Attributing inpatient care to diabetes: The case of Medicare for the elderly in Texas, 1995

Specific aims. This study estimated the accuracy of alternative numerator methods for attributing health care utilization and associated costs to diabetes by comparing findings from those methods with findings from a benchmark denominator method. ^ Methods. Using Medicare's 1995 inpatient and enrollment databases for the elderly in Texas, the researcher developed alternative estimates of costs attributable to diabetes. Among alternative numerator methods were selection of all records having diabetes as a principal or secondary diagnosis, and a complex ICD-9-CM sorting routine as previously developed for study of diabetes costs in Texas. Findings from numerator methods were compared with those from a benchmark denominator method based on attributable risk and adapted from a study of national diabetes costs by the American Diabetes Association. This study applied age, gender and ethnicity specific estimates of diabetes prevalence taken from the 1987–94 National Health Interview Surveys to person-months of Medicare Part A, non-HMO enrollment for Texas in 1995. Outcome measures were number of persons identified as having diabetes using alternative definitions of the disease; and number of hospital stays, patient days, and costs using alternative methods for attributing care and costs to diabetes. Cost estimates were based on Medicare payments plus deductibles, co-pays and third party payments. ^ Findings. Numerator methods for attributing costs to diabetes produced findings quite different than those from the benchmark denominator method. When attribution was based on diabetes as principal or secondary diagnosis, the resulting estimates were significantly higher than those obtained from the denominator method. The more complex sorting routine produced estimates near the lower boundary for the confidence interval associated with estimates from the benchmark method. ^ Conclusions. Numerator methods employed by previous researchers poorly estimate the costs of diabetes. While crude mathematical adjustment can be made to the respective numerator approaches, a more useful strategy would be to refine the complex sorting routine to include more hospitalizations. This report recommends approaches to improving methods previously employed in study of diabetes costs. ^

Evaluation of the relationship between nutrition and functional independence measures among stroke patients undergoing inpatient rehabilitation

Cerebrovascular accidents (CVA) or strokes are now the third leading cause of death in the United States. Many who suffer strokes are admitted to rehabilitation centers in order to receive therapy to help rebuild and recovery function. Nutrition plays a significant role in rehabilitation patient outcomes, and is an essential part of comprehensive care. The purpose of this study is to determine if nutrition and diet consistency are directly and independently associated with changes in the Functional Independence Measure (FIM) scores in stroke patients in an acute rehabilitation unit. This study was a retrospective secondary analysis review of medical chart records, and included a total of 84 patients. Patients were divided into groups based on their admission diet: Regular, Dysphagia Advanced, Dysphagia Mechanically Altered, Dysphagia Pureed, and Nutrition Support. Measurements included admission and discharge Total, Motor, and Cognitive FIM scores; BMI, albumin and prealbumin; age, sex, and race. Patients did show a significant improvement in their FIM scores during their stay, with patients on Regular diets having the highest FIM scores. Patients who were more debilitated and had lower FIM scores were usually in one of the altered texture diet groups, or on nutrition support. Prealbumin and BMI were also the highest in patients who had high FIM scores. Patients who were admitted on an altered diet also tended to advance in their diets, which show improvement in overall function. It is crucial to continue to improve nutrition administration to this population to help prevent morbidity and mortality. Proper nutrition in the acute phase of stroke can lay the essential groundwork for recovery.^

The determinants of improvements in health outcomes and of cost reduction in hospital inpatient care

This study aims to address two research questions. First, ‘Can we identify factors that are determinants both of improved health outcomes and of reduced costs for hospitalized patients with one of six common diagnoses?’ Second, ‘Can we identify other factors that are determinants of improved health outcomes for such hospitalized patients but which are not associated with costs?’ The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database from 2003 to 2006 was employed in this study. The total study sample consisted of hospitals which had at least 30 patients each year for the given diagnosis: 954 hospitals for acute myocardial infarction (AMI), 1552 hospitals for congestive heart failure (CHF), 1120 hospitals for stroke (STR), 1283 hospitals for gastrointestinal hemorrhage (GIH), 979 hospitals for hip fracture (HIP), and 1716 hospitals for pneumonia (PNE). This study used simultaneous equations models to investigate the determinants of improvement in health outcomes and of cost reduction in hospital inpatient care for these six common diagnoses. In addition, the study used instrumental variables and two-stage least squares random effect model for unbalanced panel data estimation. The study concluded that a few factors were determinants of high quality and low cost. Specifically, high specialty was the determinant of high quality and low costs for CHF patients; small hospital size was the determinant of high quality and low costs for AMI patients. Furthermore, CHF patients who were treated in Midwest, South, and West region hospitals had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. Gastrointestinal hemorrhage and pneumonia patients who were treated in South region hospitals also had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. This study found that six non-cost factors were related to health outcomes for a few diagnoses: hospital volume, percentage emergency room admissions for a given diagnosis, hospital competition, specialty, bed size, and hospital region.^

Variation in hospital inpatient charges by payer in Houston, Texas

An analysis of variation in hospital inpatient charges in the greater Houston area is conducted to determine if there are consistent differences among payers. Differences in charges are examined for 59 Composite Diagnosis Related Groups (CDRGs) and two regression equations estimating charges are specified. Simple comparison of mean charges by diagnostic categories are significantly different for 42 (71 percent) of the 59 categories examined. In 41 of the 42 significant categories, charges to Medicaid were less than charges to private insurers. Meta-analytic statistical techniques yielded a weighted average effect size of $-$0.7198 for the 59 diagnostic categories, indicating an overall effect that Medicaid charges were less than private insurance charges. Results of a multiple regression estimating charges showed that private insurance was a significant independent variable, along with age, length of stay, and hospital variables. Results indicated consistent differential charges in the present analysis. ^

Errors in the administration of medication in inpatient hospitals: A systematic review of the research literature on commercial computerized physician order entry systems

Errors in the administration of medication represent a significant loss of medical resources and pose life altering or life threatening risks to patients. This paper considered the question, what impact do Computerized Physician Order Entry (CPOE) systems have on medication errors in the hospital inpatient environment? Previous reviews have examined evidence of the impact of CPOE on medication errors, but have come to ambiguous conclusions as to the impact of CPOE and decision support systems (DSS). Forty-three papers were identified. Thirty-one demonstrated a significant reduction in prescribing error rates for all or some drug types; decreases in minor errors were most often reported. Several studies reported increases in the rate of duplicate orders and failures to remove contraindicated drugs, often attributed to inappropriate design or to an inability to operate the system properly. The evidence on the effectiveness of CPOE to reduce errors in medication administration is compelling though it is limited by modest study sample sizes and designs. ^

Culminating experience: Initiation of cholinesterase inhibitors in an inpatient setting

We examined the practice of initiating Cholinesterase Inhibitors (ChEI) in a Veterans Affairs Medical Center. Patients hospitalized in FY 2008 and prescribed ChEI were identified. We reviewed electronic medical records, comparing those started on ChEI during hospitalization with those continuing ChEI from outpatient status. Of 282 patients receiving ChEI during hospitalization, 15.6% (44) were new-starts and 84.3% (238) were continuing medication. Median length of stay was 16 days in new-starts vs. 6 days in continuation patients (P<0.05). 38.6% new-starts were also treated for infection, which is a delirium risk factor. Chart review also suggested possible treatment for delirium by initiation of benzodiazepines and antipsychotics in 11.4% and 22.7% new-starts respectively. We observed a substantive practice of initiating ChEIs in hospitalized elderly who were at risk of delirium. Though there was no difference in 30-day mortality and readmission rates, new-starts were more likely to have a prolonged hospital stay than continuation patients.^

Clinical decision support capabilities of commercially-available clinical information systems.

BACKGROUND: The most effective decision support systems are integrated with clinical information systems, such as inpatient and outpatient electronic health records (EHRs) and computerized provider order entry (CPOE) systems. Purpose The goal of this project was to describe and quantify the results of a study of decision support capabilities in Certification Commission for Health Information Technology (CCHIT) certified electronic health record systems. METHODS: The authors conducted a series of interviews with representatives of nine commercially available clinical information systems, evaluating their capabilities against 42 different clinical decision support features. RESULTS: Six of the nine reviewed systems offered all the applicable event-driven, action-oriented, real-time clinical decision support triggers required for initiating clinical decision support interventions. Five of the nine systems could access all the patient-specific data items identified as necessary. Six of the nine systems supported all the intervention types identified as necessary to allow clinical information systems to tailor their interventions based on the severity of the clinical situation and the user's workflow. Only one system supported all the offered choices identified as key to allowing physicians to take action directly from within the alert. Discussion The principal finding relates to system-by-system variability. The best system in our analysis had only a single missing feature (from 42 total) while the worst had eighteen.This dramatic variability in CDS capability among commercially available systems was unexpected and is a cause for concern. CONCLUSIONS: These findings have implications for four distinct constituencies: purchasers of clinical information systems, developers of clinical decision support, vendors of clinical information systems and certification bodies.

Outcomes assessment of a pediatric practice guideline

Objective. This study examines the structure, processes, and data necessary to assess the outcome variables, length of stay and total cost, for a pediatric practice guideline. The guideline was developed by a group of physicians and ancillary staff members representing the services that most commonly provide treatment for asthma patients at Texas Children's Hospital, as a means of standardizing care. Outcomes have needed to be assessed to determine the practice guideline's effectiveness.^ Data sources and study design. Data for the study were collected retrospectively from multiple hospital data bases and from inpatient chart reviews. All patients in this quasi-experimental study had a diagnosis of Asthma (ICD-9-CM Code 493.91) at the time of admission.^ The study examined data for 100 patients admitted between September 15, 1995 and November 15, 1995, whose physician had elected to apply the asthma practice guideline at the time of the patient's admission. The study examined data for 66 inpatients admitted between September 15, 1995 and November 15, 1995, whose physician elected not to apply the asthma practice guideline. The principal outcome variables were identified as "Length of Stay" and "Cost".^ Principal findings. The mean length of stay for the group in which the practice guideline was applied was 2.3 days, and 3.1 days for the comparison group, who did not receive care directed by the practice guideline. The difference was statistically significant (p value = 0.008). There was not a demonstrable difference in risk factors, health status, or quality of care between the groups. Although not showing statistical significance in the univariate analysis, private insurance showed a significant difference in the logistic regression model presenting an elevated odds ratio (odds ratio = 2.2 for a hospital stay $\le$2 days to an odds ratio = 4.7 for a hospital stay $\le$3 days) showing that patients with private insurance experienced greater risk of a shorter hospital stay than the patients with public insurance in each of the logistic regression models. Public insurance included; Medicaid, Medicare, and charity cases. Private insurance included; private insurance policies whether group, individual, or managed care. The cost of an admission was significantly less for the group in which the practice guideline was applied, with a mean difference between the two groups of $1307 per patient.^ Conclusion. The implementation and utilization of a pediatric practice guideline for asthma inpatients at Texas Children's Hospital has a significant impact in terms of reducing the total cost of the hospital stay and length of the hospital stay for asthma patients admitted to Texas Children's Hospital. ^

Healthcare provider perspectives on parental refusal of medical interventions: A qualitative study

Background. Healthcare providers in pediatrics are faced with parents making medical decisions for their children. Refusal to consent to interventions can have life threatening sequelae, yet healthcare workers are provided little training in handling refusals. The healthcare provider's experience in parental refusal has not been well described, yet is an important first step in addressing this problem. ^ Specific aims. Describe: (1) the decision-making processes made by healthcare providers when parents refuse medical interventions for their children, (2) the source of healthcare workers' skills in handling situations of refusal, and (3) the perspectives of healthcare workers on parental refusals in the inpatient setting. ^ Methods. Nurses, physicians and respiratory therapists (RT) were recruited via e-mail at Texas Children's Hospital (TCH). Interview questions were developed using Social Cognitive Theory constructs and validated. One-on-one in-depth, one hour semi-structured interviews were held at TCH, audio recorded and transcribed. Coding and analysis were done using ATLAS ti. The constant comparative method was applied to describe emergent themes that were reviewed by an independent expert. ^ Results. Interviews have been conducted with nurses (n=6), physicians and practitioners (n=6), social workers (n=3) and RT (n=3) comprising 13 females and 5 males with 3–25 years of experience. Decision-making processes relate to the experience of the caregiver, familiarity with the family, and the acuity of the patient. Healthcare workers' skills were obtained through orientation processes or by trial-and-error. Themes emerged that related to the importance of: (1) Communication, where the initial discussion about a medical procedure should be done with clarity and an understanding of the parents' views; (2) Perceived loss of control by parents, a key factor in their refusal of interventions; and (3) Training, the need for skill development to handle refusals. ^ Conclusions. Effective training involving clarity in communication and a preservation of perceived control by parents is needed to avoid the current trial-and-error experience of healthcare workers in negotiating refusal situations. Such training could lessen the more serious outcomes of parental refusal. ^

Disparities in medical expenditure and utilization among hypertensive men and women in the U.S.: Cross-section and lifetime analysis

Objectives. To investigate procedural gender equity by assessing predisposing, enabling and need predictors of gender differences in annual medical expenditures and utilization among hypertensive individuals in the U.S. Also, to estimate and compare lifetime medical expenditures among hypertensive men and women in the U.S. ^ Data source. 2001-2004 the Medical Expenditure Panel Survey (MEPS);1986-2000 National Health Interview Survey (NHIS) and National Health Interview Survey linked to mortality in the National Death Index through 2002 (2002 NHIS-NDI). ^ Study design. We estimated total medical expenditure using four equations regression model, specific medical expenditures using two equations regression model and utilization using negative binomial regression model. Procedural equity was assessed by applying the Aday et al. theoretical framework. Expenditures were estimated in 2004 dollars. We estimated hypertension-attributable medical expenditure and utilization among men and women. ^ To estimate lifetime expenditures from ages 20 to 85+, we estimated medical expenditures with cross-sectional data and survival with prospective data. The four equations regression model were used to estimate average annual medical expenditures defined as sum of inpatient stay, emergency room visits, outpatient visits, office based visits, and prescription drugs expenditures. Life tables were used to estimate the distribution of life time medical expenditures for hypertensive men and women at different age and factors such as disease incidence, medical technology and health care cost were assumed to be fixed. Both total and hypertension attributable expenditures among men and women were estimated. ^ Data collection. We used the 2001-2004 MEPS household component and medical condition files; the NHIS person and condition files from 1986-1996 and 1997-2000 sample adult files were used; and the 1986-2000 NHIS that were linked to mortality in the 2002 NHIS-NDI. ^ Principal findings. Hypertensive men had significantly less utilization for most measures after controlling predisposing, enabling and need factors than hypertensive women. Similarly, hypertensive men had less prescription drug (-9.3%), office based (-7.2%) and total medical (-4.5%) expenditures than hypertensive women. However, men had more hypertension-attributable medical expenditures and utilization than women. ^ Expected total lifetime expenditure for average life table individuals at age 20, was $188,300 for hypertensive men and $254,910 for hypertensive women. But the lifetime expenditure that could be attributed to hypertension was $88,033 for men and $40,960 for women. ^ Conclusion. Hypertensive women had more utilization and expenditure for most measures than hypertensive men, possibly indicating procedural inequity. However, relatively higher hypertension-attributable health care of men shows more utilization of resources to treat hypertension related diseases among men than women. Similar results were reported in lifetime analyses.^ Key words: gender, medical expenditures, utilization, hypertension-attributable, lifetime expenditure ^

The effect of triage team on time-in-department in a pediatric emergency department

Objective. To determine whether the use of a triage team would reduce the average time-in-department in a pediatric emergency department by 25%.^ Methods. A triage team consisting of a physician, a nurse, and a nurse's assistant initiated work-ups and saw patients who required minimal lab work-up and were likely to be discharged. Study days were randomized. Our inclusion criteria were all children seen in the emergency center between 6p and 2a Monday-Friday. Our exclusion criteria included resuscitations, inpatient-inpatient transfers, left without being seen, leaving against medical advice, any child seen outside of 6p-2am Monday-Friday and on the weekends. A Pearson-Chi square was used for comparison of the two groups for heterogeneity. For the time-in-department analysis, we performed a 2 sided t-test with a set alpha of 0.05 using Mann Whitney U looking for differences in time-in-department based on acuity level, disposition, and acuity level stratified by disposition. ^ Results. Among urgent and non-urgent patients, we found a statistically significant decrease in time-in-department in a pediatric emergency department. Urgent patients had a time-in-department that was 51 minutes shorter than patients seen on non-triage team days (p=0.007), which represents a 14% decrease in time-in-department. Non-urgent patients seen on triage team days had a time-in-department that was 24 minutes shorter than non-urgent patients seen on non-triage team days (p=0.009). From the disposition perspective, discharged patients seen on triage team days had a shorter time-in-department of 28 minutes as compared to those seen on non-triage team days (p=0.012). ^ Conclusion. Overall, there was a trend towards decreased time-in-department of 19 minutes (5.9% decrease) during triage team times. There was a statistically significant decrease in the time-in-department among urgent patients of 51 minutes (13.9% decrease) and among discharged patients of 28 minutes (8.4% decrease). Urgent care patients make up nearly a quarter of the emergency patient population and decreasing their time-in-department would likely make a significant impact on overall emergency flow.^

Burden of diabetes in cancer inpatients

Inpatient hyperglycemia has been shown to be associated with higher morbidity and mortality. Treatment of inpatient hyperglycemia reduces morbidity and mortality at least in the intensive care unit. Burden and severity of hyperglycemia in an inpatient population of a cancer center is not known. The study is a secondary analysis of the primary study 'Prevalence of Diabetes in cancer inpatient'. Finger-stick glucose concentration and pharmacy data were collected prospectively for all hospitalizations to a large cancer center. Demographic, clinical and laboratory data were collected in a retrospective fashion. Between May 1 and July 31, 2006; 3,940 patients were admitted 5,489 times. Prior to their first admissions, 920(23.4%) of the 3940 patients had unrecognized or recognized hyperglycemia. Glucose was never tested during 1714 (31.8%) hospitalizations, including 170 (12%) of the 1414 admissions of the 920 patients with previous hyperglycemia, and, 109 (58%) of 188 patients who were not tested for glucose prior to their index admissions. Overall, sustained significant hyperglycemia (>= 200 mg/dL on two separate days) was present in 765 (13.9%). Antidiabetic treatment was dispensed in 1168 (21.3%), though 627 (53.7%) of these received only short/rapid acting insulin, and, 951 (17.3%)diabetes code before and in another 80 (1.5%) during stay in hospital, out of total 5489 admissions. Therefore diabetes mellitus or hyperglycemia affected 1525 (27.8%) out of all admissions and coding alone as a criterion for diagnosis of hyperglycemia would have underreported it by 32%. Hyperglycemia occurred more commonly during hospitalization of patients with older age, males, ethnic minorities, advanced malignancies, and those receiving glucocorticoids, parenteral nutrition, and those who had a past history of coding for diabetes or past hyperglycemia, but not in those with the cancers reported to be associated with diabetes mellitus. Of the recognized diabetics half had sustained significant hyperglycemia and 10% had three quarters glucoses tested above 180 mg/dL. To conclude, diabetes affects at least 27.8% of inpatients at our cancer center. Coding for diabetes significantly underreports the burden of the disease. Significant sustained hyperglycemia of >=200 mg/dL among inpatients at a cancer center is common, under-recognized, and either untreated or inadequately treated with suboptimal glycemic control. The implications of hyperglycemia in cancer inpatient populations need further investigations. Fasting serum or plasma glucose should be checked routinely for every patient admitted to a cancer hospital, to recognize and treat hyperglycemia as clinically appropriate.^

Understanding causes of hospitalization and access to care among newly diagnosed HIV patients in Houston, TX

More than a quarter of patients with HIV in the United States are diagnosed in hospital settings most often with advanced HIV related conditions.(1) There has been little research done on the causes of hospitalization when the patients are first diagnosed with HIV. The aim of this study was to determine if the patients are hospitalized due to an HIV related cause or due to some other co-morbidity. Reduced access to care could be one possible reason why patients are diagnosed late in the course of the disease. This study compared the access to care of patients diagnosed with HIV in hospital and outpatient setting. The data used for the study was a part of the ongoing study “Attitudes and Beliefs and Steps of HIV Care”. The participants in the study were newly diagnosed with HIV and recruited from both inpatient and outpatient settings. The primary and the secondary diagnoses from hospital discharge reports were extracted and a primary reason for hospitalization was ascertained. These were classified as HIV-related, other infectious causes, non–infectious causes, other systemic causes, and miscellaneous causes. Access to care was determined by a score based on responses to a set of questions derived from the HIV Cost and Services Utilization Study (HCSUS) on a 6 point scale. The mean score of the hospitalized patients and mean score of the patients diagnosed in an outpatient setting was compared. We used multiple linear regressions to compare mean differences in the two groups after adjusting for age, sex, race, household income educational level and health insurance at the time of diagnosis. There were 185 participants in the study, including 78 who were diagnosed in hospital settings and 107 who were diagnosed in outpatient settings. We found that HIV-related conditions were the leading cause of hospitalization, accounting for 60% of admissions, followed by non-infectious causes (20%) and then other infectious causes (17%). The inpatient diagnosed group did not have greater perceived access-to-care as compared to the outpatient group. Regression analysis demonstrated a statistically significant improvement in access-to-care with advancing education level (p=0.04) and with better health insurance (p=0.004). HIV-related causes account for many hospitalizations when patients are first diagnosed with HIV. Many of these HIV-related hospitalizations could have been prevented if patients were diagnosed early and linked to medical care. Programs to increase HIV awareness need to be an integral part of activities aimed at control of spread of HIV in the community. Routine testing for HIV infection to promote early HIV diagnosis can prevent significant morbidity and mortality.^

Improving the Quality of Life of spousal caregivers of stroke survivors: A cost effectiveness analysis

Back ground and Purpose. There is a growing consensus among health care researchers that Quality of Life (QoL) is an important outcome and, within the field of family caregiving, cost effectiveness research is needed to determine which programs have the greatest benefit for family members. This study uses a multidimensional approach to measure the cost effectiveness of a multicomponent intervention designed to improve the quality of life of spousal caregivers of stroke survivors. Methods. The CAReS study (Committed to Assisting with Recovery after Stroke) was a 5-year prospective, longitudinal intervention study for 159 stroke survivors and their spousal caregivers upon discharge of the stroke survivor from inpatient rehabilitation to their home. CAReS cost data were analyzed to determine the incremental cost of the intervention per caregiver. The mean values of the quality-of-life predictor variables of the intervention group of caregivers were compared to the mean values of usual care groups found in the literature. Significant differences were then divided into the cost of the intervention per caregiver to calculate the incremental cost effectiveness ratio for each predictor variable. Results. The cost of the intervention per caregiver was approximately $2,500. Statistically significant differences were found between the mean scores for the Perceived Stress and Satisfaction with Life scales. Statistically significant differences were not found between the mean scores for the Self Reported Health Status, Mutuality, and Preparedness scales. Conclusions. This study provides a prototype cost effectiveness analysis on which researchers can build. Using a multidimensional approach to measure QoL, as used in this analysis, incorporates both the subjective and objective components of QoL. Some of the QoL predictor variable scores were significantly different between the intervention and comparison groups, indicating a significant impact of the intervention. The estimated cost of the impact was also examined. In future studies, a scale that takes into account both the dimensions and the weighting each person places on the dimensions of QoL should be used to provide a single QoL score per participant. With participant level cost and outcome data, uncertainty around each cost-effectiveness ratio can be calculated using the bias-corrected percentile bootstrapping method and plotted to calculate the cost-effectiveness acceptability curves.^

Public service use by residents of Jackson Hinds Gardens before and after enrollment

Homelessness is associated with high use of public services such as health care and criminal justice services. Intervention designs to reverse homelessness have broadly fallen into two categories: either standard care which employs requisitely addressing the causes of homelessness, or housing first, which emphasizes provision of permanent housing without requisitely addressing the causes of homelessness. Multiple cities have recently commenced housing first interventions. Locally, Houston’s first housing first development is the Jackson Hinds Gardens project. The purpose of this study is to analyze the public service use of residents of housing first in Houston. Residents of Jackson Hinds Gardens who have been enrolled for at least 6 months were evaluated for public service use for an equal amount of time preceding and during their residence at Jackson Hinds. Resident interactions with county health services and criminal justice entities were determined by electronic database searches; these data were supplemented by life experience interview data. Service usage values pre- and post-enrollment at Jackson Hinds Gardens were compared by paired t-test analyses. We found that ER and inpatient usage decreased following enrollment in Jackson Hinds, although these reductions were not significant. In contrast, outpatient care and number of medications significantly increased following enrollment. These analyses inform on the effects of housing first in another major city, as well as informing the ethical considerations regarding housing first versus standard care. ^