Lorens A. Helmchen

Changes in the distribution of body mass index of white US men, 1890–2000

Objective: The study aimed to describe changes in the distribution of body mass index (BMI) among white non-Hispanic US men aged 40–69 years throughout the 20th century. Subjects: The subjects were 12 312 randomly drawn Union Army veterans examined between 1890 and 1900, and 4059 NHANES (National Health and Nutrition Examination Survey) participants examined between 1976 and 2000. Method: The study compared descriptive statistics of the age- and year-specific distributions of BMI. Results: Between 1890 and 2000, median BMI of men aged 50–59 years increased by 5.7 kg/m2 (25%), while the standard deviation almost doubled. In this age group, the current distribution of BMI is less right-skewed than in the earlier cohort. Obesity prevalence increased from 3.4% to 35%. In 1890–1894, median BMI declined with age, but by 2000 the age pattern had been reversed. The average annual growth rate of median BMI was lowest between 1900 and 1976 and has been rising to 0.5% per annum between 1988 and 2000. Conclusions: The increase in median BMI accounts for 75% of the rise in obesity prevalence between 1890 and 2000. The remainder must be attributed to changes in other features of the distribution, most notably the increased variance of BMI.

Responding to patient safety incidents: the “seven pillars”

Background Although acknowledged to be an ethical imperative for providers, disclosure following patient safety incidents remains the exception. The appropriate response to a patient safety incident and the disclosure of medical errors are neither easy nor obvious. An inadequate response to patient harm or an inappropriate disclosure may frustrate practitioners, dent their professional reputation, and alienate patients. Methods The authors have presented a descriptive study on the comprehensive process for responding to patient safety incidents, including the disclosure of medical errors adopted at a large, urban tertiary care centre in the United States. Results In the first two years post-implementation, the “seven pillars” process has led to more than 2,000 incident reports annually, prompted more than 100 investigations with root cause analysis, translated into close to 200 system improvements and served as the foundation of almost 106 disclosure conversations and 20 full disclosures of inappropriate or unreasonable care causing harm to patients. Conclusions Adopting a policy of transparency represents a major shift in organisational focus and may take several years to implement. In our experience, the ability to rapidly learn from, respond to, and modify practices based on investigation to improve the safety and quality of patient care is grounded in transparency.

Racial disparities in emergency general surgery: Do differences in outcomes persist among universally insured military patients?

BACKGROUND Racial disparities in surgical care are well described. As many minority patients are also uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30-/90-/180- day outcomes exist within a universally insured population of military-/civilian-dependent emergency general surgery (EGS) patients and ascertain whether differences in outcomes differentially persist in care received at military versus civilian hospitals and among sponsors who are enlisted service members versus officers. It also considered longer-term outcomes of EGS care. METHODS Five years (2006–2010) of TRICARE data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18 years) with primary EGS conditions, defined by the AAST. Risk-adjusted survival analyses assessed race-associated differences in mortality, major acute care surgery-related morbidity, and readmission at 30/90/180 days. Models accounted for clustering within hospitals and possible biases associated with missing race using reweighted estimating equations. Subanalyses considered restricted effects among operative interventions, EGS diagnostic categories, and effect modification related to rank and military- versus civilian-hospital care. RESULTS A total of 101,011 patients were included: 73.5% white, 14.5% black, 4.4% Asian, and 7.7% other. Risk-adjusted survival analyses reported a lack of worse mortality and readmission outcomes among minority patients at 30, 90, and 180 days. Major morbidity was higher among black versus white patients (hazard ratio [95% confidence interval): 30 days, 1.23 [1.13–1.35]; 90 days, 1.18 [1.09–1.28]; and 180 days, 1.15 [1.07–1.24], a finding seemingly driven by appendiceal disorders (hazard ratio, 1.69–1.70). No other diagnostic categories were significant. Variations in military- versus civilian-managed care and in outcomes for families of enlisted service members versus officers altered associations, to some extent, between outcomes and race. CONCLUSIONS While an imperfect proxy of interventions is directly applicable to the broader United States, the contrast between military observations and reported racial disparities among civilian EGS patients merits consideration. Apparent mitigation of disparities among military-/civilian-dependent patients provides an example for which we as a nation and collective of providers all need to strive. The data will help to inform policy within the Department of Defense and development of disparities interventions nationwide, attesting to important differences potentially related to insurance, access to care, and military culture and values. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III

How sensitive is physician performance to alternative compensation schedules? Evidence from a large network of primary care clinics

Despite its centrality for the provision of health care, physician compensation remains understudied, and existing studies either fail to control for time trends, cover small samples from highly particular settings, or examine empirically negligible changes in reward levels. Using a four-year sample of 59 physicians and 1.1 million encounters, we study how physicians at a network of primary care clinics responded when their salaried compensation plan was replaced with a lower salary plus substantial piece rates for encounters and select procedures. Although patient characteristics remained unchanged, physicians increased encounters by 11 to 61%, both by increasing encounters per day and days worked at the network, and increased procedures to the maximum reimbursable level.

The Effects of Consumer-Directed Health Plans on Health Care Spending

We use unique data from an insurer that exclusively offers high-deductible, “consumer-directed” health plans to identify the effect of plan features, notably employer contributions to the spending account, on health care spending. Our results show that the marginal dollar contributed by the employer to the spending account is entirely spent on outpatient and pharmacy services. In contrast, out-of-pocket spending was not responsive to the amount the employer contributes to the spending account. Our results represent the first plausibly causal estimates of the components of consumer-driven health plans on health spending. The magnitudes of the effects suggest important health care spending consequences to higher employer contributions to spending accounts. Our findings are most directly relevant to health reimbursement arrangement plan designs, though our results are still of value to health savings account plan designs.

Does advanced medical technology encourage hospitalist use and their direct employment by hospitals

In the United States, inpatient medical care increasingly encompasses the use of expensive medical technology and, at the same time, is coordinated and supervised more and more by a rapidly growing number of inpatient-dedicated physicians (hospitalists). In the production of inpatient care services, Hospitalist services can be viewed as complementary to sophisticated and expensive medical equipment in the provision of inpatient medical care. We investigate the causal relationship between a hospitals access to three types of sophisticated diagnostic and therapeutic medical equipment - intensity-modulated radiation therapy, gamma knife, and multi-slice computed tomography - and its likelihood of using hospitalists. To rule out omitted variables bias and reverse causality, we use technology-specific Certificate of Need regulation to predict technology use. We find a strong positive association, yet no causal link between access to medical technology and hospitalist use. We also study the choice of employment modality among hospitals that use hospitalists, and find that access to expensive medical technology reduces the hospitals propensity to employ hospitalists directly.

Health Savings Accounts: Growth Concentrated Among High-Income Households And Large Employers

Between 2005 and 2012, the share of employers whose employees had health savings accounts (HSAs) and the share of employees working at these employers grew more than tenfold. High-income and older tax filers both established HSAs and fully funded their HSAs at least four times as often as did low-income and younger filers.

Economic and technological development and their relationships to body size and productivity

Publisher Summary The growth in material wealth has been matched by changes in body size over the past 300 years, especially during the twentieth century. Perhaps the most remarkable secular trend has been the reduction in mortality. This chapter elucidates the long-run relationship between labor productivity and body size. Improvements in the nutritional status of a number of societies in Western Europe since the early eighteenth century have initiated a virtuous circle of technophysio evolution. The theory of technophysio evolution posits the existence of a synergism between technological and physiological improvements, which has produced a form of human evolution that is biological but not genetic, rapid, culturally transmitted, and not necessarily stable over time. An increase in agricultural efficiency and labor productivity improved human physiology, in turn leading to further gains in labor productivity. The chapter concludes with a summary of the findings that outline possible scenarios for further nutrition-induced changes in body size and labor productivity.

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years

BackgroundEnhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.ObjectiveTo test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.DesignWe compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.ParticipantsA total of 1,433,297 adults aged 18–64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.InterventionCareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.MeasuresOutcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.ResultsBy the third intervention year, annual adjusted total claims payments were

Provider-Induced Demand in the Treatment of Carotid Artery Stenosis: Variation in Treatment Decisions Between Private Sector Fee-for-Service vs Salary-Based Military Physicians

109 per participating member (95 % CI: −