THE EFFECTS OF COST-SHARING ON USE OF SERVICES AND CONSUMER CHARACTERISTICS IN A STATE'S CRIPPLED CHILDREN'S DIVISION

The present study analyzed some of the effects of imposing a cost-sharing requirement on users of a state's health service program. The study population consisted of people who were in diagnosed medical need and included, but was not limited to, people in financial need.^ The purpose of the study was to determine if the cost-sharing requirement had any detrimental effects on the service population. Changes in the characteristics of service consumers and in utilization patterns were analyzed using time-series techniques and pre-post policy comparisons.^ The study hypotheses stated that the distribution of service provided, diagnoses serviced, and consumer income levels would change following the cost-sharing policy.^ Analysis of data revealed that neither the characteristics of service users (income, race, sex, etc.) nor services provided by the program changed significantly following the policy. The results were explainable in part by the fact that all of the program participants were in diagnosed medical need. Therefore, their use of "discretionary" or "less necessary" services was limited.^ The study's findings supported the work of Joseph Newhouse, Charles Phelps, and others who have contended that necessary service use would not be detrimentally affected by reasonable cost-sharing provisions. These contentions raise the prospect of incorporating cost-sharing into programs such as Medicaid, which, at this writing, do not demand any consumer payment for services.^ The study concluded with a discussion of the cost-containment problem in health services. The efficacy of cost-sharing was considered relative to other financing and reimbursement strategies such as HMO's, self-funding, and reimbursement for less costly services and places of service. ^

Targeting Families to Receive Intensive Family Preservation Services: Assessing the Use of Imminent Risk of Placement as a Service Criterion

The process for targeting families to receive intensive family preservation services was examined for 71 child welfare agencies in the United States. The focus of this exploratory/descriptive study was the concept of imminent risk of placement as a criterion for providing services. Findings indicated that agencies had difficulty defining imminent risk and were unable to successfully restrict services to imminent risk cases. Several factors besides imminent risk were identified in relation to the targeting process.

Use of contraception and contraceptive services among U.S. Hispanic women: 2006--2008

This study investigates the association between race/ethnicity and acculturation variables (language preference and nativity) with use of contraception and contraceptive services among Mexican/Mexican American and “other” Hispanic women aged 15-44 when compared to non- Hispanic white women.^ Data was analyzed from the 2006-2008 National Survey of Family Growth. The sample contained 3357 women aged 15-44. Multivariate logistic regression analysis was used to examine the association between race/ethnicity and acculturation variables and contraceptive-related behaviors adjusted for other known covariates. ^ After multivariate analysis, neither nativity nor language preference were significantly associated with contraception use or contraceptive services. Mexican/Mexican American women did not differ in their contraception-related behaviors when compared to non-Hispanic whites. Other Hispanic women, however, were less likely to obtain contraceptive services than non-Hispanic whites (OR=0.67, 95% CI=0.45-1.00). Women aged 30-39 and 40-44 were less likely to obtain contraception and contraceptive services than those aged 15-19. Single women were less likely to use contraception (OR=0.72, 95% CI=0.56-0.92) and contraceptive services (OR=0.69, 95% CI=0.53-0.89) than married/co-habiting women. Women with healthcare coverage were more likely to use contraception and contraceptive services than uninsured women.^ Among Hispanic women of different origin groups, age, marital status, and healthcare coverage were stronger indicators of contraception-related behavior than race/ethnicity, language preference, and nativity. Reproductive health programs that target increased use of contraception and contraceptive services among Hispanic origin groups should specifically target women who are over 30, single, and uninsured.^

Use of universal precautions in the workplace: A comparison of two fire /EMS services

The Health Belief Model (HBM) provided the theoretical framework for examining Universal Precautions (UP) compliance factors by Firefighter, EMTs and Paramedics (prehospital care providers). A convenient sample of prehospital care providers (n = 4000) from two cities (Houston and Washington DC), were surveyed to explore the factors related to their decision to comply with Universal Precautions. Eight hundred and sixty-five useable questionnaires were analyzed. The responders were primarily male (95.7%) eight hundred and twenty-eight and thirty-seven were female, prehospital based (100%), EMTs (60.0%) and paramedics (12.8%) who had a mean 13 years of prehospital care experience. ^ Linear regression was used to evaluate the four hypotheses. The first hypothesis evaluating perceived susceptibility and seriousness with reported UP use was statistically significant (p = < .05). Perceived susceptibility, when considered independently, did not make a significant contribution (t = −4.2852; p = 0.0000) to the stated use of Universal precautions. The hypothesis is not supported as stated. The data indicates the opposite effect. Supported is the premise that as perceived susceptibility and perceived seriousness increase the use of Universal Precautions decreases. Hypothesis two tested perceived benefits with internal and external barriers. Both perceived benefits and internal and external barriers as well as the overall regression were significant (F = 112.6, p = 0.0000). The contribution of internal and external barriers was statistically significant (t = 0.0175; p = 0.0000) and (t = 0.0128; p = 0.0000). Hypothesis three which tested modifying factors, cues to action, select demographic variables, and the main effects of the HBM with self reported UP compliance overall was significant. The variables gender, birth, education, job type, EMS certification, years of service, years of experience providing patient care, Universal Precautions training hours, type of apparatus assigned to and the number of EMS related incidents responded to in a month were found to have a significant contribution to the stated use of Universal Precautions. ^ The additive effects were tested by use of a stepwise regression that assessed the contribution of each of the significant variables. Three variables in the equation were statistically significant. Internal barriers (t = −8.5507; p = 0.0000), external barriers (t = −6.2862; p = 0.000) and job type 2 & 3. Job type two (t = −2.8464; p = 0.0045 is titled Engineer/Operator. Job type three (t = −2.5730; p = 0.0103) is titled captain. The overall regression was significant (F = 24.06; p = 0.000). The Hypothesis is supported in the certain demographic variables do influence the stated use of Universal precautions and that as internal and external barriers are decreased, there is an increase in the stated use of Universal Precautions. ^ In summary, this study demonstrated that internal and external barriers have a significant impact on the stated use of Universal Precautions. Internal barriers are those factors within the individual that require an internal change (i.e., forgetfulness, freedom, perception of the urgency of the patient's needs etc.) and external barriers are things in the environment that can be altered (i.e., equipment design, availability of equipment, ease of use). These two model variables explained 23%–30% of the variance. ^

The use of culturally related health practices and health care utilization among Hispanic women in farmworker communities

Breast and cervical cancer screening rates continue to be lower in Hispanic women than other ethnic subgroups. Several factors have been identified that influence health care utilization. The use of preventive services (cancer screenings and adherence) in addition to yearly doctor visits are often used to measure health care utilization. A secondary analysis of an existing dataset containing baseline survey data collected from participants of an intervention trial to test the Cultivando La Salud (CLS) program was used to analyze the association between cultural health practice use (use of curandero,s obador, and herbal remedies) and health care utilization. The sample consisted of women 50 years of age and older living in farmer communities in four sites: Eagle Pass, TX, Anthony, NM, Merced, CA, and Watsonville, CA (n=708). Participants reported using a curandero (5.67%), sobador (29.79%), and herbal remedies (46.65%) at some point in their lives. The use of cultural health practices was found to significantly influence utilization of certain health care services: use of herbal remedies influence doctor visits, adherence to mammography screening and adherence to Pap test screening; use of a curandero influenced ever having a mammogram; use of a sobador influenced ever having a mammogram, ever having a Pap test, and Pap test adherence. In addition, women reporting use of curandero or herbal remedies were found to be more avoidant of the health care system than those that reported not using them. Further research is needed to further analyze the influence of cultural health practices on health care utilization. ^

Use of pulsed-field gel electrophoresis in surveillance of Salmonella in Houston, Texas

Background. Pulsed-field gel electrophoresis (PFGE) is a laboratory technique in which Salmonella DNA banding patterns are used as molecular fingerprints for epidemiologic study for "PFGE clusters". State and national health departments (CDC) use PFGE to detect clusters of related cases and to discover common sources of bacteria in outbreaks. ^ Objectives. Using Houston Department of Health and Human Services (HDHHS) data, the study sought: (1) to describe the epidemiology of Salmonella in Houston, with PFGE subtype as a variable; and (2) to determine whether PFGE patterns and clusters detected in Houston were local appearances of PFGE patterns or clusters that occurred statewide. ^ Methods. During the years 2002 to 2005, the HDHHS collected and analyzed data from routine surveillance of Salmonella. We implemented a protocol, between May 1, 2007 and December 31, 2007, in which PFGE patterns from local cases were sent via e-mail to the Texas Department of State Health Services, to verify whether the local PFGE patterns were also part of statewide clusters. PFGE was performed from 106 patients providing a sample from which Salmonella was isolated in that time period. Local PFGE clusters were investigated, with the enhanced picture obtained by linking local PFGE patterns to PFGE patterns at the state and national level. ^ Results. We found that, during the years 2002 to 2005, there were 66 PFGE clusters, ranging in size from 2 to 22 patients within each cluster. Between different serotypes, there were marked differences in the sizes of PFGE clusters. A common source or risk factor was found in fewer than 5 of the 66 PFGE clusters. With the revised protocol, we found that 19 of 66 local PFGE patterns were indistinguishable from PFGE patterns at Texas DSHS. During the eight months, we identified ten local PFGE clusters with a total of 42 patients. The PFGE pattern for eight of the ten clusters matched the PFGE patterns for cases reported to Texas DSHS from other geographic areas. Five of the ten PFGE patterns matched PFGE patterns for clusters under investigation at PulseNet at the national level. HDHHS epidemiologists identified a mode of transmission in two of the ten local clusters and a common risk factor in a third local cluster. ^ Conclusion. In the extended-study protocol, Houston PFGE patterns were linked to patterns seen at the state and national level. The investigation of PFGE clusters was more efficacious in detecting a common transmission when local data were linked to state and national data. ^

Use of cognitive interviewing in the development of a Spanish language genetic knowledge instrument

Study purpose. Genetic advances are significantly impacting healthcare, yet recent studies of ethnic group participation in genetic services demonstrate low utilization rates by Latinos. Limited genetic knowledge is a major barrier. The purpose of this study was to field test items in a Spanish-language instrument that will be used to measure genetic knowledge relevant to type 2 diabetes among members of the ethnically heterogeneous U.S. Latino community. Accurate genetic knowledge measurement can provide the foundation for interventions to enhance genetic service utilization. ^ Design. Three waves of cognitive interviews were conducted in Spanish to field test 44 instrument items Thirty-six Latinos, with 12 persons representative of Mexican, Central and South American, and Cuban heritage participated, including 7 males and 29 females between 22 and 60 years of age; 17 participants had 12 years or less of education. ^ Methods. Text narratives from transcriptions of audiotaped interviews were qualitatively analyzed using a coding strategy to indicate potential sources of response error. Through an iterative process of instrument refinement, codes that emerged from the data were used to guide item revisions at the conclusion of each phase; revised items were examined in subsequent interview waves. ^ Results. Inter-cultural and cross-cultural themes associated with difficulties in interpretation and grammatical structuring of items were identified; difficulties associated with comprehension reflected variations in educational level. Of the original 44 items, 32 were retained, 89% of which were revised. Six additional items reflective of cultural knowledge were constructed, resulting in a 38-item instrument. ^ Conclusions. Use of cognitive interviewing provided a valuable tool for detecting both potential sources of response error and cultural variations in these sources. Analysis of interview data guided successive instrument revisions leading to improved item interpretability and comprehension. Although testing in a larger sample will be essential to test validity and reliability, the outcome of field testing suggests initial content validity of a Spanish-language instrument to measure genetic knowledge relative to type 2 diabetes. ^ Keywords. Latinos, genetic knowledge, instrument development, cognitive interviewing ^

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.^

Pregnancy intention, intimate partner violence, and the use of prenatal care in Jordan

Previous research has suggested an association between intimate partner violence and pregnancy intention status, and pregnancy intention status and the use of prenatal care services, however much of these studies have been conducted in high income countries (HIC) rather than low and middle income countries (LMIC). The objectives of this study were to examine the relationship between pregnancy intention status and intimate partner violence, and pregnancy intention status and the use of prenatal care among ever-married women in Jordan.^ Data were collected from a nationally representative sample of women interviewed in the 2007 Jordan Demographic and Health Survey. The sample was restricted to ever-married women, 15–49 years of age, who had a live birth within the five years preceding the survey. Multivariate logistic regression analyses was used to determine the relationship between intimate partner violence and pregnancy intention status, and pregnancy intention status and the use of prenatal care services.^ Women who reported a mistimed pregnancy (PORadj 1.96, 95% CI: 1.31–2.95), as well as an unwanted pregnancy (PORadj 1.32, 95% CI: 0.80–2.18) had a higher odds of experiencing lifetime physical and/or sexual abuse compared with women reporting a wanted pregnancy. Women not initiating prenatal care by the end of the first trimester had statistically significant higher odds of reporting both a mistimed (PORadj 2.07, 95% CI: 1.55–2.77) and unwanted pregnancy (PORadj 2.36, 95% CI: 1.68–3.31), compared with women initiating care in the first trimester. Additionally, women not receiving the adequate number of prenatal care visits for their last pregnancy had a higher odds of reporting an unwanted pregnancy (PORadj 2.11, 95% CI: 1.35–3.29) and mistimed pregnancy (POR adj 1.41, 95% CI: 0.96–2.07).^ Reducing intimate partner violence may decrease the prevalence of mistimed or unwanted pregnancies, and reducing both unwanted and mistimed pregnancies may decrease the prevalence of women not receiving timely and adequate prenatal care among women in this population. Further research, particularly in LMIC, is needed regarding the determinants of unintended pregnancy and its association with intimate partner violence as well as with the use of prenatal care services. ^

Ethnographic and epidemiologic approaches for the programming of prenatal and birth services in Mesa los Hornos, Mexico

The investigator conducted an action-oriented investigation of pregnancy and birth among the women of Mesa los Hornos, an urban squatter slum in Mexico City. Three aims guided the project: (1) To obtain information for improving prenatal and maternity service utilization; (2) To examine the utility of rapid ethnographic and epidemiologic assessment methodologies; (3) To cultivate community involvement in health development.^ Viewing service utilization as a culturally-bound decision, the study included a qualitative phase to explore women's cognition of pregnancy and birth, their perceived needs during pregnancy, and their criteria of service acceptability. A probability-based community survey delineated parameters of service utilization and pregnancy health events, and probed reasons for decisions to use medical services, lay midwives, or other sources of prenatal and labor and delivery assistance. Qualitative survey of service providers at relevant clinics, hospitals, and practices contributed information on service availability and access, and on coordination among private, social security, and public assistance health service sectors. The ethnographic approach to exploring the rationale for use or non-use of services provided a necessary complement to conventional barrier-based assessment, to inform planning of culturally appropriate interventions.^ Information collection and interpretation was conducted under the aegis of an advisory committee of community residents and service agency representatives; the residents' committee formulated recommendations for action based on findings, and forwarded the mandate to governmental social and urban development offices. Recommendations were designed to inform and develop community participation in health care decision-making.^ Rapid research methods are powerful tools for achieving community-based empowerment toward investigation and resolution of local health problems. But while ethnography works well in synergy with quantitative assessment approaches to strengthen the validity and richness of short-term field work, the author strongly urges caution in application of Rapid Ethnographic Assessments. An ethnographic sensibility is essential to the research enterprise for the development of an active and cooperative community base, the design and use of quantitative instruments, the appropriate use of qualitative techniques, and the interpretation of culturally-oriented information. However, prescribed and standardized Rapid Ethnographic Assessment techniques are counter-productive if used as research short-cuts before locale- and subject-specific cultural understanding is achieved. ^