Research roundup: Home health nurses' workloads; readmissions at the VA; SHOP choices

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

Urban Institute/Robert Wood Johnson Foundation: Year-to-Year Variation In Small-Group Health Insurance Premiums: Double-Digit Annual Increases Have Been Common Over The Past Decade
In anticipation of next year's premium announcements and given some information already made public, concerns have surfaced about the potential for double-digit percent increases in nongroup and small-group health insurance premiums. This analysis shows that, although average annual increases in small-group premiums over the past 13 years averaged roughly 5.5 percent, double-digit average premium increases are common for states and large metropolitan areas. ... The ACA's market reforms, which prohibit insurers in the small-group and nongroup insurance markets from varying premiums based upon health status or claims experience of the enrollees, should decrease year-to-year premium variation (Blumberg and Holahan, 9/17). 

Medical Journal: Home Health Agency Work Environments And Hospitalizations
An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living .... Home health nurses work more hours than nurses in almost any other setting. ... All nursing characteristics of home health agencies were drawn from the University of Pennsylvania Multistate Survey of Nursing Care and Patient Safety. Nurses provided detailed information about their work environment, nursing experience and education, job satisfaction, and burnout. ... The primary findings of this study were that home health agencies with good environments have lower rates of nurse burnout and acute care hospitalizations, and higher rates of discharges to community living (Jarrín, Flynn, Lake and Aiken, October 2014).

JAMA Surgery: Descriptive Analysis Of 30-Day Readmission After Inpatient Surgery Discharge In The Veterans Health Administration
The Centers for Medicare and Medicaid Services (CMS) report a national average all-cause 30-day readmission rate of approximately 18% .… Using 2 large national databases, we examined trends of all-cause 30-day readmission rates and mean POHLOS [post-operative hospital length of stay] following major surgery in 9 specialties at [Veterans Health Administration] facilities .... the overall readmission rate significantly declined from 12.9% to 12.2% during the 10-year period concurrent with a significant decrease in mean POHLOS from 10.6 to 9.2 days. ... The readmission rate ranged from 9.0% (urology) to 16.6% (cardiac) and the mean POHLOS ranged from 5.9 days (urology) to 17.4 days (plastic). The readmission diagnoses were diverse, but postoperative infections, UTI, and pneumonia were common for all specialties (Han, Smith and Gunnar, 9/17).

Health Affairs: Employee Choice
[T]he Affordable Care Act (ACA) created Small Business Health Options Program (SHOP) Marketplaces in each state. SHOP Marketplaces were intended to [create] … a mechanism for employee choice, in which small-business employees can select from among multiple insurers and health plans …. federal regulations have made implementation of employee choice voluntary until 2016. This feature has not yet been made available in federally run SHOP Marketplaces. ... detractors have raised concerns that employee choice may overwhelm employees with too many choices or result in higher premiums in the SHOP if higher-risk employees can select more comprehensive plans than lower-risk employees. ... both small employers and their employees are likely to continue to need personalized assistance with the plan selection process and can be expected to continue to use the services of agents and brokers (Dash and Lucia, 9/18).

Pioneer Institute: The Undisclosed Cost Of Developing An Affordable Care Act State Exchange In Massachusetts
While the state has moved forward with new contractors following its first failed attempt at launching an ACA-compliant website, there has been little transparency about the full taxpayer cost of the state-based exchange. Estimates often have been released piecemeal, and they never examine the full cost of the project across multiple agencies involved in the work. ... Pioneer Institute staff [attempted] to compile an accounting of the money that has been committed to the project so far. ... Our estimates put the cost of getting the ACA exchange up and running at over $600 million, all of which will pay for systems to administer health care, not care itself. When you add in the cost of temporary coverage and healthcare claims paid on those programs under the ACA, you are looking at a price tag closer to $1 billion just in Massachusetts (Archambault, 9/17). 

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

USA Today: Pre-Diabetes, Diabetes Rates Fuel National Health Crisis
Americans are getting fatter, and older. These converging trends are putting the USA on the path to an alarming health crisis: Nearly half of adults have either pre-diabetes or diabetes, raising their risk of heart attacks, blindness, amputations and cancer. Federal health statistics show that 12.3% of Americans 20 and older have diabetes, either diagnosed or undiagnosed. Another 37% have pre-diabetes, a condition marked by higher-than-normal blood sugar. That's up from 27% a decade ago. An analysis of 16 studies involving almost 900,000 people worldwide, published in the current issue of the journal Diabetologia, shows pre-diabetes not only sets the stage for diabetes but also increases the risk of cancer (Ungar, 9/15).

Reuters: Fewer Hospitalizations For Diabetic Vets Using VA's Home-based Care
For older U.S. military veterans with multiple chronic conditions, including diabetes, taking advantage of home-based primary care from the U.S. Department of Veterans Affairs (VA) was linked to fewer hospitalizations, in a recent study. Some VA medical centers in the U.S. offer home-based primary care, in which a physician supervises a health care team that provides services in the veteran's home, rather than through regular clinic visits. ... authors note the program could potentially improve compliance with medications and ensure that patients understood their care plans. It could also improve coordination of social and support services, referrals and specialty care. ... according to results in JAMA Internal Medicine (Doyle, 9/16). 

USA Today: Schizophrenia Is Eight Different Diseases, Not One
New research shows that schizophrenia is not a single disease, but a group of eight distinct disorders, each caused by changes in clusters of genes that lead to different sets of symptoms. The finding sets the stage for scientists to develop better ways to diagnose and treat schizophrenia, a mental illness that can be devastating when not adequately managed, says C. Robert Cloninger, co-author of the study published today in the American Journal of Psychiatry (Szabo, 9/15). 

Reuters: Study Shows Downward Trend In Sovaldi Utilization
Over the last several months there has been a "plateau and downward trend" in the use of Gilead Sciences Inc's controversial $1,000-a-pill hepatitis C treatment, Sovaldi, a CVS Health Corp analysis showed. The study, encompassing data from May through August 2014, suggests that another surge of patients will begin therapy when newer treatments of similar effectiveness and shorter duration are introduced later in the year (Grover, 9/17).

MedPage Today: Generic Statins Boost Patient Adherence, Outcomes
Going off-brand for statin medication modestly improved adherence and cardiovascular outcomes, an observational study showed. The average proportion of days covered by a filled statin prescription was 77% when starting on a generic compared with 71% when initiating a brand-name version ... , said Joshua J. Gagne, PharmD, ScD, from Brigham and Women's Hospital and Harvard Medical School in Boston, and colleagues (Phend, 9/15).

Medscape: Antibiotic Surveillance Reduces Readmission, Study Finds
An antibiotic stewardship program that guided individual prescriptions during a 6-month period significantly reduced rates of readmission due to infection, report researchers presenting here at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). It is well established that antibiotic stewardship programs can reduce the rate of antibiotic use, but very few have been able to demonstrate patient benefit, which is controversial, said lead investigator Fredrik Resman, MD, from Skåne University Hospital in Malmö, Sweden (Johnson, 9/16).

Seattle Times: Women Obtaining Free Birth Control Rises Rapidly
More American women are getting free birth control in the wake of the Affordable Care Act, which requires most private insurance plans to pay for contraception with no co-pay or other out-of-pocket costs. The percentage of women with private insurance coverage getting free oral contraception, or the pill, rose from 15 percent in the fall of 2012 to 67 percent this spring. The ACA's free birth control mandate went into effect January 2013. Free access to other forms of pregnancy prevention also rose, according to research conducted by the Guttmacher Institute and published online Thursday in the journal Contraception. The study found that the proportion of women paying nothing for the vaginal ring rose from 20 percent to 74 percent; those using injectable contraceptives with no out-of-pocket costs increased from 27 percent to 59 percent; and those using the IUD free rose from 45 percent to 62 percent (Stiffler, 9/18).

Philadelphia Inquirer: ER Waiting Times Vary Significantly, Studies Find
When it comes to emergency room waiting times, patients seeking care at larger urban hospitals are likely to spend more time staring down the clock than those seen at smaller or more rural facilities, new research suggests. The findings are from two research letters in the Sept. 15 issue of JAMA Internal Medicine. The first study focused on medical records concerning adult patients seen at almost 3,700 different emergency rooms across the country in 2012 and 2013. Nearly three-quarters of the ERs were in non-teaching hospitals. Almost two-thirds of the ERs were at private non-profit facilities. And, slightly more than half were located in an urban setting (Mozes, 9/18).