José J. Escarce

SOCIOECONOMIC, CULTURAL, AND BEHAVIORAL FACTORS AFFECTING HISPANIC HEALTH OUTCOMES

Evidence suggests that social and economic factors are important determinants of health. Yet, despite higher porverty rates, less education, and worse access to health care, health outcomes of many Hispanics living in the United States today are equal to, or better than, those of non-Hispanic whites. This paradox is described in the literature as the epidemiological paradox or Hispanic health paradox. In this paper, the authors selectively review data and research supporting the existence of the epidemiological paradox. They find substantial support for the existence of the epidemiological paradox, particularly among Mexican Americans. Census undercounts of Hispanics, misclassification of Hispanic deaths, and emigration of Hispanics do not fully account for the epidemiological paradox. Identifying protective factors underlying the epidemiological paradox, while improving access to care and the economic conditions among Hispanics, are important research and policy implications of this review.

A CASE-MIX CLASSIFICATION SYSTEM FOR MEDICAL REHABILITATION

Dissatisfaction with Medicares current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.

Race and sex differences in the management of coronary artery disease

Although numerous studies have documented race and sex differences in the treatment of coronary artery disease, the available analyses have not been comprehensively evaluated. In this review, we summarize prior estimates of race and sex disparities in the utilization of standard tests and therapies, and we evaluate studies of factors that may contribute to gaps in care. The studies presented consistently demonstrate that blacks and women with coronary artery disease, compared with whites and men, are substantially less likely to receive standard interventions. Studies also indicate that racial differences relate in part to socioeconomic factors, process-of-care variables, and patient preferences, whereas sex differences relate in part to clinical factors. In both cases, however, our understanding is limited by deficiencies in currently available datasets. Moreover, factors that have been shown to contribute to race and sex disparities in medical care fail to explain them fully. In both cases, physician decision-making appears to contribute as well, suggesting that subconscious biases may contribute to treatment disparities. We conclude by proposing initiatives to remedy race and sex disparities in medical care. Efforts should focus on increasing physician awareness of this problem. Studies should gather data that are currently unavailable for analysis, including detailed clinical variables and patient-level socioeconomic information. Finally, novel quality assurance programs, designed to evaluate and improve the care of blacks and women with coronary artery disease, should be promptly undertaken.

Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure the better effectiveness after transition-heart failure (BEAT-HF) randomized clinical trial

IMPORTANCE It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization. OBJECTIVE To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF. DESIGN, SETTING, AND PARTICIPANTS We randomized 1437 patients hospitalized for HF between October 12, 2011, and September 30, 2013, to the intervention arm (715 patients) or to the usual care arm (722 patients) of the Better Effectiveness After Transition-Heart Failure (BEAT-HF) study and observed them for 180 days. The dates of our study analysis were March 30, 2014, to October 1, 2015. The setting was 6 academic medical centers in California. Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF. INTERVENTIONS The intervention combined health coaching telephone calls and telemonitoring. Telemonitoring used electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. Centralized registered nurses conducted telemonitoring reviews, protocolized actions, and telephone calls. MAIN OUTCOMES AND MEASURES The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life at 30 and 180 days. RESULTS Among 1437 participants, the median age was 73 years. Overall, 46.2% (664 of 1437) were female, and 22.0% (316 of 1437) were African American. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported. CONCLUSIONS AND RELEVANCE Among patients hospitalized for HF, combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01360203.

Neighborhoods and cumulative biological risk profiles by race/ethnicity in a national sample of U.S. Adults: NHANES III.

PURPOSE To examine race/ethnic-specific patterns of association between neighborhood socioeconomic status (NSES) and a cumulative biological risk index in a nationally representative population. METHODS The study sample included 13,199 white, black, and Mexican-American men and women, ages 20 and older, who attended the National Health and Examination Survey examination (1988-1994). Neighborhoods were defined as census tracts and linked to U.S. Census measures from 1990 and 2000, interpolated to the survey year; the NSES score included measures of income, education, poverty, and unemployment and was categorized into quintiles, with the highest indicating greater NSES. A summary biological risk score, allostatic load (AL; range 0-9), was created from 9 biological indicators of elevated risk: serum levels of C-reactive protein, albumin, glycated hemoglobin, total and high-density lipoprotein cholesterol, waist-to-hip ratio, systolic and diastolic blood pressure, and resting heart rate. Regression models stratified by race/ethnicity examined AL as a continuous and dichotomous (>or=3 vs. <3) outcome. RESULTS We found strong inverse associations between NSES and AL for black subjects, after adjusting for age, sex, U.S. birth, urban location, and individual SES. These associations were weaker and less consistent for Mexican Americans and whites. CONCLUSIONS Our results indicate that living in low NSES neighborhoods is most strongly associated with greater cumulative biological risk profiles in the black U.S. population.

Medicare’s Bundled Payment Pilot for Acute and Postacute Care: Analysis and Recommendations on Where to Begin

In the National Pilot Program on Payment Bundling, a subset of Medicare providers will receive a single payment for an episode of acute care in a hospital, followed by postacute care in a skilled nursing or rehabilitation facility, the patients home, or other appropriate setting. This article examines the promises and pitfalls of bundled payments and addresses two important design decisions for the pilot: which conditions to include, and how long an episode should be. Our analysis of Medicare data found that hip fracture and joint replacement are good conditions to include in the pilot because they exhibit strong potential for cost savings. In addition, these conditions pose less financial risk for providers than other common ones do, so including them would make participation in the program more appealing to providers. We also found that longer episode lengths captured a higher percentage of costs and hospital readmissions while adding little financial risk. We recommend that the Medicare pilot program test alternative design features to help foster payment innovation throughout the health system.

Cost implications of reduced work hours and workloads for resident physicians.

BACKGROUND Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads. METHODS We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events. RESULTS Annual labor costs from implementing the IOM recommendations were estimated to be

Medicare Spending and Outcomes After Postacute Care for Stroke and Hip Fracture

1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs (

How Much is Post-Acute Care Use Affected by its Availability?

1.1 billion to

Does place explain racial health disparities? Quantifying the contribution of residential context to the Black/white health gap in the United States

2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from