Health Management and Policy, Department of (SPH-HMP)

Area socioeconomic status and mortality after coronary artery bypass graft surgery: the role of hospital volume

Mon, 01 Jan 2007 00:00:00 GMT

Area socioeconomic status and mortality after coronary artery bypass graft surgery: the role of hospital volume Kim, C.; Diez Roux, Ana V.; Hofer, T. P.; Nallamothu, B. K.; Bernstein, S. J.; Rogers, M. A. Background Individuals of low socioeconomic status (SES) have reduced access to coronary artery bypass graft surgery (CABG). It is unknown if low-SES CABG patients have reduced access to hospitals with better outcomes. Methods We conducted a retrospective cohort analysis of the California CABG Mortality Reporting Program, consisting of individuals with zip code information who underwent CABG at participating hospitals in 1999-2000 (n = 18 961). Primary outcome measures were inhospital mortality after CABG; primary independent variables of interest were area-level SES, clinical risk factors, and hospital volume. We used 2-level hierarchical random-effects logit models to estimate the relationship between explanatory variables and inhospital mortality. Results Within high-volume hospitals, patients of low-SES areas had greater mortality than those of mid- and high-SES areas (2.5% vs 1.5% vs 1.8%, P = .024). However, there was no relationship between SES and mortality in lower-volume hospitals. Contrary to expectations, individuals of high-SES areas (42%) underwent surgery at low-volume hospitals more often than patients of low-SES areas (28%, P < .001), although mortality at low-volume hospitals was greater than that at high-volume facilities (P < .001). Discrepancies were not explained by distance traveled. Conclusions Mortality after CABG is modified by both SES and hospital volume. Within high-volume hospitals, patients of low-SES areas fared worse than patients of higher-SES areas. Patients of high SES tended to have CABG surgery at low-volume hospitals where mortality was greater and therefore had higher mortality than expected.

Take-Up of Medicare Part D and the SSA Subsidy: Early Results from the Health and Retirement Study

Mon, 01 Oct 2007 00:00:00 GMT

Take-Up of Medicare Part D and the SSA Subsidy: Early Results from the Health and Retirement Study Levy, Helen; Weir, David R. We analyze newly available data from the Health and Retirement Study on senior citizens’ take-up of Medicare Part D and the associated SSA Low-Income Subsidy. We find that economic factors – specifically, demand for prescription drugs - drove the decision to enroll in Part D. For the most part, individuals with employer-sponsored coverage in 2004 kept that coverage, as they should have. Individuals with no prescription drug coverage in 2004 mostly enrolled in Part D or obtained other coverage; many of those who remained without coverage reported that they do not use prescribed medicines. Take-up of the SSA “Extra Help” subsidy seems to have been more problematic, with many Part D beneficiaries unaware of the subsidy program or unsure about their eligibility. There is apparent under-reporting in the HRS of participation in the subsidy program, suggesting that some who profess to be unaware of the program may actually be participating in it. In terms of respondents’ subjective experiences of decision-making, the majority report having had little or no difficulty with the Part D enrollment decision and being confident that they made the right decision. Thus, for the most part, despite the complexity of the program, Medicare beneficiaries seem to have been able to make economically rational decisions in which they had confidence, although additional intervention for low-income beneficiaries may be desirable.

Equity of skilled delivery care in developing countries: financing and policy determinants

Tue, 01 Jan 2008 00:00:00 GMT

Equity of skilled delivery care in developing countries: financing and policy determinants Kruk, Margaret Elizabeth; Prescott, Marta R.; Galea, Sandro

The impact of time and day on the presentation of acute coronary syndromes

Fri, 01 Dec 2006 00:00:00 GMT

The impact of time and day on the presentation of acute coronary syndromes LaBounty, Troy; Eagle, Kim A.; Manfredini, Roberto; Fang, Jianming; Tsai, Thomas; Smith, Dean; Rubenfire, Melvyn Background The frequency of acute myocardial infarction (AMI) peaks on Mondays and in the mornings. However, the distribution of the types of acute coronary syndromes (ACS), including unstable angina (UA), has not been systematically evaluated. Hypothesis The distribution of the types of ACS and clinical presentations varies by time and day of admission. Methods A retrospective cohort study was conducted in 1,946 consecutive nontransfer ACS admissions (1999–2004) to a tertiary-care academic center to assess presenting clinical variables in patients admitted on days versus nights (6 P.M. –6 A.M. ) and weekdays versus weekends (Friday 6 P.M. –Monday 6 A.M. ). Results There were fewer ACS admissions than expected on nights and weekends (p < 0.001), but the proportion of patients with ACS presenting with ST-elevation myocardial infarction (STEMI) is 64% higher on weekends (p < 0.001) and 31% higher on nights (p = 0.001). This increased proportion with STEMI results in a greater proportion of ACS with AMI on weekends (↑10%, p = 0.001) and nights (↑7%, p = 0.001). Using multivariate modeling, the increase in patients with AMI on weekends was not explained by conventional risk predictors. Conclusions Although fewer patients with ACS presented on nights and weekends, patients at those times were more likely to have an AMI, driven largely by an increased proportion with STEMI at those times. Consideration should be given to these findings when developing clinical care paradigms, health care staffing needs, and when comparing new treatment outcomes in patients with ACS. Copyright © 2006 Wiley Periodicals, Inc. Wiley Periodicals, Inc.