Analysis of recurrent failure times: A time-dependent Yule process approach

Analysis of recurrent events has been widely discussed in medical, health services, insurance, and engineering areas in recent years. This research proposes to use a nonhomogeneous Yule process with the proportional intensity assumption to model the hazard function on recurrent events data and the associated risk factors. This method assumes that repeated events occur for each individual, with given covariates, according to a nonhomogeneous Yule process with intensity function λx(t) = λ 0(t) · exp( x′β). One of the advantages of using a non-homogeneous Yule process for recurrent events is that it assumes that the recurrent rate is proportional to the number of events that occur up to time t. Maximum likelihood estimation is used to provide estimates of the parameters in the model, and a generalized scoring iterative procedure is applied in numerical computation. ^ Model comparisons between the proposed method and other existing recurrent models are addressed by simulation. One example concerning recurrent myocardial infarction events compared between two distinct populations, Mexican-American and Non-Hispanic Whites in the Corpus Christi Heart Project is examined. ^

The determinants of physician and pharmacist utilization and equity of access under Korean universal health insurance

This study examines the social and behavioral determinants of two types of primary care, seeing a physician or a pharmacist, for Koreans and evaluates the equity of the Korean national health insurance system. The study applies the Aday and Andersen access framework to cross-sectional data from the 1992 Korean National Health Interview Survey (N = 21,841).^ The study found that in Korea, the elderly were most likely, and children least likely, to have used physician services. Women, household heads, those in small families, and the less educated were more likely than their counterparts to use physician and pharmacist services. Health status and need were important determinants of Koreans seeing a doctor or a pharmacist. Differences in need substantially accounted for the original differences observed between subgroups. Resources associated with having insurance coverage, a regular source of care, and place of residence (rural/urban) ameliorated to some extent the subgroup differences in the use of physicians' and pharmacists' services among Koreans. They were also major independent predictors of access. Having insurance remains a particularly important predictor of who uses physician services. Among the insured, trade-offs in the use of physician and pharmacist services were found in the current system, i.e., uninsured and poor Koreans were more likely to use pharmacist services, while insured and rural Koreans were more likely to use doctor services. Among the insured, cost sharing rates are lower for physician than for pharmacist services. Self-employed persons were less likely than government and industrial workers to use physician services. An underlying expectation under universal health insurance was that the Korean health care system would be equitable. The research results, however, did not fully support this expectation.^ The policy implications of these findings are that measures are required to extend insurance coverage to the uninsured, to equalize differences in benefit packages between health plans, and to expand the availability of physicians in rural areas. Further research is also needed to understand those who do not currently have a regular source of care and why and the access barriers that may exist for selected demographic subgroups (those in large families and unmarried or divorced/widowed persons). ^

The evolution and assessment of pharmaceutical care: Structure, processes, and outcomes

The evolution of pharmaceutical care is identified through a complete review of the literature published in the American Journal of Health-System Pharmacy, the sole comprehensive publication of institutional pharmacy practice. The evolution is categorized according to characteristics of structure (organizational structure, the role of the pharmacist), process (drug delivery systems, formulary management, acquiring drug products, methods to impact drug therapy decisions), and outcomes (cost of drug delivery, cost of drug acquisition and use, improved safety, improved health outcomes) recorded from the 1950s through the 1990s. While significant progress has been made in implementing basic drug distribution systems, levels of pharmacy involvement with direct patient care is still limited.^ A new practice framework suggests enhanced direct patient care involvement through increase in the efficiency and effectiveness of traditional pharmacy services. Recommendations advance internal and external organizational structure relationships that position pharmacists to fully use their unique skills and knowledge to impact drug therapy decisions and outcomes. Specific strategies facilitate expansion of the breadth and scope of each process component in order to expand the depth of integration of pharmacy and pharmaceutical care within the broad healthcare environment. Economic evaluation methods formally evaluate the impact of both operational and clinical interventions.^ Outcome measurements include specific recommendations and methods to increase efficiency of drug acquisition, emphasizing pharmacists' roles that impact physician prescribing decisions. Effectiveness measures include those that improve safety of drug distribution systems, decrease the potential of adverse drug therapy events, and demonstrate that pharmaceutical care can significantly contribute to improvement in overall health status.^ The implementation of the new framework is modeled on a case study at the M.D. Anderson Cancer Center. The implementation of several new drug distribution methods facilitated the redeployment of personnel from distributive functions to direct patient care activities with significant personnel and drug cost reduction. A cost-benefit analysis illustrates that framework process enhancements produced a benefit-to-cost ratio of 7.9. In addition, measures of effectiveness demonstrated significant levels of safety and enhanced drug therapy outcomes. ^

The medical malpractice insurance "crises" and federal medical malpractice tort reform: Collection and analysis of bills passed by the United States House of Representatives from 1995--2005

There have been three medical malpractice insurance "crises" in the United States over a time spanning roughly the past three decades (Poisson, 2004, p. 759-760). Each crisis is characterized by a number of common features, including rapidly increasing medical malpractice insurance premiums, cancellation of existing insurance policies, and a decreased willingness of insurers to offer or renew medical malpractice insurance policies (Poisson, 2004, p. 759-760). Given the recurrent "crises," many sources argue that medical malpractice insurance coverage has become too expensive a commodity—one that many physicians simply cannot afford (U.S. Department of Health and Human Services [HHS], 2002, p. 1-2; Physician Insurers Association of America [PIAA], 2003, p. 1; Jackiw, 2004, p. 506; Glassman, 2004, p. 417; Padget, 2003, p. 216). ^ The prohibitively high cost of medical liability insurance is said to limit the geographical areas and medical specializations in which physicians are willing to practice. As a result, the high costs of medical liability insurance are ultimately said to affect whether or not people have access to health care services. ^ In an effort to control the medical liability insurance crises—and to preserve or restore peoples' access to health care—every state in the United States has passed "at least some laws designed to reduce medical malpractice premium rates" (GAO, 2003, p.5-6). More recently, however, the United States has witnessed a push to implement federal reform of the medical malpractice tort system. Accordingly, this project focuses on federal medical malpractice tort reform. This project was designed to investigate the following specific question: Do the federal medical malpractice tort reform bills which passed in the House of Representatives between 1995 and 2005 differ in respect to their principle features? To answer this question, the text of the bills, law review articles, and reports from government and private agencies were analyzed. Further, a matrix was compiled to concisely summarize the principle features of the proposed federal medical malpractice tort reform bills. Insight gleaned from this investigation and matrix compilation informs discussion about the potential ramifications of enacting federal medical malpractice tort reform legislation. ^

Government initiatives to expand access to employer-based health insurance

Employer-based health insurance is declining at records rates, which leaves an increasing number of people without access to affordable health insurance. As a result, municipalities are experiencing financial difficulties to provide health care services for their growing uninsured population. In attempt to combat this issue, three health polices have emerged within the last ten years, called Living Wage with a health insurance provision, Pay or Play, and Health Care Preference. These policies are gaining popularity as civic leaders recognize their ability to promote a public health goal by leveraging the power of city and county contracts to include a health insurance component in the competitive bidding practice for government contracts. ^ This is the first paper to conduct a retrospective analysis on whether these three health policies have been able to increase access to employer-based health insurance and/or support the local health care safety net based on the experiences of six municipalities over a 5-year period from 2001-2006. Although there was variation between the effectiveness of the policies, all three demonstrated success in that a number of contractors extended existing health insurance to employees not previously covered and the increased cost of contracting for the local government was, on average, less than 1 percent of the total operating budget. ^

The effect of immigration status on racial differences in health insurance coverage, access to care, and utilization in the United States

Background. Lack of coverage, lack of access, and failure to utilize health care services have all been linked to dismal health outcomes in the US. Such consequences have been a longstanding challenge that US minorities are faced with, in the context of a health care system believed to be lacking efficiency and equity. National population surveys in the US suggest that the number of uninsured approaches 50 millions, while some concerns and suspicions are raised by opponents to the growing number of foreign born US residents, many of whom are Hispanic. Research shows that race is a significant predictor of lack of coverage, access, and utilization, while age, gender, education, and income are also linked to these outcomes. We investigated the potential effect of immigration status or duration in the US on the association between coverage, access, use, and race. Methods. Using National Health Interview Survey (NHIS) data of 2006, we selected 22, 667 individuals of Non-Hispanic Black, Hispanic, and Non-Hispanic White descent, at least 18 years of age, US-born and foreign-born who reported their duration of residence in the US. Through complex sample survey logistic regression analysis, we computed odds ratios, beta coefficients, and 95% confidence intervals using models which excluded then included immigration status. Results. Although a significant predictor of the outcomes, immigration status did not change the relationship between each of the dependent variables (coverage, access, utilization), and the factor race, while adjusting for age, gender, education, and income. Our results show that Hispanics were least likely to have coverage (OR=.58; 95% CI[.49, .68]), access (OR=.62; 95% CI[.50, .76]), and to utilize services (OR=.60; 95% CI[.46, .79]) followed by Non-Hispanic Blacks, and Non-Hispanic Whites. These results were not changed by stratification, or the inclusion of interaction terms to eliminate the potential effect of relationships between independent variables. Recent immigrants (<5 years in US) were 0.12 times less likely to be insured, but also 0.26 times less likely to utilize services (p<0.001), and in addition they represented only 7.3% of the uninsured and 1.9% of the US population in 2006. Furthermore, 12% of the Non-Hispanic White population in the US was not covered, and 65% of the uninsured individuals were US-Born Citizens. Other predictors of lack of coverage, access and use were age below 45, male gender, education at high school or below, and income of less than $20,000. Conclusion. This investigation shows that the high percentage of uninsured was not directly caused by Hispanics, and immigration status alone could not explain racial differences in coverage, access, and utilization. An immigration reform may not be the solution to the healthcare crisis, and more specifically, will not stop the increase in the number of uninsured in the US, nor reduce the cost of health care. As a better alternative, universal health insu rance coverage should be considered, when aiming to eliminate racial disparities, and to solve the health care crisis. ^ Keywords. health insurance, coverage, access, utilization, race, immigration, disparities.^

Exploring the use of pharmaceutical patient assistance programs as an option to improve access to and affordability of prescription drugs

Background. Pharmaceutical-sponsored patient assistance programs (PAPs) are charity programs that provide free or reduced-priced medications to eligible patients. PAPs have the potential to improve prescription drug accessibility for patients but currently there is limited information about their use and effectiveness. ^ Objectives and methods. This dissertation described the use of PAPs in the U.S. through the conduct of two studies: (1) a systematic review of primary studies of PAPs from commercially-published and “grey” literature sources; and (2) a retrospective, cross-sectional study of cancer patients' use of PAPs at a tertiary care cancer outpatient center. ^ Results. (1) The systematic review identified 33 studies: 15 evaluated the impact of PAP enrollment assistance programs on patient healthcare outcomes; 7 assessed institutional costs of providing enrollment assistance; 7 surveyed stakeholders; 4 examined other aspects. Standardized mean differences calculated for disease indicator outcomes (most of which were single group, pre-posttest designs) showed significant decreases in glycemic and lipid control, and inconsistent results for blood pressure. Grey literature abstracts reported insufficient statistics for calculations. Study heterogeneity made weighted summary estimates inappropriate. Economic analyses indicated positive financial benefits to institutions providing enrollment assistance (cost) compared to the wholesale value of the medications provided (benefit); analyses did not value health outcomes. Mean quality of reporting scores were higher for observational studies in commercially-published articles versus full text, grey literature reports. (2) The cross-sectional study found that PAP outpatients were significantly more likely to be uninsured, indigent, and < 65 years old than non-PAP patients. Nearly all non-PAP and PAP prescriptions were for non-cancer conditions, either for co-morbidities (e.g., hypertension) or the management of treatment side effects (e.g., pain). Oral chemotherapies from PAPs were significantly more likely to be for breast versus other cancers, and be a newer, targeted versus traditional chemotherapy.^ Conclusions. In outpatient settings, PAP enrollment assistance plus additional medication services (e.g., counseling, reminders, and free samples) is associated with improved disease indicators for patients. Healthcare institutions, including cancer centers, can offset financial losses from uncompensated drug costs and recoup costs invested in enrollment assistance programs by procuring free PAP medications. Cancer patients who are indigent and uninsured may be able to access more outpatient medications for their supportive care needs through PAPs, than for cancer treatment options like oral chemotherapies. Because of the selective availability of drugs through PAPs, there may be more options for newer, oral, targeted chemotherapies for the treatment breast cancer versus other for other cancers.^

Systematic review of current trends of cardiovascular disease (CVD) and association between health insurance coverage and CVD mortality among women aged 60--65 in Texas in 2000--2011

Cardiovascular disease (CVD) is highly preventable, yet it is a leading cause of death among women in Texas. The primary goals of this research were to examine past and current trends of CVD, as well as identify whether there is an association between the insurance coverage and mortality from CVD among women aged 60–65 in Texas between 2000 and 2011. ^ The systematic review of the research is based on the guidelines and recommendations set by the Centre for Reviews and Dissemination for conducting reviews in health care. Over 47 citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five websites were identified, of which 7 studies met inclusion criteria for the first systematic review to examine the trends of CVD in Texas. Ten citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five web sites were reviewed for the second systematic review (to study the association between insurance coverage and cardiovascular health among Texas women 60–64 years of age), of which 3 studies met inclusion criteria and were included in the research. The results of the study highlighted key gaps in the existing literature and important areas for the further research, as well as determined directions for future public health CVD prevention programs in Texas. ^ Based on the conducted research, the major determinants of premature mortality among women attributed to cardiovascular disease are based on individual level characteristics, more specifically sex, age, race/ethnicity, and education. The results indicate that African American and non-Hispanic white women are more likely to have higher CVD mortality rates than Hispanic women due to higher prevalence of cardiac risk factors. The data also shows higher levels of mortality from CVD in the southeastern United States, with Texas ranking as the third state with the highest prevalence of CVD among women. According to the Texas Department of State Health Services, there are approximately 56,000 deaths caused by CVD annually in Texas, which represents about one death every ten minutes. Coronary artery disease and stroke were the causes of 31.2 percent of all female deaths in Texas in 2009, meaning that approximately 68 women die from any form of cardiac disease in Texas each day. ^ The data of the reviewed studies indicate that women' lack of health insurance was significantly associated with a higher prevalence of cardiovascular disease. The uninsured women were more likely to be unaware of their risk factors and more likely to have undiagnosed diabetes—a co-morbidity factor of CVD. One of the studies also reports strong correlation between state rates of uninsured and lower rates of preventive care. Given these strong correlations, those who were chronically uninsured were at a higher risk of mortality than the insured, due to prolonged periods of time without basic access to preventive and medical care. ^ Suggested recommendations to decrease CVD mortality rates in Texas are consistent with the existing literature and include state policy development that addresses elimination of health disparities, consideration of potential benefits of universal health coverage by the legislative policymakers, and maintenance of solid partnerships between public health agencies and hospitals to educate on, diagnose, and treat CVD among the female population in Texas. ^

Interpretation services for immigrants in federally qualified health centers: Barriers, best practices, and suggestions for the future

This paper examines the provision of interpretation services to immigrants with limited English proficiency in Federally Qualified Health Centers, through examination of barriers and best practices. The United States is a nation of immigrants; currently, more than 38 million, or 12.5 percent of the total population, is foreign-born. A substantial portion of this population does not have health insurance or speak English fluently: barriers that reduce the likelihood that they will access traditional health care organizations. This service void is filled by FQHCs, which are non-profit, community-directed providers that remove common barriers to care by serving communities who otherwise confront financial, geographic, language, and cultural barriers. By examining the importance and the implementation of medical interpretation services in FQHCs, suggestions for the future are presented.^

Effect of insurance status on stage of breast cancer diagnosis

Objective: The purpose of this study is to compare the stages of breast cancer presented between the insured and uninsured patients diagnosed at The Rose, an active non-profit breast healthcare organization to determine if uninsured patients present with more advanced stage breast cancer as compared to their insured counterparts. ^ Study Design: Retrospective cross-sectional study. ^ Methods: The study included 1,265 patients who received breast healthcare services and were diagnosed with breast cancer at The Rose between FY 2007 and FY 2012. 738 of the patients in the study were presumably uninsured since their breast healthcare services were sponsored through various funding sources and they were navigated into treatment through The Rose patient navigation program. We compared breast cancer stages for women who had insurance with those who did not have insurance. The effects of age and race/ethnicity along with the insurance status on the stage of reast cancer diagnosis were also analyzed. We calculated the odds ratio using the contingency tables; and estimated odds ratios (ORs) and 95% confidence intervals (CIs) using ordinal logistic regression by applying multiple imputation method for missing tumor stage data. ^ Results: The ordered logistic regression analysis with ordered tumor stage as dependent variable and uninsured as independent variable gave us an odds ratio of 1.73 (OR=1.73; p-value<0.05; 95% CI: 1.36 - 2.12). ^ Conclusions: Insurance status is a strong predictor of stage of breast cancer diagnosed among women seen at The Rose. Uninsured women seen at The Rose are almost twice as likely to present at a advanced stage of breast cancer as opposed to their insured counterparts.^