Objective

To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17).

Design

Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions.

Setting

United States.

Participants

A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey.

Main outcomes and measures

Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons.

Results

37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change -28.0% (95% confidence interval -38.4% to -15.8%); adjusted absolute change -$122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (-29.0% (-40.5% to -15.3%); -$442; adjusted P<0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change -4.7 (-7.9 to -1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions.

Conclusion

Medicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act's implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults.

Objective

To identify organizational complementarities of adoption and use of electronic health records (EHRs) and assess what organizational strategies were associated with more advanced EHR use.

Data sources

Primary survey data of US hospitals combined with secondary data from the American Hospital Association Annual Survey and IT Supplement.

Study design

In this cross-sectional study, we describe hospital organizational practices around EHR adoption and use and identify how these practices coalesce into distinct strategies. We then assess the association between those organizational strategies and adoption of advanced EHR functions.

Data collection

Primary data collection consisted of surveys sent to 797 US acute care hospitals in 2018-2019, with 451 complete respondents.

Principal findings

There was significant variation in hospital organizational practices for EHR adoption and use. Factor analysis identified practices in three domains: leadership engagement, human capital, and systems integration. Hospitals in the top quartile of the leadership engagement factor were 14 percentage points more likely to have adopted patient engagement EHR functions (P = 0.01) while hospitals in the top quartile of human capital were 14 percentage points less likely to have adopted these functions (P = 0.02). Hospitals in the top quartile of systems integration were 12 percentage points more likely to have adopted patient engagement functions (P = 0.02) and 14 percentage points more likely to have adopted EHR data analytics functions (P = 0.02).

Conclusions

Our findings suggest that specific organizational strategies are associated with more advanced EHR adoption. Hospital leaders interested in realizing more value from their EHR investment may find it useful to know that there is an association between adoption of more advanced EHR functions, and engaging senior leadership as well as building connectivity between clinical and administrative systems.

Objectives

Japan is considering policies to set the target health expenditure level for each region, a policy approach that has been considered in many other countries. The objective of this study was to examine the relationship between regional health expenditure and health outcomes after out-of-hospital cardiac arrest (OHCA), which incorporates the qualities of prehospital, in-hospital and posthospital care systems.

Design

We examined the association between prefecture-level per capita health expenditure and patients' health outcomes after OHCA.

Setting

We used a nationwide, population-based registry system of OHCAs that captured all cases with OHCA resuscitated by emergency responders in Japan from 2005 to 2011.

Participants

All patients with OHCA aged 1-100 years were analysed.

Outcome measures

The patients' 1-month survival rate, and favourable neurological outcome (defined as cerebral performance category 1-2) at 1-month.

Results

Among 618,154 cases with OHCA, the risk-adjusted 1-month survival rate varied from 3.3% (95% CI 2.9% to 3.7%) to 8.4% (95% CI 7.7% to 9.1%) across prefectures. The risk-adjusted probabilities of favourable neurological outcome ranged from 1.6% (95% CI 1.4% to 1.9%) to 3.7% (95% CI 3.4% to 3.9%). Compared with prefectures with lowest tertile health expenditure, 1-month survival rate was significantly higher in medium-spending (adjusted OR 1.31, 95% CI 1.03 to 1.66, p=0.03) and high-spending prefectures (adjusted OR 1.30, 95% CI 1.03 to 1.64, p=0.02), after adjusting for patient characteristics. There was no difference in the survival between medium-spending and high-spending regions. We observed similar patterns for favourable neurological outcome. Additional adjustment for regional per capita income did not affect our overall findings.

Conclusions

We observed a wide variation in the health outcomes after OHCA across regions. Low-spending regions had significantly worse health outcomes compared with medium-spending or high-spending regions, but no difference was observed between medium-spending and high-spending regions. Our findings suggest that focusing on the median spending may be the optimum that allows for saving money without compromising patient outcomes.

A series of poly(styrene-b-dimethylsiloxane-b-styrene) (SDS) triblock copolymers with molecular weights ranging from 55 to 150 kg/mol and polydimethylsiloxane (PDMS) volume fractions ranging from 0.59 to 0.83 were used to fabricate membranes for ethanol/water separation by pervaporation. The rigid polystyrene (PS) microphase provides the membrane with structural integrity, while the rubbery PDMS microphase provides nanoscale channels for ethanol transport. We use a simple model to study the effect of morphology and PDMS volume fraction on permeabilitites of ethanol and water through the block copolymer membranes. We defined normalized permeabilities of ethanol and water to account for differences in morphology and PDMS volume fraction. We found that the normalized ethanol permeability in SDS copolymers was independent of the total polymer molecular weight. This is qualitatively different from what was previously reported for poly(styrene-b-butadiene-b-styrene) (SBS) membranes, where the normalized ethanol permeability was found to be a sensitive function of total molecular weight [J. Membr. Sci. 2011, 373, 112]. We demonstrate that this is due to differences in the Flory-Huggins interaction parameter (χ) for the two systems. When χN is less than 100 (N is the number of segments per chain), the two microphases are weakly segregated, and the presence of glassy PS segments in the transporting microphase impedes ethanol transport. When χN exceeds 100, the two microphases are strongly segregated and the glassy PS segments do not mix with the transporting phase. We compare these results with normalized ionic conductivity data previously reported for mixtures of a lithium salt and polystyrene-b-poly(ethylene oxide) (SEO). Evidence suggests that the product χN governs the transport of widely different species such as ethanol and lithium salts through block copolymer membranes. Surprisingly, the normalized permeability of water is independent of total molecular weight for both SDS and SBS block copolymers. © 2013 American Chemical Society.

Background

This study sought to characterize the possible relationship between US geopolitical priorities and annual decisions on health foreign assistance among recipient nations between 2009 and 2016.

Methods

Data on total planned United States (US) foreign aid and health aid were collected for the 194 member nations of the World Health Organization (WHO) from publicly available databases. Trends in per-capita spending were examined between 2009 and 2016 across the six regions of the WHO (Africa, Americas, Eastern Mediterranean, Europe, Southeast Asia, and the Western Pacific). Data on US national security threats were obtained from the Council on Foreign Relations' annual Preventive Priorities Survey. Multivariable regression models were fitted specifying planned health aid as the dependent variable and threat level of a recipient aid nation as the primary independent variable.

Results

Across the aggregate 80 planned recipient countries of US health aid over the duration of the study period, cumulative planned per-capita spending was stable (US$ 0.65 in both 2009 and 2016). The number of annual planned recipients of this aid declined from 74 in 2009 to 56 in 2016 (24.3% decline), with planned allocations decreasing in the Americas, Eastern Mediterranean, and Europe; corresponding increases were observed in Africa, Southeast Asia, and the Western Pacific. Regression analyses demonstrated a dose-response, whereby higher levels of threat were associated with larger declines in planned spending (critical threat nations: b = -3.81; 95% confidence interval (CI) -5.84 to -1.78, P ≤ 0.001) and one-year lagged (critical threat nations: b = -3.91; 95% CI, -5.94 to -1.88, P ≤ 0.001) analyses.

Conclusions

Higher threat levels are associated with less health aid. This is a novel finding, as prior studies have demonstrated a strong association between national security considerations and decisions on development aid.