Abstract 1: The Impact of State Medicaid Expansions on Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure

2018 ◽  
Vol 11 (suppl_1) ◽  
Author(s):  
Rishi K Wadhera ◽  
Karen E Joynt Maddox ◽  
Gregg C Fonarow ◽  
Xin Zhao ◽  
Paul A Heidenreich ◽  
...  
Keyword(s):  
Heart Failure ◽  
Hospital Mortality ◽  
Outcome Measures ◽  
Low Income ◽  
Inpatient Care ◽  
The United States ◽  
Care Quality ◽  
National Quality ◽  
Quality And Outcomes ◽  
The Impact

Background: Heart failure (HF) is the leading cause of morbidity and mortality in the United States. Despite considerable advancement in the management of HF, outcomes remain suboptimal, particularly among the uninsured. In 2014, the ACA expanded Medicaid eligibility, and millions of low-income, non-elderly adults gained insurance coverage in 32 states. Little is known about Medicaid expansion’s effect on quality and outcomes of inpatient care for HF. Methods: We used the American Heart Association’s Get With The Guidelines-HF registry to assess changes in inpatient care quality and outcomes among low income, non-elderly patients hospitalized for HF prior to and following Medicaid expansion, in expansion and non-expansion states. Patients were classified as low income if covered by Medicaid, uninsured, or missing insurance. We considered expansion states to be those that implemented expansions in 2014. We constructed piecewise logistic multivariable regression models to track quarterly trends over time of quality and outcome measures in the pre-expansion (1/1/2010-12/31/2013) and post-expansion (1/1/14 - 6/30/17) periods, by state expansion status. Results: The cohort included 58,804 patients hospitalized across 391 sites - 53% were covered by Medicaid, 21.3% uninsured, and 25.6% missing insurance. Among expansion states, defect-free HF care increased significantly during the pre-expansion period (aOR 1.06, 95% CI 1.03-1.08) but did not change after expansion (aOR 0.99, 95% CI 0.97-1.02). Similarly, other quality measures, such as use of aldosterone antagonists, evidence-based beta blockers, and ICD implantation significantly increased prior to expansion, but did not change following expansion (Table). In-hospital mortality rates remained similar during the pre-expansion (aOR 0.99, 95% CI 0.96-1.02) and post-expansion periods (aOR 1.00, 95% CI 0.97-1.03). Trends in quality and outcome measures for non-expansion states are also shown in the table. Conclusion: The ACA Medicaid state expansions were not associated with improvements in quality of care or in-hospital mortality in expansion states among sites participating in a national quality improvement initiative. Future investigation should evaluate the long-term impact of expansion on HF care during the post-discharge period.

Demonstrating Nutrient Cost Gradients: A Brooklyn Case Study

2014 ◽  
Vol 84 (5-6) ◽  
pp. 244-251 ◽  
Author(s):  
Robert J. Karp ◽  
Gary Wong ◽  
Marguerite Orsi
Keyword(s):  
Low Income ◽  
Energy Content ◽  
Food Selection ◽  
The United States ◽  
United States Department ◽  
Micronutrient Deficiencies ◽  
Caloric Density ◽  
Low Income Families ◽  
The Cost ◽  
The Impact

Abstract. Introduction: Foods dense in micronutrients are generally more expensive than those with higher energy content. These cost-differentials may put low-income families at risk of diminished micronutrient intake. Objectives: We sought to determine differences in the cost for iron, folate, and choline in foods available for purchase in a low-income community when assessed for energy content and serving size. Methods: Sixty-nine foods listed in the menu plans provided by the United States Department of Agriculture (USDA) for low-income families were considered, in 10 domains. The cost and micronutrient content for-energy and per-serving of these foods were determined for the three micronutrients. Exact Kruskal-Wallis tests were used for comparisons of energy costs; Spearman rho tests for comparisons of micronutrient content. Ninety families were interviewed in a pediatric clinic to assess the impact of food cost on food selection. Results: Significant differences between domains were shown for energy density with both cost-for-energy (p < 0.001) and cost-per-serving (p < 0.05) comparisons. All three micronutrient contents were significantly correlated with cost-for-energy (p < 0.01). Both iron and choline contents were significantly correlated with cost-per-serving (p < 0.05). Of the 90 families, 38 (42 %) worried about food costs; 40 (44 %) had chosen foods of high caloric density in response to that fear, and 29 of 40 families experiencing both worry and making such food selection. Conclusion: Adjustments to USDA meal plans using cost-for-energy analysis showed differentials for both energy and micronutrients. These differentials were reduced using cost-per-serving analysis, but were not eliminated. A substantial proportion of low-income families are vulnerable to micronutrient deficiencies.

scholarly journals School's Out

Elements ◽  
2021 ◽  
Vol 16 (1) ◽  
pp. 39-52
Author(s):  
Charlie Power
Keyword(s):  
United States ◽  
Low Income ◽  
Education System ◽  
The United States ◽  
Current Evidence ◽  
Learning Loss ◽  
Summer Learning ◽  
Elementary And Secondary Education ◽  
Heated Debate ◽  
The Impact

The debate over the future direction of elementary and secondary education in the United States is fractious and contentious. Many of these are rooted in concerns over disparities in financial circumstances and race. While the full extent of the gaps, in addition to the United States' mediocre education system relative to other industrialized nations, has been a subject of frequent research and heated debate, one crucial component of this divide has yet to be analyzed: summer learning loss. This paper will closely analyze published literature in order to analyze the impact of summer education loss. Additionally, this paper will argue that summer learning varies by socioeconomic status (SES), with low-income populations gradually regressing over the years. This phenomenon has ramifications on students' achievement and explains the disparities that accumulate over a student's educational career. Finally, based on current evidence, this paper will make policy recommendations on how to change the current education system to better address summer's inherent inequities. 

scholarly journals Food Stamp Participation Among Low-Income Households: Theoretical Considerations of the Impact on the Demand for Food

1975 ◽  
Vol 7 (1) ◽  
pp. 223-231 ◽  
Author(s):  
Ron Mittelhammer ◽  
Donald A. West
Keyword(s):  
World War Ii ◽  
Low Income ◽  
The United States ◽  
Food Stamps ◽  
Food Stamp ◽  
World War ◽  
On Demand ◽  
The Impact ◽  
Theoretical Considerations ◽  
Direct Distribution

The USDA's Food Stamp Program (FSP) is a major item in the department's budget. In effect from 1939 to 1943 and revived as a pilot program in 1961, FSP has grown until, in 1973, it provided nearly $4 billion in food stamps to an average of 12 million persons per month. About 55 percent of the $4 billion is federal subsidy. The program is continuing to expand as a result of a congressional mandate that FSP be in effect nationwide after June 30, 1974. Because of the FSP's growth, questions are now being asked about the program's impact on demand for food in the United States.In its pre-World War II inception, FSP was developed as an alternative to direct distribution of commodities to relief families. Although the objective of improving food consumption among needy households was recognized, FSP was viewed primarily as a method for stimulating demand for farm products.

Abstract 19212: Racial Differences in Clinical Outcomes and Resource Utilization Associated With Heart Failure Hospitalizations in the United States: A Nationwide Analysis From 2011-2012

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Nilay Kumar ◽  
Rohan Khera ◽  
Neetika Garg
Keyword(s):  
Heart Failure ◽  
Native Americans ◽  
Hospital Mortality ◽  
Racial Differences ◽  
Resource Utilization ◽  
The United States ◽  
Primary Diagnosis ◽  
Hospital Charges ◽  
Nationally Representative ◽  
Racial Ethnic

Background and objectives: Heart failure (HF) incidence is higher among Blacks compared to Whites. There is a paucity of recent data on racial differences in in-hospital mortality and resource utilization in a nationally representative, multiracial cohort of HF hospitalizations. Hypothesis: There are significant racial-ethnic differences in HF hospitalization outcomes. Methods: We used the 2011-2012 Nationwide/National Inpatient Sample to identify hospitalizations with a primary diagnosis of HF using relevant ICD-9 codes. Outcomes of interest were in-hospital mortality, length of stay (LOS) and mean inflation adjusted charges. The effect of race on outcomes was ascertained using logistic or linear regression. Results: 375,740 primary HF hospitalizations representing 1.8 million hospitalizations nationwide were included. Mean age was 72.6 (SD 14.6) years and 50.1% were females. After adjusting for age, sex, hypertension, diabetes, APR-DRG mortality risk and socioeconomic status, in-hospital mortality was significantly lower for Blacks (OR 0.69, 95% CI 0.64 - 0.74; p<0.001), Hispanics (OR 0.82, 95% CI 0.75 - 0.91; p<0.001) and Asians or Pacific Islanders (OR 0.85, 95% CI 0.73 - 0.99; p=0.04) compared to Whites. Average inflation adjusted charges were significantly higher for all minorities compared to Whites except for Native Americans for whom charges were significantly lower than Whites (p<0.05 for Black, Hispanic, Asian, NA or Others vs. Whites). LOS was modestly higher for Blacks or Other races vs. Whites (p=0.01 B vs. W and Others vs. W) and lower for Native Americans vs. Whites (p<0.001). Conclusions: Blacks, Hispanics and Asians hospitalized for HF are significantly less likely to die in the hospital compared to Whites. Hospital charges for racial-ethnic minorities are significantly higher compared to Whites. The reasons for racial differences in HF hospitalization outcomes require further investigation.

Essays in Labour Economics: Evidence from Voluntary and Mandatory Wage Floors in the United States and New Zealand

2021 ◽  
Author(s):  
◽  
Jaime Lancaster
Keyword(s):  
New Mexico ◽  
New Zealand ◽  
Minimum Wage ◽  
Low Income ◽  
Fixed Effects ◽  
Local Minimum ◽  
The United States ◽  
Living Wage ◽  
Earnings Growth ◽  
The Impact

<p>This thesis expands the literature on minimum and living wages by investigating local minimum wage ordinances and voluntary living wage programs. This thesis is presented as three distinct papers; the first explores a county-wide minimum wage ordinance in New Mexico, USA, while papers 2 and 3 explore New Zealand’s voluntary living wage program. In the United States, local minimum wage ordinances are growing in popularity, and research is emerging on their effects. Setting minimum wages at the local level is politically easier than enacting Federal legislation, and local minimum wages may be better targeted to local economic conditions. In my first chapter, “Local Minimum Wage Laws and Labour Market Outcomes: Evidence from New Mexico,” I use fixed effects and synthetic control analysis to uncover the effects of a local minimum wage law on the Albuquerque/Bernalillo region of New Mexico, with a focus on how provisions exempting tipped workers affect gains in earnings. My findings reveal that these provisions can lead to reductions in hourly wages for workers exempted from the minimum wage even when the labour market is not harmed overall. I find that the minimum wage ordinance did not reduce teen employment but that it served to increase the supply of teen labour leading to an increase in the teen unemployment rate.  The second and third papers in this thesis address the voluntary living wage program in New Zealand. In the first quantitative work on New Zealand’s living wage, I utilize data from Statistics New Zealand’s Integrated Data Infrastructure (IDI) to explore several facets of the living wage experience for employers and employees. In the second paper, “The New Zealand Living Wage: Earnings, Labour Costs and Turnover,” I investigate the characteristics of New Zealand living wage firms and use fixed effects to examine the impact of living wage certification on employment, worker earnings and turnover. My results provide some evidence for increases in labour costs and worker earnings following certification but find that this change is driven by changes in small firms that employ few workers. I find no evidence of a reduction in turnover.  In my final chapter, “Who Benefits from Living Wage Certification?” I investigate the distribution of benefits from the living wage based on an employees’ pre-treatment earnings, time of hire and whether or not they remained employed with the living wage firm. To do this, I utilize a worker-level panel dataset containing the full earnings history of all workers that were employed for a living wage or matched control firm between January 2014 and December 2015. I use fixed effects models containing fixed effects for worker, firm and month to compare patterns of earnings growth for workers hired before certification (‘pre-hires’) with those hired after certification (‘joiners’) and those who left their living wage job but remained in the workforce (‘leavers’). I also estimate the impact of living wage employment on the earnings of low-income workers. I find that the financial benefit of the living wage accrues almost exclusively to workers hired after certification and to low income workers. In addition, my analysis on the worker-level panel suggests that overall earnings growth in living wage firms lagged that in control firms over the observation period. This result is driven by relative declines in earnings for living wage workers in large firms and is attributed to increases in the published living wage rate that lags behind wage growth in the relevant segments of the job market.</p>

Abstract 186: Improving Identification and Assessment of Readmission Risk for Acute Myocardial Infarction and Heart Failure Patients Following Implementation of a National Quality Improvement Program

2018 ◽  
Vol 11 (suppl_1) ◽  
Author(s):  
Ty J Gluckman ◽  
Nancy M Albert ◽  
Robert L McNamara ◽  
Gregg C Fonarow ◽  
Adnan Malik ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Acute Myocardial Infarction ◽  
Quality Improvement ◽  
Improvement Program ◽  
Patient Level ◽  
Transition Care ◽  
National Quality ◽  
The Impact ◽  
Readmission Risk

Background: Optimal transition care represents an important step in mitigating the risk of early hospital readmission. For many hospitals, however, resources are not available to support transition care processes, and hospitals may not be able to identify patients in greatest need. It remains unknown whether a coordinated quality improvement campaign could help to increase a) identification of at-risk patients and b) use of a readmission risk score to identify patients needing extra services/resources. Methods: The American College of Cardiology Patient Navigator Program was designed as a 2-year (2015-2017) quality improvement campaign to assess the impact of transition-care interventions on transition care performance metrics for patients with acute myocardial infarction (AMI) and heart failure (HF) at 35 acute care hospitals. All sites were active participants in the NCDR ACTION Registry. Facilities were free to choose their transition care priorities, with at least 3 goals established at baseline. Pre-discharge identification of AMI and HF patients and assessment of their respective readmission risk were 4 of the 36 metrics tracked quarterly. Performance reports were provided regularly to the individual institutions. Sharing of best practices was actively encouraged through webinars, a listserv, and an online dashboard with display of blinded performance for all 35 hospitals. Results: At baseline, 31% (11/35) and 23% (8/35) of facilities did not have a process for prospectively identifying AMI and HF patients, respectively. At 2 years, the rate of not having processes decreased to 8% (3/35) and 3% (1/35), respectively. Among hospitals able to identify AMI and HF patients, there was high patient-level identification performance from the outset (91% for AMI and 86% for HF at baseline), with added improvement over 2 years (+2.2% for AMI and +9.3% for HF). At baseline, processes to assess readmission risk for AMI and HF patients were only completed by 26% (9/35) and 31% (11/35) of facilities, respectively. At 2 years, AMI and HF readmission risk assessment rose to 80% (28/35) and 86% (30/35), respectively. Similar improvements were noted at the patient-level, with 34% (52% --> 86%) and 16% (75% --> 91%) absolute 2-year increases in the percentage of AMI and HF patients undergoing assessment of readmission risk, respectively. Conclusions: Implementation of a quality improvement campaign focused on care transition can substantially improve prospective identification of AMI and HF patients and assessment of their readmission risk. It remains to be determined whether process improvement lead to reduction in 30-day readmission and/or improvement in other clinically important outcome measures.

Abstract 289: Hospital Volume of LVAD Procedures Determines Patient Outcome

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Katherine Feldman ◽  
Rami Doukky ◽  
Tricia Johnson ◽  
David Levine ◽  
Sam Hohmann
Keyword(s):  
Heart Failure ◽  
Hospital Mortality ◽  
The United States ◽  
Left Ventricular ◽  
Policy Implications ◽  
Ventricular Assist Devices ◽  
Categorical Variables ◽  
Procedure Volume ◽  
End Stage Heart Failure ◽  
End Stage

Background: Left ventricular assist devices (LVADs) provide mechanical circulatory support to patients with end-stage heart failure. The use of these devices in the United States has been increasing since the FDA approved the first device in 1994. There are no published studies that have evaluated the relationship between LVAD procedural volume and hospital mortality, despite large variation across hospitals in the volume of LVAD procedures performed. This study sought to explore whether a correlation exists between hospital and surgeon’s procedural volumes and patient outcomes, and also to identify a critical threshold. Methods: We conducted a retrospective cross-sectional analysis of all patient discharges from UHC member hospitals from January 2008 through June 2012 after an insertion of an LVAD during their hospitalization. Patients were identified from UHC’s Clinical Database/Resource Manager (CDB/RM) on the basis of the principal or secondary International Classification of Diseases Ninth Revision, Clinical Modification ( ICD-9-CM) procedure code 37.66. The primary outcome was all cause mortality. Results: There were 87 hospitals that admitted at least 1 patient for an LVAD procedure during the study period (77.5 percent males, mean age 54.3). The mean length of stay was 42.1 days and a mean total cost of $299,067. We identified variation of in-hospital mortality by hospital LVAD procedure volume quartile. Quartile 1 included hospitals performing 1-9 procedures (38.8% mortality), quartile 2 performed 10-46 procedures (18.1% mortality), quartile 3 performed 55-97 procedures (12.8% mortality), and the fourth quartile performed 107-319 procedures (16.1% mortality) during the study period. Categorical variables were compared with the Chi-Square Test, and continuous variables were compared with t-tests. There was significant variation in the mortality for almost all study variables including age, gender, admission severity of illness, and admission risk of mortality, and the variation persisted by volume quartile. Conclusion: Initial results suggest that there is a correlation between hospital LVAD procedure volume and in-hospital mortality. LVADs are becoming an increasingly common treatment method for patients with end-stage heart failure and are either awaiting transplant or will receive the device as the final method of therapy. Identifying critical volume thresholds could improve outcomes and ultimately improve the efficiency and value of care. Implications: Identifying mortality associated with LVAD procedures at these hospitals will provide patients and physicians with more information when seeking treatment options for heart failure. This study may also have health policy implications for cardiac treatment by implementing guidelines that LVAD hospital and surgeon programs must adhere to.

Abstract 12789: Clinical Factors Associated With Mortality Among Patients Hospitalized for Heart Failure in Egypt

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Ahmed Hassanin ◽  
Mahmoud M Hassanein ◽  
Madiha F Abdel-maksoud
Keyword(s):  
Heart Failure ◽  
Hospital Mortality ◽  
Univariate Analysis ◽  
Elevated Serum ◽  
The United States ◽  
Clinical Factors ◽  
Clinical Variables ◽  
Factors Associated ◽  
The Us ◽  
One Year

Introduction: Heart failure (HF) is a growing public health burden in many low and middle-income countries (LMIC). However, most HF registries were conducted in high income countries, which often have different ethnic and cultural backgrounds from that of LMIC. Hypothesis: Independent clinical variables associated with mortality in patients hospitalized for HF in Egypt are different from those established in the United States (US). Methods: Between 2011 and 2014, 1,660 patients hospitalized for HF were enrolled from 20 centers across Egypt as part of the European Society of Cardiology HF long-term Registry. Deceased patients were compared to survivors, to identify demographic, clinical and biochemical variables associated with in-hospital and one-year mortality. Variables associated with mortality on univariate analysis, and independent variables identified in the Acute Decompensated Heart Failure National Registry (ADHERE) and in the Seattle Heart Failure Model, both based in the US, were entered into the multivariate logistic regression model. Results: In-hospital mortality was 5%. Only two independent clinical factors associated with in-hospital mortality were identified: elevated serum creatinine (sCr), OR=1.47 [95% CI: 1.23, 1.74] for every point increases above one mg/dl; and low admission systolic blood pressure (SBP), OR=1.54; [95% CI: 1.43, 1.65] for every 10 points decrease in SBP below 140 mmHg. At one-year follow up, mortality was 27%. Independent predictors of one-year mortality were: age, OR=1.47; [95% CI: 1.23,1.75] for every 10-year increase above 40; low discharge SBP, OR=1.30 [95% CI: 1.08, 1.52] for every 10 points decrease below 140 mmHg; low ejection fraction, OR=1.51 [95% CI: 0.59,0.73] for every 5 points decrease from 65%; chronic liver disease, OR=3.0 [95% CI: 1.51,5.88]; history of stroke, OR=3.2 [95% CI: 1.52,6.65]. These variables overlapped with those identified in US registries. Conclusions: Independent clinical variables associated with mortality after HF hospitalization in Egypt are similar to those reported in HF registries in the US.

P1515Female sex is an independent predictor of mortality in patients with STEMI in Spain: a study in 325,017 episodes over 11 years (2005–2015)

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Anguita ◽  
A Sambola Ayala ◽  
J Elola ◽  
J L Bernal ◽  
C Fernandez ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Hospital Mortality ◽  
Independent Predictor ◽  
National Health System ◽  
Anterior Myocardial Infarction ◽  
Female Sex ◽  
Spanish National Health System ◽  
History Of ◽  
The Impact

Abstract Background Recent studies reported a decrease in the mortality of ST-elevation myocardial infarction (STEMI) patients. This favorable evolution could not extend to women. The interaction between gender and mortality in STEMI remains controversial. Purpose To assess the impact of female sex on mortality of patients with STEMI through of period of 11 years. Methods We conducted a retrospective longitudinal study using information provided by the minimal database system of the Spanish National Health System to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015. Results A total of 325,017 STEMI were identified. Of them, 273,182 were included, and 106,277 (38.8%) were women. Women were older than men and had more comorbidities. Through the study period 53% men vs 37.2% underwent PTCA; women presented more frequently heart failure, shock and stroke than men (p<0.001, respectively). The mean crude in-hospital mortality rate for the whole study period was higher in women (OR: 2.18; 95% CI: 2.12.-2.23, p<0.0001). Female sex was independently associated with higher in-hospital mortality (adjusted OR: 1.18; 95% CI: 1.14–1.22, p<0.001) (Table 1). The risk was maintained through the whole study period (lower OR: 1.14 in 2014; higher OR: 1.28 in 2006). Table 1. Variables independently associated with in-hospital mortality adjusted by risk in a multilevel logistic regression model, 2005–2015 STEMI In-hospital mortality Odds Ratio P 95% CI Woman 1.18 <0.001 1.14 1.22 Age 1.06 <0.001 1.06 1.06 History of PTCA 1.58 <0.001 1.40 1.77 Congestive heart failure 1.26 <0.001 1.22 1.30 Acute Myocardial Infarction 1.84 <0.001 1.54 2.20 Anterior myocardial infarction 1.47 <0.001 1.23 1.76 Cardio-respiratory failure or shock 15.25 <0.001 14.78 15.75 Hypertension 0.81 <0.001 0.79 0.84 Stroke 5.76 <0.001 5.18 6.42 Cerebrovascular disease 0.86 <0.001 0.79 0.93 Renal failure 1.95 <0.001 1.88 2.02 Vascular disease and complications 7.03 <0.001 5.72 8.63 CI, Confidence Interval. Conclusions Female sex is an independent predictor of mortality in patients with STEMI in Spain, maintaining through a period of the 11 years.

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