Effect of primary care availability and health insurance coverage on risk and cost of Preventable Hospitalizations in Harris County

Preventable Hospitalizations (PHs) are hospitalizations that can be avoided with appropriate and timely care in the ambulatory setting and hence are closely associated with primary care access in a community. Increased primary care availability and health insurance coverage may increase primary care access, and consequently may be significantly associated with risks and costs of PHs. Objective. To estimate the risk and cost of preventable hospitalizations (PHs); to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs, first alone and then simultaneously; and finally, to estimate the impact of expansions in primary care availability and health insurance coverage on the burden of PHs among non-elderly adult residents of Harris County. Methods. The study population was residents of Harris County, age 18 to 64, who had at least one hospital discharge in a Texas hospital in 2008. The primary independent variables were availability of primary care physicians, availability of primary care safety net clinics and health insurance coverage. The primary dependent variables were PHs and associated hospitalization costs. The Texas Health Care Information Collection (THCIC) Inpatient Discharge data was used to obtain information on the number and costs of PHs in the study population. Risk of PHs in the study population, as well as average and total costs of PHs were calculated. Multivariable logistic regression models and two-step Heckman regression models with log-transformed costs were used to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs respectively, while controlling for individual predisposing, enabling and need characteristics. Predicted PH risk and cost were used to calculate the predicted burden of PHs in the study population and the impact of expansions in primary care availability and health insurance coverage on the predicted burden. Results. In 2008, hospitalized non-elderly adults in Harris County had 11,313 PHs and a corresponding PH risk of 8.02%. Congestive heart failure was the most common PH. PHs imposed a total economic burden of $84 billion at an average of $7,449 per PH. Higher primary care safety net availability was significantly associated with the lower risk of PHs in the final risk model, but only in the uninsured. A unit increase in safety net availability led to a 23% decline in PH odds in the uninsured, compared to only a 4% decline in the insured. Higher primary care physician availability was associated with increased PH costs in the final cost model (β=0.0020; p<0.05). Lack of health insurance coverage increased the risk of PH, with the uninsured having 30% higher odds of PHs (OR=1.299; p<0.05), but reduced the cost of a PH by 7% (β=-0.0668; p<0.05). Expansions in primary care availability and health insurance coverage were associated with a reduction of about $1.6 million in PH burden at the highest level of expansion. Conclusions. Availability of primary care resources and health insurance coverage in hospitalized non-elderly adults in Harris County are significantly associated with the risk and costs of PHs. Expansions in these primary care access factors can be expected to produce significant reductions in the burden of PHs in Harris County.^

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. ^

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.^

Market discipline by depositors : impact of deposit insurance on the Indonesian banking sector

This paper investigates market discipline by depositors in the Indonesian banking sector. Does depositor discipline fulfill its role in Indonesia? Does deposit insurance affect depositor behavior thereby imposing discipline on banks? These questions are empirically examined using panel data on Indonesian commercial banks from 1998 to 2009. In Indonesia deposit insurance was introduced in 2005. Depositor discipline is examined by two measures: change in the amount of deposits and interest rate. The empirical results show that depositors pay attention to bank soundness and riskiness and select banks based on the bank's condition with particular attention paid to equity ratio. It is found that depositors impose discipline on banks, but it varies according to regulatory and economic circumstances.

Marriage as women's old age insurance : evidence from migration and land inheritance practices in rural Tanzania

In a traditional system of exogamous and patrilocal marriage prevalent in much of Sub-Saharan Africa, when she marries, a rural woman typically leaves her kin to reside with her husband living outside her natal village. Since a village that allows a widow to inherit her late husband's land can provide her with old age security, single females living outside the village are more likely to marry into the village. Using a natural experimental setting, provided by the longitudinal household panel data drawn from rural Tanzania for the period from 1991 to 2004, during which several villages that initially banned a widow's land inheritance removed this discrimination, this study provides evidence in support of this view, whereby altering a customary land inheritance rules in a village in favor of widows increased the probability of males marrying in that village. This finding suggests that providing rural women with old age protection (e.g., insurance, livelihood protection) has remarkable spatial and temporal welfare effects by influencing their decision to marry.

Quasi-experimental evidence on the drivers of index-based livestock insurance demand in Southern Ethiopia

Microinsurance is widely considered an important tool for sustainable poverty reduction, especially in the face of increasing climate risk. Although index-based microinsurance, which should be free from the classical incentive problems, has attracted considerable attention, uptake rates have generally been weak in low-income rural communities. We explore the purchase patterns of index-based livestock insurance in southern Ethiopia, focusing in particular on the role of accurate product comprehension and price, including the prospective impact of temporary discount coupons on subsequent period demand due to price anchoring effects. We find that randomly distributed learning kits contribute to improving subjects' knowledge of the products; however, we do not find strong evidence that the improved knowledge per se induces greater uptake. We also find that reduced price due to randomly distributed discount coupons has an immediate, positive impact on uptake, without dampening subsequent period demand due to reference-dependence associated with price anchoring effects.

Accident Management Actions In An Upper-Head Small-Break Loss-Of-Coolant Accident With High-Pressure Safety Injection Failed

Since the Three Mile Island accident, an important focus of pressurized water reactor (PWR) transient analyses has been a small-break loss-of-coolant accident (SBLOCA). In 2002, the discovery of thinning of the vessel head wall at the Davis Besse nuclear power plant reactor indicated the possibility of an SBLOCA in the upper head of the reactor vessel as a result of circumferential cracking of a control rod drive mechanism penetration nozzle - which has cast even greater importance on the study of SBLOCAs. Several experimental tests have been performed at the Large Scale Test Facility to simulate the behavior of a PWR during an upper-head SBLOCA. The last of these tests, Organisation for Economic Co-operation and Development Nuclear Energy Agency Rig of Safety Assessment (OECD/NEA ROSA) Test 6.1, was performed in 2005. This test was simulated with the TRACE 5.0 code, and good agreement with the experimental results was obtained. Additionally, a broad analysis of an upper-head SBLOCA with high-pressure safety injection failed in a Westinghouse PWR was performed taking into account different accident management actions and conditions in order to check their suitability. This issue has been analyzed also in the framework of the OECD/NEA ROSA project and the Code Applications and Maintenance Program (CAMP). The main conclusion is that the current emergency operating procedures for Westinghouse reactor design are adequate for these kinds of sequences, and they do not need to be modified.

Comparación de dos métodos para la estimación de los daños por sequía en pastos de dehesa / Comparative methods for assessment of dehesa pasture drought insurance in Spain

El Sistema de Seguros Agrarios con el Seguro de cobertura de los daños por sequía en los pastos aprovechados por el ganado en régimen extensivo (línea de seguro 133) aplica la teledetección mediante un índice de vegetación (NDVI), con el fin de solucionar los problemas de peritación que surgen cuando se tiene que determinar la cantidad y calidad del pasto afectado por la sequía. Por ello el seguro de cobertura de los daños por sequía en pastos es el principal instrumento para hacer frente al gasto que supone la necesidad de suplemento de alimentación del ganado reproductor debido a la sequía. En las comarcas de Vitigudino, Trujillo y Valle de los Pedroches (España) se comparó la evolución del seguro de sequía en pastos desde 2006 a 2010 con un modelo matemático de crecimiento del pasto en función de las variables ecofisiológicas y ambientales. Sumadas las decenas de sequía extrema y sequía leve, el modelo matemático contabilizó un número mayor de decenas que las proporcionadas por Agroseguro. La recomendación es comparar las curvas de crecimiento del pasto con las curvas de evolución del NDVI, para ajustar ambos modelos

The framework for post-accident preparedness in Europe. The IRPA guiding principles for stakeholder engagement

To provide public and private actors at local, regional, national and European levels with methodologies to: – Create the conditions for them to gradually appropriate the problematic of long term rehabilitation following a situation of long‐lasting radioactive contamination; – Develop in their context appropriate means and tools for rehabilitation strategies; – Foster innovation and experimentation at territorial and national levels.

Sum Insured Determination for Cereal, Citrus and Vineyards in the Spanish Agricultural Insurance System.

In general, insurance is a form of risk management used to hedge against a contingent loss. The conventional definition is the equitable transfer of a risk of loss from one entity to another in exchange for a premium or a guaranteed and quantifiable small loss to prevent a large and possibly devastating loss being agricultural insurance a special line of property insurance. Agriculture insurance, as actually are designed in the Spanish scenario, were established in 1978. At the macroeconomic insurance studies scale, it is necessary to know a basic element for the insurance actuarial components: sum insured. When a new risk assessment has to be evaluated in the insurance framework, it is essential to determinate venture capital in the total Spanish agriculture. In this study, three different crops (cereal, citrus and vineyards) cases are showed to determinate sum insured as they are representative of the cases found in the Spanish agriculture. Crop sum insured is calculated by the product of crop surface, unit surface production and crop price insured. In the cereal case, winter as spring cereal sowing, represents the highest Spanish crop surface, above to 6 millions of hectares (ha). Meanwhile, the four citrus species (oranges, mandarins, lemons and grapefruits) occupied an extension just over 275.000 ha. On the other hand, vineyard target to wine process shows almost one million of ha in Spain.

Assessment of irrigators’ preferences for different water supply risk management tools: option contract and insurance.

Irrigators face the risk of not having enough water to meet their crops’ demand. There are different mechanisms to cope with this risk, including water markets (option contracts) or insurance. A farmer will purchase them when the expected utility change derived from the tool is positive. This paper presents a theoretical assessment of the farmer’s expected utility under two different option contracts, a drought insurance and a combination of an option contract and the insurance. We analyze the conditions that determine farmer’s reference for one instrument or the other and perform a numerical application that is relevant for a Spanish region.

Managing drought economic effects through insurance schemes based on local water availability.

In many arid or semi-arid Mediterranean regions, agriculture is dependent on irrigation. When hydrological drought phenomena occur, farmers suffer from water shortages, incurring important economic losses. Yet, there is not agricultural insurance available for lack of irrigation water. This work attempts to evaluate hydrological drought risk and its economic impact on crop production in order to provide the basis for the design of drought insurance for irrigated arable crops. With this objective a model that relates water availability with expected yields is developed. Crop water requirements are calculated from evapotranspiration, effective rainfall and soil water balance. FAO?s methodology and AquaCrop software have been used to establish the relationship between water allocations and crop yields. The analysis is applied to the irrigation zone ?Riegos de Bardenas?, which is located in the Ebro river basin, northeast Spain, to the main arable crops in the area. Results show the fair premiums of different hydrological drought insurance products. Whole-farm insurance or irrigation district insurance should be preferable to crop specific insurance due to the drought management strategies used by farmers.

Assessment of insurance coverage and claims in rainfall related risks in processing tomato in Western Spain

An extension of guarantees related to rainfall-related risks in the insurance of processing tomato crops has been accompanied with a large increase in claims in Western Spain, suggesting that damages may have been underestimated in previous years. A database was built by linking agricultural insurance records, meteorological data from local weather stations, and topographic data. The risk of rainfall-related damages in processing tomato in the Extremenian Guadiana river basin (W Spain) was studied using a logistic model. Risks during the growth of the crop and at harvesting were modelled separately. First, the risk related to rainfall was modelled as a function of meteorological, terrain and management variables. The resulting models were used to identify the variables responsible for rainfall-related damages, with a view to assess the potential impact of extending insurance coverage, and to develop an index to express the suitability of the cropping system for insurance. The analyses reveal that damages at different stages of crop development correspond to different hazards. The geographic dependence of the risk influences the scale at which the model might have validity, which together with the year dependency, the possibility of implementing index based insurances is questioned.

Bayesian model selection of structural explanatory models: Application to road accident data

Using the Bayesian approach as the model selection criteria, the main purpose in this study is to establish a practical road accident model that can provide a better interpretation and prediction performance. For this purpose we are using a structural explanatory model with autoregressive error term. The model estimation is carried out through Bayesian inference and the best model is selected based on the goodness of fit measures. To cross validate the model estimation further prediction analysis were done. As the road safety measures the number of fatal accidents in Spain, during 2000-2011 were employed. The results of the variable selection process show that the factors explaining fatal road accidents are mainly exposure, economic factors, and surveillance and legislative measures. The model selection shows that the impact of economic factors on fatal accidents during the period under study has been higher compared to surveillance and legislative measures.

Code assessment and modelling for Design Basis Accident Analysis of the European sodium fast reactor design. Part I: System description, modelling and benchmarking

The new reactor concepts proposed in the Generation IV International Forum (GIF) are conceived to improve the use of natural resources, reduce the amount of high-level radioactive waste and excel in their reliability and safe operation. Among these novel designs sodium fast reactors (SFRs) stand out due to their technological feasibility as demonstrated in several countries during the last decades. As part of the contribution of EURATOM to GIF the CP-ESFR is a collaborative project with the objective, among others, to perform extensive analysis on safety issues involving renewed SFR demonstrator designs. The verification of computational tools able to simulate the plant behaviour under postulated accidental conditions by code-to-code comparison was identified as a key point to ensure reactor safety. In this line, several organizations employed coupled neutronic and thermal-hydraulic system codes able to simulate complex and specific phenomena involving multi-physics studies adapted to this particular fast reactor technology. In the “Introduction” of this paper the framework of this study is discussed, the second section describes the envisaged plant design and the commonly agreed upon modelling guidelines. The third section presents a comparative analysis of the calculations performed by each organisation applying their models and codes to a common agreed transient with the objective to harmonize the models as well as validating the implementation of all relevant physical phenomena in the different system codes.