responded to both surveys. The key outcome measures were smoker reports of the guideline 5As for smoking-cessation support during the last physician visit. RESULTS There were small significant absolute percentage increases only for reports of being assessed (+4.9%, p=0.01) and assisted (set quit date +6.5%, p=0.0004); encouraged to use medications (+8.8%, p=0.03); and given a prescription (+8.6%, p=0.0005). However, these increases were limited to smokers reporting awareness of the coverage, asking for quitting help, or both. CONCLUSION Coverage for pharmacotherapy alone appears to have had no effect on physician behavior beyond that stimulated by smokers who were aware of the coverage, perhaps because they raised the issue. More research is needed on this suggestion that patients create physician behavior change.

Estimating regression standard errors with data from the current population survey's public use file

This study examines whether reasonable standard errors for multivariate models can be calculated using the public use file of the Current Population Surveys Annual Social and Economic Supplement (CPS ASEC). We restrict our analysis to the 2003 CPS ASEC and model three dependent variables at the individual level: income, poverty, and health insurance coverage. We compare standard error estimates performed on the CPS ASEC public use file with those obtained from the Census Bureaus restricted internal data that include all the relevant sampling information needed to compute standard errors adjusted for the complex survey sample design. Our analysis shows that the multivariate standard error estimates derived from the public use CPS ASEC following our specification perform relatively well compared to the estimates derived from the internal Census Bureau file. However, it is essential that users of CPS ASEC data do not simply choose any available method since three of the methods commonly used for adjusting for the complex sample design produce substantially different estimates.

The Impact of Gaps in Health Insurance Coverage on Immunization Status for Young Children

OBJECTIVE To examine the impact of full-year versus intermittent public and private health insurance coverage on the immunization status of children aged 19-35 months. DATA SOURCE 2001 State and Local Area Integrated Telephone Surveys National Survey of Children with Special Health Care Needs (NS-CSHCN) and the 2000-2002 National Immunization Survey (NIS). STUDY DESIGN Linked health insurance data from 2001 NS-CSHCN with verified immunization status from the 2000-2002 NIS for a nationally representative sample of 8,861 nonspecial health care needs children. Estimated adjusted rates of up-to-date (UTD) immunization status using multivariate logistic regressions for seven recommended immunizations and three series. PRINCIPAL FINDINGS Children with public full-year coverage were significantly more likely to be UTD for two series of recommended vaccines, (4:3:1:3) and (4:3:1:3:3), compared with children with private full-year coverage. For three out of 10 immunizations and series tested, children with private part-year coverage were significantly less likely to be UTD than children with private full-year coverage. CONCLUSIONS Our findings raise concerns about access to needed immunizations for children with gaps in private health insurance coverage and challenge the prevailing belief that private health insurance represents the gold standard with regard to UTD status for young children.

Unstable inferences? An examination of complex survey sample design adjustments using the current population survey for health services research

Statistical analysis of the Current Population Surveys Annual Social and Economic Supplement is used widely in health services research. However, the statistical evidence cited from the Current Population Survey (CPS) is not always consistent because researchers use a variety of methods to produce standard errors that are fundamental to significance tests. This analysis examines the 2002 Annual Social and Economic Supplements (ASEC) estimates of national and state average income, national and state poverty rates, and national and state health insurance coverage rates. Findings show that the standard error estimates derived from the public use CPS data perform poorly compared with the survey design-based estimates derived from restricted internal data, and that the generalized variance parameters currently used by the U.S. Census Bureau in its ASEC reports and funding formula inputs perform erratically. Because the majority of published research (both by academics and Census Bureau analysts) does not make use of the survey design-based information available only on the internal ASEC data file, we argue that the Census Bureau ought to use alternative methods for its official ASEC reports. We also argue that for public use data the Census Bureau should produce a set of replicate weights for the ASEC or release a set of sample design variables that incorporate statistical “noise” to maintain respondent confidentiality (e.g., pseudo-primary sampling units) as other federal government surveys do. This is essential to make appropriate inferences using the ASEC data regarding statistical significance and estimate variance for health policy analysis.

Hospital Provision of Uncompensated Care and Public Program Enrollment

Hospital provision of uncompensated care is partly a function of insurance coverage of state populations. As states expand insurance coverage options and reduce the number of uninsured, hospital provision of uncompensated care should also decrease. Controlling for hospital characteristics and market factors, the authors estimate that increases in MinnesotaCare (a state-subsidized health insurance program for the working poor) enrollment resulted in a 5-year cumulative savings of

Disparities in pediatric asthma hospitalizations.

58.6 million in hospital uncompensated care costs. Efforts to evaluate access expansions should take into account the costs of the program and the savings associated with reductions in hospital uncompensated care.

Accuracy in self-reported health insurance coverage among Medicaid enrollees

OBJECTIVE The purpose of this project was to determine to what extent rural children are hospitalized for asthma, an ambulatory care sensitive condition defined by the Agency for Healthcare Research and Quality pediatric quality indicators; to analyze differences in hospitalization rates for asthma by state and by rurality; and to examine the relationships between asthma hospitalization rates and poverty, health insurance, and physician supply. METHODS The project used 2001 through 2004 hospital inpatient discharge data for children aged 2 to 17 years from six geographically diverse states in the Healthcare Cost and Utilization Project. County-level poverty, uninsurance estimates, and physician data came from the 2004 Area Resource File. Pediatric Quality Indicator software was used to calculate county-level admission rates for asthma. Multivariate regression models were specified to assess how sensitive hospitalization rates were to characteristics of the childrens counties of residence. RESULTS Pediatric asthma hospitalization rates per 100,000 children aged 2 to 17 years varied by state ranging from 51.1 to 185.9. When comparing all six states, rural children were the most likely to be hospitalized for asthma. However, after controlling for rurality, poverty, uninsurance, and physician supply, uninsurance was the only variable to significantly impact hospitalization rates. CONCLUSIONS These findings indicate that there are significant differences in pediatric asthma hospitalizations rates by and within states, which may best be addressed by targeting public health and healthcare interventions. In addition, the findings support efforts to increase health insurance coverage for children, especially rural children who are less likely to be insured.

Does a health plan effort to increase smokers' awareness of cessation medication coverage increase utilization and cessation?

The largest portion of the Medicaid undercount is caused by survey reporting error—that is, Medicaid recipients misreport their enrollment in health insurance coverage surveys. In this study, we sampled known Medicaid enrollees to learn how they respond to health insurance questions and to document correlates of accurate and inaccurate reports. We found that Medicaid enrollees are fairly accurate reporters of insurance status and type of coverage, but some do report being uninsured. Multivariate analyses point to the prominent role of program-related factors in the accuracy of reports. Our findings suggest that the Medicaid undercount should not undermine confidence in survey-based estimates of uninsurance.

What Cost Case Management in Long-Term Care?

Purpose. To test whether a mailing describing new coverage for smoking cessation medications increases benefit knowledge, utilization, and quitting. Methods. This randomized controlled trial assigned participants to benefit communication via (1) standard contract changes or (2) enhanced communication with direct-to-member postcards. A sample of 1930 self-identified smokers from two Minnesota health plans took surveys before and 1 year after the benefits introduction. The follow-up response rate was 80%. A multilevel logistic estimator tested for differences in benefit knowledge and smoking behavior from baseline. Results. More enhanced than standard communication respondents knew about the benefit (39.0% vs. 22.2%, p < .0001) at follow-up. Groups did not differ on bupropion utilization (24.6% vs. 23.1%, p = .92); nicotine replacement therapy utilization (26.9% vs. 25.9%, p = .26), or cessation (12.8% vs. 15.6%, p = .32). Conclusion. Although limited by the low intervention intensity and potential social desirability bias, information about new coverage alone does not appear to increase quitting behaviors.