Average Marginal Effects Research Articles

Revealing the impact of individual income inequality on different types of charitable giving in China through social interactions

AbstractObjectiveThis study delves into the correlation between individual income inequality as measured by the relative deprivation index and charitable giving, while also examining urban–rural heterogeneity. Additionally, it further explores the mechanisms by which online and offline forms of social interaction operate in this context.MethodsUtilizing data from the 2014–2020 China Family Panel Studies, we employed several methodologies including Probit regression models, cross‐model average marginal effects difference testing based on bootstrap method, instrumental variable method, and the Karlson–Holm–Breen (KHB) effect decomposition method.ResultsThe findings reveal that individual income inequality measured by the relative deprivation index significantly reduces charitable giving among Chinese households. The inhibitory effect of individual income inequality on social charitable giving is higher than that on charitable giving directed toward friends or colleagues. Furthermore, this impact exhibits some heterogeneity between urban and rural areas. Mechanism analysis indicates that the adverse effect of income inequality on charitable giving operates through reducing social interaction, including both online and offline forms.ConclusionOur results demonstrate that income inequality has distinct adverse effects on two types of charitable giving and explain the mechanisms underlying these effects through social interaction. A pattern of the differential mode of association similar to “ripples” in Chinese society is beneficial for understanding these differentiated impacts. We believe it is necessary to improve economic inequality conditions and enhance the enthusiasm of the Chinese public for participating in charitable donations by promoting various forms of social interaction.

Unveiling the dynamics of social engagement and subjective health in older adults: A gendered perspective

ObjectivesAs populations age globally, understanding the dynamics that influence the well-being of older individuals become increasingly crucial. The research employs a comprehensive approach to unravel the multifaceted interplay between social engagements and subjective health perceptions of older Indians, with a special focus on gender differences. Subjects and methodsThis study used data from the Longitudinal Aging Study in India (LASI) wave 1, 2017–18 with a total sample of 30,533 older adults aged 60 years and above. Bivariate analysis, chi-square tests and unadjusted and adjusted average marginal effects from logistic regression models were used to assess the relationship between social engagements and subjective health among older adults, stratified by gender. ResultsThe prevalence of poor health status decreased with higher frequency of social networks among both men (pp. (percentage point) = 6.1; CI (Confidence Interval): 10.6, 1.6) and women (pp. = 9.2; CI: 14.9, 3.4). The adjusted average marginal effects demonstrate that with an increase in the overall score of social engagement, the likelihood of poor health is almost reduced by half. For men, the prevalence of poor health was 9.8 pp. (95 % CI: 13.7, 5.8), while for women, it was 9.3 pp. (95 % CI: 15.2, 3.1). ConclusionGendered perspectives unveil unique patterns, highlighting how societal expectations and roles assigned to each gender may influence the subjective health perceptions of older individuals. This study adds to the expanding knowledge base to enhance the well-being and fulfillment of aging populations, considering the complex interplay of social dynamics and gendered perspectives.

Disaggregated behavioral responses to willingness‐to‐pay for the electronic levy in Ghana

AbstractThis study investigates the disaggregated behavioral responses of mobile money users' willingness to pay for electronic levy payments in Ghana. We use cross‐sectional survey primary data and a probit regression estimation technique with its associated average marginal effects and check robustness with a linear probability model. The evidence from the study indicates that the disaggregated behavioral factors that drive willingness to pay for the e‐levy include individuals maintaining their current levels of electronic fund transfers, the intention to increase their electronic fund transactions, and intention to stop using electronic fund transfers that attract the e‐levy. Beyond the disaggregated behavioral responses, psychological (e.g., trust in government) and socioeconomic factors (individual income and gender) are identified as important drivers of willingness to pay for the e‐levy. We suggest that policies around e‐levies must not only focus on individual behavioral responses alone, as the drivers include behavioral, psychological, and socioeconomic factors.Related ArticlesAdegboye, Alex, Kofo Adegboye, Uwalomwa Uwuigbe, Stephen Ojeka, and Eyitemi Fasanu. 2023. “Taxation, Democracy, and Inequality in Sub‐Saharan Africa: Relevant Linkages for Sustainable Development Goals.” Politics & Policy 51(4): 696–722. https://doi.org/10.1111/polp.12547.Lachapelle, Erick, Thomas Bergeron, Richard Nadeau, Jean‐François Daoust, Ruth Dassonneville, and Éric Bélanger. 2021. “Citizens' Willingness to Support New Taxes for COVID‐19 Measures and the Role of Trust.” Politics & Policy 49(3): 534–65. https://doi.org/10.1111/polp.12404.Shock, David R. 2013. “The Significance of Opposition Entrepreneurs on Local Sales Tax Referendum Outcomes.” Politics & Policy 41(4): 588–614. https://doi.org/10.1111/polp.12028.

Resilience, Survival, and Functional Independence in Older Adults Facing Critical Illness

Older adults surviving critical illness often experience new or worsening functional impairments. Modifiable positive psychological constructs, like resilience, may mitigate post-intensive care morbidity. Is pre-ICU resilience associated with: (1) post-ICU survival; (2) the drop in post-ICU functional independence; and (3) a lesser decline of independence before versus after the ICU? We performed a retrospective cohort study using Medicare-linked Health and Retirement Study surveys from 2006-2018. We included Older adults ≥65 years admitted to an ICU. We calculated resilience before ICU admission. The resilience measure was defined from the Simplified Resilience Score which was previously adapted and validated for the Health and Retirement Study. Resilience was scored using the leave-behind survey normalized to 0 (lowest resilience) to 12 (highest resilience) point scale. Outcomes were survival and probability of functional independence. We modeled survival using Gompertz models and independence using joint survival models adjusting for sociodemographic and clinical variables. We estimated average marginal effects to determine independence probabilities. Across 3,409 patients ≥65 years old admitted to ICUs, pre-existing frailty (30.5%) and cognitive impairment (24.3%) were common. Most patients were previously independent (82.7%). Mechanical ventilation occurred in 14.8% and sepsis in 43.2%. Highest versus lowest resilience had lower risk of post-ICU mortality (aHR 0.81 95% CI [0.70, 0.94]). Higher resilience was associated with greater likelihood in post-ICU independence (estimated probability of independence 5 years post-ICU in highest-to-lowest resilience: 0.53 CI 95% [0.33, 0.74], 0.47 [0.26, 0.68], 0.49 [0.28, 0.70], 0.36 [0.17, 0.55] p<0.01). Resilience was not associated with a difference in the drop of independence across resilience groups, nor a difference in declines of independence post-ICU. ICU survivors with higher resilience had increased rates of survival and functional independence, though the slope of functional decline did not differ by resilience group pre- to post-ICU.

Do no harm: the impact of implementing cancer prevention strategies on other preventive health measures

BackgroundTranslational efforts to increase uptake of evidence-based practices typically look at those outcomes in isolation of their impact on other aspects of care delivery. If we are in fact to “do no harm”, we must consider the possible negative impact of improving use of one practice on other quality measures. Alternatively, a focus on one practice could lead to spread of effective strategies to other practices, which would be highly beneficial. We studied the impact of a colorectal cancer (CRC) screening initiative on delivery of other preventive care measures.MethodsWe used an interrupted time series design with implementation year as the interruption point. The initiative was conducted between 2015 and 2020, with three staggered cohorts. Main outcomes were quality measures for colorectal cancer screening, cervical cancer screening, hypertension management, diabetes management, weight screening and follow-up, tobacco use screening and cessation treatment, and depression screening and follow-up.ResultsThe initiative was associated with an increase in CRC screening (OR = 1.67, p ≤ 0.01; average marginal effect = 12.2% points), and did not reduce performance on other quality measures in the year of CRC program implementation or a change in their respective secular trends.ConclusionsThe initiative led to a clinically meaningful increase in CRC screening and was not associated with reductions in delivery of six other preventive services. Quality improvement (QI) initiatives typically approach implementation with an eye towards reducing unintended impact and leveraging existing staff and resources. Implementation research studies may benefit from considering how QI initiatives factor in the local context in implementation efforts.

A Primary Care–Based Weight Navigation Program

Evidence-based weight management treatments (WMTs) are underused; strategies are needed to increase WMT use and patients' weight loss. To evaluate the association of a primary care-based weight navigation program (WNP) with WMT use and weight loss. This cohort study comprised a retrospective evaluation of a quality improvement program conducted from October 1, 2020, to September 30, 2021. Data analysis was performed from August 2, 2022, to March 7, 2024. Adults with obesity and 1 or more weight-related condition from intervention and control sites in a large academic health system in the Midwestern US were propensity matched on sociodemographic and clinical factors. WNP, in which American Board of Obesity Medicine-certified primary care physicians offered weight-focused visits and guided patients' selection of preference-sensitive WMTs. Primary outcomes were feasibility measures, including rates of referral to and engagement in the WNP. Secondary outcomes were mean weight loss, percentage of patients achieving 5% or more and 10% or more weight loss, referral to WMTs, and number of antiobesity medication prescriptions at 12 months. Of 264 patients, 181 (68.6%) were female and mean (SD) age was 49.5 (13.0) years; there were no significant differences in demographic characteristics between WNP patients (n = 132) and matched controls (n = 132). Of 1159 WNP-eligible patients, 219 (18.9%) were referred to the WNP and 132 (11.4%) completed a visit. In a difference-in-differences analysis, WNP patients lost 4.9 kg more than matched controls (95% CI, 2.11-7.76; P < .001), had 4.4% greater weight loss (95% CI, 2.2%-6.4%; P < .001), and were more likely to achieve 5% or more weight loss (odds ratio [OR], 2.90; 95% CI, 1.54-5.58); average marginal effects, 21.2%; 95% CI, 8.8%-33.6%) and 10% or more weight loss (OR, 7.19; 95% CI, 2.55-25.9; average marginal effects, 17.4%; 95% CI, 8.7%-26.2%). Patients in the WNP group were referred at higher rates to WMTs, including bariatric surgery (18.9% vs 9.1%; P = .02), a low-calorie meal replacement program (16.7% vs 3.8%; P < .001), and a Mediterranean-style diet and activity program (10.6% vs 1.5%; P = .002). There were no between-group differences in antiobesity medication prescribing. The findings of this cohort study suggest that WNP is feasible and associated with greater WMT use and weight loss than matched controls. The WNP warrants evaluation in a large-scale trial.

Association of Opioid and Concurrent Benzodiazepine, Skeletal Muscle Relaxant, and Gabapentinoid Usage on Healthcare Expenditure and Resource Utilization: A Serial Cross-Sectional Study, 2009 to 2019.

Healthcare providers may be utilizing central nervous system (CNS) depressants to reduce opioid use due to recent changes in public policy. Combination use of these agents with opioids increases the risk of respiratory depression and death. Healthcare expenditures by individuals using these drug combinations have not been previously quantified. We sought to characterize healthcare costs and expenditures associated with a population reporting concurrent CNS depressants and opioid use compared with nonopioid analgesics in the United States from 2009 to 2019. A serial cross-sectional design was used to compare the healthcare expenditures of adult Medical Expenditure Panel Survey respondents who were prescribed nonopioid analgesics, opioids only, opioids/benzodiazepines (BZD), opioids/BZD/skeletal muscle relaxants (SMR), or opioids/gabapentin (gaba) using pooled data from 2009 to 2019. Expenditure (cost and resource utilization) categories included inpatient, outpatient, office-based, and prescription medicine. Average marginal effects were used to compare survey-weighted annual costs and resource utilizations across the groups as compared to nonopioid analgesic respondents, adjusted for covariates. A weighted total of 34 241 838 individuals were identified. Most were opioid-only respondents (46.5%), followed by nonopioid analgesic (43.4%), opioid/BZD (5.3%), opioid-gaba (3.5%), and opioid/BZD/SMR respondents (1.3%). In comparison to the study groups with nonopioid analgesics, opioid-gaba users had the highest significant incremental cost difference among the different pairings (+$11 684, P < .001). Opioid-gaba, opioid/BZD, and opioid/BZD/SMR respondents had significantly higher inpatient, emergency department, and prescription drug costs and use compared to nonopioid analgesic respondents. Opioid-only respondents had higher outpatient and office-based costs and visits compared to nonopioid analgesic respondents. As healthcare providers seek to utilize fewer opioids for pain management, attention must be paid to ensuring safe and effective use of concurrent CNS depressants to mitigate high healthcare costs and burden.

Association of Patient-Reported Social Needs with Emergency Department Visits and Hospitalizations Among Federally Qualified Health Center Patients.

Health care systems are increasingly screening for unmet social needs. The association between patient-reported social needs and health care utilization is not well understood. To investigate the association between patient-reported social needs, measured by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), and inpatient and emergency department (ED) utilization. This cohort study analyzed merged 2017-2019 electronic health record (EHR) data across multiple health systems. Adult patients from a federally qualified health center (FQHC) in central North Carolina who completed PRAPARE as part of a primary care visit with behavioral health services. The count of up to 12 unmet social needs, aggregated as 0, 1, 2, or 3 + . Outcomes include the probability of an ED visit and hospitalization 12months after PRAPARE assessment, modeled by logistic regressions controlling for age, sex, race, ethnicity, comorbidity burden, being uninsured, and prior utilization in the past 12months. The study population consisted of 1924 adults (38.7% male, 50.1% Black, 36.3% Hispanic, 55.9% unemployed, 68.2% of patients reported 1 + needs). Those with more needs were younger, more likely to be unemployed, and experienced greater comorbidity burden. 35.3% of patients had ED visit(s) and 36.3% had hospitalization(s) 1year after PRAPARE assessment. In adjusted analysis, having 3 + needs was associated with a percentage point increase in the predicted probability of hospitalization (average marginal effect 0.06, SE 0.03, p < 0.05) compared with having 0 needs. Similarly, having 2 needs (0.07, SE 0.03, p < 0.05) or 3 + needs (0.06, SE 0.03, p < 0.05) was associated with increased probability of ED visits compared to 0 needs. Patient-reported social needs were common and associated with health care utilization patterns. Future research should identify interventions to address unmet social needs to improve health and avoid potentially preventable escalating medical intervention.

Costs and health care resource utilization among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia. However, published studies of CLL have either only focused on costs among individuals diagnosed with CLL without a non-CLL comparator group or focused on costs associated with specific CLL treatments. An examination of utilization and costs across different care settings provides a holistic view of utilization associated with CLL. To quantify the health care costs and resource utilization types attributable to CLL among Medicare beneficiaries and identify predictors associated with each of the economic outcomes among beneficiaries diagnosed with CLL. This retrospective study used a random 20% sample of the Medicare Chronic Conditions Data Warehouse (CCW) database covering the 2017-2019 period. The study population consisted of individuals with and without CLL. The CLL cohort and non-CLL cohort were matched using a 1:5 hard match based on baseline categorical variables. We characterized economic outcomes over 360 days across cost categories and places of services. We estimated average marginal effects using multivariable generalized linear regression models of total costs and across type of services. Total cost was compared between CLL and non-CLL cohorts using the matched sample. We used generalized linear models appropriate for the count or binary outcome to identify factors associated with various categories of health care resource utilization, such as inpatient admissions, emergency department (ED) visits, and oncologist/hematologist visits. A total of 2,736 beneficiaries in the CLL cohort and 13,571 beneficiaries in the non-CLL matched cohort were identified. Compared with the non-CLL cohort, the annual cost for the CLL cohort was higher (CLL vs non-CLL, mean [SD]: $22,781 [$37,592] vs $13,901 [$24,725]), mainly driven by health care provider costs ($6,535 vs $3,915) and Part D prescription drug costs ($5,916 vs $2,556). The main categories of health care resource utilization were physician evaluation/management visits, oncologist/hematologist visits, and laboratory services. Compared with beneficiaries aged 65-74 years, beneficiaries aged 85 years or older had lower use and cost in maintenance services (ie, oncologist visits, hospital outpatient costs, and prescription drug cost) but higher use and cost in acute services (ie, ED). Compared with residency in a metropolitan area, living in a nonmetropolitan area was associated with fewer physician visits but higher ED visits and hospitalizations. The cooccurrence of lower utilization of routine care services, along with higher utilization of acute care services among some individuals, has implications for patient burden and warrants further study.

Impact of anemia on outcomes and resource utilization in patients with myocardial infarction: A national database analysis

BackgroundAlthough anemia is common in patients with myocardial infarction (MI), management remains controversial. We quantified the association of anemia with in-hospital outcomes and resource utilization in patients admitted with MI using a large national database. MethodsAll hospitalizations with a primary diagnosis code for acute MI in the National Inpatient Sample (NIS) between 2014 and 2018 were identified. Among these hospitalizations, patients with anemia were identified using a secondary diagnosis code. Data on demographic and clinical variables were collected. Outcomes of interest included in-hospital adverse events, length of stay (LOS), and total cost. Multivariable logistic regression and generalized linear models were used to evaluate the relationship between anemia and outcomes. ResultsAmong 1,113,181 MI hospitalizations, 254,816 (22.8%) included concomitant anemia. Anemic patients were older and more likely to be women. After adjustment for demographics and comorbidities, anemia was associated with higher mortality (7.1 vs. 4.3%; odds ratio 1.09; 95% confidence interval [CI] 1.07–1.12, p < 0.001). Anemia was also associated with a mean of 2.71 days longer LOS (average marginal effects [AME] 2.71; 95% CI 2.68–2.73, p < 0.05), and $ 9703 mean higher total costs (AME $9703, 95% CI $9577–$9829, p < 0.05). Anemic patients who received blood transfusions had higher mortality as compared with those who did not (8.2% vs. 7.0, p < 0.001). ConclusionIn MI patients, anemia was associated with higher in-hospital mortality, adverse events, total cost, and length of stay. Transfusion was associated with increased mortality, and its role in MI requires further research.

Moderating Effects of Informal Care on the Relationship Between ADL Limitations and Adverse Outcomes in Stroke Survivors.

Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes. In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011-2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [<5.8], moderate [5.8-27.1], and high [27.2-350.4] hours per week) and their number of ADL limitations (ranging from 0 to 7). Participants were surveyed 1 year later to determine the number of adverse outcomes (ie, falls, hospitalizations, and physical function decline) experienced over the year. Poisson regression coefficients were converted to average marginal effects and estimated the moderating effects of informal caregiving hours per week on the relationship between ADL limitations and adverse outcomes. Stroke survivors were 69.7% White, 54.5% female, with an average age of 80.5 (SD, 7.6) years and 1.2 adverse outcomes at 2 years after the incident stroke. The relationships between informal caregiving hours and adverse outcomes and between ADL limitations and adverse outcomes were positive. The interaction between informal caregiving hours per week and ADL limitations indicated that those who received the lowest amount of informal caregiving had a rate of 0.12 more adverse outcomes per ADL (average marginal effect, 0.12 [95% CI, 0.005-0.23]; P=0.041) than those who received the highest amounts. Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.

Comparison of Hospital Mortality and Readmission Rates by Physician and Patient Sex.

Little is known as to whether the effects of physician sex on patients' clinical outcomes vary by patient sex. To examine whether the association between physician sex and hospital outcomes varied between female and male patients hospitalized with medical conditions. Retrospective observational study. Medicare claims data. 20% random sample of Medicare fee-for-service beneficiaries hospitalized with medical conditions during 2016 to 2019 and treated by hospitalists. The primary outcomes were patients' 30-day mortality and readmission rates, adjusted for patient and physician characteristics and hospital-level averages of exposures (effectively comparing physicians within the same hospital). Of 458 108 female and 318 819 male patients, 142 465 (31.1%) and 97 500 (30.6%) were treated by female physicians, respectively. Both female and male patients had a lower patient mortality when treated by female physicians; however, the benefit of receiving care from female physicians was larger for female patients than for male patients (difference-in-differences, -0.16 percentage points [pp] [95% CI, -0.42 to 0.10 pp]). For female patients, the difference between female and male physicians was large and clinically meaningful (adjusted mortality rates, 8.15% vs. 8.38%; average marginal effect [AME], -0.24 pp [CI, -0.41 to -0.07 pp]). For male patients, an important difference between female and male physicians could be ruled out (10.15% vs. 10.23%; AME, -0.08 pp [CI, -0.29 to 0.14 pp]). The pattern was similar for patients' readmission rates. The findings may not be generalizable to younger populations. The findings indicate that patients have lower mortality and readmission rates when treated by female physicians, and the benefit of receiving treatments from female physicians is larger for female patients than for male patients. Gregory Annenberg Weingarten, GRoW @ Annenberg.

Effect of exchange rate uncertainty, energy prices and sectoral spending on agriculture value added, household consumption, and domestic investment

The agricultural value chain is underpinned by the interdependence of agricultural value added, household consumption and domestic investment. Understanding the complex interactions between these microeconomic outcomes and the uncertainties in the macroeconomic variables of exchange rates, energy prices and sectoral spending remains under-researched. Therefore, this study examines the impact of exchange rate, energy prices and sectoral spending on agricultural value added, household consumption and domestic investment in Nigeria from 1981 to 2020. Using Kernel regularized least squares (KRLS), the results show that the average pointwise marginal effects of exchange rate and agricultural spending are positive, while the average pointwise marginal effect of energy price is significantly negative for the agricultural value-added model. The results also show that the exchange rate, energy prices and agricultural expenditure all have a positive effect on household consumption. Regarding domestic investment, the effect of the exchange rate is positive and statistically insignificant, while the effects of energy prices and agricultural expenditure are negative and statistically significant. The study recommends the need to strengthen the social safety nets currently in place in Nigeria to support households that are vulnerable to exchange rate fluctuations. In addition, incentives should be given to households and farmers to help use renewable energy sources such as solar or wind power for agricultural activities. Also, investment in value chains and agribusiness initiatives should be encouraged rather than just in crop production.

Demographics and clinical characteristics of patients of prescribing psychologists, psychiatrists, and primary care physicians.

To describe the characteristics of patients receiving psychotropic medication from prescribing psychologists, psychiatrists, and primary care physicians. This descriptive study was conducted using private insurance claims of patients from New Mexico and Louisiana receiving psychotropic medications (anticonvulsants, antidepressants, antipsychotics, hypotensive agents, anxiolytics/sedatives/hypnotics, and stimulants) from 2004 to 2021 (N = 307,478). Patient characteristics were captured during the 6 months prior to their first psychotropic medication using administrative information, diagnosis and procedure codes, and medication data. Logistic regression models estimated the associations of patient characteristics with prescriber type. Additional logistic regression models estimated the association of prescriber type with medication classes prescribed. Patients were most likely to see specialists (psychologists or psychiatrists) if they had bipolar disorder (average marginal effect and 95% CI 0.214 [0.196, 0.231]), schizophrenia/psychotic disorders (0.118 [0.097, 0.138]), or had 1-4 visits of psychotherapy (0.267 [0.258, 0.026]). Specialist patients were most likely to see a prescribing psychologist if they had 1-4 visits of psychotherapy (0.196 [0.183, 0.210]) or had insomnia (0.309 [0.203, 0.415]). Prescribing psychologists were more likely to prescribe antidepressants (0.028 [0.011, 0.045]) and less likely to prescribe antipsychotics (-0.016 [-0.020, -0.012]) than psychiatrists. Primary care physicians were less likely to prescribe all psychotropic medications except antidepressants (0.011 [0.002, 0.019]) and anxiolytics (0.074 [0.067, 0.080]). Prescribing psychologists treat patients who are more similar to those of psychiatrists than patients of primary care physicians; they are less likely to prescribe antipsychotics and more likely to prescribe antidepressants. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

DO seniors and IMGs have lower match probabilities than MD seniors after adjusting for specialty choice and USMLE Step 1 score.

It is unknown if US residency applicants of different educational backgrounds (US allopathic [MD], Doctor of Osteopathic Medicine [DO], and international medical graduates [IMG]) but comparable academic performance have similar match success. Our objective was to compare match probabilities between applicant types after adjusting for specialty choice and United States Medical Licensing Examination (USMLE) Step 1 scores. We performed a secondary analysis of published data in National Resident Matching Program (NRMP) reports from 2016, 2018, 2020, and 2022 for US MD seniors, DO seniors, and IMGs (US citizens and non-US citizens). We examined the 10 specialties with the most available spots in 2022. Average marginal effects from a multiple variable logistic regression model were utilized to estimate each non-MD senior applicant type's probability of matching into their preferred specialty compared to MD seniors adjusting for specialty choice, Step 1 score, and match year. Each non-MD applicant type had a lower adjusted percent difference in matching to their preferred specialty than MD seniors,-7.1 % (95 % confidence interval [CI],-11.3 to-2.9) for DO seniors,-45.6 % (-50.6 to-40.5) for US IMGs, and-56.6 % (-61.5 to-51.6) for non-US IMGs. Similarly, each non-MD applicant type had a lower adjusted percent difference in matching than MD seniors across almost all Step 1 score ranges, except for DO seniors with Step 1 scores <200 (-2.0 % [-9.5 to 5.5]). After adjusting for specialty choice, Step 1 score, and match year, non-US MD applicants had lower probabilities of matching into their preferred specialties than their US MD colleagues.

Goals of Care Among Patients With Advanced Cancer and Their Family Caregivers in the Last Years of Life

Understanding goals of care for terminally ill patients at the end of life is crucial to ensure that patients receive care consistent with their preferences. To investigate the patterns of goals of care among patient-caregiver dyads over the last years of the patient's life and the associations of the goals of care with patient-caregiver characteristics. This prospective cohort study of 210 patient-caregiver dyads involved surveys every 3 months from July 8, 2016, until the patient's death or February 28, 2022. Data from the last 2 years of the patients' lives were analyzed. Dyads, which comprised patients with stage IV solid cancer and their caregivers, were recruited from outpatient clinics at 2 major cancer centers in Singapore. Goals of care were examined via the tradeoffs between life extension and symptom management and between life extension and cost containment. The actor-partner interdependence framework was implemented using mixed-effects linear regressions. This study included 210 dyads (patients: mean [SD] age, 62.6 [10.5] years; 108 men [51.4%]; caregivers: mean [SD] age, 49.4 [14.6] years; 132 women [62.9%]). On average, 34% of patients (264 of 780 observations; range, 23%-42%) and 29% of caregivers (225 of 780 observations; range, 20%-43%) prioritized symptom management over life extension, whereas 24% of patients (190 of 780 observations; range, 18%-32%) and 19% of caregivers (148 of 780 observations; range, 8%-26%) prioritized life extension. Between cost containment and life extension, on average, 28% of patients (220 of 777 observations; range, 22%-38%) and 17% of caregivers (137 of 780 observations; range, 10%-25%) prioritized cost containment, whereas 26% of patients (199 of 777 observations; range, 18%-34%) and 35% of caregivers (271 of 780 observations; range, 25%-45%) prioritized life extension. Goals of care did not change as patients approached death. Patients prioritized symptom management if they experienced higher symptom burden (average marginal effect [SE], 0.04 [0.01]), worse spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and accurate (vs inaccurate) prognostic awareness (average marginal effect [SE], 0.40 [0.18]) and if their caregivers reported accurate prognostic awareness (average marginal effect [SE], 0.53 [0.18]), lower impact of caregiving on finances (average marginal effect [SE], -0.28 [0.08]), and poorer caregiving self-esteem (average marginal effect [SE], -0.48 [0.16]). Compared with patients, caregivers expressed lower preferences for cost containment (average marginal effect [SE], -0.63 [0.09]). Patients prioritized cost containment if they were older (average marginal effect [SE], 0.03 [0.01]), had higher symptom burden (average marginal effect [SE], 0.04 [0.01]), had poorer spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and their caregivers reported poorer caregiving self-esteem (average marginal effect [SE], -0.51 [0.16]) and more family support (average marginal effect [SE], -0.30 [0.14]). In this cohort study of patient-caregiver dyads, findings suggested the importance of interventions aimed at reducing discordance in goals of care between patients and caregivers and helping them develop realistic expectations to avoid costly, futile treatments.

Is Electronic Information Exchange Associated With Lower 30-Day Readmission Charges Among Medicare Beneficiaries?

Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions. Medicare Fee-for-Service Data, 2018. We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics. We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason. In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other. There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.

Association of Hospitals' Experience with Bundled Payment for Care Improvement Model with the Diffusion of Acute Hospital Care at Home.

To examine whether hospitals' experience in a prior payment model incentivizing care coordination is associated with their decision to adopt a new payment program for a care delivery innovation. Data were sourced from Medicare fee-for-service claims in 2017, the list of participants in Bundled Payment for Care Improvement initiatives (BPCI and BPCI-Advanced), the list of hospitals approved for Acute Hospital Care at Home (AHCaH) between November 2020 and August 2022, and the American Hospital Association Survey. Retrospective cohort study. Hospitals' adoption of AHCaH was measured as a function of hospitals' BPCI experiences. Hospitals' BPCI experiences were categorized into five mutually exclusive groups: (1) direct BPCI participation, (2) indirect participation through physician group practices (PGPs) after dropout, (3) indirect participation through PGPs only, (4) dropout only, and (5) no BPCI exposure. All data are derived from pre-existing sources. General acute hospitals eligible for both BPCI initiatives and AHCaH are included. Of 3248 hospitals included in the sample, 7% adopted AHCaH as of August 2022. Hospitals with direct BPCI experience had the highest adoption rate (17.7%), followed by those with indirect participation through BPCI physicians after dropout (11.8%), while those with no exposure to BPCI were least likely to participate (3.2%). Hospitals that adopted AHCaH were more likely to be located in communities where more peer hospitals participated in the program (median 10.8% vs. 0%). After controlling for covariates, the association of the adoption of AHCaH with indirect participation through physicians after dropout was as strong as with early BPCI adopter hospitals (average marginal effect: 5.9 vs. 6.2 pp, p < 0.05), but the other categories were not. Hospitals that participated in the bundled payment model either directly or indirectly PGPs were more likely to adopt a care delivery innovation requiring similar competence in the next period.

The Importance of Autonomy and Performance Goals in Perceived Workload Among Behavioral Health Providers.

The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration. The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models. In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload. Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.

Misspecified Exponential Regressions: Estimation, Interpretation, and Average Marginal Effects

Abstract Exponential regressions are frequently used when outcomes are non-negative. They are attractive because they are easy to interpret and to estimate, using pseudo maximum likelihood (PML). However, the validity of these methods depends on the correct specification of the conditional expectation, and little is known regarding their properties when the conditional expectation is misspecified. We show that PML estimators of misspecified exponential models provide optimal approximations to the conditional expectation, in a weighted mean squared error sense, and we give conditions under which their Poisson PML estimator identifies average marginal effects.