Medical Care[JOURNAL]
Sun
200 papers
Use of Telemental Health Care by Adults in the United States.
Olfson M, McClellan C, Zuvekas SH … +1 more , Blanco C
Med Care · 2026 Apr · PMID 41805661 · Publisher ↗
BACKGROUND: Although the recent proliferation of telemental health care has transformed delivery of outpatient mental health care for many patients, little is known about population-level access to telehealth, hybrid, an...
BACKGROUND: Although the recent proliferation of telemental health care has transformed delivery of outpatient mental health care for many patients, little is known about population-level access to telehealth, hybrid, and in-person outpatient mental health care in the US. OBJECTIVES: The objective of this report is to characterize patterns of all telehealth, hybrid, and all in-person outpatient mental health care by US adults. METHODS: An analysis is presented of 2021-2022 Medical Expenditure Panel Survey data (n=39,561) focusing on annual percentages of adults receiving all telehealth, hybrid, and all in-person outpatient mental health care. Results are presented overall and stratified by sociodemographic characteristics. Differences are reported in average marginal estimates from logistic regressions for each sociodemographic characteristic controlling for age group, sex, and psychological distress (Kessler-6). RESULTS: Approximately 12.0% of adults annually received outpatient mental health care, including 3.3% all telemental health care, 2.6% hybrid, and 6.1% all in-person mental health care. After controlling for age, sex, and distress, unemployed adults 65 years of age or younger were less likely than employed adults to receive all mental health care (-1.0 percentage points, 95% CI: -1.6 to -0.4), and uninsured individuals were less likely than those with private insurance (-2.8 percentage points, 95% CI: -3.6 to -1.9). By contrast, college graduates were 3.2 percentage points (95% CI: 2.3-4.0) more likely than those with less than a high school diploma, higher-income individuals were 1.6 percentage points (95% CI: 0.8-2.30) more likely than those below the poverty level, and urban residents were 1.9 percentage points (95% CI: 1.1-2.7) more likely than rural residents to receive all telemental health care. CONCLUSIONS: These national patterns highlight differences in US telemental health care access across employment, education, income, insurance, and geographic groups.
Telehealth Uptake and Rural-Urban and Racial/Ethnic Disparities in Postpartum Care Access Among Medicaid Beneficiaries in South Carolina, 2018-2022.
Chatterjee A, Zhao X, Liu J … +6 more , Campbell BA, Yu J, Boghossian NS, Cai B, Li X, Hung P
Med Care · 2026 May · PMID 41778532 · Full text
BACKGROUND: Although telehealth is increasingly being used for providing postpartum care, its role in ensuring timely postpartum care initiation in racial/ethnic minorities and rural residents is unknown. OBJECTIVES: To...
BACKGROUND: Although telehealth is increasingly being used for providing postpartum care, its role in ensuring timely postpartum care initiation in racial/ethnic minorities and rural residents is unknown. OBJECTIVES: To compare attendance and timeliness of postpartum care initiation by pandemic exposure and telehealth uptake across race/ethnicity and rural-urban residences. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Medicaid-insured individuals who gave birth in South Carolina between January 1, 2018, and September 30, 2022, were aged 15-49 years, and were followed up until December 31, 2022. MEASURES: Cox proportional hazards models examined associations between pandemic exposures, telehealth uptake, and racial/ethnic and rural/urban disparities in postpartum care initiation timeliness. RESULTS: Median time to postpartum care initiation was 25 days [interquartile range (IQR): 14-41 d] with variations across race/ethnicity and residence. Fully-exposed nontelehealth users had slower initiation [adjusted hazard ratio (aHR): 0.95; 95% CI: 0.91-1.00], while telehealth users had quicker initiation (aHR: 2.19; 95% CI: 1.93-2.48) compared with non- or partially-exposed individuals. Among minimal- or no-telehealth users, postpartum care initiation was slower for Hispanic and non-Hispanic Black individuals compared with their non-Hispanic White peers. There were no differences in timely care initiation by race or residence among fully-exposed telehealth users. CONCLUSIONS: Telehealth may improve racial/ethnic disparities in timely postpartum care initiation. Rural-urban disparities in initiating timely postpartum care still warrant further investigation.
Measuring Income Inequality Within 8 Health Care Professions in the United States.
Popovici I, Carvajal MJ
Med Care · 2026 May · PMID 41778531 · Publisher ↗
OBJECTIVES: This study investigated intraoccupational income and wage-rate distributions across 8 health care professions: physicians and surgeons, dentists, physician assistants, optometrists, pharmacists, nurse practit...
OBJECTIVES: This study investigated intraoccupational income and wage-rate distributions across 8 health care professions: physicians and surgeons, dentists, physician assistants, optometrists, pharmacists, nurse practitioners and nurse midwives, physical therapists, and registered nurses. METHODS: The research was based on a sample of 142,527 U.S. practitioners from the 2019 to 2022 American Community Survey (ACS) and focused on 4 inequality indicators: the coefficient of variation, lower median share, 90-10 decile ratio, and Gini coefficient. RESULTS: Findings revealed substantial income dispersion, with dentists and physicians/surgeons displaying the highest levels of inequality, while pharmacists, registered nurses, physical therapists, and nurse practitioners and nurse midwives exhibited more even distributions. The occupations' degree of inequality was correlated with average annual income and wage-rate levels. Gender disparities were significant across all professions, with male practitioners consistently earning more than their female counterparts. The degree of inequality was greater for professions in which there were more male than female practitioners. Annual income and wage-rate inequality also was identified within genders. CONCLUSIONS: This research contributes to understanding income disparities within health care professions and suggests that further exploration is needed to identify the determinants of these inequalities and their long-term evolution.
Adding Self-Care Complementary and Integrative Health Therapies to Care for Chronic Pain: The Assessing Pain, Patient Reported Outcomes and Complementary Health (APPROACH) Study.
Zeliadt SB, Coggeshall SS, Bokhour B … +9 more , Elwy AR, Kligler B, Der-Martirosian C, Rosser EW, Shin M, Toyama J, Upham ML, Zhang X, Taylor SL
Med Care · 2026 May · PMID 41771006 · Publisher ↗
BACKGROUND: Health care systems and insurers are expanding coverage for practitioner-delivered and self-care complementary and integrative health (CIH) therapies for chronic pain. OBJECTIVES: To determine if combining pr...
BACKGROUND: Health care systems and insurers are expanding coverage for practitioner-delivered and self-care complementary and integrative health (CIH) therapies for chronic pain. OBJECTIVES: To determine if combining practitioner-delivered and self-care CIH therapies (PD/SC-CIH) improves pain outcomes more than practitioner-delivered CIH (PD-CIH) therapies alone. RESEARCH DESIGN: Pragmatic nonrandomized trial. Structural nudges and the availability of CIH therapies were used as a surrogate to randomization. SUBJECTS: Of 3306 veterans with chronic musculoskeletal pain at 18 medical centers in the Veterans Health Administration between March 2021 and March 2023. MEASURES: PD-CIH therapies included acupuncture, chiropractic care, or massage therapy. Participants in the PD/SC-CIH arm also received yoga, mindfulness/meditation, and/or Tai Chi/Qigong. The primary outcome was the change in pain-related functional interference at 6 months. RESULTS: Pain interference improved in both arms (-0.62 and -0.70), with 39.5% and 41.1%, respectively, achieving clinically meaningful improvement with no difference between arms in improvement in pain interference: -0.12 (-0.28 to 0.05). At 6 months, more participants in the PD/SC-CIH arm reported their use of CIH therapies specifically led to perceived improvements across 4 global patient-centered measures: pain (11%; 5%-18%); fatigue (28%; 17%-40%); mental health (24%; 14%-35%); and overall well-being (27%; 18%-35%). CONCLUSIONS: Both approaches to offering CIH therapies were equally associated with improvements in pain interference among this large cohort with real-world CIH therapy engagement. More patients in the PD/SC-CIH arm perceived that their use of CIH therapies improved multiple health dimensions. Patients with chronic musculoskeletal pain should be encouraged to add self-care CIH therapies and health care systems should expand their availability. STUDY REGISTRATION: ClinicalTrials.gov Identifier: NCT05097521.
Comparing Logistic Regression and Artificial Neural Network Models for Analyzing Medicare Utilization and Costs Among Older Adults.
Chen J, Jang S, Wang MQ
Med Care · 2026 Jun · PMID 41770991 · Full text
BACKGROUND: Artificial neural networks (ANNs) are increasingly applied in health care outcome prediction, yet their relative benefits compared with traditional methods in health services research remain unclear. OBJECTIV...
BACKGROUND: Artificial neural networks (ANNs) are increasingly applied in health care outcome prediction, yet their relative benefits compared with traditional methods in health services research remain unclear. OBJECTIVE: To examine health care utilization and costs among community-dwelling older adults using the Andersen Behavioral Model, and to compare the performance of logistic regression and ANN models. RESEARCH DESIGN: Cross-sectional study utilizing linked data from CMS Medicare fee-for-service (FFS) claims and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys (2018-2022). The sample included 254,748 Medicare beneficiaries aged 65 and older. Outcomes were high Medicare costs (top 25%), 30-day readmissions, and preventable hospitalizations (PQIs). Predictors included socioeconomic factors, chronic conditions, and patient-reported measures. Model performance was assessed using the area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Brier scores. RESULTS: Chronic conditions, including heart disease and depression, significantly predicted higher Medicare costs. Poor self-rated health, functional limitations, dual eligibility, and lower educational attainment correlated strongly with readmissions and preventable hospitalizations. ANN and logistic regression models demonstrated comparable performance across outcomes, with similar AUC, sensitivity, specificity, PPV, NPV, and Brier scores. CONCLUSIONS: Both logistic regression and ANN models effectively predict health care utilization and high-risk outcomes among older adults using structured Medicare data. Logistic regression offers interpretability and robust predictive power, whereas ANN models may provide additional value as healthcare datasets grow increasingly complex and comprehensive.
Improving Diagnosis: Evaluation of Diagnostic Experiences Classified as Problems, Mistakes, or Both by Patients and Care Partners From a Nationally Representative Survey.
Gleason KT, McDonald KM, Grob R … +4 more , Yuan CT, Dhingra I, Warne E, Schlesinger M
Med Care · 2026 Jun · PMID 41744298 · Full text
BACKGROUND: Understanding patients' experiences with diagnosis is crucial for improving care. Clarifying how best to ask about these experiences is an essential step in doing so. OBJECTIVE: To elicit and then categorize...
BACKGROUND: Understanding patients' experiences with diagnosis is crucial for improving care. Clarifying how best to ask about these experiences is an essential step in doing so. OBJECTIVE: To elicit and then categorize diagnostic problems and mistakes in a national, population-based survey. METHODS: Drawing from a nationally representative panel, respondents were asked whether they had experienced (directly or as a care partner) a diagnostic problem or mistake in the last 4 years. They then classified the experience as a mistake, a problem only, or a combination of both. Respondents who experienced multiple problems and mistakes reported on their most memorable experience. We compared responses among those reporting a problem, a mistake, or a combination of both. RESULTS: A third [1216/3684 (33.0%)] of screened households reported diagnostic problems or mistakes involving themselves [697/3684 (18.9%)] or someone close to them [519/3684 (14.1%)]. A plurality [448/3684 (12.2%)] categorized these as a mistake, 382 (10.4%) as a problem, and 371 (10.1%) as both. Experiences reported as problems versus mistakes were equally likely to be associated with harmful consequences and concrete clinician responses. The distribution of problems and mistakes across the 3 categories did not significantly differ when reported by patients versus care partners, though there were checkered differences in the reported impact. CONCLUSIONS: Whether labeled as problems or mistakes, diagnostic experiences reported by patients and care partners are accompanied by substantial emotional, physical, and financial impacts. Responding to this full range of patient experiences is important for guiding improvements in diagnostic quality within learning health systems.
Validating ICD-10 Algorithms for Identifying Patient Safety Indicators Through 10,655 Charts Review.
Wu G, Pan J, Southern DA … +4 more , Cheligeer C, Xu Y, Eastwood CA, Quan H
Med Care · 2026 May · PMID 41738520 · Publisher ↗
BACKGROUND: Patient Safety Indicators (PSIs) derived from administrative data are widely used for monitoring and improving hospital care quality. However, the validity of ICD-10-based PSI algorithms remains uncertain, pa...
BACKGROUND: Patient Safety Indicators (PSIs) derived from administrative data are widely used for monitoring and improving hospital care quality. However, the validity of ICD-10-based PSI algorithms remains uncertain, particularly in terms of their sensitivity and specificity. OBJECTIVES: To evaluate the diagnostic performance of ICD-10-CA-based algorithms for identifying fifteen PSIs using chart review as the reference standard. RESEARCH DESIGN: Multicenter retrospective cohort validation study. SUBJECTS: A random sample of 10,665 adult patients admitted to 4 acute care hospitals in Calgary, Alberta, between January 1, 2017, and March 31, 2022. MEASURES: Fifteen PSIs were identified using ICD-10-CA codes and validated against detailed chart reviews. Diagnostic performance was measured using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy. Analyses were stratified by diagnosis code type and relevant patient characteristics. RESULTS: Among 10,665 patients, 1688 had at least one PSI confirmed by chart review. ICD-10-CA coding detected any PSI with 67.0% sensitivity (95% CI, 64.7%-69.2%), 72.8% specificity (95% CI, 71.8%-73.7%), 31.6% PPV (95% CI, 30.1%-33.1%), 92.2% NPV (95% CI, 91.5%-92.8%), and 71.8% accuracy (95% CI, 71.0%-72.7%). Restricting PSIs to conditions that occurred after admission (limited diagnosis type II code) improved specificity (95.7%; 95% CI, 95.3%-96.1%) and PPV (56.5%; 95% CI, 53.2%-59.7%) but reduced sensitivity (29.6%; 95% CI, 27.4%-31.8%). Validity varied by PSI and patient characteristics, with higher sensitivity and PPV among older adults, males, and those with greater comorbidity, longer hospital and ICU stays, 30-day readmission, or in-hospital death. CONCLUSIONS: ICD-10 coded administrative data demonstrate high specificity and NPV but varied sensitivity and PPV in identifying PSIs. Restricting to type II codes improves PPV but reduces sensitivity. Tailoring coding strategies to specific surveillance or quality improvement goals is critical.
Hospital Nursing Has Not Returned to Pre-COVID Conditions: Time for a Different Approach.
Lasater KB, McHugh MD, Aiken LH
Med Care · 2026 May · PMID 41733171 · Publisher ↗
BACKGROUND: Hospital nurse burnout, job dissatisfaction, and intent to leave were high before the COVID-19 pandemic and reached alarmingly new heights during the pandemic. OBJECTIVE: Evaluate whether hospital nurses' job...
BACKGROUND: Hospital nurse burnout, job dissatisfaction, and intent to leave were high before the COVID-19 pandemic and reached alarmingly new heights during the pandemic. OBJECTIVE: Evaluate whether hospital nurses' job outcomes and evaluations of patient safety, quality of care, and hospital management responsiveness have returned at least to prepandemic levels. DESIGN: Cross-sectional study of survey data from 50,044 nurses in New York and Illinois hospitals: prepandemic (December 2019-February 2020), during (April 2021-June 2021), and postpandemic (December 2023-March 2024). MEASURES: Nurse outcomes (ie, high burnout, job dissatisfaction, intention to leave employer). Hospital nursing resources (eg, unfavorable work environment, nurse staffing ratio). Hospital management responsiveness (eg, nurses' confidence in management to resolve clinical care problems). RESULTS: Nurses' job dissatisfaction and intentions to leave their hospital employer rose significantly over time, with the highest percentages postpandemic-32.2% of nurses reporting job dissatisfaction and 27.4% intending to leave. Percentages of nurses with high burnout have remained high before (48.0%), during (51.0%), and after (48.5%) the pandemic. Nurses' evaluations of their working conditions are at their worst postpandemic: 49.2% reported unfavorable work environments, 61.5% reported not enough staff, and objective measures of staffing ratios on medical-surgical units were 6.0 patients-to-nurse, up from 5.7 prepandemic. Evaluations of patient safety, quality of care, and management responsiveness were significantly worse postpandemic. CONCLUSIONS: Job dissatisfaction and intentions to leave employment continue to rise even after the pandemic has receded, and more nurses lack confidence in their management to act in the best interest of patients. New policy approaches seem warranted, including setting minimum safe hospital nurse staffing requirements.
Designing Cluster Randomized Trials: A Practical Guide for Investigators.
Davis-Plourde K, Yu X, Teresi JA
Med Care · 2026 Apr · PMID 41733160 · Full text
BACKGROUND: An important consideration in the design stage of randomized controlled trials is whether individuals within each site should or can be randomized to study arms (an individually randomized controlled trial) o...
BACKGROUND: An important consideration in the design stage of randomized controlled trials is whether individuals within each site should or can be randomized to study arms (an individually randomized controlled trial) or whether entire sites should be randomized (a cluster randomized trial) where the clusters are sites. Recently, cluster randomized trials have grown in popularity; however, investigators have expressed a need for guidelines related to selection of the best design-especially when considering more complex designs such as stepped wedge. This commentary attempts to provide such guidance. METHODS: In this commentary, we address common misconceptions surrounding the appropriate use of cluster randomization and crossover designs (such as the stepped wedge design). The intracluster correlation coefficients for different levels of clustering are presented, and the impact of different designs on sample size discussed. We provide practical recommendations that are accessible to investigators from all disciplines, regardless of their level of statistical training. On the basis of these recommendations, we present a flowchart to help researchers identify a suitable trial design for their study. In addition, we provide a table of commonly used statistical definitions related to cluster randomized trials and a table of design considerations for more complex designs to support effective consultation with a statistician during the design phase. CONCLUSION: On the basis of these guidelines, it is recommended that researchers prioritize the use of individual randomization and a parallel trial design when the goal of the study is to assess the efficacy or effectiveness of an intervention.
The Impact of the COVID-19 Pandemic on Registered Nurse Employment Across Settings.
Ahr C, Gates C, Nguyen TD … +3 more , Friese CR, Manojlovich M, Davis MA
Med Care · 2026 May · PMID 41636701 · Publisher ↗
BACKGROUND: It is unknown whether the stress of the COVID-19 pandemic, which had a particular impact on inpatient and long-term care (LTC) nurses, had an effect on nurses' choice of employment settings. OBJECTIVE: Determ...
BACKGROUND: It is unknown whether the stress of the COVID-19 pandemic, which had a particular impact on inpatient and long-term care (LTC) nurses, had an effect on nurses' choice of employment settings. OBJECTIVE: Determine whether the COVID-19 pandemic contributed to changes in nurses' choice of employment setting. METHODS: This study used data from the 2018 and 2022 National Sample Survey of Registered Nurses to conduct a difference-in-difference analysis. We constructed a state-level measure of COVID-19 caseload, defined as COVID-19 cases per hospital bed; High versus Low COVID-19 states were defined as those above versus below the median, respectively. Logistic regression models were used to estimate the effect of exposure to High COVID-19 caseload (vs. Low) and time (2022 vs. 2018) on nurse employment choices across inpatient, LTC, outpatient, and nonclinical settings. RESULTS: From 2018 to 2022, the size of the US nursing workforce grew from 3.27 to 3.57 million nurses; however, RN FTEs increased in outpatient settings and decreased in all other settings. In adjusted analyses, nurses were less likely to work in LTC settings in 2022 than in 2018; yet, those exposed to High COVID-19 caseloads were 0.9% (95% CI: 0.3-1.5) more likely to work in LTC than those exposed to Low COVID-19 caseloads. Differences between High versus Low COVID-19 caseload exposure were not statistically significant for the likelihood of working in inpatient, outpatient, and nonclinical settings. CONCLUSIONS: Our findings suggest that exposure to High COVID-19 caseload was not associated with changes in nurses' employment settings.
Personal Health Goals in Homeless-Experienced Veterans: Rates, Patterns, and Associations With Health-Related Needs.
Ward M, Macia KS, Shaffer P … +3 more , Hyde J, Smelson D, Blonigen DM
Med Care · 2026 Apr · PMID 41632861 · Full text
OBJECTIVE: To advance patient-centered care for high-need homeless-experienced patients, we identified the rates of various personal health goals, the broader domains that underlie these goals, and associations between t...
OBJECTIVE: To advance patient-centered care for high-need homeless-experienced patients, we identified the rates of various personal health goals, the broader domains that underlie these goals, and associations between these domains and the health-related needs of this population. METHOD: The sample consisted of 176 veterans from 3 VA Medical Centers who were enrolled in primary care, on VA's Homeless Registry, and high utilizers of acute care. An interview was conducted with each participant to collect information on their personal health goals and health-related needs. Exploratory factor analysis was used to identify broad domains underlying endorsement of personal health goals. Associations between these broad goal domains and health-related needs (substance use, mental and physical health, treatment engagement, and psychosocial) were examined using an exploratory structural equation modeling-within-confirmatory factor analysis approach. RESULTS: Three broad domains were found to underlie the personal health goals of the sample: social functioning, health promotion, and substance use. Social functioning and health promotion were highly correlated, whereas substance use was weakly correlated with both social functioning and health promotion. All substance use-related needs were positively associated with substance use goals. Mental and physical health needs were primarily associated with health promotion goals. Treatment engagement and psychosocial needs demonstrated associations across all 3 goal domains. CONCLUSIONS: Findings highlight the high value that many high-need homeless-experienced patients place on their social well-being and the potential benefits to measuring both deficiency and growth needs in this population. Clinical implications and future directions for research are discussed.
Improving the Evaluation of Low-Volume Hospitals.
Silber JH, Rosenbaum PR, Reiter JG … +2 more , Hill AS, Fleisher LA
Med Care · 2026 Apr · PMID 41627086 · Publisher ↗
BACKGROUND AND OBJECTIVE: Low volume has been recognized as a problem when benchmarking hospitals due to outcome rate instability. We asked if low-volume hospital outcomes, using matching to control for many clinical and...
BACKGROUND AND OBJECTIVE: Low volume has been recognized as a problem when benchmarking hospitals due to outcome rate instability. We asked if low-volume hospital outcomes, using matching to control for many clinical and sociodemographic characteristics, would expose quality problems not observed with CMS methods. RESEARCH DESIGN: Matched cohort study. Grades derive from mortality differences between all patients at the low-volume hospital and their matched controls. SUBJECTS: Medicare patients admitted with Acute Myocardial Infarction, Heart Failure and Pneumonia in 78 low-volume Pennsylvania acute care hospitals (combined condition volume=75≤N≤750 for the 3 y, 2017-2019), using Medicare's Virtual Research Data Center. MEASURES: Thirty-day mortality. RESULTS: Using matching, 10 of 78 reportable low-volume hospitals had significantly higher mortality versus matched typical controls and 16 low-volume hospitals displayed significantly higher mortality versus well-resourced controls. In contrast, Medicare reported that only 3 of these same 78 hospitals had significantly higher mortality than "the national rate" on AMI, HF, or pneumonia. CONCLUSIONS: We find that some low-volume hospitals performed well. Other low-volume hospitals had significantly worse outcomes than both well-resourced and typical hospitals; and some displayed significantly worse mortality compared with well-resourced controls but did not reach significant differences from typical controls. In short, performing "no different from the national rate," as is almost always reported for low-volume hospitals when using CMS methods, does not imply a low-volume hospital has acceptable outcomes. Reports based on matching can expose low-volume hospital quality problems not apparent using standard methods. Low-volume hospitals have more quality problems than generally reported.
Predictive Accuracy of Natural Language Processing Extracted 3-Step Theory of Suicide Factor Scores Derived From Veterans' Clinical Progress Notes.
Meerwijk EL, Shotqara AS, Finlay AK … +4 more , Reeves RM, Tamang SR, Ilgen MA, Harris AHS
Med Care · 2026 Apr · PMID 41622646 · Publisher ↗
OBJECTIVES: To compare predictive accuracy of 3-step theory of suicide (3ST) factor scores derived from natural language processing of Veterans Health Administration (VHA) clinical progress notes versus a model that unde...
OBJECTIVES: To compare predictive accuracy of 3-step theory of suicide (3ST) factor scores derived from natural language processing of Veterans Health Administration (VHA) clinical progress notes versus a model that underlies VHA's Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program retrained to predict the combined outcome of suicide attempt or suicide death, and to compare characteristics of patients accurately predicted by both approaches. BACKGROUND: As health systems incorporate risk prediction models to guide suicide prevention efforts, it is important to evaluate their predictive accuracy and to consider the benefits of different modeling approaches. METHODS: A comparative cohort design in which both risk prediction approaches were evaluated for the same random sample (n=162,132) of VHA patients alive on May 1, 2018, who had clinical encounters during the 4 weeks before that date. RESULTS: At the highest risks (top 1%-5%), the model based on REACH VET variables outperformed the 3ST approach in terms of positive predictive value and false-negative rate. Among patients who attempted or died by suicide, uniquely identified by the 3ST approach and not by the retrained REACH VET model, none had attempted suicide during the prior 6 months, emergency department visits during the prior month, discharges from mental health hospitalizations during the prior 12 months, or a diagnosis of bipolar disorder during the prior 24 months. CONCLUSIONS: Additional research is recommended to further prepare 3ST factor scores based on NLP of clinical progress notes for use in clinical decision-making.
Psychiatric Medication Prescribing by Nurse Practitioners and Physician Associates for Medicare Beneficiaries.
Hooker RS, Reinhart GM, Yamzon JM … +1 more , McKenna RE
Med Care · 2026 Apr · PMID 41610335 · Publisher ↗
BACKGROUND: There is a significant shortage of psychiatrists compared with the demand for their services. We studied Medicare Part D claims of psychiatrists and similar clinician prescribers to identify possible shifts i...
BACKGROUND: There is a significant shortage of psychiatrists compared with the demand for their services. We studied Medicare Part D claims of psychiatrists and similar clinician prescribers to identify possible shifts in medication prescribing to address this gap. OBJECTIVE: This pharmacoepidemiology study aimed to identify prescribing patterns among psychiatrists, family physicians, internists, physician associates/assistants (PAs), and nurse practitioners (NPs), as well as trends. DESIGN: An observational, retrospective cohort study of Medicare Part D claims from 2013 to 2022 was conducted. Psychiatrists' prescription patterns were compared with those of non-psychiatrists, using the National Provider Identifier (NPI). Diagnosis information was not available in the dataset. PARTICIPANTS: In 2022, more than 32,400 psychiatrists' prescriptions were submitted for more than 36.6 million Medicare Part D claims for various medications. MAIN MEASURES: Prescribers and medication claim counts were analyzed to determine the most commonly prescribed drugs by psychiatrists. Total psychiatrist prescription counts and trends were compared with those of primary care physicians, PAs, and NPs. KEY RESULTS: Family practice physicians wrote more than 55 million prescriptions in 2022, nearly twice the number written by psychiatrists. From 2013 to 2022, prescriptions written by PAs and NPs showed a strong upward trend. In 2020, prescription claims by NPs surpassed psychiatrists, and by 2022, they had exceeded those of internal medicine physicians. CONCLUSIONS: Claims by NPs increased from 8.6% to 24.8%, whereas psychiatrists' claims decreased from 24.4% to 18.0%. As of 2023, NPs and PAs comprise a significant portion of the workforce that addresses gaps in mental health medication care for Medicare patients.
Persistent Frequent Emergency Department Use Before and During the COVID-19 Pandemic: A Longitudinal Study of One Million Users.
Giannouchos TV, Bkheit W, Kum HC … +1 more , Ohsfeldt RL
Med Care · 2026 Apr · PMID 41558015 · Publisher ↗
OBJECTIVE: To examine changes in persistent emergency department (ED) use by adult frequent ED (FED) users over time comparing prepandemic versus peripandemic periods, and to identify distinct characteristics of individu...
OBJECTIVE: To examine changes in persistent emergency department (ED) use by adult frequent ED (FED) users over time comparing prepandemic versus peripandemic periods, and to identify distinct characteristics of individuals who remained FED users over time during the pandemic versus the prepandemic era. METHODS: We conducted a retrospective, secondary, longitudinal analysis in Texas, following 2 cohorts of ED users over 36 months (cohort 1: March 2017-February 2020; cohort 2: March 2019-February 2022). The main outcomes were whether a baseline FED (≥9 ED visits/12 mo) user remained a FED user persistently over the next 24 months and whether they were persistent FED users prepandemic or peripandemic. Multivariable regressions estimated changes in persistent FED use across cohorts and assessed differences between individuals who remained persistent FED users during the pandemic compared with the prepandemic period. SETTING: All-payer Texas Hospital ED Research Data File from 2016 to 2022. RESULTS: About 1 million individuals had at least one ED visit in the baseline years, totaling 4.6 million visits. Overall, FED users accounted for 8% of all ED users but over 40% of visits. Although more than half of FED users at baseline exhibited persistent FED use over the next 24 months, there was a 7% decline in the proportion of return FED users after the onset of COVID-19 which was statistically significant (AOR=0.82; 95% CI=0.80-0.84), and this effect was more pronounced when patients with any COVID-19-related ED visit during the study period were excluded (AOR=0.10; 95% CI=0.09-0.11). Individuals aged 45 years or older, those with congestive heart failure and diabetes with complications, and those with public insurance (when COVID-19-related visits were excluded) had higher odds of remaining persistent FED users during the pandemic. CONCLUSIONS: Many FED users will seek ED care for multiple years, given their medical complexity. Future research should identify heterogeneous subgroups among persistent FED users to tailor interventions towards their needs.
Differences in the Measurement of Comorbidities Based on ICD-10-CM Coding Definitions Using Medicare Advantage Encounter Data and Fee-For-Service Claims.
Duchesneau ED, Musty A, Miller E … +8 more , Kuzma A, Reutinger B, Stürmer T, Hanchate A, Kim DH, Webster-Clark M, Lin MY, Lund JL
Med Care · 2026 Mar · PMID 41557539 · Full text
BACKGROUND: Medicare Advantage (MA) encounter data became available for research in 2019; data quality concerns remain. OBJECTIVES: We evaluated the consistency of ICD-10-CM comorbidity coding between MA and Fee-For-Serv...
BACKGROUND: Medicare Advantage (MA) encounter data became available for research in 2019; data quality concerns remain. OBJECTIVES: We evaluated the consistency of ICD-10-CM comorbidity coding between MA and Fee-For-Service (FFS) data. METHODS: We used round 7 (2017) of the National Health and Aging Trends Study (NHATS) linked to Medicare enrollment, MA encounter, and FFS claims (2016-2017). We included participants continuously enrolled in MA or FFS for 1 year before round 7. Comorbidities were identified using ICD-10-CM codes from the Gagne combined comorbidity index. Demographic, socioeconomic, and clinical covariates from NHATS for FFS beneficiaries were standardized to resemble those for MA beneficiaries. We estimated crude and standardized comorbidity prevalence differences (PDs) between MA and FFS beneficiaries. RESULTS: Among 5158 beneficiaries (MA: 40%, FFS: 60%), MA beneficiaries were more likely to be Black, Hispanic, and socioeconomically disadvantaged. After standardization, comorbidity prevalence was similar between groups. Peripheral vascular disorder (PD=7.2%, 95% CI: 3.8%-10.6%) and renal failure (PD=3.7%, 95% CI: 0.9%-6.5%) were more common in MA beneficiaries; fluid/electrolyte disorders (PD=-3.2%, 95% CI: -5.5 to -1.0%) and deficiency anemias (PD=-5.0%, 95% CI: -7.6 to -2.3%) were more common in FFS beneficiaries. Other PDs were less than 3 percentage points. CONCLUSIONS: Discrepancies in comorbidity prevalence may reflect true differences or coding variations influenced by provider incentives, documentation standards, or diagnostic priorities. Comorbidity prevalence was largely consistent between MA encounters and FFS claims, supporting the reliability of MA encounter data for aging research. Additional validation studies should address remaining discrepancies.
Patient and Provider Concordance: Do Patients Prefer Physicians of Their Own Race or Ethnicity?
Walker B, Wisniewski J, Sharma R … +3 more , Tinkler S, Tsai E, Neighbors HW
Med Care · 2026 Mar · PMID 41544122 · Publisher ↗
BACKGROUND: Understanding whether patients' preferences for physicians are influenced by racial or ethnic concordance is crucial for balancing patient care satisfaction and health care workforce diversity. OBJECTIVES: To...
BACKGROUND: Understanding whether patients' preferences for physicians are influenced by racial or ethnic concordance is crucial for balancing patient care satisfaction and health care workforce diversity. OBJECTIVES: To investigate whether patients' preferences for physicians are influenced by racial or ethnic concordance and whether these preferences are reflected in the availability of physicians by race. RESEARCH DESIGN: A patient-focused randomized online experiment was conducted to evaluate preferences for physicians while a physician-focused randomized field experiment was conducted to evaluate physician availability by race. The patient-focused experiment involved respondents selecting primary care physicians, while the physician-focused field experiment was conducted on a random sample of primary care physicians in Texas, which reports physician race. RESULTS: White respondents preferred White physicians by 10 percentage points (ppts) (95% CI: 0.048-0.157, P <0.01). Hispanic respondents favored Hispanic physicians by 27 ppts (95% CI: 0.148-0.398, P <0.01) while Black respondents favored Black physicians by 15 ppts (95% CI: -0.013 to 0.395, P =0.07). Overall, White physicians were preferred by 4.8 ppts (95% CI: 0.004-0.092, P =0.030) at the expense of Asian physicians, who were less preferred by 9.2 ppts (95% CI: -0.187 to 0.003, P =0.06). These findings are consistent with the physician-focused field experiment where Asian physicians offered appointments 3 days sooner than White providers (95% CI: -6.1 to 0.1 days, P =0.05). CONCLUSION: We find that concordance preferences for physicians varied by race. Some patients may be dissatisfied if these preferences are not met while some physicians may face unequal employment outcomes if they are met.
Reducing Readmission Disparities in Hospitals Serving High Volumes of Patients With Limited English Proficiency: Evidence From New Jersey.
Sliwinski K, McHugh MD, Squires AP … +3 more , Muir KJ, Margo Brooks Carthon J, Lasater KB
Med Care · 2026 Mar · PMID 41544106 · Publisher ↗
BACKGROUND: Despite national attention to address disparities in health care, significant language-based health inequities exist in the United States. OBJECTIVES: To evaluate whether readmissions for patients with limite...
BACKGROUND: Despite national attention to address disparities in health care, significant language-based health inequities exist in the United States. OBJECTIVES: To evaluate whether readmissions for patients with limited English proficiency (LEP) are associated with the LEP volume of the hospital and to determine whether and to what extent the effect of hospital LEP volume on readmissions for LEP patients is conditional on the hospitals' nurse work environment. RESEARCH DESIGN: Cross-sectional analysis using 3 data sources from 2016: New Jersey Discharge Data Collection System, RN4CAST-US survey, and American Hospital Association Annual Survey. SUBJECTS: A total of 424,745 patients, 9.2% of which were defined as having LEP (n=38,906), in 68 hospitals. MEASURES: The RN4CAST survey utilized the Practice Environment Scale of the Nursing Work Index to measure nurses' ratings of their hospitals' nurse work environment. The outcome variable was 7-day readmissions, representing a potentially avoidable re-visit to the hospital. Hospital LEP volume was measured as the percentage of index admissions of LEP patients. RESULTS: In the fully adjusted stratified model, in hospitals with poor work environments, a 10-percentage point increase in LEP volume was significantly associated with 6% higher odds of a 7-day readmission for LEP patients [OR=1.06, 95% CI (1.04-1.08), P <0.001]. In hospitals with favorable environments, a 10-percentage point increase in LEP volume was associated with 2% higher odds of a 7-day readmission; however, this difference was not statistically significant [OR=1.02, 95% CI (0.99-1.06)]. CONCLUSION: Readmission disparities were greatest in hospitals serving higher proportions of patients with LEP; however, the disparities were rendered insignificant in hospitals with the favorable nurse work environments.
Risk for Acute Care Utilization in Housing-Insecure Adults: A National Study of a Hot Spotter Program in the US Veterans Health Administration.
Blonigen DM, Macia KS, Raikov I … +2 more , Yoon J, Weber J
Med Care · 2026 Apr · PMID 41536037 · Full text
BACKGROUND: To identify patients at the highest risk for acute care utilization, health care systems have developed "hot spotter" programs. Homelessness is a robust social determinant of acute care utilization. OBJECTIVE...
BACKGROUND: To identify patients at the highest risk for acute care utilization, health care systems have developed "hot spotter" programs. Homelessness is a robust social determinant of acute care utilization. OBJECTIVES: To describe the prevalence, patterns, and correlates of meeting criteria for a hot spotter program among housing-insecure adults in the US Veterans Health Administration (VHA). RESEARCH DESIGN: Among veterans on the VHA Homeless Registry in Fiscal Years 2018-2022 (N=1,469,893), we identified those who met criteria for a Hot Spotter Report [ie, ≥1 hospital admissions and/or ≥2 emergency department (ED) visits in at least one quarter], described their patterns of acute care use, and examined differences in patient characteristics and outpatient service use between those who met report criteria in multiple quarters (vs. one). RESULTS: Thirty percent (N=446,974) met report criteria in at least one quarter; most (56%) met report criteria in ≥2 quarters. Diagnoses of depression (58%) and/or a substance use disorder (51%) were common; however, the rate of hospitalization in an acute medical setting during the cohort period was twice that of being hospitalized in an acute mental health setting (50% vs. 25%). Being on the Hot Spotter Report in multiple quarters (vs. one) was associated with more chronic conditions (M=5.08 vs. 3.29), higher rates of suicidality (23.7% vs. 11.7%), and higher likelihood of all types of outpatient care ( P <0.0001). CONCLUSIONS: Given rates of chronic medical conditions and medical hospitalizations, it may behoove hot spotter programs to increase care coordination with medical respite programs to support patients in the postacute phase.
The Impact of Nurse Practitioner Full Practice Authority on Chronic Condition-Related Readmissions and Emergency Department Visits in the United States.
Fitzpatrick JJ, Mehlman MJ, Plemmons A … +5 more , Duffy EG, Votruba M, Gerlick JA, Davis S, Norful AA
Med Care · 2026 Apr · PMID 41532526 · Full text
BACKGROUND: Chronic conditions affect over 60% of US adults and drive nearly 90% of the nation's $4.9 trillion in annual health care costs. Nurse practitioners (NPs), particularly in Full Practice Authority (FPA) states,...
BACKGROUND: Chronic conditions affect over 60% of US adults and drive nearly 90% of the nation's $4.9 trillion in annual health care costs. Nurse practitioners (NPs), particularly in Full Practice Authority (FPA) states, may be critical to improving outcomes and reducing health care burdens. OBJECTIVES: To evaluate whether nurse practitioner FPA reduces hospital readmissions and emergency department visits related to chronic conditions across the United States. RESEARCH DESIGN: A secondary data analysis using restricted Medical Expenditure Panel Survey (MEPS) data (2010-2019) was performed on site at the Agency of Health Research and Quality. We applied incidence rate ratios (IRRs) and difference-in-difference (DiD) models. MEASURES: Primary outcomes included readmission and emergency visit rates for five chronic conditions: high cholesterol (n=33,409), high blood pressure (n=38,858), diabetes (n=13,075), emphysema (n=2,509), and asthma (n=17,018). Covariates included county-level socioeconomic factors and rurality. RESULTS: States with FPA had modestly lower IRRs for high cholesterol (0.9863), high blood pressure (0.9758), diabetes (0.9746), and asthma (0.9710) compared with restricted states. DiD models showed inconsistent effects, with most FPA*Post coefficients lacking statistical significance. However, rural FPA counties frequently showed significantly lower readmission rates, notably for diabetes and high cholesterol. CONCLUSIONS: NP FPA is associated with slight reductions in chronic condition readmissions, particularly in rural areas. While DiD models showed limited policy-specific impact, IRR findings support FPA as a promising strategy to enhance chronic disease management and access to care. Future research should address model limitations and explore causal pathways.
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