Research roundup: Health care and prisoners; hospitalized patients' surrogates; suicides in the army

Mar 10 2014

Each week, KHN compiles a selection of recently released health policy studies and briefs.

Health Affairs: The Critical Link Between Health Care And Jails
As a group, jail-involved individuals, which we define here as people with a history of arrest and jail admission in the recent past, carry a heavy illness burden, with high rates of infectious and chronic disease as well as mental illness and substance use. Because these people have tended to also be uninsured, jail frequently has been their only regular source of health care. ... The Urban Institute estimated as much as 30 percent of some local corrections budgets is allocated to inmate health care services. This investment is largely lost when people are released back into the community, where they typically do not get treatment. ... With the expansion of Medicaid eligibility under the Affordable Care Act, there is now a critical opportunity to bring the jail-involved population into the mainstream health care system (Marks and Turner, 3/3).

Health Affairs: What The Affordable Care Act Means For People With Jail Stays
[The Affordable Care Act's] provision of better access to care before and after people are incarcerated could have positive long-term effects on both the health of those individuals and overall health care costs. Achieving these results will require careful planning and coordination among jail health care programs, Medicaid, and Marketplace health plans. The use of electronic health records by jails and community providers could help ensure that treatments are consistent no matter where a patient resides. Policy makers and health plans could also ensure continuity of care by including in their networks some of the same safety-net providers that are under contract to furnish care to jail inmates (Regenstein and Rosenbaum, 3/3).

JAMA Internal Medicine: Scope And Outcomes Of Surrogate Decision Making Among Hospitalized Older Adults
Our observational study found that 67.8% of hospitalized older adults face at least 1 major decision in the first 48 hours of hospitalization. Surrogate decision makers were involved in these decisions for nearly half of these older adults (47.4%). Most patients who required a surrogate faced decisions about life-sustaining care, and nearly half faced decisions about procedures and operations or discharge placement. ... there are substantial barriers to communication for surrogate decision makers. In the hospital, family members are considered "visitors" rather than crucial participants in their family member's care. ... surrogates often have trouble contacting hospital staff and struggle for information about the patient (Torke et al., 3/3).

JAMA Internal Medicine: Sociodemographic Differences In Fast Food Price Sensitivity
Fiscal food policies (eg, taxation) are increasingly proposed to improve population-level health, but their impact on health disparities is unknown. ... We found greater fast food price sensitivity on fast food consumption and insulin resistance among sociodemographic groups that have a disproportionate burden of chronic disease. Our findings have implications for fiscal policy, particularly with respect to possible effects of fast food taxes among populations with diet-related health disparities (Meyer, 3/3).

JAMA Psychiatry: Predictors Of Suicide And Accident Death In The Army Study To Assess Risk And Resilience In Servicemembers (Army STARRS)
To our knowledge, this is the first report of suicide trends by deployment category during a period when the Army suicide rate increased above the civilian rate. While we found suicide risk to be highest during deployment, the rise in the suicide rate was found not only among the currently and previously deployed but also among the never deployed. We also found suicide risk to be significantly associated with a number of sociodemographic characteristics and Army experiences. ... Other associations reported herein are new, including the disproportionate increase in suicide risk among deployed women soldiers, soldiers demoted in the past 2 years, and soldiers without either a high school diploma or general equivalency diploma (Schoenbaum et al., 3/3).

JAMA Psychiatry: Prevalence And Correlates Of Suicidal Behavior Among Soldiers
The lifetime prevalence estimates of suicidal ideation, suicide plans, and suicide attempts [representative cross-sectional survey of 5428 nondeployed soldiers] are 13.9%, 5.3%, and 2.4%. Most reported cases (47.0%-58.2%) had pre-enlistment onsets. Pre-enlistment onset rates were lower than in a prior national civilian survey (with imputed/simulated age at enlistment), whereas post-enlistment onsets of ideation and plans were higher, and post-enlistment first attempts were equivalent to civilian rates (Nock et al., 3/3).

JAMA Psychiatry: Thirty-Day Prevalence Of DSM-IV Mental Disorders Among Nondeployed Soldiers In The US Army
Although high rates of current mental disorder are known to exist in the US Army, little is known about the proportions of these disorders that had onsets prior to enlistment. ... Thirty-day DSM-IV internalizing (major depressive, bipolar, generalized anxiety, panic, and posttraumatic stress) and externalizing (attention-deficit/hyperactivity, intermittent explosive, alcohol/drug) disorders were assessed with validated self-report scales. Age at onset was assessed retrospectively. ... A total of 25.1% of respondents met criteria for any 30-day disorder (15.0% internalizing; 18.4% externalizing) and 11.1% for multiple disorders. A total of 76.6% of cases reported pre-enlistment age at onset of at least one 30-day disorder (49.6% internalizing; 81.7% externalizing). Also, 12.8% of respondents reported severe role impairment (Kessler et al., 3/3).

American Journal of Managed Care/Commonwealth Fund: Trends In The Financial Burden Of Medical Care For Nonelderly Adults With Diabetes, 2001 to 2009
Despite the increased prevalence of diabetes over the past decade, the financial burden borne by patients for treatment of the disease has actually decreased. ... Diabetes is a large and growing public health issue in the United States. From 2000 to 2010, the proportion of the adult population with this chronic condition increased from 6 percent to 9 percent, or to about 21 million people. In addition to its serious health consequences, diabetes presents a major financial challenge for individuals and the health system. In 2007, the estimated medical costs associated with diabetes were $116 billion, with average medical expenses 2.3 times higher for people with the disease compared to those without. The high cost and intensity of treatment, combined with the prevalence of comorbid conditions, can often act as a barrier for patients (Cunningham and Carrier, 2/28).

The Kaiser Family Foundation: Adding An Out-of-Pocket Spending Maximum To Medicare: Implementation Issues And Challenges
Adding an out-of-pocket maximum to traditional Medicare would strengthen financial protections under Medicare for the beneficiary population and mitigate beneficiaries' need for supplemental coverage. Varying the out-of-pocket maximum by income could achieve the policy goal of targeting resources to those most in need, but at the same time would add to the complexity of administering Medicare benefits. This brief describes the options for adding an out-of-pocket spending limit to Medicare and examines the operational issues that could arise in implementing both a uniform and an income-based out-of-pocket spending limit. Because the implementation of an income-related out-of-pocket maximum would pose somewhat greater complexity for Medicare, the operational issues associated with this approach are discussed in greater detail (Cubanski, Neuman and Levinson, 2/27).

Health Affairs/Robert Wood Johnson Foundation: Geographic Variation In Medicare Spending
While geographic variation in Medicare spending per beneficiary is itself well documented, the causes of that variation, whether it is appropriate, and what can be done to reduce spending in high-cost areas are less clear. This brief describes the research on geographic variation in Medicare spending and different interpretations of what it suggests for Medicare payment policy. ... Spending patterns are specific to Medicare ... Studies indicate that there is no single answer to addressing variation in Medicare spending by region (Cassidy, 3/6).

Mathematica/Agency for Healthcare Research and Quality: How Are CHIPRA Quality Demonstration States Designing And Implementing Caregiver Peer Support Programs?
This Evaluation Highlight is the seventh in a series that presents descriptive and analytic findings from the national evaluation of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Quality Demonstration Grant Program. ... Maryland, Georgia, Utah, and Idaho are using different approaches to test and refine caregiver peer support programs as a vehicle for improving the quality of care for [children with special health care needs (CSHCN)]. ... States have also learned that peer support caregivers themselves lead a complex life. To be effective, they need comprehensive training on their roles and responsibilities, a clear understanding of the time commitment required, and access to a support system. The experiences of the four States profiled in this Highlight suggest that implementing a peer support program can be challenging, especially with regard to financing and reimbursement (Ferry et al., February 2014).

Here is a selection of news coverage of other recent research:

The New York Times: Birth By C-Section May Raise Obesity Risk
A large review of studies has found that birth by cesarean section is associated with being overweight and obese in adult life. Researchers pooled data from 15 studies with a combined population of 142,702 for their analysis. The studies classified overweight as a body mass index of 25 or higher and obesity as 30 or higher, and covered various types of vaginal and cesarean deliveries. Compared with babies delivered vaginally, those delivered by C-section were 26 percent more likely to be overweight and 22 percent more likely to be obese. ... The analysis, published in the February issue of PLOS One, included a large sample from 10 countries, which gives it considerable strength (Bakalar, 3/3).

The Washington Post: Hospital Antibiotic Use Can Put Patients At Risk, Study Says
Doctors in some hospitals prescribe up to three times as many antibiotics as doctors at other hospitals, putting patients at greater risk for deadly superbug infections, according to a federal study released Tuesday. In addition, about one-third of the time, prescriptions to treat urinary tract infections and prescriptions for the drug vancomycin were given without proper testing or evaluation, or prescribed for too long, according to the Centers for Disease Control and Prevention (Sun, 3/4).

Time: Doctors' Stethoscopes Are Germ-Ridden And Disgusting
A new study says doctor's stethoscopes carry lots of bacteria that can be transferred from patient to patient during appointments. Researchers from University of Geneva Hospitals collected and studied bacteria from the fingers, palms, and stethoscopes of three doctors who had 71 patient appointments. They looked specifically for a deadly bacteria called methicillin-resistant Staphylococcus aureus (MRSA). They found the most bacteria on the finger tips of the doctors' dominant hand. However, stethoscopes–specifically the part that comes in contact with patients–came in second, with more bacteria than doctors' palms. There was a decent amount of MRSA identified (Sifferlin, 2/28).

Reuters: Spine Surgery Patients Mostly Unaware Of Costs, Compensation
Orthopedic surgery patients go in and out of the operating room "blind" to the cost of their procedures, ... The misperceptions among spinal surgery patients are emblematic of a major barrier to controlling healthcare costs, according to the authors, which is that nobody knows what the costs are. ... 62 percent believed their surgeons earned thousands of dollars more for the procedures than they did, according to the results published in The Spine Journal. For minor procedures, patients estimated reimbursement was between $5,000 and $10,000, whereas the highest reimbursement for any minor procedure from Medicare was $1,363 and from a private insurer, $2,038 (Cohen, 2/27).