Health Services Research

Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care. This article describes integration principles and practices at three levels in mixed methods research and provides illustrative examples. Integration at the study design level occurs through three basic mixed method designs-exploratory sequential, explanatory sequential, and convergent-and through four advanced frameworks-multistage, intervention, case study, and participatory. Integration at the methods level occurs through four approaches. In connecting, one database links to the other through sampling. With building, one database informs the data collection approach of the other. When merging, the two databases are brought together for analysis. With embedding, data collection and analysis link at multiple points. Integration at the interpretation and reporting level occurs through narrative, data transformation, and joint display. The fit of integration describes the extent the qualitative and quantitative findings cohere. Understanding these principles and practices of integration can help health services researchers leverage the strengths of mixed methods.

OBJECTIVE: To provide practical strategies for conducting and evaluating analyses of qualitative data applicable for health services researchers. DATA SOURCES AND DESIGN: We draw on extant qualitative methodological literature to describe practical approaches to qualitative data analysis. Approaches to data analysis vary by discipline and analytic tradition; however, we focus on qualitative data analysis that has as a goal the generation of taxonomy, themes, and theory germane to health services research. PRINCIPLE FINDINGS: We describe an approach to qualitative data analysis that applies the principles of inductive reasoning while also employing predetermined code types to guide data analysis and interpretation. These code types (conceptual, relationship, perspective, participant characteristics, and setting codes) define a structure that is appropriate for generation of taxonomy, themes, and theory. Conceptual codes and subcodes facilitate the development of taxonomies. Relationship and perspective codes facilitate the development of themes and theory. Intersectional analyses with data coded for participant characteristics and setting codes can facilitate comparative analyses. CONCLUSIONS: Qualitative inquiry can improve the description and explanation of complex, real-world phenomena pertinent to health services research. Greater understanding of the processes of qualitative data analysis can be helpful for health services researchers as they use these methods themselves or collaborate with qualitative researchers from a wide range of disciplines.

BACKGROUND: Controlling costs and achieving health care quality improvements require the participation of activated and informed consumers and patients. OBJECTIVES: We describe a process for conceptualizing and operationalizing what it means to be "activated" and delineate the process we used to develop a measure for assessing "activation," and the psychometric properties of that measure. METHODS: We used the convergence of the findings from a national expert consensus panel and patient focus groups to define the concept and identify the domains of activation. These domains were operationalized by constructing a large item pool. Items were pilot-tested and initial psychometric analysis performed using Rasch methodology. The third stage refined and extended the measure. The fourth stage used a national probability sample to assess the measure's psychometric performance overall and within different subpopulations. STUDY SAMPLE: Convenience samples of patients with and without chronic illness, and a national probability sample (N=1,515) are included at different stages in the research. CONCLUSIONS: The Patient Activation Measure is a valid, highly reliable, unidimensional, probabilistic Guttman-like scale that reflects a developmental model of activation. Activation appears to involve four stages: (1) believing the patient role is important, (2) having the confidence and knowledge necessary to take action, (3) actually taking action to maintain and improve one's health, and (4) staying the course even under stress. The measure has good psychometric properties indicating that it can be used at the individual patient level to tailor intervention and assess changes.

OBJECTIVE: The Patient Activation Measure (PAM) is a 22-item measure that assesses patient knowledge, skill, and confidence for self-management. The measure was developed using Rasch analyses and is an interval level, unidimensional, Guttman-like measure. The current analysis is aimed at reducing the number of items in the measure while maintaining adequate precision. STUDY METHODS: We relied on an iterative use of Rasch analysis to identify items that could be eliminated without loss of significant precision and reliability. With each item deletion, the item scale locations were recalibrated and the person reliability evaluated to check if and how much of a decline in precision of measurement resulted from the deletion of the item. DATA SOURCES: The data used in the analysis were the same data used in the development of the original 22-item measure. These data were collected in 2003 via a telephone survey of 1,515 randomly selected adults. Principal Findings. The analysis yielded a 13-item measure that has psychometric properties similar to the original 22-item version. The scores for the 13-item measure range in value from 38.6 to 53.0 (on a theoretical 0-100 point scale). The range of values is essentially unchanged from the original 22-item version. Subgroup analysis suggests that there is a slight loss of precision with some subgroups. CONCLUSIONS: The results of the analysis indicate that the shortened 13-item version is both reliable and valid.

OBJECTIVE: To determine if professional medical interpreters have a positive impact on clinical care for limited English proficiency (LEP) patients. DATA SOURCES: A systematic literature search, limited to the English language, in PubMed and PsycINFO for publications between 1966 and September 2005, and a search of the Cochrane Library. STUDY DESIGN: Any peer-reviewed article which compared at least two language groups, and contained data about professional medical interpreters and addressed communication (errors and comprehension), utilization, clinical outcomes, or satisfaction were included. Of 3,698 references, 28 were found by multiple reviewers to meet inclusion criteria and, of these, 21 assessed professional interpreters separately from ad hoc interpreters. Data were abstracted from each article by two reviewers. Data were collected on the study design, size, comparison groups, analytic technique, interpreter training, and method of determining the participants' need for an interpreter. Each study was evaluated for the effect of interpreter use on four clinical topics that were most likely to either impact or reflect disparities in health and health care. PRINCIPAL FINDINGS: In all four areas examined, use of professional interpreters is associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to raise the quality of clinical care for LEP patients to approach or equal that for patients without language barriers. CONCLUSIONS: Published studies report positive benefits of professional interpreters on communication (errors and comprehension), utilization, clinical outcomes and satisfaction with care.

OBJECTIVE: To examine potential sources of errors at each step of the described inpatient International Classification of Diseases (ICD) coding process. DATA SOURCES/STUDY SETTING: The use of disease codes from the ICD has expanded from classifying morbidity and mortality information for statistical purposes to diverse sets of applications in research, health care policy, and health care finance. By describing a brief history of ICD coding, detailing the process for assigning codes, identifying where errors can be introduced into the process, and reviewing methods for examining code accuracy, we help code users more systematically evaluate code accuracy for their particular applications. STUDY DESIGN/METHODS: We summarize the inpatient ICD diagnostic coding process from patient admission to diagnostic code assignment. We examine potential sources of errors at each step and offer code users a tool for systematically evaluating code accuracy. PRINCIPLE FINDINGS: Main error sources along the "patient trajectory" include amount and quality of information at admission, communication among patients and providers, the clinician's knowledge and experience with the illness, and the clinician's attention to detail. Main error sources along the "paper trail" include variance in the electronic and written records, coder training and experience, facility quality-control efforts, and unintentional and intentional coder errors, such as misspecification, unbundling, and upcoding. CONCLUSIONS: By clearly specifying the code assignment process and heightening their awareness of potential error sources, code users can better evaluate the applicability and limitations of codes for their particular situations. ICD codes can then be used in the most appropriate ways.

OBJECTIVE: To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades. DATA SOURCES/STUDY SETTING: Data were primarily derived from OECD Health Data 2001 and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (total n = 504). STUDY DESIGN: Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression. DATA COLLECTION/EXTRACTION METHODS: Secondary analysis of public-use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in-country experts. PRINCIPAL FINDINGS: The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro-level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health. CONCLUSIONS: (1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.

OBJECTIVE: To evaluate the effectiveness of training and institutionalizing teamwork behaviors, drawn from aviation crew resource management (CRM) programs, on emergency department (ED) staff organized into caregiver teams. STUDY SETTING: Nine teaching and community hospital EDs. STUDY DESIGN: A prospective multicenter evaluation using a quasi-experimental, untreated control group design with one pretest and two posttests of the Emergency Team Coordination Course (ETCC). The experimental group, comprised of 684 physicians, nurses, and technicians, received the ETCC and implemented formal teamwork structures and processes. Assessments occurred prior to training, and at intervals of four and eight months after training. Three outcome constructs were evaluated: team behavior, ED performance, and attitudes and opinions. Trained observers rated ED staff team behaviors and made observations of clinical errors, a measure of ED performance. Staff and patients in the EDs completed surveys measuring attitudes and opinions. DATA COLLECTION: Hospital EDs were the units of analysis for the seven outcome measures. Prior to aggregating data at the hospital level, scale properties of surveys and event-related observations were evaluated at the respondent or case level. PRINCIPAL FINDINGS: A statistically significant improvement in quality of team behaviors was shown between the experimental and control groups following training (p = .012). Subjective workload was not affected by the intervention (p = .668). The clinical error rate significantly decreased from 30.9 percent to 4.4 percent in the experimental group (p = .039). In the experimental group, the ED staffs' attitudes toward teamwork increased (p = .047) and staff assessments of institutional support showed a significant increase (p = .040). CONCLUSION: Our findings point to the effectiveness of formal teamwork training for improving team behaviors, reducing errors, and improving staff attitudes among the ETCC-trained hospitals.

OBJECTIVE: The purpose of this study is to determine whether patient activation is a changing or changeable characteristic and to assess whether changes in activation also are accompanied by changes in health behavior. STUDY METHODS: To obtain variability in activation and self-management behavior, a controlled trial with chronic disease patients randomized into either intervention or control conditions was employed. In addition, changes in activation that occurred in the total sample were also examined for the study period. Using Mplus growth models, activation latent growth classes were identified and used in the analysis to predict changes in health behaviors and health outcomes. DATA SOURCES: Survey data from the 479 participants were collected at baseline, 6 weeks, and 6 months. PRINCIPAL FINDINGS: Positive change in activation is related to positive change in a variety of self-management behaviors. This is true even when the behavior in question is not being performed at baseline. When the behavior is already being performed at baseline, an increase in activation is related to maintaining a relatively high level of the behavior over time. The impact of the intervention, however, was less clear, as the increase in activation in the intervention group was matched by nearly equal increases in the control group. CONCLUSIONS: Results suggest that if activation is increased, a variety of improved behaviors will follow. The question still remains, however, as to what interventions will improve activation.

OBJECTIVE: The goal of this study was to assess the validity of the International Classification of Disease, 10th Version (ICD-10) administrative hospital discharge data and to determine whether there were improvements in the validity of coding for clinical conditions compared with ICD-9 Clinical Modification (ICD-9-CM) data. METHODS: We reviewed 4,008 randomly selected charts for patients admitted from January 1 to June 30, 2003 at four teaching hospitals in Alberta, Canada to determine the presence or absence of 32 clinical conditions and to assess the agreement between ICD-10 data and chart data. We then re-coded the same charts using ICD-9-CM and determined the agreement between the ICD-9-CM data and chart data for recording those same conditions. The accuracy of ICD-10 data relative to chart data was compared with the accuracy of ICD-9-CM data relative to chart data. RESULTS: Sensitivity values ranged from 9.3 to 83.1 percent for ICD-9-CM and from 12.7 to 80.8 percent for ICD-10 data. Positive predictive values ranged from 23.1 to 100 percent for ICD-9-CM and from 32.0 to 100 percent for ICD-10 data. Specificity and negative predictive values were consistently high for both ICD-9-CM and ICD-10 databases. Of the 32 conditions assessed, ICD-10 data had significantly higher sensitivity for one condition and lower sensitivity for seven conditions relative to ICD-9-CM data. The two databases had similar sensitivity values for the remaining 24 conditions. CONCLUSIONS: The validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions was generally similar though validity differed between coding versions for some conditions. The implementation of ICD-10 coding has not significantly improved the quality of administrative data relative to ICD-9-CM. Future assessments like this one are needed because the validity of ICD-10 data may get better as coders gain experience with the new coding system.

OBJECTIVE: To determine whether the Veterans Health Administration's (VHA) Stepped Care for Opioid Use Disorder Train-the-Trainer (SCOUTT) initiative increased medication treatment for opioid use disorder (MOUD) among persons experiencing homelessness (PEH). STUDY SETTING AND DESIGN: We conducted a national retrospective cohort study of MOUD, including buprenorphine, naltrexone, or methadone, in federal fiscal years (FY) 2016-2020. In late FY2018, VHA regional directors nominated facilities to receive SCOUTT implementation support to expand prescribing of MOUD (primarily buprenorphine) in select primary care, pain, and general mental health settings. We used mixed-effects quasi-Poisson regression models with entropy balancing to estimate the Average Treatment Effect on the Treated in the years after SCOUTT was implemented (FY2019-2020), controlling for pre-implementation levels of MOUD. Secondary analyses applied synthetic difference-in-differences (DiD) to estimate changes associated with SCOUTT. DATA SOURCES AND ANALYTIC SAMPLE: We used yearly pooled cross-sectional data from VHA electronic health records, FY2016-2020. The sample included annual cohorts of PEH with an opioid use disorder diagnosis and ≥ 1 primary care visit in the pre-implementation (FY2016-2018, n = 31,354) or post-implementation (FY2019-2020, n = 20,746) periods. PRINCIPAL FINDINGS: From FY2016-2020, MOUD receipt increased more in SCOUTT facilities (n = 30, 45.0% to 61.1%) than in non-SCOUTT facilities (n = 811, 41.9% to 49.7%). In post-implementation years, PEH in SCOUTT facilities, compared to non-SCOUTT facilities, were more likely to receive any MOUD (risk difference [RD] = 6.16, 95% CI = 2.33-9.99), including buprenorphine (RD = 7.16, 95% CI = 4.35-9.97). There were no significant differences in methadone (RD = -0.19, 95% CI = -1.03-0.65) or naltrexone (RD = 0.10, 95% CI = -1.85-2.05). Synthetic DiD offered similar results: any MOUD DiD = 7.85, 95% CI = 2.15-13.55; buprenorphine DiD = 9.31, 95% CI = 3.56-15.06. CONCLUSIONS: A national initiative to advance a stepped-care model that encourages MOUD initiation outside specialty addiction settings improved access to buprenorphine among PEH. Similar initiatives could help to close treatment gaps in health care settings serving PEH.

OBJECTIVE: To examine Medicare Advantage (MA) plan, dialysis provider organization, and kidney care management company perspectives on how MA enrollment impacts access to care among persons with end-stage kidney disease (ESKD). The 21st Century Cures Act enabled persons with ESKD to enroll in MA, resulting in over 70% growth in enrollment among this group. However, the impact of MA enrollment on access to healthcare and services for people with ESKD remains unknown. STUDY SETTING AND DESIGN: This was a qualitative study that included 48 semistructured interviews with 56 participants representing eight MA plans, six dialysis provider organizations, and five kidney care management companies across all US regions. DATA SOURCES AND ANALYTIC SAMPLE: Interviews were conducted from January 2022 to May 2024. Deductive and inductive coding methods were used and organized around Donabedian's structure-process-outcomes framework. PRINCIPLE FINDINGS: Perspectives diverged by organization and staff type across four themes. Regarding dialysis access, MA plan and large dialysis organization representatives reported no barriers for patients, while small dialysis providers described patients traveling farther to in-network facilities. Concerning specialists, frontline staff reported patients were often unaware of network restrictions limiting access. Regarding transplant, MA plans noted selecting "centers of excellence," while other participants reported these restrictions may be impeding patient access to transplants. For supplementary benefits, executives emphasized their value, while frontline staff reported benefits were often more limited than advertised. CONCLUSIONS: Participant perspectives suggest MA enrollment may differentially impact access depending on dialysis provider size and MA network restrictions. Persons with ESKD may need additional support to make informed insurance enrollment decisions.

OBJECTIVE: To compare health care utilization between Medicare Advantage (MA) and Traditional Medicare (TM) beneficiaries, stratified by Alzheimer's disease and related dementias (ADRD) status. STUDY SETTING AND DESIGN: Repeated cross-sectional observational analysis of community-dwelling Medicare beneficiaries aged ≥ 65 years continuously enrolled in MA or TM. Eight self- or proxy-reported binary utilization outcomes over a 12-month reference period were estimated by survey-weighted linear probability models stratified by ADRD status. DATA SOURCES AND ANALYTIC SAMPLE: Secondary analysis of pooled 2018-2022 Medicare Current Beneficiary Survey (MCBS) public use files (N = 43,995: 974 TM and 954 MA with ADRD; 23,050 TM and 19,017 MA without ADRD), excluding beneficiaries entitled through disability or end-stage renal disease and records with missing covariates. Dual-eligible beneficiaries were retained and dual eligibility included as a covariate. Stabilized inverse probability of treatment weights multiplied by MCBS full-sample weights addressed non-random MA enrollment. PRINCIPAL FINDINGS: Among beneficiaries with ADRD, seven of eight adjusted MA - TM differences were not statistically significant. Specialist visits were more common among MA beneficiaries with ADRD (5.2 percentage points; 95% CI, -0.1 to 10.2). Among beneficiaries without ADRD, MA was associated with lower outpatient hospital visits (-2.6; -3.7 to -1.6) and lower reported need for home health visits (-0.9; -1.5 to -0.3). Effect modification by ADRD status was significant only for specialist visits (interaction 6.3 percentage points; p = 0.004). CONCLUSIONS: Adjusted health care utilization was broadly comparable between MA and TM for beneficiaries with ADRD, with the exception of higher specialist use in MA. Among beneficiaries without ADRD, MA was associated with lower outpatient hospital use. Plan-type differences were smaller and fewer for beneficiaries with ADRD.

ABSTRACT Objective To investigate the association between recovery support services (peer and community support services) and Medicaid claims. Study Setting and Design This is an observational study. We estimated multivariate models with Medicaid billing charges and Medicaid reimbursements as the primary outcome and the yearly number of peer and community support encounters as the variables of interest. Data Sources and Analytical Samples We obtained New Mexico Medicaid claims data for 3094 individuals aged 18 years and older who received recovery support services for substance use disorder (SUD) treatment between 2018 and 2021. Principal Findings An additional community support worker encounter was associated with decreases of $278.42 ( p < 0.01) in annual Medicaid billing charges and $89.69 ( p < 0.01) in annual reimbursements. Results are robust across different types of substance use disorders, different types of charges, and a variety of functional forms. We found less consistent evidence for the association between peer support workers and Medicaid claims. Point estimates were statistically significant for the association between encounters with peer support workers and billing charges ($119.01; p < 0.05), but not for reimbursements. Larger and more precisely estimated effects were found for the association between encounters with peer support workers and Medicaid claims for individuals with alcohol use disorder and for inpatient services. Conclusion These results suggest that increased engagement with community support workers for substance use disorder is associated with reductions in Medicaid billing charges and reimbursements for other services.

OBJECTIVE: To evaluate hospital and community characteristics associated with attributes of charity care policies. Charity care is a highly utilized avenue for medical debt relief. Hospitals are allowed some discretion when setting charity care policies, yielding heterogeneity in charity care generosity and availability to patients. STUDY SETTING AND DESIGN: We conducted a cross-sectional study using data on charity care policies from US hospitals collected through hospital websites and direct email and phone contact between September 2023 and April 2025 by the Lown Institute. DATA SOURCES AND ANALYTIC SAMPLE: We reviewed 2418 hospitals from 50 US states, including non-profit, for-profit, and government-owned hospitals. The primary outcomes were the likelihood that certain hospital characteristics were associated with offering fully or partially discounted care and income limits for patient eligibility. Additional outcomes include eligibility for the underinsured, patients with large bills, residency requirements, and use of presumptive eligibility screening. PRINCIPAL FINDINGS: System affiliation was positively associated with offering fully discounted (Est, 90.5%; 95% CI, 88.9%-92.0% compared with Est, 78.9%; 95% CI, 76.4%-81.5% for non-affiliated hospitals) and partially discounted care (Est, 85.5%; 95% CI, 83.5%-87.2% compared with Est, 77.1%; 95% CI, 74.2%-80.0% for non-affiliated hospitals), and was associated with a significant percentage-point increase in charity care income thresholds (32.69, 95% CI, 25.20-40.17; for fully discounted care). Non-profit hospitals reported the highest likelihood of offering both fully (Est, 96.7%; 95% CI, 95.8%-97.7%) and partially discounted care (Est, 85.5%; 95% CI, 83.5%-87.2%), and were significantly more likely to use presumptive eligibility screening (Est, 82.7%; 95% CI, 80.8%-84.6%) compared with for-profit hospitals. CONCLUSIONS: Overall, tax-exemption status, system affiliation, and community socio-economic and legislative factors were associated with more expansive and generous charity care policies. Policymakers can consider hospital incentives and capabilities when designing policies to address medical debt.

OBJECTIVE: To measure the impact of pregnancy and childbirth on debt and personal credit scores by race, ethnicity, and geography. STUDY SETTING AND DESIGN: We used Medicaid claims data, credit report data, and the Callaway Sant'Anna difference-in-differences method to compare relative changes in credit score, medical debt, and nonmedical debt between women moving through their pregnancies and women who weren't pregnant. DATA SOURCES AND ANALYTIC SAMPLE: Louisiana Medicaid claims data (January 2017 to December 2020). PRINCIPAL FINDINGS: While outcomes were not adversely impacted for non-Hispanic White women, non-Hispanic Black women experienced worsening financial measures following their pregnancies: credit scores decreased from Month 4 to 14 (4 points, 95% CI: -5.65 to -1.81, p < 0.01), medical debt increased from Month 8 to 12 ($41, 95% CI: $6-$75, p = 0.02), and nonmedical debt increased from Month 2 to 21 ($44, 95% CI: $15-$74, p < 0.01). CONCLUSIONS: Pregnancy and childbirth were associated with worsening financial outcomes among low-income Medicaid-enrolled mothers, particularly among non-Hispanic Black women. These findings highlight the importance of broader economic supports to reduce financial disruption associated with pregnancy and childbirth among low-income families and address disparities in maternal and child well-being.

OBJECTIVE: To assess existing algorithms for measuring Home- and Community-Based Services (HCBS) in Medicaid claims, and to develop and evaluate a unified, modified algorithm. STUDY SETTING AND DESIGN: Using Transformed Medicaid Statistical Information System Analytic Files (TAF), we compared two existing algorithms for identifying and classifying 1915(c) waiver and state plan HCBS. Informed by that analysis, we developed a third, unified and modified algorithm. Using each algorithm, we constructed annual state-level estimates of HCBS use per 100,000 residents, which we compared from 2021 to 2023. DATA SOURCES AND ANALYTIC SAMPLE: National 20% sample of TAF data. The sample included continuously enrolled, full-benefit Medicaid beneficiaries age 19 or older in 2021 for primary analyses, and 2022-2023 to compare counts over time. PRINCIPAL FINDINGS: = 93% and kappa = 0.77). Disagreement resulted from missing or inconclusive program type codes, differences in service-related codes used to classify HCBS, and differences in classifying claims for capitated payments. Our algorithm addressed some of this disagreement with the novel use of waiver identification numbers and modification of some TAF data elements and codes. HCBS user counts were mostly consistent across algorithms, with our algorithm identifying the broadest population of users. However, some states exhibited inconsistent counts depending on the algorithm, implausibly high counts (Pennsylvania and Illinois), or implausibly low counts (Mississippi). In several states, HCBS user counts varied substantially from 2021 to 2023 (> 50% in absolute value), suggesting changes in data quality or reporting in those states across years. CONCLUSIONS: Our algorithm resolves some discordances between two existing algorithms for measuring HCBS use in TAF. However, in certain states and years, inconsistent or implausible HCBS user counts suggest variations in data reliability and coding patterns that could limit accurate measurement of HCBS, regardless of the algorithm used.

OBJECTIVE: To estimate how often immigrant adults are asked for a Social Security number or proof of citizenship to obtain care or enroll in school, who is asked for these documents, and whether being asked relates to health care access. STUDY SETTING AND DESIGN: Cross-sectional analysis of four pooled waves (2019-2022) of a population-based, multilingual survey of California adults. The exposure was the documentation request; outcomes were lacking a usual source of care and delaying or forgoing care. DATA SOURCES AND ANALYTIC SAMPLE: California Health Interview Survey public-use files were used. The documentation item is asked only of foreign-born respondents, yielding 21,133 immigrant adults (15,313 naturalized, 5820 noncitizen). Survey-weighted logistic models with jackknife variance reported average marginal effects. PRINCIPAL FINDINGS: Overall, 15.7% (95% CI: 14.9-16.5) reported being asked. After adjustment, noncitizens were 5.3 percentage points more likely than naturalized citizens (3.5-7.1) and limited-English-proficient adults 5.8 points more likely (3.5-8.1) to be asked. Being asked was associated with delaying or forgoing care (6.1 points; 4.2-8.0) but not with lacking a usual source of care (0.2 points; -1.9 to 2.3). CONCLUSIONS: Documentation requests were common, concentrated among noncitizen and limited-English-proficient immigrants, and associated with forgone care. The cross-sectional design cannot establish causation.

OBJECTIVE: To compare the use of brokers in Medicare Advantage plans and standalone Part D plans. STUDY SETTING AND DESIGN: We used plan-level broker enrollment data from 2014 to 2023 to compare the rates of broker use in Medicare Advantage and standalone Part D plans. DATA SOURCES AND ANALYTIC SAMPLE: We used broker enrollment data obtained from the Centers for Medicare and Medicaid Services through a Freedom of Information Act request and data from the Medicare Master Beneficiary Summary File. Our sample included 47,862 plan-years from 2014 to 2023. PRINCIPAL FINDINGS: In 2023, new enrollees in Medicare Advantage plans were more likely to be enrolled by a broker than those in standalone part D plans (35.6% compared to 27.1%). These results were generally consistent over time, within insurers, and across states. CONCLUSIONS: Broker use is more common in Medicare Advantage plans than in standalone Part D plans. Given that brokers are often paid more to enroll beneficiaries in Medicare Advantage plans than in standalone Part D plans, these results suggest that brokers may play a key role in driving Medicare Advantage enrollment growth.

OBJECTIVE: To evaluate whether the Brandon Act, a 2021 legislation establishing confidential, self-initiated mental health referral pathways for US military service members, was associated with reductions in medically attended suicide attempts among active duty service members (ADSMs). STUDY SETTING AND DESIGN: We employed an interrupted time series design using person-quarter panel data from the Military Health System (MHS) from 2018 to 2024. Segmented regression and event study specifications estimated immediate and trajectory effects of the Brandon Act on suicide attempt rates. DATA SOURCES AND ANALYTIC SAMPLE: Data were drawn from the MHS Data Repository, comprising 39.1 million person-quarters from 2.5 million ADSMs aged 18-64. Suicide attempts were identified from inpatient, outpatient, and emergency department claims. PRINCIPAL FINDINGS: Prior to the Brandon Act, suicide attempt rates increased by 4.29 per 100,000 per quarter (95% CI: 3.56, 5.02). Enactment in December 2021 was associated with an immediate reduction of 6.51 per 100,000 (95% CI: -10.54, -2.47) and a downward trajectory shift of 2.25 per 100,000 per quarter (95% CI: -3.81, -0.70). Official implementation in May 2023 was associated with a further immediate reduction of 21.19 per 100,000 (95% CI: -26.83, -15.55) relative to the projected trend, with a compounding decline of 1.50 per 100,000 per quarter (95% CI: -2.34, -0.66). The policy was associated with approximately 3800 prevented suicide attempts over 3 years. Effects were largest among junior enlisted, female service members, and Army and Marine Corps personnel. CONCLUSIONS: The Brandon Act is associated with a sustained, compounding decline in medically attended suicide attempts among ADSMs. Immediate reductions upon enactment suggest a signaling effect, while intensifying effects following implementation underscore the role of confidential pathways in addressing structural barriers to care-seeking. These findings highlight the importance of non-financial policy levers in military mental health and offer a replicable model for other health systems where stigma limits care utilization.