Between-state Variation Research Articles

Impact of the Affordable Care Act on health insurance access, coverage, and cost for refugees resettled in the USA

Abstract Background Refugees arriving in the USA are a vulnerable population with limited access to health insurance. The Affordable Care Act (ACA) has been heralded as an opportunity to reduce health-care disparities by improving access to health insurance. However there is substantial between-state variation with respect to enactment of Medicaid expansion and implementation of health-care insurance exchanges. We sought to describe the relation between 2012 refugee resettlement patterns and health-care insurance improvements created by the ACA. Methods We conducted a cross-sectional analysis of 2012 refugee resettlement data from all 50 states and the District of Columbia. We obtained data from the Office of Refugee Resettlement, the Kaiser Family Foundation, and the US Government health insurance website healthcare.gov. We compared resettlement data for states that have expanded Medicaid and implemented Health Insurance Exchange schemes and those that have not. We used the Wilcoxon rank sum test to investigate whether there was a relation between the price of insurance policies in each state and refugee resettlement rates there. Findings In 2012, 58 238 refugees from 85 countries were resettled in the USA. 32 389 refugees were resettled to 27 states that expanded Medicaid coverage under the ACA (median 555, range 0–5173 refugees per state). This rate did not differ from that for the 25 849 refugees who were resettled to 24 states not expanding Medicaid coverage (median 775 [0–5293]; p=0·7341). The median number of refugees resettled to the 17 states creating health insurance exchanges was 817 (1–5173), which was no higher than the median number of refugees resettled to the 34 states using the federal insurance exchange (601 [0–5923]; p=0·4906). The median monthly premium for a bronze health insurance plan did not differ between states with insurance exchanges ($232) and states with only the federal exchange ($264; p=0·1365). Interpretation In 2012, more refugees were resettled to states that have not expanded Medicaid or created state health insurance exchanges. Because many states have small or no refugee resettlement programmes, the difference in distribution of resettlement based on state insurance policies does not reach statistical significance. Future research should explore the effect of these differences in state policies on refugee health outcomes. Policymakers should consider between-state variation in access to insurance when devising refugee resettlement strategies. Funding None.

PRM105 - Valuing EQ-5D-5L: Can latent utilities derived from a discrete choice model be transformed to health utilities derived from time trade-off tasks?

The EuroQol Group is evaluating the use of discrete choice experiments (DCEs) in valuing health states from the 5-level EQ-5D (EQ-5D-5L). Notably, a discrete choice (DC) model yields a latent utility that is ordinal and unbounded, whereas health utilities must have interval properties and be anchored at 0 (representing death) and 1 (representing full health). Latent utilities must therefore be transformed to health utilities. This pilot study investigated the feasibility of performing such a transformation. 545 respondents from Canada and 403 respondents from the UK each completed a series of DC and TTO tasks. Generalised linear mixed models were used to derive latent utilities. Linear regression models incorporating logarithmic and polynomial terms, as well as non-parametric LOESS and spline models were assessed as candidate functions for transforming the latent utilities onto the health utilities. There was a high correlation between health utilities measured through TTO tasks and latent utilities derived from modelling of DC data (Spearman rho of 0.79 in Canada and 0.86 in the UK). All transforming functions explained the between-state variation in health utilities, and, upon cross-validation, had minimal bias and small mean squared errors. Whilst the transformation functions derived through linear regression had the desirable feature of being monotone, the LOESS transform in Canada and the spline transform in the UK lacked monotonicity. This pilot study suggests that transforming latent utilities to health utilities is feasible, and provides preliminary evidence that linear regression involving polynomial and logarithmic terms may be more desirable than non-parametric spline or LOESS functions.

Effect of latitude on the rate of change in incidence of Lyme disease in the United States

Tick-borne illnesses represent an important class of emerging zoonoses, with climate change projected to increase the geographic range within which tick-borne zoonoses might become endemic. We evaluated the impact of latitude on the rate of change in the incidence of Lyme disease in the United States, using publicly available data. We estimated state-level year-on-year incidence rate ratios (IRRs) for Lyme disease for the period 1993 to 2007 using Poisson regression methods. We evaluated between-state heterogeneity in IRRs using a random-effects meta-analytic approach. We identified state-level characteristics associated with increasing incidence using random-effects meta-regression. The incidence of Lyme disease in the US increased by about 80% between 1993 and 2007 (IRR per year 1.049, 95% CI [confidence interval] 1.048 to 1.050). There was marked between-state heterogeneity in the average incidence of Lyme disease, ranging from 0.008 per 100000 person-years in Colorado to 75 per 100000 in Connecticut, and significant between-state heterogeneity in temporal trends (p < 0.001). In multivariable meta-regression models, increasing incidence showed a linear association with state latitude and population density. These 2 factors explained 27% of the between-state variation in IRRs. No independent association was identified for other state-level characteristics. Lyme disease incidence increased in the US as a whole during the study period, but the changes were not uniform. Marked increases were identified in northern-most states, whereas southern states experienced stable or declining rates of Lyme disease.

480 DOES REGIONAL VARIATION IN BLADDER AUGMENTATION RATES CORRELATE WITH VARIATION IN RENAL OUTCOMES AMONG CHILDREN WITH SPINA BIFIDA?

You have accessJournal of UrologyPediatrics: Neuropathic Bladder/Reconstruction1 Apr 2013480 DOES REGIONAL VARIATION IN BLADDER AUGMENTATION RATES CORRELATE WITH VARIATION IN RENAL OUTCOMES AMONG CHILDREN WITH SPINA BIFIDA? Jessica Lloyd, Sherry Ross, John Wiener, and Jonathan Routh Jessica LloydJessica Lloyd Durham, NC More articles by this author , Sherry RossSherry Ross Durham, NC More articles by this author , John WienerJohn Wiener Durham, NC More articles by this author , and Jonathan RouthJonathan Routh Durham, NC More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1872AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bladder augmentation (BA) is a urologic surgical intervention for children with spina bifida (SB) and may be used to prevent renal failure. Recent research has suggested that the use of BA varies significantly between institutions. Our objectives were to (1) determine whether variation in rates of BA and other surgical procedures correlates with variation in urologic outcomes and (2) determine what factors are associated with variation in urologic surgery rates in children with SB. METHODS We used the 4 most recent years of the Kids' Inpatient Database (KID) (2000, 2003, 2006, & 2009) to identify hospitalized children with SB. Using ICD-9 codes from each inpatient hospitalization, we determined rates of BA and renal failure by state. We broadly defined renal outcomes as a diagnosis of acute or chronic renal failure or a procedure code for dialysis or renal transplant. We defined urologic surgery in SB children as BA, bladder outlet procedures or urinary diversion (eg, vesicostomy or ileal conduit). We calculated Spearman's correlation coefficients and used multivariate logistic regression to assess the relationship between surgical rates, renal failure rates, and other clinical predictors of interest. RESULTS We identified 32,259 inpatient SB admissions in 35 states. Of these, 863 (2.7%) were associated with a diagnosis of renal failure and 768 (2.4%) with BA. Renal failure rates in individual states varied from 1 to 9%, while BA rates varied from 0.4 to 6% between states. There was only a weak correlation between each state's rates of BA and renal failure (r=0.17, p<0.001). On multivariate analysis, urologic surgery rates were most closely associated with the specific state in which a patient was treated (OR range 0.2-6.9, p<0.001), patient age (OR 0.05/year, p<0.001), hospital teaching status (OR 4.1, p<0.001), lesion level (OR 6.9, p<0.001), and year of admission (OR 1.1, p<0.001. Renal failure was not associated with BA (p=0.34). These results were similar when analyzing either BA alone or BA in combination with other urologic surgeries. CONCLUSIONS There is significant between-state variation in the rates of both BA and renal failure. BA rates are only weakly correlated with renal failure, and on multivariate analysis renal failure was not associated with urologic surgery. The factors most strongly associated with variation in surgery rates were the state in which a patient was treated, patient age, hospital teaching status, level of SB lesion, and year of treatment. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byWang H, Lloyd J, Wiener J and Routh J (2016) Nationwide Trends and Variations in Urological Surgical Interventions and Renal Outcome in Patients with Spina BifidaJournal of Urology, VOL. 195, NO. 4 Part 2, (1189-1195), Online publication date: 1-Apr-2016. Volume 189Issue 4SApril 2013Page: e197 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jessica Lloyd Durham, NC More articles by this author Sherry Ross Durham, NC More articles by this author John Wiener Durham, NC More articles by this author Jonathan Routh Durham, NC More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Scoring the 5-Level EQ-5D

The EuroQol Group is evaluating the use of discrete choice experiments (DCEs) in valuing health states from the 5-level EQ-5D. Notably, a discrete choice (DC) model yields a latent utility that is ordinal and unbounded, whereas health utilities must have interval properties and be anchored at 0 (representing death) and 1 (representing full health). Latent utilities must therefore be transformed to health utilities. This pilot study investigated the feasibility of performing such a transformation. 545 respondents from Canada and 403 respondents from the UK each completed a series of DC and time tradeoff (TTO) tasks. Generalized linear mixed models were used to derive latent utilities. Linear regression models incorporating logarithmic and polynomial terms, as well as nonparametric LOESS and spline models, were assessed as candidate functions for transforming the latent utilities onto the health utilities. There was a high correlation between health utilities measured through TTO tasks and latent utilities derived from modeling of DC data (Spearman rho of 0.79 in Canada and 0.86 in the UK). All transforming functions explained the between-state variation in health utilities and, upon cross-validation, had minimal bias and small mean squared errors. Although the transformation functions derived through linear regression had the desirable feature of being monotone, the LOESS transform in Canada and the spline transform in the UK lacked monotonicity. This pilot study suggests that transforming latent utilities to health utilities is feasible, and the study provides preliminary evidence that linear regression involving polynomial and logarithmic terms may be more desirable than nonparametric spline or LOESS functions.

State Disparities in Time Trends of Adolescent Body Mass Index Percentile and Weight-Related Behaviors in the United States

Evidence is conflicting as to whether youth obesity prevalence has reached a plateau in the United States overall. Trends vary by state, and experts recommend exploring whether trends in weight-related behaviors are associated with changes in weight status trends. Thus, our objective was to estimate between-state variation in time trends of adolescent body mass index (BMI) percentile and weight-related behaviors from 2001 to 2007. A time series design combined cross-sectional Youth Risk Behavior Survey data from 272,044 adolescents in 29 states from 2001 to 2007. Self-reported height, weight, sports participation, physical education, television viewing, and daily consumption of 100% fruit juice, milk, and fruits and vegetables were collected. Linear mixed models estimated state variance in time trends of behaviors and BMI percentile. Across states, BMI percentile trends were consistent despite differences in behavioral trends. Boys experienced a modest linear increase in BMI percentile (ß=0.18, 95% CI: 0.07, 0.30); girls experienced a non-linear increase, as the rate of increase declined over time from 1.02 units in 2001-2002 (95% CI: 0.68, 1.36) to 0.23 units in 2006-2007 (95% CI: -0.09, 0.56). States in which BMI percentile decreased experienced a greater decrease in TV viewing than states where BMI percentile increased. Otherwise, states with disparate BMI percentile trends did not differ with respect to behaviors. Future research should explore the role of other behaviors (e.g., soda consumption), measurement units (e.g., portion size), and societal trends (e.g., urban sprawl) on state and national adiposity trends.

Geographic variation in opioid prescribing for acute, work‐related, low back pain and associated factors: A multilevel analysis

Given reports about variation in opioid prescribing, concerns about increasing opioid use and its associated negative consequences make understanding the sources of variability important. The aims of the study were to assess the extent of and factors associated with geographic variation in early opioid prescribing for acute, work-related, low back pain (LBP). Cases were selected from workers compensation administrative data filed between January 1, 2002 and December 31, 2003 and included claims from states with more than 40 cases. Early opioid prescribing (one or more prescriptions within first 15 days) was the outcome. Weighted coefficient of variation (wCOV) estimated geographic variation, and multilevel models measured variability controlling for individual and contextual factors. Of the 8,262 claimants, 21.3% received at least one early opioid prescription. Significant between-state variation was found (wCOV = 53%), from 5.7% (Massachusetts) to 52.9% (South Carolina). Seventy-nine percent of the between-state variation was explained by three contextual factors: state household income inequality (prevalence ratio [PR] 1.06, 95% confidence interval [CI] = 1.01, 1.12), number of physicians per capita (PR 0.99, 95% CI = 0.98, 0.99), and workers compensation cost containment effort score (PR 1.12, 95% CI = 1.02, 1.24). Individual-level factors, including severity, explained only a small portion of the geographic variability. Geographic variation of early opioid prescribing for acute LBP is important and almost fully explained by state-level contextual factors. The study suggests that clinician and patient interaction and the subsequent decision to use opioids are substantially framed by social conditions and control systems. Am. J. Ind. Med. 52:162-171, 2009. (c) 2008 Wiley-Liss, Inc.

The "Crisis" in Medical Malpractice Insurance

Since 1999, many states have experienced a "crisis" in medical malpractice insurance. The median premium increase for internists, general surgeons, and obstetricians-gynecologists increased from 0-2 percent in 1996-97 to 17-18 percent in 2003, climbing to 60 percent in some states in 2001-02, after adjusting for inflation. In December 2001, St. Paul Travelers, which was the largest malpractice insurer operating in forty-five states, announced its decision to withdraw from the market, citing losses of millions of dollars on its medical liability business. Two other major insurers— PHICO and Frontier Insurance Group—exited from the market entirely. Faced with insolvency, the Medical Inter-Insurance Exchange reorganized and restricted its operations to New Jersey. In some states, including Pennsylvania and New Jersey, physicians went on strike, threatened to leave the state, and discontinued high-risk services; however, a recent General Accounting Office study finds no conclusive evidence of widespread, measurable effects of the crisis on the availability of medical services.1 This most recent malpractice insurance crisis followed an unusually long period of flat or modest increases in premium rates and widespread availability of insurance, which, in turn, followed a severe crisis of affordability [End Page 55] in the 1980s and a severe crisis of affordability and availability in the mid-1970s. In response to these earlier crises, many states adopted reforms of tort law that were intended to reduce the level and unpredictability of claims, including caps on awards for noneconomic damages, collateral source offset, and shorter statutes of limitations. At the same time, some states adopted measures to assure the availability of insurance and reduce its cost to physicians. Joint underwriting associations serve as residual market mechanisms for physicians who are unable to obtain coverage in the voluntary market. Patient compensation funds limit the physician's liability at some threshold (for example, $200,000 per claim); additional compensation to the patient up to a higher threshold (for example, $1 million) is financed through assessments on all physicians practicing in the state. By shifting costs from individual defendants to all practicing physicians, with assessments levied on a pay-as-you-go basis, these funds produced short-term relief for physicians facing the highest premiums, particularly specialists in urban areas. In addition to these statutory changes, malpractice insurance markets adopted voluntary changes to reduce insurer risk and establish more robust sources of coverage. Most insurers replaced the occurrence policy form with the claims-made policy form, thereby shifting from insurer to policyholder the risk related to losses incurred, but not reported, during the policy period.2 In addition, in many states physicians established their own physician-owned mutuals, reciprocals, and risk retention groups. These physician-directed companies replaced the traditional commercial stock companies, many of which either withdrew or sharply curtailed their malpractice exposure during the crises of the 1970s and 1980s. In theory, physician-owned companies may have informational or risk-sharing advantages over stock companies in writing a line such as medical malpractice insurance.3 The most recent malpractice insurance crisis raises the question of whether these tort and insurance market reforms have achieved their goals of moderating premium increases. A General Accounting Office report on the current crisis concludes that, although physicians in most states have [End Page 56] experienced some increase in premium rates since 1999, the between-state variation has been significant.4 From 1999 to 2002, the largest writer of medical malpractice premiums for general surgeons in Dade County, Florida, increased premiums 75 percent, while Minnesota's largest insurer for general surgeons increased premiums only 2 percent for a similar level of coverage. Moreover, the rate of premium increase was significantly lower in states that enacted tort reforms, specifically, the placement of caps on awards for noneconomic damages (see figure 1). Although this evidence suggests that caps on awards for noneconomic damages slowed the growth in premiums, such...

Does the state you live in make a difference? Multilevel analysis of self-rated health in the US

This paper investigates the different sources of variation between US states in self-rated health using multilevel statistical procedures. The different sources that are considered are based on individual- and state-level factors. Data for the analysis comes from the 1993-94 Behavioral Risk Factor Surveillance System and the 1986-90 General Social Surveys. Results show that individual-level factors (such as low income, being black, smoking) are strongly associated with self-rated poor health. Significant variation, however, remain between states after allowing for individual characteristics. Crucially, between-state variation in self-rated health is different for different income groups. State-level contextual effects are found for per-capita median-income and ‘social capital’. While not strong, there seems to be a differential impact of state income-inequality on high-income groups, such that the affluent report better health from living in high inequality states. The paper substantiates the need to connect individual health to their macro socio-economic context. Importantly, it is argued that without adopting an explicitly multilevel approach, the debate on linkages between individual health and income-inequality/social capital cannot be adequately addressed.

VARIATION IN DEATH CERTIFICATION OF ISCHEMIC HEART DISEASE IN AUSTRALIA AND NEW ZEALAND

This study was designed to test the hypothesis that the between-State variation in death rates from ischemic heart disease may be due in part to variation in the manner in which death certificates are completed or the diagnoses on them are assigned numerical codes. Random samples of 75 doctors who had recently completed a death certificate in an Australian State or in Auckland, New Zealand, as well as all doctors who had recently completed a death certificate in the Northern Territory were asked to participate. They were sent a book of 10 actual case histories and asked to complete a death certificate for each case. Seventy per cent of the doctors returned death certificates (range from 64% to 81%). Each certificate was coded by the Australian Bureau of Statistics (ABS) in the doctor's State of residence, or by the New Zealand Health Statistics Centre for Auckland respondents, and then coded again by the federal office of the ABS in Canberra. There was considerable variation in the codes assigned to each case history but systematic variation large enough to account for the variation in between-State ischemic heart disease death rates was not seen. There was little systematic variation between codes assigned in each State and by the federal ABS office, although a few isolated discrepancies were identified which need attention by the ABS.(ABSTRACT TRUNCATED AT 250 WORDS)