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JAMA Jan 2020The tort liability system is intended to serve 3 functions: compensate patients who sustain injury from negligence, provide corrective justice, and deter negligence....
IMPORTANCE
The tort liability system is intended to serve 3 functions: compensate patients who sustain injury from negligence, provide corrective justice, and deter negligence. Deterrence, in theory, occurs because clinicians know that they may experience adverse consequences if they negligently injure patients.
OBJECTIVE
To review empirical findings regarding the association between malpractice liability risk (ie, the extent to which clinicians face the threat of being sued and having to pay damages) and health care quality and safety.
DATA SOURCES AND STUDY SELECTION
Systematic search of multiple databases for studies published between January 1, 1990, and November 25, 2019, examining the relationship between malpractice liability risk measures and health outcomes or structural and process indicators of health care quality.
DATA EXTRACTION AND SYNTHESIS
Information on the exposure and outcome measures, results, and acknowledged limitations was extracted by 2 reviewers. Meta-analytic pooling was not possible due to variations in study designs; therefore, studies were summarized descriptively and assessed qualitatively.
MAIN OUTCOMES AND MEASURES
Associations between malpractice risk measures and health care quality and safety outcomes. Exposure measures included physicians' malpractice insurance premiums, state tort reforms, frequency of paid claims, average claim payment, physicians' claims history, total malpractice payments, jury awards, the presence of an immunity from malpractice liability, the Centers for Medicare & Medicaid Services' Medicare malpractice geographic practice cost index, and composite measures combining these measures. Outcome measures included patient mortality; hospital readmissions, avoidable admissions, and prolonged length of stay; receipt of cancer screening; Agency for Healthcare Research and Quality patient safety indicators and other measures of adverse events; measures of hospital and nursing home quality; and patient satisfaction.
RESULTS
Thirty-seven studies were included; 28 examined hospital care only and 16 focused on obstetrical care. Among obstetrical care studies, 9 found no significant association between liability risk and outcomes (such as Apgar score and birth injuries) and 7 found limited evidence for an association. Among 20 studies of patient mortality in nonobstetrical care settings, 15 found no evidence of an association with liability risk and 5 found limited evidence. Among 7 studies that examined hospital readmissions and avoidable initial hospitalizations, none found evidence of an association between liability risk and outcomes. Among 12 studies of other measures (eg, patient safety indicators, process-of-care quality measures, patient satisfaction), 7 found no association between liability risk and these outcomes and 5 identified significant associations in some analyses.
CONCLUSIONS AND RELEVANCE
In this systematic review, most studies found no association between measures of malpractice liability risk and health care quality and outcomes. Although gaps in the evidence remain, the available findings suggested that greater tort liability, at least in its current form, was not associated with improved quality of care.
Topics: Humans; Insurance, Liability; Liability, Legal; Malpractice; Obstetrics; Outcome Assessment, Health Care; Postoperative Complications; Quality of Health Care
PubMed: 31990319
DOI: 10.1001/jama.2019.21411 -
BMJ (Clinical Research Ed.) Nov 2023To summarize the breadth and quality of evidence supporting commonly recommended early childhood autism interventions and their estimated effects on developmental... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To summarize the breadth and quality of evidence supporting commonly recommended early childhood autism interventions and their estimated effects on developmental outcomes.
DESIGN
Updated systematic review and meta-analysis (autism intervention meta-analysis; Project AIM).
DATA SOURCES
A search was conducted in November 2021 (updating a search done in November 2017) of the following databases and registers: Academic Search Complete, CINAHL Plus with full text, Education Source, Educational Administration Abstracts, ERIC, Medline, ProQuest Dissertations and Theses, PsycINFO, Psychology and Behavioral Sciences Collection, and SocINDEX with full text, , and ClinicalTrials.gov.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Any controlled group study testing the effects of any non-pharmacological intervention on any outcome in young autistic children younger than 8 years.
REVIEW METHODS
Newly identified studies were integrated into the previous dataset and were coded for participant, intervention, and outcome characteristics. Interventions were categorized by type of approach (such as behavioral, developmental, naturalistic developmental behavioral intervention, and technology based), and outcomes were categorized by domain (such as social communication, adaptive behavior, play, and language). Risks of bias were evaluated following guidance from Cochrane. Effects were estimated for all intervention and outcome types with sufficient contributing data, stratified by risk of bias, using robust variance estimation to account for intercorrelation of effects within studies and subgroups.
RESULTS
The search yielded 289 reports of 252 studies, representing 13 304 participants and effects for 3291 outcomes. When contributing effects were restricted to those from randomized controlled trials, significant summary effects were estimated for behavioral interventions on social emotional or challenging behavior outcomes (Hedges' g=0.58, 95% confidence interval 0.11 to 1.06; P=0.02), developmental interventions on social communication (0.28, 0.12 to 0.44; P=0.003); naturalistic developmental behavioral interventions on adaptive behavior (0.23, 0.02 to 0.43; P=0.03), language (0.16, 0.01 to 0.31; P=0.04), play (0.19, 0.02 to 0.36; P=0.03), social communication (0.35, 0.23 to 0.47; P<0.001), and measures of diagnostic characteristics of autism (0.38, 0.17 to 0.59; P=0.002); and technology based interventions on social communication (0.33, 0.02 to 0.64; P=0.04) and social emotional or challenging behavior outcomes (0.57, 0.04 to 1.09; P=0.04). When effects were further restricted to exclude caregiver or teacher report outcomes, significant effects were estimated only for developmental interventions on social communication (0.31, 0.13 to 0.49; P=0.003) and naturalistic developmental behavioral interventions on social communication (0.36, 0.23 to 0.49; P<0.001) and measures of diagnostic characteristics of autism (0.44, 0.20 to 0.68; P=0.002). When effects were then restricted to exclude those at high risk of detection bias, only one significant summary effect was estimated-naturalistic developmental behavioral interventions on measures of diagnostic characteristics of autism (0.30, 0.03 to 0.57; P=0.03). Adverse events were poorly monitored, but possibly common.
CONCLUSION
The available evidence on interventions to support young autistic children has approximately doubled in four years. Some evidence from randomized controlled trials shows that behavioral interventions improve caregiver perception of challenging behavior and child social emotional functioning, and that technology based interventions support proximal improvements in specific social communication and social emotional skills. Evidence also shows that developmental interventions improve social communication in interactions with caregivers, and naturalistic developmental behavioral interventions improve core challenges associated with autism, particularly difficulties with social communication. However, potential benefits of these interventions cannot be weighed against the potential for adverse effects owing to inadequate monitoring and reporting.
Topics: Child; Humans; Child, Preschool; Autistic Disorder; Behavior Therapy; Early Intervention, Educational; Social Skills; Adaptation, Psychological
PubMed: 37963634
DOI: 10.1136/bmj-2023-076733 -
Health Affairs (Project Hope) Jun 2023During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing...
During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.
Topics: Aged; Humans; United States; Medicare; Value-Based Purchasing; Medicaid; Quality of Health Care
PubMed: 37276480
DOI: 10.1377/hlthaff.2022.01455 -
Home-Based Primary and Palliative Care in the Medicaid Program: Systematic Review of the Literature.Journal of the American Geriatrics... Jan 2021To describe the use of home-based medical care (HBMC) among Medicaid beneficiaries.
BACKGROUND/OBJECTIVES
To describe the use of home-based medical care (HBMC) among Medicaid beneficiaries.
DESIGN
A systematic review of the peer-reviewed and gray literature of home-based primary care and palliative care programs among Medicaid beneficiaries including dual eligibles.
SETTING
HBMC including home-based primary care and palliative care programs.
PARTICIPANTS
Studies describing Medicaid beneficiaries receiving HBMC.
MEASUREMENTS
Three groups of studies were included: those focused on HBMC specifically for Medicaid beneficiaries, studies that described the proportion of Medicaid patients receiving HBMC, and those that used Medicaid status as a dependent variable in studying HBMC.
RESULTS
The peer-reviewed and gray literature searches revealed 574 unique studies of which only 16 met inclusion criteria. Few publications described HBMC as an integral care delivery model for Medicaid programs. Data from the programs described suggest the use of HBMC for Medicaid beneficiaries can reduce healthcare costs. The addition of social supports to HBMC appears to convey additional savings and benefits.
CONCLUSION
This systematic literature review highlights the relative dearth of literature regarding the use and impact of HBMC in the Medicaid population. HBMC has great potential to reduce Medicaid costs, and innovative programs combining HBMC with social support systems need to be tested.
Topics: Delivery of Health Care; Home Care Services; Humans; Medicaid; Palliative Care; Primary Health Care; United States
PubMed: 32959375
DOI: 10.1111/jgs.16837 -
Circulation. Cardiovascular Quality and... Jun 2023The goal of the Affordable Care Act was to improve health outcomes through expanding insurance, including through Medicaid expansion. We systematically reviewed the...
BACKGROUND
The goal of the Affordable Care Act was to improve health outcomes through expanding insurance, including through Medicaid expansion. We systematically reviewed the available literature on the association of Affordable Care Act Medicaid expansion with cardiac outcomes.
METHODS
Consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we performed systematic searches in PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature using the keywords such as Medicaid expansion and cardiac, cardiovascular, or heart to identify titles published from 1/2014 to 7/2022 that evaluated the association between Medicaid expansion and cardiac outcomes.
RESULTS
A total of 30 studies met inclusion and exclusion criteria. Of these, 14 studies (47%) used a difference-in-difference study design and 10 (33%) used a multiple time series design. The median number of postexpansion years evaluated was 2 (range, 0.5-6) and the median number of expansion states included was 23 (range, 1-33). Commonly assessed outcomes included insurance coverage of and utilization of cardiac treatments (25.0%), morbidity/mortality (19.6%), disparities in care (14.3%), and preventive care (41.1%). Medicaid expansion was generally associated with increased insurance coverage, reduction in overall cardiac morbidity/mortality outside of acute care settings, and some increase in screening for and treatment of cardiac comorbidities.
CONCLUSIONS
Current literature demonstrates that Medicaid expansion was generally associated with increased insurance coverage of cardiac treatments, improvement in cardiac outcomes outside of acute care settings, and some improvements in cardiac-focused prevention and screening. Conclusions are limited because quasi-experimental comparisons of expansion and nonexpansion states cannot account for unmeasured state-level confounders.
Topics: United States; Humans; Medicaid; Patient Protection and Affordable Care Act; Insurance Coverage; Poverty; Health Services Accessibility
PubMed: 37339189
DOI: 10.1161/CIRCOUTCOMES.122.009753 -
Global Spine Journal Mar 2023Systematic review. (Review)
Review
STUDY DESIGN
Systematic review.
OBJECTIVES
We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regards to 2 types of elective spine surgery, lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF).
METHODS
Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regards to rates of LF and ACDF, costs/reimbursement, and health outcomes.
RESULTS
A total of 573 articles were assessed. Twenty-five articles were included in the analysis. We found that the literature is consistent with regards to Medicaid disparities. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes (such as higher rates of readmission and emergency department utilization) compared to other insurance categories.
CONCLUSIONS
In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regards to access to care and health outcomes. Efforts should focus on identifying causes and interventions for such disparities in this vulnerable population.
PubMed: 35658589
DOI: 10.1177/21925682221103530 -
International Journal of Environmental... Apr 2021Access to healthcare for adolescents is often overlooked in the United States due to federal and state-sponsored insurance programs such as Medicaid and the Children's... (Review)
Review
Access to healthcare for adolescents is often overlooked in the United States due to federal and state-sponsored insurance programs such as Medicaid and the Children's Health Insurance Program. While these types of programs provide some relief, the issue of healthcare access goes beyond insurance coverage and includes an array of ecological factors that hinder youths from receiving services. The purpose of this scoping review was to identify social-ecological barriers to adolescents' healthcare access and utilization in the United States. We followed the PRISMA and scoping review methodological framework to conduct a comprehensive literature search in eight electronic databases for peer-reviewed articles published between 2010 and 2020. An inductive content analysis was performed to thematize the categories identified in the data extraction based on the Social-Ecological Model (SEM). Fifty studies were identified. Barriers across the five SEM levels emerged as primary themes within the literature, including intrapersonal-limited knowledge of and poor previous experiences with healthcare services, interpersonal-cultural and linguistic barriers, organizational-structural barriers in healthcare systems, community-social stigma, and policy-inadequate insurance coverage. Healthcare access for adolescents is a systems-level problem requiring a multifaceted approach that considers complex and adaptive behaviors.
Topics: Adolescent; Child; Health Facilities; Health Services; Health Services Accessibility; Humans; Insurance Coverage; Medicaid; United States
PubMed: 33919813
DOI: 10.3390/ijerph18084138 -
Journal of the National Cancer Institute Jul 2020Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among...
BACKGROUND
Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival.
METHODS
We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively.
RESULTS
Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions.
CONCLUSIONS
Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes.
Topics: Early Detection of Cancer; Health Services Accessibility; Humans; Insurance Coverage; Insurance, Health; Medicaid; Medically Uninsured; Neoplasms; Observational Studies as Topic; Patient Protection and Affordable Care Act; Poverty; Publications; United States
PubMed: 32337585
DOI: 10.1093/jnci/djaa048 -
European Journal of Surgical Oncology :... Aug 2021Head and neck cancers (HNC) are relatively fast-growing tumours, and delay in treatment initiation is associated with tumour progression and adverse outcome. An overview...
INTRODUCTION
Head and neck cancers (HNC) are relatively fast-growing tumours, and delay in treatment initiation is associated with tumour progression and adverse outcome. An overview of factors contributing to delay can provide critical insights on necessary adjustments to optimize care pathways. This systematic review aims to identify factors associated with delay and summarize the effect of delay on oncological outcome measures.
METHODS
A search strategy was conducted according to PRISMA guidelines to search electronic databases for studies assessing the carepathway interval (days between first visit in head and neck oncology center and treatment initiation) and/or time-to-treatment-initiation interval (days between histological diagnosis and treatment initiation) and 1) determinants of delay and/or 2) effect of delay on outcome within these timeframes. Due to heterogeneity between included studies, a meta-analysis was not possible.
RESULTS
Fifty-two studies were eligible for quantitative analysis. Non-Caucasian race, academic setting, Medicaid/no insurance and radiotherapy as primary treatment were associated with delay. Advanced tumour stage was related to increased time-to-treatment initiation in the four common sites combined (oral cavity, oropharynx, hypopharynx, larynx). Separate determinants for delay in different tumour locations were identified. In laryngeal, oral cavity cancer and the four common HNC sites combined, delay in start of treatment is associated with decreased overall survival, although no cut-off time point could be determined.
CONCLUSION
Race, facility type, type of insurance and radiotherapy as primary treatment were associated with delay and subsequent inferior survival in the four common sites combined.
Topics: Academic Medical Centers; Ethnic and Racial Minorities; Ethnicity; Head and Neck Neoplasms; Humans; Insurance, Health; Medicaid; Medically Uninsured; Neoplasm Staging; Radiotherapy; Risk Factors; Squamous Cell Carcinoma of Head and Neck; Survival Rate; Time-to-Treatment; United States
PubMed: 33715909
DOI: 10.1016/j.ejso.2021.02.029