Significant State-level Variation Research Articles

Using U.S. Business Registry Data to Corroborate Corporate Identity: Case Study of the Legal Entity Identifier

This paper offers a fresh perspective on fundamental issues in using official incorporation records to corroborate the identity of corporate entities by comparing two publicly-available sets of information, namely, business registry incorporation records and reference data from the Legal Entity Identifier (LEI) system, with some focus on the monitoring function performed by LEI issuers as agents for LEI data users. Three modes of analysis are used to consider these issues, high-level analysis of LEI system data about U.S. entities with LEIs, interviews conducted with U.S. business registries, and entity-level comparisons of business registry and LEI records for entities with LEIs incorporated in the states of Ohio and Massachusetts. The fresh perspective provided here includes attention to key comparison issues such as truncation of Legal Names in official records; significant state-level variation in requirements to provide business address information in incorporation records or periodic reports; recognition that some key business register data may not be readily available or available only at a cost; whether in this context enhancements can be made to the expectations for, and disclosures by, LEI issuers in their monitoring role; and to what extent the high incidence of non-renewal of LEIs might play a role in the quality of LEI reference data. The paper develops measures of scope and degree for many key issues that can arise in using business registry information within an identity-corroboration context. The exceptional transparency of the LEI system allows for detailed comparisons that connect its data quality and value proposition with its sources and methods.

Associations of Obesity, Physical Activity, and Screening With State-Level Trends and Racial and Ethnic Disparities of Breast Cancer Incidence and Mortality in the US

Breast cancer causes disproportionate disease burden among various racial and ethnic groups in the US. However, state-level temporal trends and racial and ethnic disparities and whether metabolic and lifestyle factors and screening access are associated with temporal changes remain largely unknown. To investigate temporal trends and racial and ethnic variations at the state level and ecological correlations between obesity, physical activity, and mammography screening and breast cancer incidence and mortality trends among women in the US. A cross-sectional study was conducted to analyze breast cancer incidence and mortality trends among women in the US from January 1, 1999, to December 31, 2017, whereas an ecological analysis was performed to assess the associations. Data were analyzed from March 1, 2021, to September 30, 2021. Population-based cancer registry data were obtained from US Cancer Statistics incidence and mortality data. Prevalence of obesity, physical activity, and mammography screening were obtained from the Behavioral Risk Factor Surveillance System. Prevalence of obesity, physical activity, and mammography screening. Breast cancer incidence and mortality trends from 1999 to 2017 in the 50 US states and the District of Columbia. A total of 4 136 123 breast cancer cases and 782 454 deaths were included in the analysis, with a significant reduction in incidence (average annual percent change [AAPC], -0.4% [95% CI, -0.6% to -0.2%)]) and mortality (AAPC, -1.7% [95% CI, -1.8% to -1.5%]) during the study period. A significant state-level variation in breast cancer incidence and mortality between White women and those of other races and ethnicities was observed. A significant positive correlation was found between obesity and breast cancer incidence (r = 0.316; P = .02) and mortality (r = 0.400; P = .004) and an inverse correlation was found between physical activity and incidence (r = -0.577; P < .001) in women 55 years or older and mammography screening and mortality trends (r = -0.644; P < .001) in women 40 years or older. The findings of this cross-sectional study suggest that racial and ethnic disparities exist at the state level with regard to breast cancer incidence and mortality among women in the US. Metabolic and lifestyle factors and screening access were associated with the observed trends and racial and ethnic disparities. Interventions targeting these factors may help reduce the incidence of breast cancer and related deaths.

Does the Geographical Distribution of Facial Trauma Surgeons Correspond to Facial Trauma Burden? A Nationwide Population-Level Analysis.

It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/ regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x? = 2330.6 PMP), 28,004 surgeons (x? = 83.5 PMP), and 746 training positions (x? = 1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P < 0.01), surgeon (70.8 versus 98.8, P < 0.01), training positions (0 versus 3.4, P < 0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density ( P < 0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP ( P < 0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.

Prevalence and Correlates of HIV Testing among Sexual Minorities.

Objectives: We established baseline prevalence rates of HIV testing among adult, sexual minorities and identified the correlates of never being HIV tested. Methods: We used a 20-state sample of the 2017-2019 Behavioral Risk Factor Surveillance System to identify sexual minorities who responded to the HIV testing question (N=433,042). Using weighted multivariate logistic regression analysis, we identified the characteristics associated with never being HIV tested and the impact of state health departments' HIV testing messages on testing status. Results: Overall, 41.6% of sexual minorities reported never being HIV tested with statistically significant state-level variation. Being younger (18-24 years) or older (65+ years), not black, married, and in good health significantly increased the odds of never being HIV tested as did lacking regular healthcare access and reporting no high-risk HIV behaviors. States' HIV testing messages had no statistically significant effect on HIV testing status. Conclusions: Although sexual minorities were less likely than straight respondents to report never being HIV tested, a sizable population remained untested. Specific characteristics associated with sexual minorities' HIV testing status can be used to tailor public health messages and optimize testing rates.

Racial and geographic disparities in influenza vaccination in the U.S. among individuals with atherosclerotic cardiovascular disease: Renewed importance in the setting of COVID-19

IntroductionThe importance of receiving an annual influenza vaccine among patients with atherosclerotic cardiovascular disease (ASCVD) is well established. With the rapid community spread and the possibility of another wave of COVID-19 infections in the fall, receiving an influenza vaccine is of particular importance to mitigate the risk associated with overlapping influenza and COVID-19 infections. MethodsWe utilized cross-sectional data from the 2016 to 2019 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative U.S. telephone-based survey of adults 18 years or older. Race/ethnicity was our exposure of interest. We assessed the relative difference in influenza vaccination by race/ethnicity for each U.S. state in the overall U.S. population and among those with ASCVD as prevalence of receipt of influenza vaccination among Blacks or Hispanics minus prevalence among Whites divided by prevalence among Whites. We used multivariable-adjusted logistic regression models to evaluate the association between socioeconomic risk factors and receipt of influenza vaccination. ResultsThe study population consisted of 1,747,397 participants of whom 21% were older than 65 years, 51% women, 63% White, 12% Black, 17% Hispanic, and 9% with history of ASCVD. The receipt of influenza vaccine was 38% in the overall population and 51% among those with self-reported ASCVD, which translates to approximately to 97 million and 12 million US adults, respectively. The receipt of influenza vaccine among individuals with ASCVD was 54% for Whites, 45% for Blacks, and 42% for Hispanics (p<0.001). In the overall U.S. population, the median (interquartile range) relative difference for influenza vaccination between Blacks and Whites was 17% (-27%, -9%) and –22% (-29%, -9%) between Hispanics and Whites across all U.S. states. Among individuals with and without ASCVD, age older than 65 years, greater than college education, higher income, and having a primary care physician were significantly associated with higher odds of receipt of influenza vaccination, while being employed, lack of healthcare coverage, Black race, and delay in healthcare access were significantly inversely associated with having received an influenza vaccine ConclusionsOnly 50% patients with ASCVD receive influenza vaccines. The receipt of influenza vaccination among individuals with ASCVD is lower among Blacks and Hispanics compared to Whites with significant state-level variation. There are important socioeconomic determinants that are associated with receipt of the influenza vaccine.

State-Level Variation in Waitlist Mortality and Transplant Outcomes Among Patients Listed for Heart Transplantation in the US From 2011 to 2016

Little is known about geographic variation in the outcomes of adult patients listed for heart transplantation in the US. Identifying the patterns and extent of variation is important to minimize disparity in outcomes. To evaluate the geographic patterns, extent, and factors associated with state-level variation in outcomes of adult patients listed for heart transplantation in the US. This nationwide retrospective cohort study used data from the United Network for Organ Sharing database to identify adult patients listed for heart transplantation at status 1A between January 1, 2011, and December 31, 2016. Patients were followed up until March 31, 2018. Data were analyzed from November 1, 2019, to September 19, 2020. The study evaluated state-level variation in the 3 main organ transplant measures: waitlist mortality, transplant rate, and risk-adjusted 1-year graft survival. The rate of death while on the waitlist and the rate of transplant were calculated for each state per 1000 waitlist person-days listed at status 1A over the study period. Risk-adjusted 1-year graft survival was calculated based on the Scientific Registry of Transplant Recipients risk-adjustment model. State-level variation in each outcome measure was evaluated via multivariable-adjusted models. Across 50 states and the District of Columbia, a total of 15 036 patients (mean [SD] age, 52 [13] years; 3531 women [24%]; 9626 White [64%]) were listed at status 1A for adult heart transplantation between 2011 and 2016. Of those, 2146 patients (14.3%) died while on the waitlist, and 10 982 patients (73.0%) received transplants. Among those who received transplants, the median time on the waitlist was 31 days (interquartile range, 13-61 days). State-level outcomes ranged from 1.0 to 7.8 deaths per 1000 waitlist person-days for waitlist mortality, 5.6 to 34.5 transplants per 1000 waitlist person-days for transplant rate, and 87% to 92% for risk-adjusted 1-year graft survival. In a comparison of the highest and lowest quartiles, significant state-level variation was found in waitlist mortality (hazard ratio [HR], 1.53; 95% CI, 1.27-1.86), transplant rate (HR, 1.57; 95% CI, 1.31-1.87), and 1-year graft survival (odds ratio, 2.07; 95% CI, 1.64-2.62). The study's findings indicate that significant state-level variation exists in the outcomes of patients listed for heart transplantation in the US. Identifying and addressing the factors associated with these geographic variations in outcomes is important to ensure a fair allocation system.

The burden of anthropometric failure and child mortality in India

The public health burden of nutritional deficiency and child mortality is the major challenge India is facing upfront. In this context, using National Family Health Survey, 2015–16 data, this study estimated rate of composite index of anthropometric failure (CIAF) among Indian children by their population characteristics, across states and examined the multilevel contextual determinants. We further investigated district level burden of infant and child mortality in terms of multiple anthropometric failure prevalence across India. The multilevel analysis confirms a significant state, district and PSU level variation in the prevalence of anthropometric failures. Factors like- place of residence, household’s economic wellbeing, mother’s educational attainment, age, immunization status and drinking water significantly determine the different forms of multiple anthropometric failures. Wealth status of the household and mother’s educational status show a clear gradient in terms of the estimated odds ratios. The district level estimation of infant and child mortality demonstrates that districts with higher burden of multiple anthropometric failures show elevated risk of infant and child mortality. Unlike previous studies, this study does not use the conventional indices, instead considered the CIAF to identify the exact and severe form of undernutrition among Indian children and the associated nexus with infant and child mortality at the district level.

120. An enhanced risk-adjustment method for defining bundled payments in complex spine surgery: an analysis of Medicare beneficiaries

BACKGROUND CONTEXT Despite an increasing interest in adoption of bundled-payments as a means of controlling costs in the elective spine surgical cases, providers remain wary of extending these value-based reimbursement models in complex spine surgeries. Due to the variability seen in the difficulty of these complex cases–bundled-payment models will ultimately create dis-incentives among surgeons and providers if adequate risk-adjustment is not carried out in order to define appropriate target episode prices. The current BCPI model for complex spine surgery relies on the use of three DRG systems to stratify prices: (1) DRG-456: Spinal fusion except cervical, with spinal curvature/malignancy/infections or 9+ fusions with major comorbidities, (2) DRG-457: Spinal fusion except cervical, with spinal curvature/malignancy/infections or 9+ fusions with clinical complications and (3) DRG-459: Spinal fusion except cervical, with spinal curvature/malignancy/infections or 9+ fusions without clinical complications or major co-morbidities. While these DRG systems may be able to risk-adjust prices to some degree, based on the complexity of the patient at presentation, they do not take into account other important clinical factors. For instance, anterior fusions fall under one broad DRG umbrella, despite them having a different postoperative outcome as compared to posterior-only fusions. Similarly, these DRG systems also do not account for differences in principal diagnosis (infection vs tumor vs deformity). PURPOSE We propose an enhanced risk-adjustment model for defining 90-day bundled payments in complex spine surgeries. STUDY DESIGN/SETTING Retrospective analysis of 2008-2014 100% Medicare Standard Analytical Files (SAF100). PATIENT SAMPLE The 2008-2014 100% Medicare Standard Analytical Files (SAF5) were queried using DRG codes (456, 457 and 458) to identify patients undergoing complex spine surgery. Records were filtered to include those patients who had complete follow-up data starting from day 0 of surgery up to 90-days postoperatively. Patients who died during the 90-day follow-up period and/or had incomplete follow-up were excluded. Patients who had missing data with regard to gender, age and state were also excluded. OUTCOME MEASURES Factors associated with significant cost-variation in a DRG-based 90-day bundle for complex spine surgery. METHODS Multivariate linear regression models were built to assess the marginal cost-increase of patient-level (age and gender), geography-level (state), co-morbidities and principal diagnosis on 90-day costs, while controlling for other co-variates. RESULTS A total of 28,444 patients with complete cost-data were included in the study. The average 90-day cost of the entire study sample was $55,978 ± $33,741, with individual 90-day bundled reimbursements of DRG-456 = $87,281 ± $42,135, DRG-457 = $56,252 ± $29,359 and DRG-458 = $38,108 ± $19,356. Procedure-level factors associated with significant increases in 90-day costs were anterior fusions (+ $4,242), undergoing a 4-8 level fusion (+ $4,421), >8 level fusion (+ $16,416), use of interbody (+ $919), concurrent discectomy (+ $1,043), concurrent laminectomy (+ $2,202) and use of intraoperative neuromonitoring (+ $3,082). Undergoing surgery for infection/osteomyelitis was associated with higher costs (+ $6,217), as compared to patients undergoing surgical correction for primary deformity. The top five co-morbidities associated with the highest marginal cost increases were malnutrition (+ $12,511), CVA/stroke (+ $11,397), coagulopathy (+ $8,597), hyper-coagulopathy (+ $8,157) and obesity (+ $7,124). Significant state-level variation was seen, with Alaska (+ $29,208), Maryland (+ $20,126), Massachusetts (+ $18,834), Washington (+ $14,865), Vermont (+ $13,764) having the highest costs. CONCLUSIONS Due to the significant heterogeneity present in the DRG definitions of complex spine surgery, the current BPCI DRG-based bundled payment model is not entirely adequate for defining payments associated with these patients. For instance, infection cases should not be part of the same bundled payment episode as primary deformity cases. Physicians should promote the utilization of these additional, yet crucial factors, for risk-adjusting target 90-day episode prices and prevent the creation of a financial disincentive in a value-based care approach in complex spine cases. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Early Impact of India's Nationwide Lockdown on Aggregate Population Mobility and COVID-19 Cases

Background: In March 2020, India imposed a strict nationwide lockdown, making social distancing the primary nonpharmacologic mitigation strategy for the COVID-19 pandemic. To date, there has not been a comprehensive evaluation of the policy’s impact on mobility changes and state-level trajectory of COVID case growth. Understanding the effectiveness of the initial lockdown will inform policy efforts, given rising case counts in India following relaxation of the lockdown. Methods: Using a dataset on aggregated mobility changes in India, we conducted a retrospective interrupted time series analysis between February 15th and April 26th, 2020 to assess the combined impact of India’s nationwide curfew and lockdown on aggregate community mobility. Our primary outcomes were change in mobility to retail and recreation sites and change in state-level COVID-19 case growth rate. Secondary outcomes included mobility changes to other sites and time spent at home. We next assessed state-level variation. Finally, we examined the relationship between changes in aggregate mobility and the case growth rate of COVID-19. Findings: We observed an immediate and pronounced decrease in mobility following the policy’s implementation for all location categories examined. For our primary outcome, the national lockdown was associated with an 86% decrease to retail and recreational sites. However, the effects were not homogeneously sustained in the post-policy period. Visits to grocery stores and pharmacies (slope = 0.62% increase in visits per day) and transit stations (slope = 0.24%) began to recover, whereas visits to retail and recreation (slope = -0.41%), and parks (slope -0.47%) continued to decline during the post period. Significant state-level variation in mobility response was observed (71% to 95% decrease in visits to retail and recreation sites). States with the largest decrease in visits to retail and recreational sites were associated with a 7.2% rate of increase of COVID-19 in contrast to those states with the lowest decrease in mobility, which exhibited a 53% rate increase in COVID-19 cases (p=0.03). Interpretation: Our findings provide early evidence that India’s nationwide policy has been effective in both achieving its initial goal of decreased mobility and slowing the spread of COVID-19 cases. As the policy was nationwide, further research is needed to understand the drivers of state-level variation in mobility and COVID-19 case growth. Funding: This study was not funded. Declaration of Interests: GAW is a paid visiting scientist at Google Research. Other authors declare no conflict of interest.

Refining Risk-Adjustment of 90-day Costs Following Surgical Fixation of Ankle Fractures: Implications for a Bundled Payment Model

Category:TraumaIntroduction/Purpose:Current literature revolving around understanding cost-determinants of 90-day payments following ankle fractures is limited to single-institution studies. As the current healthcare model transitions from fee-for-service to value- based payments, risk-adjustment of 90-day payments will be a key factor driving success of these bundled payment models. The current study, utilizes a national Medicare database, to understand patient-level, procedure-level and state-level variation in 90-day payments following open reduction internal fixation (ORIF) of isolated ankle fractures.Methods:The 2005-2014 5% Medicare SAF (Standard Analytical Files) database was queries using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. All payments starting from day 0 of surgery up to day 90 post-operatively were used to calculate 90-day costs. Patients with missing data were excluded. Multi-variate linear regression modeling was used to derive marginal cost-impact of patient-level (age, gender, co-morbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy and syndesmotic fixation) and state-level factors on 90-day costs following surgery.Results:Following application of inclusion/exclusion criteria, a total of 6,499 patients were included in the study. The risk- adjusted 90-day price of a non-geriatric (age<65) female patient undergoing outpatient ORIF for a closed uni-malleolar ankle fracture was $8,915 ± $1,054. Individuals aged 65-69 vs. <65 had significantly lower costs (-$1,967). Procedure-level factors associated with significant marginal cost-increases were inpatient surgery (+$5,577), tri-malleolar fracture (+$1,082) and syndesmotic fixation (+$2,822). The top 5 co-morbidities with largest marginal cost-increases were chronic kidney disease (+$8,897), malnutrition (+$7,908), obesity (+$5,362), cerebrovascular disease/stroke (+$4,159) and anemia (+$3,087). Significant state-level variation in 90-day costs was seen with Nevada (+$6,371), Massachusetts (+$4,497), Oklahoma (+$4,002), New Jersey (+$3,802) and Maryland (+$3,043) having the highest marginal cost-increase and Idaho (-$6,025) having the lowest.Conclusion:Using a national administrative claims database, the study identifies numerous patient-level, procedure-level and state-level factors that significantly contribute to the cost-variation seen in 90-day payments following ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in fracture patients.

Refining risk adjustment for bundled payment models in cervical fusions—an analysis of Medicare beneficiaries

BACKGROUND CONTEXTThe current Bundled Payment for Care Improvement model relies on the use of “Diagnosis Related Groups” (DRGs) to risk-adjust reimbursements associated with a 90-day episode of care. Three distinct DRG groups exist for defining payments associated with cervical fusions: (1) DRG-471 (cervical fusions with major comorbidity/complications), (2) DRG-472 (with comorbidity/complications), and (3) DRG-473 (without major comorbidity/complications). However, this DRG system may not be entirely suitable in controlling the large amounts of cost variation seen among cervical fusions. For instance, these DRGs do not account for area/location of surgery (upper cervical vs. lower cervical), type of surgery (primary vs. revision), surgical approach (anterior vs. posterior), extent of fusion (1–3 level vs. >3 level), and cause/indication of surgery (fracture vs. degenerative pathology). PURPOSETo understand factors responsible for cost variation in a 90-day episode of care following cervical fusions. STUDY DESIGNRetrospective study of a 5% national sample of Medicare claims from 2008 to 2014 5% Standard Analytical Files (SAF5). OUTCOME MEASURESTo calculate the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day reimbursements for patients undergoing cervical fusions under DRG-471, DRG-472, and DRG-473. METHODSThe 2008 to 2014 Medicare SAF5 was queried using DRG codes 471, 472, and 473 to identify patients receiving a cervical fusion. Patients undergoing noncervical fusions (thoracolumbar), surgery for deformity/malignancy, and/or combined anterior-posterior fusions were excluded. Patients with missing data and/or those who died within 90 days of the postoperative follow-up period were excluded. Multivariate linear regression modeling was performed to assess the independent marginal cost impact of DRG, gender, age, state, procedure-level factors (including cause/indication of surgery), and comorbidities on total 90-day reimbursement. RESULTSFollowing application of inclusion/exclusion criteria, a total of 12,419 cervical fusions were included. The average 90-day reimbursement for each DRG group was as follows: (1) DRG-471=$54,314±$32,643, (2) DRG-472=$28,535±$17,271, and (3) DRG-473=$18,492±$10,706. The risk-adjusted 90-day reimbursement of a nongeriatric (age <65) female, with no major comorbidities, undergoing a primary 1- to 3-level anterior cervical fusion for degenerative cervical spine disease was $14,924±$753. Male gender (+$922) and age 70 to 84 (+$1,007 to +$2,431) was associated with significant marginal increases in 90-day reimbursements. Undergoing upper cervical surgery (−$1,678) had a negative marginal cost impact. Among other procedure-level factors, posterior approach (+$3,164), >3 level fusion (+$2,561), interbody (+$667), use of intra-operative neuromonitoring (+$1,018), concurrent decompression/laminectomy (+$1,657), and undergoing fusion for cervical fracture (+$3,530) were associated higher 90-day reimbursements. Severe individual comorbidities were associated with higher 90-day reimbursements, with malnutrition (+$15,536), CVA/stroke (+$6,982), drug abuse/dependence (+$5,059), hypercoagulopathy (+$5,436), and chronic kidney disease (+$4,925) having the highest marginal cost impacts. Significant state-level variation was noted, with Maryland (+$8,790), Alaska (+$6,410), Massachusetts (+$6,389), California (+$5,603), and New Mexico (+$5,530) having the highest reimbursements and Puerto Rico (−$7,492) and Iowa (−$3,393) having the lowest reimbursements, as compared with Michigan. CONCLUSIONSThe current cervical fusion bundled payment model fails to employ a robust risk adjustment of prices resulting in the large amount of cost variation seen within 90-day reimbursements. Under the proposed DRG-based risk adjustment model, providers would be reimbursed the same amount for cervical fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion, use of adjunct procedures (decompressions), and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Our findings suggest that defining payments based on DRG codes only is an imperfect way of employing bundled payments for spinal fusions and will only end up creating major financial disincentives and barriers to access of care in the healthcare system.

Patterns of Opioid Use in the 12 Months Following Geriatric Fragility Fractures: A Population-Based Cohort Study

ObjectivesFractures of the hip, distal radius, and proximal humerus are common in the Medicare population. This study's objective was to characterize patterns and duration of opioid use, including regional variations in use, after both surgical and nonoperative management. DesignPopulation-based cohort study. Setting and participantsA cohort of opioid-naïve community-dwelling US Medicare beneficiaries who survived a hip, distal radius, or proximal humerus fracture between January 1, 2007 and December 31, 2010. Cohort members were required to be opioid-naïve for 4 months prior to fracture. MeasuresWe analyzed the proportion of patients with an active opioid prescription in each month following the index fracture, and report continued fills at 12 months postfracture. We also compared opioid prescription use in fractures treated surgically and nonsurgically and characterized state-level variation in opioid prescription use at 3 months postfracture. ResultsThere were 91,749 patients included in the cohort. Hip fracture patients had the highest rate of opioid use at 12 months (6.4%), followed by proximal humerus (5.7%), and distal radius (3.7%). Patients who underwent surgical fixation of proximal humerus and wrist fractures had higher rates of opioid use in each of the first 12 postoperative months compared with those managed nonoperatively. There was significant variation of opioid use at the state level, ranging from 7.6% to 18.2% of fracture patients filling opioid prescriptions 3 months after the index fracture. Conclusions/ImplicationsOpioid-naïve patients sustaining fragility fractures of the hip, proximal humerus, or distal radius are at risk to remain on opioid medications 12 months after their index injury, and surgical management of proximal humerus and distal radius fractures increases opioid use in the 12 months after the index fracture. There is significant state-level variation in opiate consumption after index fracture in nonvertebral geriatric fragility fractures. Opportunity exists for targeted quality improvement efforts to reduce the variation in opioid use following common geriatric fragility fractures.

Burnout in Young Family Physicians: Variation Across States.

Family physicians 3 years out of training report high rates of emotional exhaustion and depersonalization, symptoms of burnout, with considerable variation between states. High rates of burnout among new family physicians is concerning and significant state-level variation suggests that state-related factors may contribute to or reduce burnout.

Payment Choice and the Future of Currency: Insights from Two Billion Retail Transactions

This paper uses transaction-level data from a large discount chain together with zip-code-level explanatory variables to learn about consumer payment choices across size of transaction, location, and time. With three years of data from thousands of stores across the country, we identify important economic and demographic effects; weekly, monthly, and seasonal cycles in payments, as well as time trends and significant state-level variation that is not accounted for by the explanatory variables. We use the estimated model to forecast how the mix of consumer payments will evolve and to forecast future demand for currency. Our estimates based on this large retailer, together with forecasts for the explanatory variables, lead to a benchmark prediction that the cash share of retail sales will decline by 2.54 percentage points per year over the next several years.

The effects of state-level scope-of-practice regulations on the number and growth of nurse practitioners

BackgroundIt is widely recognized that there is significant state-level variation in scope-of-practice regulations (SSoPRs) for nurse practitioners (NPs). PurposeThis study was designed to examine whether SSoPRs influence labor markets for NPs. MethodCross-sectional analysis examining how SSoPRs influence the number and growth in NPs; data from the Area Resource File and 2008 Pearson report were used. DiscussionRestrictive SSoPRs reduced the number of NPs by about 10 per 100,000 and reduced the growth rate by 25%. No difference was found between states with the most restriction and those with some restrictions. ConclusionsThese results imply that changes to practice regulations should not be incremental but should follow the current practices in the least restrictive states. Results also indicate that other factors (poverty, uninsurance rates, rurality) decreased the number of NPs, suggesting that solving the primary care provider shortage will require multiple strategies.

The Rise of Electronic Health Record Adoption Among Family Physicians

Realizing the benefits of adopting electronic health records (EHRs) in large measure depends heavily on clinicians and providers' uptake and meaningful use of the technology. This study examines EHR adoption among family physicians using 2 different data sources, compares family physicians with other office-based medical specialists, assesses variation in EHR adoption among family physicians across states, and shows the possibility for data sharing among various medical boards and federal agencies in monitoring and guiding EHR adoption. We undertook a secondary analysis of American Board of Family Medicine (ABFM) administrative data (2005-2011) and data from the National Ambulatory Medical Care Survey (NAMCS) (2001-2011). The EHR adoption rate by family physicians reached 68% nationally in 2011. NAMCS family physician adoption rates and ABFM adoption rates (2005-2011) were similar. Family physicians are adopting EHRs at a higher rate than other office-based physicians as a group; however, significant state-level variation exists, indicating geographical gaps in EHR adoption. Two independent data sets yielded convergent results, showing that adoption of EHRs by family physicians has doubled since 2005, exceeds other office-based physicians as a group, and is likely to surpass 80% by 2013. Adoption varies at a state level. Further monitoring of trends in EHR adoption and characterizing their capacities are important to achieve comprehensive data exchange necessary for better, affordable health care.

Geographic variation in cardiovascular inflammation among healthy women in the Women's Health Study.

BackgroundGeographic variation in traditional cardiovascular disease (CVD) risk factors has been observed among women in the US. It is not known whether state-level variation in cardiovascular inflammation exists or could be explained by traditional clinical risk factors and behavioral lifestyle factors.Methods and ResultsWe used multilevel linear regression to estimate state-level variation in inflammatory biomarker patterns adjusted for clinical and lifestyle characteristics among 26,029 women free of CVD. Participants derived from the Women's Health Study, a national cohort of healthy middle-aged and older women. Inflammatory biomarker patterns (plasma levels of high-sensitivity C-reactive protein (hsCRP), soluble intercellular adhesion molecule-1 (sICAM-1), and fibrinogen) were compared to state-level patterns of traditional CVD risk factors and global risk scores. We found that all three inflammatory biomarkers exhibited significant state-level variation including hsCRP (lowest vs. highest state median 1.3 mg/L vs. 2.7 mg/L, unadjusted random effect estimate 1st to 99th percentile range for log hsCRP 0.52, p<.001), sICAM-1 (325 ng/ml vs. 366ng/ml, unadjusted random effect estimate 1st to 99th percentile range 0.44, p<.001), and fibrinogen (322 mg/dL vs. 367 mg/dL, unadjusted random effect estimate 1st to 99th percentile range 0.41, p = .001). Neither demographic, clinical or lifestyle characteristics explained away state-level effects in biomarker patterns. Southern and Appalachian states (Arkansas, West Virginia) had the highest inflammatory biomarker values. Regional geographic patterns of traditional CVD risk factors and risk scores did not completely overlap with biomarkers of inflammation.ConclusionsThere is state-level geographic variation in inflammatory biomarkers among otherwise healthy women that cannot be completely attributed to traditional clinical risk factors or lifestyle characteristics. Future research should aim to identify additional factors that may explain geographic variation in biomarkers of inflammation among healthy women.

Access to community-based long-term care: Medicaid's role.

The authors explore state variation in expenditures for Medicaid community-based care services for the period 1990 to 1997. A random effects panel model is used to explore the relationship between state demographic, supply, economic, programmatic, and political factors and states' Medicaid community-based care expenditures. Although states increased provision of services over the study period, significant state-level variation was evident. Expenditures were positively associated with state per capita income, regulation of nursing home bed supply, and the number of Medicare home health users but were negatively related to nursing home bed supply. Recent legal rulings, combined with the demonstrated preferences of most individuals to receive care in the community, require policies to foster the expansion of Medicaid community-based care. The most consistent relationships that are amenable to policy intervention relate to state fiscal resources and long-term care supply regulation.