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1.
ObjectiveTo assess the impact of the Medicare Shared Savings Program (MSSP) ACOs on mental health and substance use services utilization and racial/ethnic disparities in care for these conditions.Data sourcesFive percent random sample of Medicare claims from 2009 to 2016.Study designWe compared Medicare beneficiaries in MSSP ACOs to non‐MSSP beneficiaries, stratifying analyses by Medicare eligibility (disability vs age 65+). We estimated difference‐in‐difference models of MSSP ACOs on mental health and substance use visits (outpatient and inpatient), medication fills, and adequate care for depression adjusting for age, sex, race/ethnicity, region, and chronic medical and behavioral health conditions. To examine the differential impact of MSSP on our outcomes by race/ethnicity, we used a difference‐in‐difference‐in‐differences (DDD) design.Data collection/extraction methodsNot applicable.Principal findingsMSSP ACOs were associated with small reductions in outpatient mental health (Coeff: −0.012, < .001) and substance use (Coeff: −0.001, < .01) visits in the disability population, and in adequate care for depression for both the disability‐ and age‐eligible populations (Coeff: −0.028, < .001; Coeff: −0.012, < .001, respectively). MSSP ACO''s were also associated with increases in psychotropic medications (Coeff: 0.007 and Coeff: 0.0213, for disability‐ and age‐eligible populations, respectively, both < .001) and reductions in inpatient mental health stays (Coeff:‐0.004, < .001, and Coeff:‐0.0002, < .01 for disability‐ and age‐eligible populations, respectively) and substance use‐related stays for disability‐eligible populations (Coeff:‐0.0005, P<.05). The MSSP effect on disparities varied depending on type of service.ConclusionsWe found small reductions in outpatient and inpatient stays and in rates of adequate care for depression associated with MSSP ACOs. As MSSP ACOs are placed at more financial risk for population‐based treatment, it will be important to include more robust behavioral health quality measures in their contracts and to monitor disparities in care.  相似文献   

2.
ObjectiveTo assess changes in physicians’ provision of care to duals (low‐income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully pay Medicare''s cost sharing for office visits with these patients. This policy—a provision of the Affordable Care Act—effectively increased payments for office visits with duals by 0%‐20%, depending on the state, in 2013 and 2014.Data SourcesFee‐for‐service claims for a 5% random sample of Medicare beneficiaries in 2010‐2016.Study DesignWe conducted a difference‐in‐differences analysis to compare changes in office visits among Qualified Medicare Beneficiaries (QMBs)—the largest subpopulation of duals for whom payment rates were affected by this policy—to changes among other low‐income Medicare beneficiaries for whom payment rates were unaffected (pooled across all states). Next, we conducted a triple‐differences analysis that compared changes between QMBs and other low‐income beneficiaries in 33 states with payment rate increases of approximately 20% to analogous changes in 14 states without payment increases.Data CollectionThe study included administrative Medicare enrollment and claims data for QMBs and a comparison group of other low‐income Medicare beneficiaries (1 914 073 beneficiary‐years from 2010 to 2016).Principal FindingsNationally, we did not find a differential increase in office visits among QMBs versus other low‐income beneficiaries that coincided with this payment change. In the triple‐differences analysis, we did not observe a greater increase in visits among QMBs vs other low‐income beneficiaries in states where the policy resulted in large (approximately 20%) increases in payment rates vs states where payment rates were unaffected (triple‐differences estimate: −0.12 annual visits, 95% CI: −0.28, 0.04; P = 0.15).ConclusionsPhysicians’ provision of care to low‐income Medicare beneficiaries may not be responsive to short‐run payment changes.  相似文献   

3.
ObjectiveDual Eligible Special Needs Plans (D‐SNPs) were intended to provide better care for beneficiaries eligible for both Medicare and Medicaid through better coordination of these two programs.Data Sources671 913 dual eligible (DE) respondents to the 2009‐2019 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.Study DesignWe compared the 2015‐2019 experiences of DE beneficiaries in D‐SNPs relative to fee‐for‐service Medicare (FFS) and non‐SNP Medicare Advantage (MA) using propensity‐score weighted linear regression. Comparisons were made to 2009‐2014. 12 patient experience measures were considered.Data Collection MethodsAnnual mail survey with telephone follow‐up of non‐respondents.Principal FindingsMore than 65% of DE beneficiaries enrolled in FFS. Of 12 measures, D‐SNP performance was higher than non‐SNP MA on two (P < .05), lower than non‐SNP MA on two (P < .05), and higher than FFS on four (P < .01). DE beneficiaries did not report better coordination of care in D‐SNPs. D‐SNP performance was often worse than other coverage types in prior periods.ConclusionsRelative to FFS Medicare, DE beneficiaries report higher immunization rates in D‐SNPs, but slight or no better performance on other dimensions of patient experience. New requirements in 2021 may help D‐SNPs attain their goal of better care coordination.  相似文献   

4.
ObjectivesTo develop two practice‐site‐level measures of comprehensiveness and examine their associations with patient outcomes, and how their performance differs from physician‐level measures.Data SourcesMedicare fee‐for‐service claims.Study DesignWe calculated practice‐site‐level comprehensiveness measures (new problem management and involvement in patient conditions) across 5286 primary care physicians (PCPs) at 1339 practices in the Comprehensive Primary Care initiative evaluation in 2013. We assessed their associations with practices’ attributed beneficiaries’ 2014 total Medicare expenditures, hospitalization rates, ED visit rates. We also examined variation in PCPs’ comprehensiveness across PCPs within practices versus between primary care practices. Finally, we compared associations of practice‐site and PCP‐level measures with outcomes.Principal FindingsThe measures had good variation across primary care practices, strong validity, and high reliability. Receiving primary care from a practice at the 75th versus 25th percentile on the involvement in patient conditions measure was associated with $21.93 (2.8%) lower total Medicare expenditures per beneficiary per month (P < .01). Receiving primary care from a practice at the 75th versus 25th percentile on the new problem management measure was associated with $14.77 (1.9%) lower total Medicare expenditures per beneficiary per month (P < .05); 8.84 (3.0%) fewer hospitalizations (P < .001), and 21.27 (3.1%) fewer ED visits per thousand beneficiaries per year (P < .01). PCP comprehensiveness varied more within than between practices.ConclusionsMore comprehensive primary care practices had lower Medicare FFS expenditures, hospitalization, and ED visit rates. Both PCP and practice‐site level comprehensiveness measures had strong construct and predictive validity; PCP‐level measures were more precise.  相似文献   

5.
ObjectivesTo estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community‐dwelling older veterans with dementia.Data SourcesCombined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014‐2015.Study DesignFY 2014 COC was measured by the Bice‐Boxerman Continuity of Care (BBC) index on a 0‐1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long‐/short‐stay nursing home, and noninstitutional long‐term care (LTC) cost for medical (like skilled‐) and social (like unskilled‐) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders.Data CollectionCommunity‐dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073).Principal FindingsMean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long‐stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short‐stay nursing home cost.ConclusionsCOC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.  相似文献   

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ObjectiveTo evaluate the relationship between direct cognitive assessment introduced with the Medicare Annual Wellness Visit (AWV) and new diagnoses of dementia, and to determine if effects vary by race.Data SourcesMedicare Limited Data Set 5% sample claims 2003‐2014 and the HRSA Area Health Resources Files.Study DesignInstrumental Variable approach estimating the relationship between AWV utilization and new diagnoses of dementia using county‐level Welcome to Medicare Visit rates as an instrument.Data Collection/Extraction MethodsThree hundred twenty‐four thousand three hundred and eighty‐five fee‐for‐service Medicare beneficiaries without dementia when the AWV was introduced in 2011.Principal FindingsAnnual Wellness Visit utilization was associated with an increased probability of new dementia diagnosis with effects varying by racial group (categorized as white, black, Hispanic/Latino, or Asian based on Social Security Administration data). Hazard ratios (95% confidence intervals) for new dementia diagnosis within 6 months of AWV utilization were as follows: 2.34 (2.13, 2.58) white, 2.22 (1.71, 2.89) black, 4.82 (2.94, 7.89) Asian, and 6.14 (3.70, 10.19) Hispanic (< .001 for each). Our findings show that estimates that do not control for selection underestimate the effect of AWV on new diagnoses.ConclusionsDementia diagnosis rates increased with AWV implementation with heterogenous effects by race and ethnicity. Current recommendations by the United States Preventive Services Task Force state that the evidence is insufficient to recommend for or against screening for cognitive impairment in older adults.  相似文献   

8.
ObjectiveTo estimate the impact of a new, two‐sided risk model accountable care network (ACN) on Washington State employees and their families.Data Sources/Study SettingAdministrative data (January 2013‐December 2016) on Washington State employees.Study DesignWe compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0‐5, 6‐18, 19‐26, 18‐64).Data Collection/Extraction MethodsWe used difference‐in‐difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children.Principal FindingsWe estimate a 1‐2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: −1.8, P < .01; age 0‐5: −1.2, P = .07; age 6‐18: −1.2, P = .06; age 19‐26; −1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19‐26 were also responsive with inpatient admissions declines (−0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures.ConclusionsWashington''s state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.  相似文献   

9.
ObjectiveTo determine the association between a large‐scale, multi‐payer primary care redesign—the Comprehensive Primary Care (CPC) Initiative—on outpatient emergency department (ED) and urgent care center (UCC) use and to identify the types of visits that drive the overall trends observed.Data SourcesMedicare claims data capturing characteristics and outcomes of 565 674 Medicare fee‐for‐service (FFS) beneficiaries attributed to 497 CPC practices and 1 165 284 beneficiaries attributed to 908 comparison practices.Study DesignWe used an adjusted difference‐in‐differences framework to test the association between CPC and beneficiaries’ ED and UCC use from October 2012 through December 2016. Regression models controlled for baseline practice and patient characteristics and practice‐level clustering of standard errors. Our key outcomes were all‐cause and primary care substitutable (PC substitutable) outpatient ED and UCC visits, and potentially primary care preventable (PPC preventable) ED visits, categorized by the New York University Emergency Department Algorithm. We used a propensity score‐matched comparison group of practices that were similar to CPC practices before CPC on multiple dimensions. Both groups of practices had similar growth in ED and UCC visits in the two‐year period before CPC.Principal FindingsComprehensive Primary Care practices had 2% (P = .06) lower growth in all‐cause ED visits than comparison practices. They had 3% (P = .02) lower growth in PC substitutable ED visits, driven by lower growth in weekday PC substitutable visits (4%, P = .002). There was 3% (P = .04) lower growth in PPC preventable ED visits with no weekday/nonweekday differential. As expected, our falsification test showed no difference in ED visits for injuries. UCC visits had 9% lower growth for both all‐cause (P = .08) and PC substitutable visits (P = .07).ConclusionsOur results suggest that greater access to the practice and more effective primary care both contributed to the lower growth in ED and UCC visits during the initiative.  相似文献   

10.
ObjectiveTo examine racial/ethnic differences in risk factors, and their associations with COVID-19–related outcomes among older adults with Alzheimer’s disease and related dementias (ADRD).DesignObservational study.Setting and ParticipantsNational Medicare claims data and the Minimum Data Set 3.0 from April 1, 2020, to December 31, 2020, were linked in this study. We included community-dwelling fee-for-service Medicare beneficiaries with ADRD, diagnosed with COVID-19 between April 1, 2020, and December 1, 2020 (N = 138,533).MethodsTwo outcome variables were defined: hospitalization within 14 days and death within 30 days of COVID-19 diagnosis. We obtained information on individual sociodemographic characteristics, chronic conditions, and prior health care utilization based on the Medicare claims and the Minimum Dataset. Machine learning methods, including lasso regression and discriminative pattern mining, were used to identify risk factors in racial/ethnic subgroups (ie, White, Black, and Hispanic individuals). The associations between identified risk factors and outcomes were evaluated using logistic regression and compared across racial/ethnic subgroups using the coefficient comparison approach.ResultsWe found higher risks of COVID-19–related outcomes among Black and Hispanic individuals. The areas under the curve of the models with identified risk factors were 0.65 to 0.68 for mortality and 0.61 to 0.62 for hospitalization across racial/ethnic subgroups. Although some identified risk factors (eg, age, gender) for COVID-19–related outcomes were common among all racial/ethnic subgroups, other risk factors (eg, hypertension, obesity) varied by racial/ethnic subgroups. Furthermore, the associations between some common risk factors and COVID-19–related outcomes also varied by race/ethnicity. Being male was related to 138.2% (95% CI: 1.996–2.841), 64.7% (95% CI: 1.546–1.755), and 37.1% (95% CI: 1.192–1.578) increased odds of death among Hispanic, White, and Black individuals, respectively. In addition, the racial/ethnic disparity in COVID-19–related outcomes could not be completely explained by the identified risk factors.Conclusions and ImplicationsRacial/ethnic differences were detected in the likelihood of having COVID-19–related outcomes, specific risk factors, and relationships between specific risk factors and COVID-19–related outcomes. Future research is needed to elucidate the reasons for these differences.  相似文献   

11.
ObjectiveTo evaluate the impact of the Health and Recovery Plan (HARP), a capitated special needs Medicaid managed care product that fully integrates physical and behavioral health delivery systems in New York State.Data Sources2013‐2019 claims and encounters data on continuously enrolled individuals from the New York State Medicaid data system.Study DesignWe used a difference‐in‐difference approach with inverse probability of exposure weights to compare service use outcomes in individuals enrolled in the HARP versus HARP eligible comparison group in two regions, New York City (NYC) pre‐ (2013‐2015) versus post‐ (2016‐2018) intervention periods, and rest of the state (ROS) pre‐ (2014‐2016) versus post‐ (2017‐2019) intervention periods.Data Collection/Extraction MethodsNot applicable.Principal FindingsHARPs were associated with a relative decrease in all‐cause (RR = 0.78, 95% CI 0.68‐0.90), behavioral health‐related (RR = 0.76, 95% CI 0.60‐0.96), and nonbehavioral‐related (RR = 0.87, 95% CI 0.78‐0.97) stays in the NYC region. In the ROS region, HARPs were associated with a relative decrease in all‐cause (RR = 0.87, 95% CI 0.80‐0.94) and behavioral health‐related (RR = 0.80, 95% CI 0.70‐0.91) stays. Regarding outpatient visits, the HARPs benefit package were associated with a relative increase in behavioral health (RR = 1.21, 95% CI 1.13‐1.28) and nonbehavioral health (RR = 1.08, 95% CI 1.01‐1.15) clinic visits in the NYC region. In the ROS region, the HARPs were associated with relative increases in behavioral health (RR = 1.47, 95% CI 1.32‐1.64) and nonbehavioral health (RR = 1.17, 95% CI 1.11‐1.25) clinic visits.ConclusionsCompared to patients with similar clinical needs, HARPs were associated with a relative increase in services used and led to a better engagement in the HARPs group regardless of the overall decline in services used pre‐ to postperiod.  相似文献   

12.
ObjectiveTo develop outcome measures that are more sensitive than current measures for evaluating primary or transitional care after hospitalizations, emergency department (ED) visits, or observation stays.Data SourcesMedicare claims data from January 1, 2015, to October 31, 2017, for 1 261 707 Medicare fee‐for‐service beneficiaries served by (a) primary care practices participating in Track 1 of the Comprehensive Primary Care Plus (CPC+) initiative, and (b) their matched comparison practices.Study DesignGiven the poor statistical power in many studies to detect effects on readmissions, we developed two novel claims‐based measures of unplanned acute care (UAC) following an index acute care event. The first measure assesses the proportion of hospitalizations followed by an unplanned readmission, ED visit, or observation stay within 30 days of discharge; the second assesses the proportion of ED visits and observation stays followed by a hospitalization, ED visit, or observation stay within 30 days. We calculate minimum detectable effects (MDEs) for both measures and for a conventional measure of 30‐day unplanned readmissions, using CPC+ data.Principal FindingsRepeat UAC events are common among Medicare beneficiaries served by the CPC+ practices. In 2017, 22% of discharges and 21% of ED visits and observation stays had a UAC event within 30 days. Readmissions were the most common UAC event following discharge, whereas ED visits were most common following index ED visits or observation stays. MDEs are 25%‐40% lower for the new measures than for the standard 30‐day readmissions measure, indicating better statistical power to detect impacts of primary or transitional care interventions.ConclusionsThis study introduces two new claims‐based measures to assess quality of care during a patient''s vulnerable period following acute care. The new measures complement existing measures, covering a broader range of UAC events than the standard 30‐day readmissions measure, and yielding greater statistical power.  相似文献   

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ObjectiveTo provide evidence on the effects of expansions to private and public insurance programs on adolescent specialty substance use disorder (SUD) treatment use.Data Source/Study SettingThe Treatment Episodes Data Set (TEDS), 1996 to 2017.Study DesignA quasi‐experimental difference‐in‐differences design using observational data.Data CollectionThe TEDS provides administrative data on admissions to specialty SUD treatment.Principal FindingsExpansions of laws that compel private insurers to cover SUD treatment services at parity with general health care increase adolescent admissions by 26% (P < .05). These increases are driven by nonintensive outpatient admissions, the most common treatment episodes, which rise by 30% (P < .05) postparity law. In contrast, increases in income eligibility for public insurance targeting those 6‐18 years old are not statistically associated with SUD treatment.ConclusionsPrivate insurance expansions allow more adolescents to receive SUD treatment, while public insurance income eligibility expansions do not appear to influence adolescent SUD treatment.  相似文献   

16.
ObjectiveTo estimate the impact of urgent care centers on emergency department (ED) use.Data SourcesSecondary data from a novel urgent care center database, linked to the Healthcare Cost and Utilization Project State Emergency Department Databases (SEDD) from six states.Study DesignWe used a difference‐in‐differences design to examine ZIP code‐level changes in the acuity mix of emergency department visits when local urgent care centers were open versus closed. ZIP codes with no urgent care centers served as a control group. We tested for differential impacts of urgent care centers according to ED wait time and patient insurance status.Data Collection/Extraction MethodsUrgent care center daily operating times were determined via the urgent care center database. Emergency department visit acuity was assessed by applying the NYU ED algorithm to the SEDD data. Urgent care locations and nearby emergency department encounters were linked via zip code.Principal FindingsWe found that having an open urgent care center in a ZIP code reduced the total number of ED visits by residents in that ZIP code by 17.2% (P < 0.05), due largely to decreases in visits for less emergent conditions. This effect was concentrated among visits to EDs with the longest wait times. We found that urgent care centers reduced the total number of uninsured and Medicaid visits to the ED by 21% (P < 0.05) and 29.1% (P < 0.05), respectively.ConclusionsDuring the hours they are open, urgent care centers appear to be treating patients who otherwise would have visited the ED. This suggests that urgent care centers have the potential to reduce health care expenditures, though questions remain about their net cost impact. Future work should assess whether urgent care centers can improve health care access among populations that often experience barriers to receiving timely care.  相似文献   

17.
ObjectiveTo examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies.DesignRetrospective cross-sectional study.Setting and ParticipantsThe study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017.Methods2010–2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a “choice” set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies.ResultsAmong the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01).Conclusions and ImplicationsBlack individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.  相似文献   

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ObjectiveTo examine variation in trajectories of abandoning conventionally fractionated whole‐breast irradiation (CF‐WBI) for adjuvant breast radiotherapy among physician peer groups and the associated cost implications.Data SourcesMedicare claims data were obtained from the Chronic Conditions Data Warehouse for fee‐for‐service beneficiaries with breast cancer in 2011‐2014.Study DesignWe used social network methods to identify peer groups of physicians that shared patients. For each physician peer group in each time period (T1 = 2011‐2012 and T2 = 2013‐2014), we calculated a risk‐adjusted rate of CF‐WBI use among eligible women, after adjusting for patient clinical characteristics. We applied a latent class growth analysis to these risk‐adjusted rates to identify distinct trajectories of CF‐WBI use among physician peer groups. We further estimated potential savings to the Medicare program by accelerating abandonment of CF‐WBI in T2 using a simulation model.Data Collection/Extraction MethodsUse of conventionally fractionated whole‐breast irradiation was determined from Medicare claims among women ≥ 66 years of age who underwent adjuvant radiotherapy after breast conserving surgery.Principal FindingsAmong 215 physician peer groups caring for 16 988 patients, there were four distinct trajectories of abandoning CF‐WBI: (a) persistent high use (mean risk‐adjusted utilization rate: T1 = 94.3%, T2 = 90.6%); (b) decreased high use (T1 = 81.3%, T2 = 65.3%); (c) decreased medium use (T1 = 60.1%, T2 = 44.0%); and (d) decreased low use (T1 = 31.6%, T2 = 23.6%). Peer groups with a smaller proportion of patients treated at free‐standing radiation facilities and a larger proportion of physicians that were surgeons tended to follow trajectories with lower use of CF‐WBI. If all physician peer groups had practice patterns in T2 similar to those in the “decreased low use” trajectory, the Medicare program could save $83.3 million (95% confidence interval: $58.5 million‐$112.2 million).ConclusionsPhysician peer groups had distinct trajectories of abandoning CF‐WBI. Physician composition and setting of radiotherapy were associated with the different trajectories. Distinct practice patterns across the trajectories had important cost implications.  相似文献   

19.
ObjectiveTo test for equivalence between providers with and without advanced degrees in multiple domains related to delivery of evidence‐based treatment.Data SourceProvider and client data from an effectiveness trial of Alternatives for Families: A Cognitive Behavioral Therapy (AF‐CBT) in a major metropolitan area in the United States.Study DesignWe tested for equivalence between providers (N = 182) with and without advanced degrees in treatment‐related knowledge, practices, and attitudes; job demands and stress; and training engagement and trainer‐rated competence in AF‐CBT. We also conducted exploratory analyses to test for equivalence in family clinical outcomes.Data CollectionProviders completed measures prior to randomization and at 6‐month follow‐up, after completion of training and consultation in AF‐CBT. Children and caregivers completed assessments at 0, 6, 12, and 18 months.Principal FindingsProviders without advanced degrees were largely non‐inferior to those with advanced degrees in treatment‐related knowledge, practices, and attitudes, while findings for job demands and stress were mixed. Providers without advanced degrees were non‐inferior to providers with advanced degrees in consultation attendance (B = −1.42; confidence interval (CI) = −3.01‐0.16; margin of equivalence (Δ) = 2), number of case presentations (B = 0.64; CI = −0.49‐1.76; Δ = 2), total training hours (B = −4.57; CI = −10.52‐1.37; Δ = 3), and trainer‐rated competence in AF‐CBT (B = −0.04; CI = −3.04‐2.96; Δ = 4), and they were significantly more likely to complete training (odds ratio = 0.66; CI = 0.10‐0.96; Δ = 30%). Results for clinical outcomes were largely inconclusive.ConclusionsProvider‐level outcomes for those with and without advanced degrees were generally comparable. Additional research is needed to examine equivalence in clinical outcomes. Expanding evidence‐based treatment training to individuals without advanced degrees may help to reduce workforce shortages and improve reach of evidence‐based treatments.  相似文献   

20.
ObjectiveWe examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007‐2009 Great Recession.Data Source2004‐2010 Behavioral Risk Factor Surveillance System (BRFSS).Study DesignFlexible difference‐in‐difference regressions were used to compare the impact of county‐level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines.Data Collection/Extraction MethodsNonelderly adults (aged 19‐64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics’ Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state''s 2007 Medicaid guidelines using data from the 2007 Current Population Survey''s Annual Social and Economic Supplement.Principal FindingsA percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9‐1.6, P < .01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6‐1.1, P < .01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P < .01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county‐level unemployment were associated with a 0.68 PPT (P < .10) increase in unmet medical needs due to cost—a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines.ConclusionsIncreased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income.  相似文献   

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