Category: Statistics

Am J Manag Care. 2025 Jan 1;31(1):e15-e19. doi: 10.37765/ajmc.2025.89666.

ABSTRACT

OBJECTIVES: Unused medical appointments affect both patient care and clinic operations, and the frequency of cancellations due to clinic reasons is underreported. The prevalence of these unused appointments in primary care in the Veterans Affairs Health Care System (VA) is unknown. This study examined the prevalence of unused primary care appointments and compared the relative frequency of cancellations and no-shows for patient and clinic reasons.

STUDY DESIGN: In this retrospective, observational study, we collected all in-person and virtual VA primary care appointments from October 1, 2018, to April 1, 2024.

METHODS: We examined the proportion of appointments canceled on the same day as the appointment and classified these into canceled by patient, canceled by clinic, and no-show.

RESULTS: Of more than 90 million in-person and nearly 24 million virtual primary care appointments, 11.9 million (10.87%) were canceled on the day of the appointment. For in-person care cancellations, the most common reasons were canceled by the patient (3.92%; n = 3,531,016), no-show (3.87%; n = 3,487,944), and clinic cancellation (3.08%; n = 2,780,259).

CONCLUSIONS: Although this study shows that same-day cancellations of primary care appointments in the VA are common, comparisons with other providers and health care systems indicate similar or lower levels of unused appointments in the VA.

PMID:39847790 | DOI:10.37765/ajmc.2025.89666

Am J Manag Care. 2025 Jan;31(1):33-36. doi: 10.37765/ajmc.2025.89663.

ABSTRACT

OBJECTIVES: To assess trends in the medical loss ratio (MLR) and understand how health insurance premiums in the large group market are driven by medical claims spending and insurer margins.

STUDY DESIGN: Study of approximately 500 insurers covering more than 40 million lives annually in the large group market that submitted an MLR submission form (2014-2022).

METHODS: We assessed trends in the MLR, premiums, medical claims spending, administrative costs, quality improvement spending, and margins among all insurers in the large group market.

RESULTS: The mean MLR was 90.0% (2014-2020), which increased to 91.8% in 2021 before declining in 2022. Spending on both administrative costs and quality improvement was small and stable during this period. In contrast, premiums and medical claims spending grew between 2014 and 2020, with claims spending increasing 9.4% between 2020 and 2021 compared with just 3.9% for premiums. This mirrored the observed trend in insurer margins, which increased from 2014 to 2020 before experiencing a temporary decline in 2021.

CONCLUSIONS: Medical spending is the primary driver of premiums in the large group market. Efforts to address growing health insurance premiums in the US will require consideration of how medical spending contributes to this growth.

PMID:39847786 | DOI:10.37765/ajmc.2025.89663

Am J Manag Care. 2025 Jan;31(1):25-32. doi: 10.37765/ajmc.2025.89662.

ABSTRACT

OBJECTIVES: Medicaid is the largest payer of mental health (MH) services in the US, and more than 80% of its enrollees are covered by Medicaid managed care (MMC). States are required to establish quantitative network adequacy standards (NAS) to regulate MMC plans’ MH care access. We examined the association between quantitative NAS and MH care access among Medicaid-enrolled adults and among those with MH conditions.

STUDY DESIGN: Cross-sectional study with a difference-in-differences design.

METHODS: Using the 2016-2019 National Survey on Drug Use and Health, we included Medicaid enrollees aged 18 to 64 years in 15 states. Subgroup analyses included enrollees with MH conditions who experienced in the past year (1) serious psychological distress, (2) a major depressive episode, and/or (3) suicidal thoughts. Outcomes assessed whether in the past year the enrollee had any (1) MH services, (2) inpatient MH stays, (3) outpatient MH visits, (4) MH prescription, and (5) unmet MH care needs.

RESULTS: Among 9300 adults aged 18 to 64 years, 27.2% had MH conditions. Among all adults, NAS were marginally associated with increased use of any MH services (adjusted OR, 1.4; 95% CI, 1.0-2.1; P = .055) but were not associated with other outcomes. Among enrollees with MH conditions, no statistically significant association between NAS and MH care access was observed.

CONCLUSIONS: Current quantitative NAS requirements may have few impacts on improving MH care access for adults and those with MH conditions without the implementation of additional interventions. States should consider adjusting enforcement strategies and adopting other interventions alongside NAS.

PMID:39847785 | DOI:10.37765/ajmc.2025.89662

Am J Manag Care. 2025 Jan;31(1):12-18. doi: 10.37765/ajmc.2025.89660.

ABSTRACT

OBJECTIVES: Patients are often discharged to a skilled nursing facility (SNF) for postacute rehabilitation. Functional outcomes achieved in SNFs are variable, and costs are high. Especially for accountable care organizations (ACOs), home-based postacute rehabilitation offers a high-value option if outcomes are not compromised. The objective was to compare outcomes for episodes in a novel high-intensity home-based rehabilitation (HIHR) model vs an SNF.

STUDY DESIGN: Retrospective cohort study.

METHODS: Medicare patients from a large integrated multihospital health system who had low to moderate medical complexity and mild to moderate mobility deficits at hospital discharge were included. The primary exposure was discharge to HIHR (intervention) or an SNF (control) after hospitalization. The primary outcome was Activity Measure for Post-Acute Care (AM-PAC) mobility score. Secondary outcomes were Medicare costs within 30 and 90 days post hospitalization, 30-day readmission rate, and index hospital length of stay (LOS). Inverse probability of treatment-weighted regression was used for comparison between cohorts.

RESULTS: There were 171 patients discharged to HIHR and 841 to SNFs. The adjusted AM-PAC mobility T-score was 8.2 (95% CI, 6.3-10.1) points higher after HIHR vs SNF. Adjusted Medicare costs were lower for the HIHR cohort (within 90 days, -$17,123; 95% CI, -$20,757 to -$13,490). Hospital LOS and odds for readmission did not differ between cohorts.

CONCLUSIONS: The HIHR cohort demonstrated better functional outcomes and lower posthospital costs. HIHR may be a high-value option for patients attributed to a Medicare ACO who have moderate medical complexity and moderate functional deficits at the time of hospital discharge.

PMID:39847783 | DOI:10.37765/ajmc.2025.89660

J Particip Med. 2025 Jan 23;17:e60263. doi: 10.2196/60263.

ABSTRACT

BACKGROUND: It remains unclear if there is agreement between physicians and patients on the definition of treatment success following orthopedic treatment. Clinical progress notes are generated during each health care encounter and include information on current disease symptoms, rehabilitation progress, and treatment outcomes.

OBJECTIVE: This study aims to assess if physicians and patients agree on whether patient outcomes captured in clinical progress notes reflect a successful treatment outcome following orthopedic care.

METHODS: We performed a cross-sectional analysis of a subset of clinical notes for patients presenting to a Level-1 Trauma Center and Regional Health System for follow-up for an acute proximal humerus fracture (PHF). This study was part of a larger study of 1000 patients with PHF receiving initial treatment between 2019 and 2021. From the full dataset of 1000 physician-labeled notes, a stratified random sample of 25 notes from each outcome label group was identified for this study. A group of 2 patients then reviewed the sample of 100 clinical notes and labeled each note as reflecting treatment success or failure. Cohen κ statistics were used to assess the degree of agreement between physicians and patients on clinical note content.

RESULTS: The average age of the patients in the sample was 67 (SD 13) years and 82% of the notes came from female patients. Patients were primarily White (91%) and had Medicare insurance coverage (65%). The note sample came from fracture-related encounters ranging from the second to the tenth encounter after the index PHF visit. There were no significant differences in patient or visit characteristics across concordant and discordant notes labeled by physicians and patients. Among agreement levels ranging from poor to perfect agreement, physician and patient evaluators exhibited only a fair level of agreement in what they deemed as treatment success based on a Cohen κ of 0.32 (95% CI 0.10-0.55; P=.01). Furthermore, interpatient and interphysician agreement also demonstrated relatively low levels of agreement.

CONCLUSIONS: The findings suggest that physicians and patients demonstrated low levels of agreement when assessing whether a patient’s clinical note reflected a successful outcome following treatment for a PHF. As low levels of agreement were also observed within physician and patient groups, it is clear the definition of success varied highly across both physicians and patients. Further research is needed to elucidate physician and patient perceptions of treatment success. As outcome measurement and demonstrating the value of orthopedic treatment remain important priorities, it is important to better define and reach a consensus on what treatment success means in orthopedic medicine.

PMID:39847773 | DOI:10.2196/60263

JMIR Hum Factors. 2025 Jan 23;12:e56941. doi: 10.2196/56941.

ABSTRACT

BACKGROUND: The internet is a key source of health information, but the quality of content from popular search engines varies, posing challenges for users-especially those with low health or digital health literacy. To address this, the “tala-med” search engine was developed in 2020 to provide access to high-quality, evidence-based content. It prioritizes German health websites based on trustworthiness, recency, user-friendliness, and comprehensibility, offering category-based filters while ensuring privacy by avoiding data collection and advertisements.

OBJECTIVE: This study aims to evaluate the acceptance and usability of this independent, noncommercial search engine from the users’ perspectives and their actual use of the search engine.

METHODS: For the questionnaire study, a cross-sectional study design was used. In total, 802 participants were recruited through a web-based panel and were asked to interact with the new search engine before completing a web-based questionnaire. Descriptive statistics and multiple regression analyses were used to assess participants’ acceptance and usability ratings, as well as predictors of acceptance. Furthermore, from October 2020 to June 2021, we used the open-source web analytics platform Matomo to collect behavior-tracking data from consenting users of the search engine.

RESULTS: The study indicated positive findings on the acceptance and usability of the search engine, with more than half of the participants willing to reuse (465/802, 58%) and recommend it (507/802, 63.2%). Of the 802 users, 747 (93.1%) valued the absence of advertising. Furthermore, 92.3% (518/561), 93.9% (553/589), 94.7% (567/599), and 96.5% (600/622) of those users who used the filters agreed at least partially that the filter functions were helpful in finding trustworthy, recent, user-friendly, or comprehensible results. Participants criticized some of the search results regarding the selection of domains and shared ideas for potential improvements (eg, for a clearer design). Regression analyses showed that the search engine was especially well accepted among older users, frequent internet users, and those with lower educational levels, indicating an effective targeting of segments of the population with lower health literacy and digital health literacy. Tracking data analysis revealed 1631 sessions, comprising 3090 searches across 1984 unique terms. Users performed 1.64 (SD 1.31) searches per visit on average. They prioritized the search terms “corona,” “back pain,” and “cough.” Filter changes were common, especially for recency and trustworthiness, reflecting the importance that users placed on these criteria.

CONCLUSIONS: User questionnaires and behavior tracking showed the platform was well received, particularly by older and less educated users, especially for its advertisement-free design and filtering system. While feedback highlighted areas for improvement in design and filter functionality, the search engine’s focus on transparency, evidence-based content, and user privacy shows promise in addressing health literacy and navigational needs. Future updates and research will further refine its effectiveness and impact on promoting access to quality health information.

PMID:39847765 | DOI:10.2196/56941

Am J Public Health. 2025 Jan 23:e1-e5. doi: 10.2105/AJPH.2024.307906. Online ahead of print.

ABSTRACT

Objectives. To assess the impact of state COVID-19 vaccine mandates for health care workers (HCWs) on health sector employment in the United States. Methods. Using monthly state-level employment data from the Quarterly Census of Employment and Wages between January and October 2021, we employed a partially pooled synthetic control method that accounted for staggered mandate adoption and heterogeneous treatment effects. We conducted analyses separately for the 4 health care subsectors-ambulatory health care services, hospitals, nursing and residential care, and social assistance-with an additional analysis of 2 industry groups-skilled nursing care and community care for the elderly-under the nursing and residential care subsector. We further explored possible heterogeneous impacts according to the test-out option availability. Results. Mandate impact estimates were statistically indistinguishable from zero. Results further ruled out a mandate-associated decrease in employment larger than 2.1% of premandate employment levels for the 6 health care domains examined and for states with no test-out option. Conclusions. State COVID-19 vaccine mandates for HCWs were not found to be associated with significant adverse impacts on health sector employment even in states without a testing alternative to vaccination. The findings support vaccine mandates as a viable preventive measure without material disruption to the health care workforce, including in times of public health emergencies. (Am J Public Health. Published online ahead of print January 23, 2025:e1-e5. https://doi.org/10.2105/AJPH.2024.307906).

PMID:39847751 | DOI:10.2105/AJPH.2024.307906

Neurology. 2025 Feb 25;104(4):e213349. doi: 10.1212/WNL.0000000000213349. Epub 2025 Jan 23.

ABSTRACT

BACKGROUND AND OBJECTIVES: Although multiple sclerosis (MS) can be conceptualized as a network disorder, brain network analyses typically require advanced MRI sequences not commonly acquired in clinical practice. Using conventional MRI, we assessed cross-sectional and longitudinal structural disconnection and morphometric similarity networks in people with MS (pwMS), along with their relationship with clinical disability.

METHODS: In this longitudinal monocentric study, 3T structural MRI of pwMS and healthy controls (HC) was retrospectively analyzed. Physical and cognitive disabilities were assessed with the expanded disability status scale (EDSS) and the symbol digit modalities test (SDMT), respectively. Demyelinating lesions were automatically segmented, and the corresponding masks were used to assess pairwise structural disconnection between atlas-defined brain regions based on normative tractography data. Using the Morphometric Inverse Divergence method, we computed morphometric similarity between cortical regions based on FreeSurfer surface reconstruction. Using network-based statistics (NBS) and its extension NBS-predict, we tested whether subject-level connectomes were associated with disease status, progression, clinical disability, and long-term confirmed disability progression (CDP), independently from global lesion burden and atrophy.

RESULTS: We studied 461 pwMS (age = 37.2 ± 10.6 years, F/M = 324/137), corresponding to 1,235 visits (mean follow-up time = 1.9 ± 2.0 years, range = 0.1-13.3 years), and 55 HC (age = 42.4 ± 15.7 years; F/M = 25/30). Long-term clinical follow-up was available for 285 pwMS (mean follow-up time = 12.4 ± 2.8 years), 127 of whom (44.6%) exhibited CDP. At baseline, structural disconnection in pwMS was mostly centered around the thalami and cortical sensory and association hubs, while morphometric similarity was extensively disrupted (p_FWE < 0.01). EDSS was related to frontothalamic disconnection (p_FWE < 0.01) and disrupted morphometric similarity around the left perisylvian cortex (p_FWE = 0.02), while SDMT was associated with cortico-subcortical disconnection in the left hemisphere (p_FWE < 0.01). Longitudinally, both structural disconnection and morphometric similarity disruption significantly progressed (p_FWE = 0.04 and p_FWE < 0.01), correlating with EDSS increase (ρ = 0.07, p = 0.02 and ρ = 0.11, p < 0.001), while baseline disconnection predicted long-term CDP (accuracy = 59% [58-60], p = 0.03).

DISCUSSION: Structural disconnection and morphometric similarity networks, as assessed through conventional MRI, are sensitive to MS-related brain damage and its progression. They explain disease-related clinical disability and predict its long-term evolution independently from global lesion burden and atrophy, potentially adding to established MRI measures as network-based biomarkers of disease severity and progression.

PMID:39847748 | DOI:10.1212/WNL.0000000000213349

JCO Glob Oncol. 2025 Jan;11:e2400326. doi: 10.1200/GO-24-00326. Epub 2025 Jan 23.

ABSTRACT

PURPOSE: Patients with adolescent and young adult (AYA) cancer are recognized as a vulnerable subpopulation in high-income countries (HICs). Although survival gaps between HIC and low- and middle-income country (LMIC) children with cancer are well described, LMIC AYAs have been neglected. We conducted a systematic review to describe cancer outcomes among LMIC AYAs.

METHODS: We captured English language studies published from 2010 onward reporting LMIC AYA cancer survival outcomes. LMICs were defined according to World Bank 2019 classifications, whereas AYAs were defined as diagnosed between age 15 and 39 years. Cohorts were considered AYA if >75% of patients were AYA, the mean/median age and standard deviation were between 15 and 39 years, or the range was within 5 years of the AYA range (ie, 10-45 years). Cohort characteristics were abstracted, including country, cancer type, and cancer outcomes.

RESULTS: Of 6,207 studies identified by the search strategy, 658 underwent full-text review; 60 met inclusion criteria. No low-income countries were represented. Forty-four (73.3%) studies were conducted in upper-middle-income countries (UMICs) although these represented only 12 of 55 countries currently classified as UMICs. The most common cancers studied were acute lymphoblastic leukemia (n = 13 studies), breast cancer (n = 5), and osteosarcoma (n = 3). Five-year overall survival was highly variable, ranging from 39% to 63% for ALL, 60%-85% for breast cancer, and 47%-83% for osteosarcoma.

CONCLUSION: Although three billion AYAs reside in LMICs, their cancer outcomes are neglected in the current literature. Existing data indicate variable survival, ranging from comparable with HIC outcomes to substantially inferior. These studies, however, represent only a limited number of LMICs and are biased toward UMICs. Systematic efforts to describe and improve LMIC AYA cancer outcomes are required.

PMID:39847745 | DOI:10.1200/GO-24-00326

JCO Glob Oncol. 2025 Jan;11:e2400275. doi: 10.1200/GO-24-00275. Epub 2025 Jan 23.

ABSTRACT

PURPOSE: We aimed to evaluate the impact of COVID-19 on breast cancer care in terms of the stage at presentation, treatment delays, and follow-up in a tertiary care center in Lebanon.

MATERIALS AND METHODS: This retrospective study compared patients with breast cancer who presented to a tertiary care center in Lebanon before (September 2019-December 2019) and during (September 2020-December 2020) the COVID-19 pandemic. We extracted data from the electronic medical records of patients with breast cancer who had their initial presentation, were under treatment, or were on follow-up during our period of interest.

RESULTS: Of the 333 patients, 186 visited the hospital in the pre-COVID-19 period and 147 during the pandemic, showing almost a 12% reduction in the number of patients during the COVID-19 pandemic. In the pre-COVID period, more patients were presented for screening (52%); however, more symptomatic patients were presented during the pandemic (51.4%). Almost 54% had an advanced stage at presentation during the pandemic compared with 48% before the pandemic but with no statistical significance (P = .50). Significantly fewer patients came for chemotherapy in the COVID-19 period (38.1%) compared with the pre-COVID-19 period (52.2%). Fewer patients underwent surgery during the pandemic, although the difference was not statistically significant. Multivariate analysis showed that the COVID-19 pandemic was not associated with having an advanced stage at presentation (P = .24).

CONCLUSION: The management of breast cancer was not substantially affected by the COVID-19 pandemic in a sample of Lebanese patients. However, 4 months might not be sufficient to draw a solid conclusion.

PMID:39847743 | DOI:10.1200/GO-24-00275