Priority access to health care: Evidence from an exogenous policy shock

Challenges and Opportunities in Accessing Surgery for Glioblastoma in Low-Middle Income Countries: A Narrative Review

Glioblastoma: a highly aggressive brain tumor, presents substantial challenges in treatment and management, with surgical intervention playing a pivotal role in improving patient outcomes. Disparities in access to brain tumor surgery arise from a multitude of factors, including socioeconomic status, geographical location, and healthcare resource allocation. Low- and middle-income countries (LMICs) often face significant barriers to accessing surgical services, such as shortages of specialized neurosurgical expertise, limited healthcare infrastructure, and financial constraints. Consequently, glioblastoma patients in LMICs experience delays in diagnosis, suboptimal treatment, and poorer clinical outcomes compared to patients in high-income countries (HICs). The clinical impact of these disparities is profound. Patients in LMICs are more likely to be diagnosed at advanced disease stages, receive less effective treatment, and have lower survival rates than their counterparts in HICs. Additionally, disparities in access to surgical care exacerbate economic and societal burdens, emphasizing the urgent need for targeted interventions and health policy reforms to address healthcare inequities. This review highlights the importance of addressing global disparities in access to brain tumor surgery for glioblastoma through collaborative efforts, policy advocacy, and resource allocation, aiming to improve outcomes and promote equity in surgical care delivery for all glioblastoma patients worldwide.

Buprenorphine Treatment Episodes During the First Year of COVID: a Retrospective Examination of Treatment Initiation and Retention

BACKGROUND

During the COVID pandemic, overall buprenorphine treatment appeared to remain relatively stable, despite some studies suggesting a decrease in patients starting buprenorphine. There is a paucity of empirical information regarding patterns of buprenorphine treatment during the pandemic.

OBJECTIVE

To better understand the patterns of buprenorphine episodes during the pandemic and how those patterns compared to pre-pandemic patterns.

DESIGN

Pharmacy claims representing approximately 92% of all prescriptions filled at retail pharmacies in all 50 US states and the District of Columbia.

PARTICIPANTS

Individuals filling buprenorphine prescriptions indicated for treatment of opioid use disorder.

MAIN MEASURES

The number of active, starting, and ending buprenorphine treatment episodes March 13 to December 1, 2020, and the expected number of such episodes in 2020 based on the growth in treatment episodes from March 13 to December 1, 2019.

KEY RESULTS

The observed number of active buprenorphine episodes in December 2020 was comparable to the expected number, but new treatment episodes starting between March 13 and December 1, 2020, were 17.2% fewer than expected based on the 2019 experience. Similarly, the number of episodes that ended between March 13 and December 1, 2020, was 16.0% fewer than expected. Decreases from expected episode starts and ends occurred throughout the period but were greatest in the 2 months after the declaration of the public health emergency.

CONCLUSIONS AND RELEVANCE

Beneath the apparent stability of buprenorphine patient numbers during the pandemic, the flow of individuals receiving buprenorphine treatment changed substantially. Our findings shed light on how policy changes meant to support buprenorphine prescribing influenced prescribing dynamics during that period, suggesting that while policy efforts may have been successful in maintaining existing patients in treatment, that success did not extend to individuals not yet in treatment.

Provider supply and access to primary care

Resource-constrained delivery systems often have access issues, causing patients to wait a long time to see a provider. We develop theoretical and empirical models of wait times and apply them to primary care delivery by the U.S. Veterans Health Administration (VHA). Using instrumental variables to handle simultaneity issues, we estimate the effect of clinician supply on new patient wait times. We find that it has a sizable impact. A 10% increase in capacity reduces wait times by 2.1%. Wait times are also associated with clinician productivity, scheduling protocols, and patient access to alternative sources of care. The VHA has adopted our models to identify underserved areas as specified by the MISSION Act of 2018.

Dually-enrolled patients choose providers with lower wait times: Budgetary implications for the VHA

OBJECTIVE

To estimate the effect of wait times on patients' choice of provider and simulate changes in choice of provider due to compliance with VA MISSION Act wait time targets.

DATA SOURCES

We use nationwide administrative data (2014-2017) on Veterans who are enrolled in Medicare and the Veterans Health Administration (VHA), the Survey of VHA Enrollees, Area Health Resource Files, and other data provided by the Centers for Medicare & Medicaid Services.

STUDY DESIGN

We use an instrumental variables approach to identify the effect of VHA wait times on the proportion of total (Medicare and VHA) services that are paid for by the VHA ("reliance"). We exploit shocks to VHA provider supply to isolate supply-driven changes in wait times and estimate the effect on VHA reliance. We control for market and time fixed effects and local demand factors.

DATA COLLECTION/EXTRACTION METHODS

We use monthly aggregated data on 140 markets (groups of counties). VHA reliance is computed among patients aged 65 years or older who are dually enrolled in VHA and Medicare. VHA wait times and reliance are calculated for multiple specialties: cardiology, gastroenterology, orthopedics, urology, dermatology, and ophthalmology/optometry.

PRINCIPAL FINDINGS

A 10% increase in the mean wait time (+2.8 days) reduces VHA reliance by 2.3 percentage points (95% CI: 2.3, 2.7), or 7.9% of the sample mean. This implies that meeting the MISSION Act wait time targets may have multi-billion-dollar budgetary impacts. Effects vary across specialties. For example, a 10% increase in the mean wait time for cardiology services (+2.0 days) reduces reliance by 1.8 percentage points (95% CI: 1.6, 2.1), or 6.3% of the sample mean for cardiology services.

CONCLUSIONS

Meeting statutory wait time targets may have substantial unforeseen impacts on federal health care spending as patients sort to providers who have lower wait times.

Association of Secure Messaging with Primary Care In-Person and Telephone Visits Among Veterans: a Matched Difference-in-Difference Analysis

BACKGROUND

Secure messaging (SM) between patients and primary care teams has expanded care access but may impact other clinical encounters.

OBJECTIVE

To study associations between SM use and primary care in-person and telephone visits in the Veterans Health Administration (VHA).

DESIGN

The SM feature of VHA's patient portal, MyHealtheVet, supports asynchronous communication between patients and primary care teams. To study the impact of SM on in-person and telephone visits, two analyses were performed: (1) a retrospective pre-/post-analysis comparing changes after initiating SM use and (2) a difference-in-difference comparison among SM users and non-users 1 year before and after index SM use. Matching to non-users was by primary care team, demographics, and predicted propensity of SM use by Nosos comorbidity score and drive time to clinic.

PATIENTS

In 2016, 154,053 Veterans initiated SM from all primary care patients (N = 5,891,893); 25,683 were propensity-matched to controls (N = 49,266) from the same primary care team not using SM.

MAIN MEASURES

Primary care provider in-person visits and telephone contacts between patients and their primary care team were assessed 1 year prior and post index SM.

KEY RESULTS

Overall, primary care in-person visits decreased 13.3% (p < 0.0001); telephone visits increased 13.5% (p < 0.0001). In the matched analysis, in-person primary care visits decreased by 16.0% (p < 0.0001) by SM users and 9.9% (p < 0.0001) among controls, resulting in a across-group decrease of 6.1% in-person visits after SM initiation. Telephone visits increased by 11.0% (p < 0.0001) for SM users and 4.5% for controls (p < 0.0001) resulting in an across-group increase of 6.5% telephone visits after SM initiation.

CONCLUSIONS

Use of SM was associated with decreased in-person visits and increased telephone visits. This may improve clinic appointment availability, while increasing time commitments for providers for non-traditional forms of access.

Assessing the Accessibility of Home-Based Healthcare Services for the Elderly: A Case from Shaanxi Province, China

With the rapid increase of the elderly population in China, healthcare services for the elderly have gradually become an important welfare resource. However, the healthcare service for the elderly still has problems such as mismatched supply and demand and unbalanced resources. In order to effectively eliminate the path barriers to match supply and demand, and improve the accessibility of healthcare services, this paper introduces the sustainability of the healthcare service based on the accessibility theory, and constructs an index system from the three dimensions of potential accessibility, realized accessibility, and sustainable accessibility of healthcare services for the elderly. Then, the paper makes a practice application of the index system based on survey data of healthcare services from Shaanxi province, China. Finally, the paper finds that the total accessibility and sustainable accessibility of healthcare services for the elderly in Shaanxi Province are at an average level. The score of potential accessibility is high, indicating that elderly people have greater opportunities to use healthcare services. The realized accessibility score is low, which indicates that the actual use of healthcare services for the elderly presents low satisfaction.