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Open Access Publications from the University of California

Scholarly Works (33 results)

  • Thesis
  • Peer Reviewed
UCLA Electronic Theses and Dissertations (2017)

Access to high-quality mental health specialty care for primary care patients has historically been problematic. Behavioral health care integration into the patient-centered medical homes has been shown to be effective, but dissemination and implementation of these team-based models of care remain challenging to healthcare systems. As such, lessons can be learned from VA's national implementation of Primary Care–Mental Health Integration (PC-MHI). Here we devise and validate a new metric for VA clinic engagement in PC-MHI (number of PC-MHI service users/number of primary care patients) during each year.

This is a retrospective longitudinal cohort study of 112,737 primary care patients in 29 Southern California VA clinics from October 1, 2008 to September 30, 2013. First, we examined a subset of 66,638 patients with mental health diagnoses to understand access to mental health care and other healthcare services. Our multilevel regression models used clinic PC-MHI engagement to predict relative rates for the full-range of patient healthcare utilization and total VA costs, adjusting for year and clinic fixed effects, other clinic interventions, and patient characteristics. Then, we constructed quality metrics for 12,663 patients who were newly diagnosed to have depression. Our fully-adjusted regression models used clinic PC-MHI engagement to predict probabilities of follow-up within 84 and 180 days and receipt of minimally appropriate treatment for these patients.

Greater clinic PC-MHI engagement was associated with significantly more mental health visits and less non-primary care based mental health specialty (MHS) visits, consistent with a substitution of PC-MHI visits for MHS visits. It was associated with less general MHS visits, rather than more specialized MHS visits. This reduction appeared targeted at patients with mild-to-moderate mental illnesses (i.e., depression), rather than with serious mental illness (i.e., schizophrenia, bipolar disorder). Despite shifting mental health care for Veterans with less complicated mental illnesses from specialty to primary care, our findings demonstrated no difference in depression care quality. We did not find adverse impacts on ED visits, hospitalizations, total patient costs, or mortality. Therefore, PC-MHI may improve mental healthcare value for primary care patients, as it may have improved realized accessibility to mental health care without necessarily increasing costs.

    Cover page: Toward Understanding the Healthcare Value of Veterans Affairs' Primary Care – Mental Health Integration
    • Article
    • Peer Reviewed
    UCLA Previously Published Works (2010)

    Introduction

    Little is known about the effect of family structure on childhood obesity among US children. This study examines the effect of number of parents and number of siblings on children's body mass index and risk of obesity.

    Methods

    We conducted a secondary data analysis of the Early Childhood Longitudinal Study - Kindergarten Cohort (ECLS-K), which consists of a nationally representative cohort of children who entered kindergarten during 1998-1999. Our analyses included 2 cross-sectional outcomes and 1 longitudinal outcome: body mass index (BMI) calculated from measured height and weight, obesity defined as BMI in the 95th percentile or higher for age and sex, and change in BMI from kindergarten through fifth grade.

    Results

    Other things being equal, children living with single mothers were more likely to be obese by fifth grade than were children living with 2 parents (26% vs 22%, P = .05). Children with siblings had lower BMI and were less likely to be obese than children without siblings. We also found that living with a single mother or no siblings was associated with larger increases in BMI from kindergarten through fifth grade.

    Conclusion

    Children from single-mother families and, especially, children with no siblings are at higher risk for obesity than children living with 2 parents and children with siblings. These findings highlight the influential role that families play in childhood obesity. Additionally, they suggest that health care providers should consider the structure of children's families in discussions with families regarding childhood obesity.
      Cover page: Family structure and childhood obesity, Early Childhood Longitudinal Study - Kindergarten Cohort.
      • Article
      • Peer Reviewed
      UCLA Previously Published Works (2017)
      Traditional fee-for-service (FFS) Medicare's prospective payment systems for postacute care provide little incentive to coordinate care or control costs. In contrast, Medicare Advantage plans pay for postacute care out of monthly capitated payments and thus have stronger incentives to use it efficiently. We compared the use of postacute care in skilled nursing and inpatient rehabilitation facilities by enrollees in Medicare Advantage and FFS Medicare after hospital discharge for three high-volume conditions: lower extremity joint replacement, stroke, and heart failure. After accounting for differences in patient characteristics at discharge, we found lower intensity of postacute care for Medicare Advantage patients compared to FFS Medicare patients discharged from the same hospital, across all three conditions. Medicare Advantage patients also exhibited better outcomes than their FFS Medicare counterparts, including lower rates of hospital readmission and higher rates of return to the community. These findings suggest that payment reforms such as bundling in FFS Medicare may reduce the intensity of postacute care without adversely affecting patient health.
        Cover page: Less Intense Postacute Care, Better Outcomes For Enrollees In Medicare Advantage Than Those In Fee-For-Service
        • Article
        • Peer Reviewed
        UCLA Previously Published Works (2018)
        OBJECTIVE:To determine whether skilled nursing facilities (SNFs) chosen by health systems to participate in preferred provider networks exhibited differences in quality, costs, and patient outcomes relative to other SNFs after accounting for differences in case mix. DATA SOURCES:Medicare provider and claims data, 2012 and 2013. STUDY DESIGN:We compared SNFs included in preferred networks relative to other SNFs in the same market, prior to the establishment of preferred provider networks. DATA EXTRACTION METHODS:We linked the SNFs in our sample to facility characteristics and quality data. We identified SNF admissions and hospitalizations in claims data and limited the analysis to patients discharged from the hospitals in our sample. We obtained patient characteristics from Medicare summary files and the preceding hospital stay. PRINCIPAL FINDINGS:Preferred SNFs exhibited better performance across publicly reported quality measures. Patients admitted to preferred SNFs exhibited shorter stays, lower Medicare payments, and lower probability of SNF readmission relative to nonpreferred SNFs. CONCLUSIONS:Our results imply that health systems selected SNFs with lower resource use and better performance on quality measures. Thus, the trend toward preferred provider networks could have implications for Medicare spending and patient health.
          Cover page: Do Skilled Nursing Facilities Selected to Participate in Preferred Provider Networks Have Higher Quality and Lower Costs?
          • Article
          • Peer Reviewed
          UCLA Previously Published Works (2017)

          Background

          The belief that there is inefficiency, or the potential to improve patient health at current levels of spending, is driving the push for greater value in health care. Previous studies demonstrate overuse of a narrow set of services, suggesting provider inefficiency, but existing studies neither quantify inefficiency more broadly nor assess its variation across physician organizations (POs).

          Data and methods

          We used data on quality of care and total cost of care from 129 California POs participating in a statewide value-based pay-for-performance program. We estimated a production function with quality as the output and cost as the input, using a stochastic frontier model, to develop a measure of relative efficiency for each PO. To validate the efficiency measure, we examined correlations of PO efficiency estimates with indicators representing overuse of services.

          Results

          The estimated production function showed that PO quality was positively associated with costs, although there were diminishing marginal returns to spending. A certain minimum level of spending was associated with high quality even among efficient POs. Most strikingly, however, POs had substantial variation in efficiency, producing widely differing levels of quality for the same cost.

          Conclusions

          Differences among POs in the efficiency with which they produce quality suggest opportunities for improvements in care delivery that increase quality without increasing spending.
            Cover page: What Role Does Efficiency Play in Understanding the Relationship Between Cost and Quality in Physician Organizations?
            • Article
            • Peer Reviewed
            UCLA Previously Published Works (2014)
            Medicare continues to implement payment reforms that shift reimbursement from fee-for-service toward episode-based payment, affecting average and marginal payment. We contrast the effects of two reforms for home health agencies. The home health interim payment system in 1997 lowered both types of payment; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The home health prospective payment system in 2000 raised average but lowered marginal payment with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality.
              Cover page: Effects of Medicare payment reform: Evidence from the home health interim and prospective payment systems
              • Article
              • Peer Reviewed
              UCLA Previously Published Works (2016)
              PURPOSE: Much variation in individual-level cognitive function in late life remains unexplained, with little exploration of area-level/contextual factors to date. Income inequality is a contextual factor that may plausibly influence cognitive function. METHODS: In a nationally-representative cohort of older Americans from the Health and Retirement Study, we examined state- and metropolitan statistical area (MSA)-level income inequality as predictors of individual-level cognitive function measured by the 27-point Telephone Interview for Cognitive Status (TICS-m) scale. We modeled latency periods of 8-20 years, and controlled for state-/metropolitan statistical area (MSA)-level and individual-level factors. RESULTS: Higher MSA-level income inequality predicted lower cognitive function 16-18 years later. Using a 16-year lag, living in a MSA in the highest income inequality quartile predicted a 0.9-point lower TICS-m score (β = -0.86; 95% CI = -1.41, -0.31), roughly equivalent to the magnitude associated with five years of aging. We observed no associations for state-level income inequality. The findings were robust to sensitivity analyses using propensity score methods. CONCLUSIONS: Among older Americans, MSA-level income inequality appears to influence cognitive function nearly two decades later. Policies reducing income inequality levels within cities may help address the growing burden of declining cognitive function among older populations within the United States.
                Cover page: Lagged Associations of Metropolitan Statistical Area- and State-Level Income Inequality with Cognitive Function: The Health and Retirement Study.
                • Article
                • Peer Reviewed
                UCLA Previously Published Works (2023)
                BACKGROUND: Physician Orders for Life Sustaining Treatment (POLST) document instructions for intensity of care based upon patient care preferences. POLST forms generally reflect patients wishes and dictate subsequent medical care, but it is not known how POLST use and content among nursing home residents is associated with inpatient utilization across a large population. OBJECTIVE: Evaluate the relationship between POLST use and content with hospital utilization among nursing home residents in California. DESIGN: Retrospective cohort study using the Minimum Data Set linked to California Section S (POLST documentation), the Medicare Beneficiary Summary File, and Medicare line item claims. PATIENTS: California nursing home residents with Medicare fee-for-service insurance, 2011-2016. MAIN MEASURES: Hospitalization, days in the hospital, and days in the intensive care unit (ICU) after adjustment for resident and nursing home characteristics. KEY RESULTS: The 1,112,834 residents had a completed and signed (valid) POLST containing orders for CPR with Full treatment 29.6% of resident-time (in person-years) and a DNR order with Selective treatment or Comfort care 27.1% of resident-time. Unsigned POLSTs accounted for 11.3% of resident-time. Residents experienced 14 hospitalizations and a mean of 120 hospital days and 37 ICU days per 100 person-years. Residents with a POLST indicating CPR Full treatment had utilization nearly identical to residents without a POLST. A gradient of decreased utilization was related to lower intensity of care orders. Compared to residents without a POLST, residents with a POLST indicating DNR Comfort care spent 56 fewer days in the hospital and 22 fewer days in the ICU per 100 person-years. Unsigned POLST had a weaker and less consistent relationship with hospital utilization. CONCLUSIONS: Among California NH residents, there is a direct relationship between intensity of care preferences in POLST and hospital utilization. These findings emphasize the importance of a valid POLST capturing informed preferences for nursing home residents.
                  Cover page: Relationship of POLST to Hospitalization and ICU Care Among Nursing Home Residents in California.
                  • Article
                  • Peer Reviewed
                  UCLA Previously Published Works (2018)

                  Objective

                  To evaluate the association between racial residential segregation, a prominent manifestation of systemic racism, and the White-Black survival gap in a contemporary cohort of adults, and to assess the extent to which socioeconomic inequality explains this association.

                  Design

                  This was a cross sectional study of White and Black men and women aged 35-75 living in 102 large US Core Based Statistical Areas. The main outcome was the White-Black survival gap. We used 2009-2013 CDC mortality data for Black and White men and women to calculate age-, sex- and race adjusted White and Black mortality rates. We measured segregation using the Dissimilarity index, obtained from the Manhattan Institute. We used the 2009-2013 American Community Survey to define indicators of socioeconomic inequality. We estimated the CBSA-level White-Black gap in probability of survival using sequential linear regression models accounting for the CBSA dissimilarity index and race-specific socioeconomic indicators.

                  Results

                  Black men and women had a 14% and 9% lower probability of survival from age 35 to 75 than their white counterparts. Residential segregation was strongly associated with the survival gap, and this relationship was partly, but not fully, explained by socioeconomic inequality. At the lowest observed level of segregation, and with the Black socioeconomic status (SES) assumed to be at the White SES level scenario, the survival gap is essentially eliminated.

                  Conclusion

                  White-Black differences in survival remain wide notwithstanding public health efforts to improve life expectancy and initiatives to reduce health disparities. Eliminating racial residential segregation and bringing Black socioeconomic status (SES) to White SES levels would eliminate the White-Black survival gap.
                    Cover page: Racial residential segregation, socioeconomic disparities, and the White-Black survival gap
                    • Article
                    • Peer Reviewed
                    UCLA Previously Published Works (2007)

                    Background

                    The Robert Wood Johnson Foundation funded Hablamos Juntos (HJ), a $10-million multiyear demonstration to improve access to health care for Latinos with limited English proficiency and to explore cost-effective ways for health care organizations to provide language access services.

                    Hablamos juntos

                    In this manuscript, the authors draw on their experiences in evaluating HJ, provide brief descriptions of innovative interventions, estimate operating costs, and synthesize lessons learned about implementation. A number of barriers and facilitators are documented.

                    Conclusion

                    The experience of HJ grantees provides guidance for organizations contemplating similar efforts. In particular, it highlights the need for health care organizations to involve physicians in the design and adoption of language services.
                      Cover page: Language Access Services for Latinos with Limited English Proficiency: Lessons Learned from Hablamos Juntos
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