Li Wu Chen

Reducing Racial And Ethnic Disparities In Colorectal Cancer Screening Is Likely To Require More Than Access To Care

Colorectal endoscopy, an effective screening intervention for colorectal cancer, is recommended for people age fifty or older, or earlier for those at higher risk. Rates of colorectal endoscopy are still far below those recommended by the US Preventive Services Task Force. This study examined whether factors such as the supply of gastroenterologists and the proportion of the local population without health insurance coverage were related to the likelihood of having the procedure, and whether these factors explained racial and ethnic differences in colorectal endoscopy. We found evidence that improving access to health care at the county and individual levels through expanded health insurance coverage could improve colorectal endoscopy use but might not be sufficient to reduce racial and ethnic disparities in colorectal cancer screening. Policy action to address these disparities will need to consider other structural and cultural factors that may be inhibiting colorectal cancer screening.

Tracking the effectiveness of health care reform in China: A case study of community health centers in a district of Beijing

OBJECTIVES To track and evaluate the effectiveness since 2007 of urban health reform policies in Beijing that provided universal health insurance and strengthened local government-owned community health centers (CHCs). METHODS Pre- and post-reform data on outpatient visits, staff, and financial statements among all CHCs in a district in Beijing were analyzed by the nonparametric Kruskal-Wallis method. Field surveys were also conducted to supplement the statistical analysis. RESULTS The post-reform data showed a substantial increase in outpatient visits at the district level, but the number of outpatient visits was flat at the CHC level. In addition, short-term CHC responses to reform policies, such as employment growth, and operating expense-to-revenue ratio, have not been cost effective. CONCLUSION The overall increase in outpatient visits at the district level, including at large hospitals, conceals the fact that CHCs within the district were unable to attract a greater number of patients. The lack of operational efficiency in the process of establishing and transforming CHCs may put the primary care system at financial risk in the long run. Well-synchronized policy measures should be considered in future reforms, especially in shaping the behaviors of patients, CHCs, and physicians.

The magnitude, variation, and determinants of rural hospital resource utilization associated with hospitalizations due to ambulatory care sensitive conditions.

Using data from the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, we examined the magnitude, variation, and determinants of rural hospital resource utilization associated with hospitalizations due to ambulatory care sensitive conditions (ACSCs). An estimated

Uninsured hospitalizations: rural and urban differences.

9.5 billion in charges incurred in rural hospitals nationwide in 2002 was found to be associated with hospitalizations due to ACSCs. Our findings suggest that the smaller a rural hospital, the greater the portion of its financial resources used to treat patients with ACSC. Regional variation in ACSC-related hospital charges is generally consistent with the geographic variation in the populations economic status and primary care physician supply-residents of the South region have the poorest access to primary healthcare. In summary, smaller rural communities spend more of their healthcare resources on avoidable hospital inpatient care than do larger rural communities, leaving smaller rural communities potentially fewer resources to spend on preventive and primary healthcare. Health intervention programs and health policies should be designed to increase access to and utilization of appropriate preventive and primary healthcare in rural areas, especially in small and remote communities.

Does Prospective Payment Really Contain Nursing Home Costs

CONTEXT Few studies have examined hospitalization patterns among the uninsured, especially from the perspective of rural and urban differences. PURPOSE To examine whether the patterns of uninsured hospitalizations differ in rural and urban hospitals and to identify the most prevalent and costly diagnoses among uninsured hospitalizations. METHODS We conducted a cross-sectional analysis of the Healthcare Cost and Utilization Projects National Inpatient Sample representing a total of 37,804,021 hospital discharges, with 4.9% of them generated by uninsured persons in 2002. We compared demographic and clinical characteristics and the proportion of frequent and costly diagnoses by rural and urban hospitals. We used multiple logistic regression models to examine the relationship between preventable conditions and rural and urban hospitals among uninsured hospitalizations. FINDINGS Uninsured persons discharged from rural hospitals were more likely than their urban counterparts to be working-age adults (82% vs 79%) and to reside in a ZIP code area with a median household income of less than

Predictive Model to Determine Need for Nursing Workforce

35,000 per year (56% vs 26%). Rural uninsured hospitalizations were more likely to be for preventable conditions than were urban uninsured hospitalizations (P < .001). The proportion of total hospital charges related to preventable hospitalizations was 15.5% in rural hospitals versus 10.0% in urban hospitals. CONCLUSIONS The patterns of uninsured hospitalizations in rural and urban hospitals were different in many ways. Providing adequate access to primary care could result in potential savings related to preventable hospitalizations for the uninsured, especially for rural hospitals.

The Economies of Scale for Nursing Home Care

OBJECTIVE To examine whether nursing homes would behave more efficiently, without compromising their quality of care, under prospective payment. DATA SOURCES Four data sets for 1994: the Skilled Nursing Facility Minimum Data Set, the Online Survey Certification and Reporting System file, the Area Resource File, and the Hospital Wage Indices File. A national sample of 4,635 nursing homes is included in the analysis. STUDY DESIGN Using a modified hybrid functional form to estimate nursing home costs, we distinguish our study from previous research by controlling for quality differences (related to both care and life) and addressing the issues of output and quality endogeneity, as well as using more recent national data. Factor analysis was used to operationalize quality variables. To address the endogeneity problems, instrumental measures were created for nursing home output and quality variables. PRINCIPAL FINDINGS Nursing homes in states using prospective payment systems do not have lower costs than their counterpart facilities under retrospective cost-based payment systems, after quality differences among facilities are controlled for and the endogeneity problem of quality variables is addressed. CONCLUSIONS The effects of prospective payment on nursing home cost reduction may be through quality cuts, rather than cost efficiency. If nursing home payments under prospective payment systems are not adjusted for quality, nursing homes may respond by cutting their quality levels, rather than controlling costs. Future outcomes research may provide useful insights into the adjustment of quality in the design of prospective payment for nursing home care.

Disparities in the receipt of robot-assisted radical prostatectomy: between-hospital and within-hospital analysis using 2009–2011 California inpatient data

This article describes a statistical modeling study designed to improve targets of need for registered nurse (RN) workforce. The model is place-based and incorporates the concepts of clinical need and regional service utilization. A cross-sectional study was conducted in Nebraska (1993-1999), and the unit of study was the county (N = 66). A mixed-model approach was used, and five predictor variables (% age 20-44,% age 45-64,% age 65+,% White non-Hispanic, and area) were significantly (p < .001) associated with service demand. Coefficient estimates were applied to various population projection scenarios, and the model’s algorithm converted service demand into number of RNs needed to compare numbers of RNs employed with projected need. The implications for RN workforce policy and funding decisions—at both federal and state levels—are significant. Further research with a larger, multistate database will be conducted to refine the model and demonstrate generalizability.

Effectiveness and challenges of regional public health partnerships in Nebraska.

Using a modified hybrid short-term operating cost function and a national sample of nursing homes in 1994, the authors examined the scale economies of nursing home care. The results show that scale economies exist for Medicare postacute care, with an elasticity of –0.15 and an optimal scale of around 4,000 patient days annually. However, more than 68 percent of nursing homes in the analytic sample produced Medicare days at a level below the optimal scale. The financial pressures resulting from the implementation of a prospective payment system for Medicare skilled nursing facilities may further reduce the quantity of Medicare days served by nursing homes. In addition, the results show that chain-owned nursing homes do not have lower short-term operating costs than do independent facilities. This indicates that the rationale behind recent increasing horizontal integration among nursing homes may not be seeking greater cost efficiency but some other consideration.

A Comparison of the J-1 Visa Waiver and Loan Repayment Programs in the Recruitment and Retention of Physicians in Rural Nebraska

Objectives Despite the rapid proliferation of robot-assisted radical prostatectomy (RARP), little attention has been paid to patient utilisation of this newest surgical innovation and barriers that may result in disparities in access to RARP. The goal of this study is to identify demographic and economic factors that decrease the likelihood of patients with prostate cancer (PC) receiving RARP. Design, setting and participants A retrospective, pooled, cross-sectional study was conducted using 2009–2011 California State Inpatient Data and American Hospital Association data. Patients who were diagnosed with PC and underwent radical prostatectomy (RP) from 225 hospitals in California were identified, using ICD-9-CM diagnosis and procedure codes. Primary outcome measures Patients’ likelihood of receiving RARP was associated with patient and hospital characteristics using the two models: (1) between-hospital and (2) within-hospital models. Multivariate binomial logistic regression was used for both models. The first model predicted patient access to RARP-performing hospitals versus non-RARP-performing hospitals, after adjusting for patient and hospital-level covariates (between-hospital variation). The second model examined the likelihood of patients receiving RARP within RARP-performing hospitals (within-hospital variation). Results Among 20 411 patients who received RP, 13 750 (67.4%) received RARP, while 6661 (32.6%) received non-RARP. This study found significant differences in access to RARP-performing hospitals when race/ethnicity, income and insurance status were compared, after controlling for selected confounding factors (all p<0.001). For example, Hispanic, Medicare and Medicaid patients were more likely to be treated at non-RARP-performing hospitals versus RARP-performing hospitals. Within RARP-performing hospitals, Medicaid patients had 58% lower odds of receiving RARP versus non-RARP (adjusted OR 0.42, p<0.001). However, there were no significant differences by race/ethnicity or income within RARP-performing hospitals. Conclusions Significant differences exist by race/ethnicity and payer status in accessing RARP-performing hospitals. Furthermore, payer status continues to be an important predictor of receiving RARP within RARP-performing hospitals.