Abstracts

"Tightening Income Documentation in a Means-Tested Program: Who Stays Away?" Philip Gleason, John Burghardt, Paul Strasberg, and Lara Hulsey, Evaluation Review (subscription required), June 2008. Programs using means tests to identify low-income households face a trade-off between promoting access and ensuring program integrity. In the case of the National School Lunch Program, the U.S. Department of Agriculture recently implemented a pilot program to improve the accuracy of the process of certifying students for free or reduced-price meals. This pilot program required households to provide income documentation with their applications for these benefits. This paper uses a comparison district design to estimate the effects of the up-front income documentation requirement on free/reduced-price certification among ineligible families as well as on access to the program among eligible low-income families. The key finding was that requiring income documentation did not reduce the proportion of ineligible households getting free or reduced-price meals, but it did reduce access to the program among eligible households.

"Removing the Barriers: Modifying Telephone Survey Methodology to Increase Self-Response Among People with Disabilities." In Towards Best Practices for Surveying People with Disabilities, 2007, Anne B. Ciemnecki and Karen A. CyBulski. Information collected directly and cost-effectively from respondents with disabilities is necessary to determine how well public programs meet their needs. This chapter reports on simple modifications to telephone survey design and procedures to increase accessibility. For example, minor changes to questionnaire design include short recall periods, concrete questions, elimination of high frequency sounds, inclusion of breaks to overcome fatigue, checks for unexpected responses, and structured probes. Procedural modifications include sensitivity training for interviewers, compassion fatigue support for interviewers, and modified expectation regarding time to administer questionnaires. The authors note that modifications to increase participation are neither costly nor difficult to implement.

"Living Arrangements and School Dropout Among Teen Mothers Following Welfare Reform." Social Science Quarterly, December 2007, Heather Koball. The 1996 welfare reform laws required parents under the age of 18 to live with their parents or an adult relative and enroll in school to be eligible for benefits. This article examines whether minor mothers were less likely to drop out of school and more likely to live with parents following welfare reform. Data from the National Education Longitudinal Survey 1988 and the National Longitudinal Survey of Youth 1997 were used in difference-in-difference analyses. The article notes that after welfare reform, teen mothers living with parents increased and dropout rates decreased.

"Measuring Trends in Mental Health Care Disparities, 2000–2004." Psychiatric Services, December 2007, Benjamin L. Cook, Thomas McGuire, and Jeanne Miranda. This article reports on trends in disparities in mental health care by use of an improved method that applies the Institute of Medicine (IOM) definition of racial-ethnic disparities. Data from the 2000–2001 and 2003–2004 Medical Expenditure Panel Surveys were used to estimate trends in two global measures of racial-ethnic disparities in mental health care: (1) having any mental health visit, and (2) total mental health care expenditure in the past year. Disparities between African Americans, Hispanics, and white Americans were examined by applying a new methodology based on the IOM definition of racial disparity that adjusts for health status and allows for mediation of racial-ethnic disparities through socioeconomic factors. Results found by use of this measure show that the mental health care system continues to provide less care to persons in African American and Hispanic minority groups than to whites, suggesting the need for policy initiatives to improve services for these minority groups.

"The Co-Occurrence of Smoking and a Major Depressive Episode Among Mothers 15 Months After Delivery." Preventive Medicine, December 2007, Robert C. Whitaker, Sean M. Orzol, and Robert S. Kahn. Using data from the Fragile Families and Child Wellbeing Study, the authors examine the association between maternal smoking 15 months after delivery and the occurrence of a major depressive episode in the prior 12 months. After adjusting for sociodemographic characteristics, the authors found that the prevalence of a major depressive episode was higher among smokers than nonsmokers. Smoking was also more common among mothers with a major depressive episode than in those without one. This suggests that these conditions should not be diagnosed or treated in isolation from each other and that the care of mothers and children should be integrated. Reprints available while supply lasts; call 609-275-2350.

"Material Hardship, Poverty, and Disability Among Working-Age Adults." Social Science Quarterly, December 2007, Peiyun She and Gina A. Livermore. The authors used data from the 1996 panel of SIPP to examine the extent to which working-age people with disabilities experience several types of material hardships. The findings indicate that disability is an important determinant of material hardship, even after controlling for income and other sociodemographic characteristics. In addition, a large majority of the low-income respondents who reported a material hardship also reported being limited for some period of time in the amount or kind of work they can perform. The findings provide support for policies that account for disability-related expenditures and needs when determining eligibility for means-tested assistance programs. They also suggest that the official poverty measure overstates the relative economic well-being of people with disabilities.

"When Schools Stay Open Late: Results from the National Evaluation of the 21st Century Community Learning Centers Program." Educational Evaluation and Policy Analysis, December 2007, Susanne James-Burdumy, Mark Dynarski, and John Deke. This article presents evidence from the elementary school component of Mathematica's national evaluation of the 21st Century Community Learning Center afterschool programs. The findings indicate that the programs affected the supervision students received after school, with parents less likely to care for their child and other adults more likely, but there was no statistically significant effect on the incidence of self-care. Students in the program reported feeling safer after school, but their academic outcomes were not affected, and they had more incidents of negative behavior. The elementary study was conducted in 12 school districts and 26 afterschool centers.

"Convergence and Dissonance: Evolution in Private-Sector Approaches to Disease Management and Care Coordination." Health Affairs, November/December 2007, Glen P. Mays, Melanie Au, and Gary Claxton. Disease management approaches survived the 1990s backlash against managed care because of their potential for consumer-friendly cost containment, but purchasers have been cautious about investing heavily in them because of uncertainty about return on investment. This article examines how private-sector approaches to disease management have evolved over the past two years in the midst of the movement toward consumer-driven health care. Findings indicate that these programs have become standard features of health plan design, despite a thin evidence base concerning their effectiveness.

"Physician and Patient Characteristics Associated with Discussion of Psychosocial Health During Pediatric Primary Care Visits." Clinical Pediatrics, November 2007, Jonathan D. Brown, Lawrence S. Wissow, and Anne W. Riley. Primary care providers often miss opportunities to address child mental health problems but research has not clarified specific mechanisms for intervention. This article, based on 800 primary care visits to 54 providers in 13 diverse health clinics, examines factors associated with the discussion of children’s behavior, mood, getting along with others, school performance, family stress, and parent stress. The discussion of these topics was more common when the child demonstrated hyperactivity symptoms and when the provider was female or had greater confidence in mental health treatment skills. The presence of moderate physical pain interfered with the discussion of psychosocial health, even when parents were seeking help for their child’s mental health problem and when youth demonstrated mental health impairment according to a standardized assessment. The article notes that primary care providers need clinical skills that can be used to effectively communicate with families about mental health and overcome the competing demands of physical and mental health problems.

“Receiving Advice About Child Mental Health from a Primary Care Provider: African American and Hispanic Parent Attitudes.” Medical Care, November 2007, Jonathan D. Brown, Lawrence S. Wissow, Ciara Zachary, and Benjamin L. Cook. African American and Hispanic youth with mental health problems are less likely than their Caucasian counterparts to receive mental health services. Primary care providers are often the source of mental health care for children and may play a role in reducing disparities. This research investigated parent attitudes associated with receiving advice about child mental health in primary care and whether attitudes differed according to race and ethnicity during 773 visits to 54 providers in 13 clinics. Hispanics were more likely than non-Hispanics to agree that primary care providers should treat child mental health and were more willing to allow their child to receive medications or visit a therapist for a mental health problem if recommended by the provider. African American parents were significantly less willing than Caucasians and Hispanics to allow their child to receive medications for mental health but did not differ in their willingness to visit a therapist. These findings suggest that African American parents are generally as willing as Caucasian parents to have their child’s mental health needs addressed in primary care and that primary care may be a particularly good point of intervention for Hispanic youth with mental health problems.

“Stepping Stones to a Degree: The Impact of Enrollment Pathways and Milestones on Community College Student Outcomes.” Research in Higher Education, November 2007, Juan Carlos Calcagno, Peter Crosta, Thomas Bailey, and Davis Jenkins. This paper presents findings from a study of the experiences and outcomes of older and younger community college students. The authors developed a discrete-time hazard model using longitudinal transcript data on a cohort of first-time community college students in Florida to compare the impact of enrollment pathways (such as remediation) and enrollment milestones (such as attaining a certain number of credits) on educational outcomes of older students—those who enter college for the first time at age 25 or later—with those of traditional-age students. Results suggest that reaching milestones such as obtaining 20 credits or completing 50 percent of a program is a more important positive factor affecting graduation probabilities for younger students than it is for older students.

"Federal Policy Efforts to Improve Outcomes Among Disadvantaged Families by Supporting Marriage and Family Stability.” In Handbook of Families and Poverty, October 2007, M. Robin Dion and Alan J. Hawkins. There is broad consensus that family structure is inextricably linked with poverty and the well-being of children. This paper reviews the connections between poverty, family structure, and child well-being; explains the rationale for a new policy strategy focused on intervening more directly at the level of family structure, and describes several major federal initiatives under way to develop and test the new strategies.

“Authorship and Publication Practices: Evaluation of the Effect of Responsible Conduct of Research Instruction to Postdoctoral Trainees.” Accountability in Research, October 2007, Carolyn L. Funk, Kirsten A. Barrett, and Francis L. Macrina. The authors studied postdoctoral trainees funded by National Institutes of Health F32 fellowship awards to test the effectiveness of responsible conduct of research (RCR) education in the areas of authorship and publication practices. Overall, the responses suggested a clear awareness of standards and practices in publication. However, the results failed to suggest that RCR education significantly increased the level of ethically appropriate behavioral responses measured in the study. The authors note the importance of careful articulation of course goals and objectives with attention to the background and experience of the student audience when developing RCR curricula.

"Impact of Drug Coverage on Medical Expenditures Among the Elderly.” Health Care Financing Review, fall 2007, Boyd H. Gilman, Barbara Gage, Susan Haber, Sonja Hoover, and Jyoti Aggarwal. The authors compare expenditures for Medicare-covered medical services among enrollees in three state pharmacy assistance programs with spending among low-income residents eligible or near eligible for but not enrolled in these programs, after controlling for between-group differences in demographic, socioeconomic, health status, and insurance status characteristics. The article notes that drug coverage has no discernible effect on the use and cost of inpatient services, but it is associated with a statistically significant increase in Medicare spending for physician services. Reprints available while supply lasts; call 609-275-2350.

"Intergenerational Neighborhood-Type Mobility: Examining Differences Between Blacks and Whites." Housing Studies, September 2007, Thomas P. Vartanian, Page Walker Buck, and Philip Gleason. Using sibling data from the Panel Study of Income Dynamics linked with U.S. Census data, the authors examine whether the quality of a person's childhood neighborhood influences where one resides as an adult. Descriptively, the study finds that childhood neighborhood conditions of black and white children are vastly different. Few whites live in the most disadvantaged neighborhoods, and few blacks live in the most advantaged neighborhoods. Using a sibling fixed effects regression model, the authors find that living in a disadvantaged neighborhood as a child negatively influences the quality of the neighborhood one lives in as an adult. These neighborhood effects are particularly strong among children who grow up in the most disadvantaged neighborhoods.

“Impact of Multitiered Copayments on the Use and Cost of Prescription Drugs Among Medicare Beneficiaries.” Health Services Research, September 2007, Boyd H. Gilman and John Kautter. This article reports on a study that exploits cross-sectional variation on copayment structures among firms with a self-insured retiree health plan to measure the impact of the number of copayment tiers on total and enrollee drug payments, number of prescriptions filled, and generic substitution. The study also assessed the effect of enrollee cost sharing on the cost and use of prescription medications for the long-term treatment of chronic conditions. The researchers found that Medicare beneficiaries in three-tiered plans had 14.3 percent lower total drug expenditures, 14.6 fewer prescriptions filled, and 57.6 percent higher out-of-pocket costs than individuals in lower-tiered plans. While individuals in higher-tiered plans had lower purchases of both brand name and generic prescriptions, a higher percentage of total purchases was filled with generics. The researchers estimated a price elasticity of demand for prescription drugs among the elderly of -0.23, consistent with other studies. Beneficiaries were less responsive to cost sharing incentives when using drugs to treat chronic conditions.

“What Have We Learned About Homeschooling?” Peabody Journal of Education, June 2007, Eric J. Isenberg. This article discusses quantitative research on homeschooling, including the available data, pitfalls of using the data, estimates of the number of homeschooled children, part-time homeschooling, and reasons why families homeschool. The author compares research on homeschooling to research on charter schools, voucher programs, and private schools. Reprints available while supply lasts; call 609-275-2350.

"Making Pay-For-Performance Work in Medicaid." Health Affairs, June 2007, Suzanne Felt-Lisk, Gilbert Gimm, and Stephanie Peterson. This article examines five Medicaid-focused health plans that implemented new financial incentives for physicians to improve the timeliness of well-baby care. By contrasting the experiences of plans with better and worse outcome trends, the authors identify key program features, including strong communication with providers and placing enough dollars at stake to compensate providers for the effort required to obtain the desired outcomes. The article also highlights barriers to improvement that future Medicaid pay-for-performance efforts should consider. Reprints available while supply lasts; call 609-275-2350.

"Consumer Response to Dual Incentives Under Multitiered Prescription Drug Formularies." The American Journal of Managed Care, June 2007, Boyd Gilman and John Kautter. This article uses retiree drug plan data to decompose the overall impact of multitiered formularies into a "price effect" and a "substitution effect." The authors conclude that increasing the copayment differential between drug equivalents provides a similarly effective strategy for reducing total spending as increasing the copayment amount for all drug equivalents, but does a better job of maintaining access to prescription medications. The findings support recent recommendations for replacing price-based formularies with value-based formularies that link copayments to the cost-effectiveness or value of the drug. Reprints available while supply lasts; call 609-275-2350.

“Dietary Methodology: Advancements in the Development of Short Instruments to Assess Dietary Fat.” Journal of the American Dietetic Association, May 2007, Ronette R. Briefel. Measuring dietary fat in a brief manner is a goal of many research and community-based studies. Short instruments for assessing diet have utility if they meet acceptable standards of reliability and validity for the population groups with which they are used. This research editorial reviews progress in dietary assessment and the development of short dietary instruments; it also provides an overview of three recent studies that used different short instruments to assess dietary fat intake and compared estimates with those derived from other dietary assessment methods. The author notes that these three studies contribute to the knowledge base on dietary assessment, and in particular, on the development and application of short instruments to rank or screen individuals for intervention studies, estimate dietary fat intake among specific population groups, and assess dietary risk and change in intake over time.

“Identification of Youth Psychosocial Problems During Pediatric Primary Care Visits.” Administration and Policy in Mental Health and Mental Health Services Research, May 2007, Jonathan D. Brown, Anne W. Riley, and Lawrence S. Wissow. Pediatric primary care providers (PCPs) are the gateway to mental health services for children and adolescents. However, PCPs often fail to identify youth with mental health needs during visits, and few studies have examined how identification could be improved. This study found that PCPs who reported greater burden associated with treating mental health problems and those who reported easier access to mental health specialists were less likely to accurately identify youth with mental health needs, compared with a standard screening tool, even after accounting for the severity of the mental health problem, reason for the visit, and other PCP characteristics.

“Medicare Advantage in 2006-2007: What Congress Intended?” Health Affairs Web Exclusive, May 2007, Marsha Gold. The Medicare Modernization Act has succeeded in providing seniors with more choice in Medicare Advantage private insurance plans. This article analyzes available information on these options and what they mean for beneficiaries. The author notes that most of the growth in choice stems from a proliferation of private fee-for-service plans. These plans were far more likely to be offered, and enrollment was highest in them, in “floor” counties—those where the gap between traditional Medicare and Medicare Advantage rates was higher. Despite higher payments, private fee-for-service benefits are less comprehensive than those historically offered by HMOs. The author discusses the policy implications of these trends and issues for policymakers to consider. Reprints available while supply lasts; call 609-275-2350.

"Hospital Response to Public Reporting of Quality Indicators." Health Care Financing Review, spring 2007, Mary Laschober, Myles Maxfield, Suzanne Felt-Lisk, and David J. Miranda. Senior hospital executives responding to a 2005 national telephone survey report that Hospital Compare and other public reports on hospital quality measures have helped to focus hospital leadership attention on quality matters. This article notes that the executives also report increased investment in quality improvement projects and in people and systems to improve documentation of care. In addition, more consideration is given to best practices guidelines and internal sharing of quality measure results among hospital staff. Large hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) appear to be responding to public reporting efforts more consistently than small, non-JCAHO accredited hospitals. Reprints available while supply lasts; call 609-275-2350.

"Testing Consumers' Comprehension of Quality Measures Using Alternative Reporting Formats." Health Care Financing Review, spring 2007, Margaret Gerteis, Jessie S. Gerteis, David Newman, and Christopher Koepke. The Centers for Medicare & Medicaid Services has publicly reported nursing home quality measures since 2002, but research has shown that many users do not understand the measures. This article reports on efforts to develop and test seven alternative reporting templates to improve comprehension. Fewer than one-half of respondents accurately interpreted bar graphs. Respondents made fewest errors on templates using words to characterize performance as better, average, or worse. Reprints available while supply lasts; call 609-275-2350.

“Addressing the Epidemic of Childhood Obesity Through School-Based Interventions: What Has Been Done and Where Do We Go From Here?” Journal of Law, Medicine, & Ethics, spring 2007, Karen E. Peterson and Mary Kay Fox. Schools are ideal settings for implementing programs to prevent and control childhood obesity. The authors review the evidence on the effectiveness of school-based interventions; offer suggestions for improvements based on the existing evidence, findings from related research, and recommendations from expert groups; and identify critical gaps in the existing body of research that future studies should address.

"Moving Research into Practice: Lessons from the US Agency for Healthcare Research and Quality's IDSRN Program." Implementation Science, March 2007, Marsha Gold and Erin Fries Taylor. Applied research aims to provide answers to "real world" questions. Whether that research is used in the real world to encourage innovation and change, however, has typically not been a major research focus. The U.S. Agency for Healthcare Research and Quality’s Integrated Delivery Systems Research Network (IDSRN) was established to encourage implementation of research into practice. This article looks at IDSRN’s success in generating research findings that could be applied in practice. Factors important to success were responsiveness of project work to delivery system needs, ongoing funding to support multiple project phases, and development of applied products or tools that helped users see their operational relevance. Factors impeding success include limited project funding, competing demands on potential research users, and failure to reach the appropriate audience. Reprints available while supply lasts; call 609-275-2350.

"Using Propensity Scoring to Estimate Program-Related Subgroup Impacts in Experimental Program Evaluations." Evaluation Review, March 2007, Peter Z. Schochet and John Burghardt. This article discusses the use of propensity scoring in experimental program evaluations to estimate impacts for subgroups defined by program features and participants' program experiences. The authors discuss estimation issues, provide specification tests, and review an overlooked data collection design—obtaining predictions that program intake staff make about applicants' likely assignments and experiences—that could improve the quality of matched comparison samples. They demonstrate the approach's effectiveness in producing credible subgroup findings using data from Mathematica's Job Corps evaluation.

“Commentary: Should I Blame Mom or Dad? Identifying the Relative Contribution of Each Parent's Body Size to that of Their Offspring.” International Journal of Epidemiology, February 2007, Robert C. Whitaker. The author responds to an article that proposes a mechanism to statistically test the difference in the relative contribution of the size of each parent to a child's birth weight and rate of weight gain during infancy—two factors associated with the development of obesity—urging care in applying the study's methodological innovation. Epidemiological research that assigns a relative contribution of each parent to a child's weight poses the risk that some might use this information to split parents over an issue on which they need to be united in support of their child. The author also cautions that as researchers make advances in epidemiological research, they should remain vigilant about unintended harms.

"Effect of Medicaid Managed Care on Racial Disparities in Health Care Access." Health Services Research, February 2007, Benjamin Cook. This article evaluates the impact of Medicaid managed care on racial disparities in access to care. It uses the Institute of Medicine definition of racial disparity, which excludes differences stemming from health status but includes differences mediated by socioeconomic status. Enrollment is associated with lowered disparities in having any doctor visit in the past year for blacks, and in having any usual source of care for both blacks and Hispanics. To address selection issues, the author also looked at the effect of Medicaid HMO market share on disparities. Increased Medicaid HMO market share lowered disparities in having any doctor visits in the past year for both blacks and Hispanics. On a less positive note, blacks used the ER more than whites in areas of high Medicaid HMO market share. The reduction of some disparities suggests that recent shifts in Medicaid policy toward managed care plans have benefited minority enrollees. Reprints available while supply lasts; call 609-275-2350.

“Immigrants and Employer-Sponsored Health Insurance.” Health Services Research, February 2007, Thomas C. Buchmueller, Anthony T. Lo Sasso, Ithai Lurie, and Sarah Dolfin. Interest in the health status of immigrant populations has increased dramatically in response to their rapid growth over the past two decades. This study investigated the factors underlying the lower rate of employer-sponsored health insurance for foreign-born workers. The authors found that the substantially higher rate of uninsurance among immigrants is driven by the lower rate of health insurance offered by the employers of immigrants, rather than by differences in eligibility or take-up.

“Impact of Influenza Immunization on Medical Expenditures Among Medicare Elderly, 1999-2003.” American Journal of Preventive Medicine, February 2007, Boyd H. Gilman, Arthur J. Bonito, and Celia Eicheldinger. This study examines the impact of influenza immunization on medical expenditures for acute and chronic respiratory conditions among elderly Medicare beneficiaries between 1999 and 2003. The study advances the literature by using self-reported survey data from the fee-for-service module of the Medicare Consumer Assessment of Health Plans Survey, linked with respondents' Medicare claims for inpatient, outpatient, and professional services. The researchers found that total expenditures were lower among the immunized population during all four annual influenza seasons. The amount and statistical significance of the savings varied with the severity of the virus and the vaccine match to the prevalent influenza strains. The relative reduction in expenditures among vaccinated beneficiaries is attributable to less frequent use of inpatient services. The authors conclude that in addition to improving the health of older Americans, meeting the Healthy People 2010 influenza immunization goal of 90 percent among the elderly should also result in lower Medicare expenditures. Reprints available while supply lasts; call 609-275-2350.


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