Medical care
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Although hospice use may be increasing among heart failure patients, its association with both cost and intensity of care in this population has not been well examined. ⋯ Despite lower rates of hospitalization, ICU days, and invasive procedures, hospice care was not associated with reduced expenditures in heart failure. Financial savings related to reduced intensive medical care seems to be offset by the expenditures related to hospice care itself.
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Significant racial disparities have been reported regarding nursing home residents' use of hospital and hospice care at the end of life (EOL). ⋯ Differential use of feeding tubes, do-not-resuscitate and do-not-hospitalize orders lead to racial differences in in-hospital death and hospice use. The remaining disparities are primarily due to overall EOL care practices in predominately black facilities, not to differential hospitalization and hospice-referral patterns within facilities.
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Free clinics play an important role in the safety net but little is known about what factors drive their existence within a given community. The anecdotal literature suggests that they exist due to growing numbers of uninsured and a lack of affordable care. ⋯ None of the demographic variables has a positive, statistically significant relationship to the number of free clinics in a metropolitan statistical area. However, the number of FQHC grantees per 10,000 uninsured individuals [incidence rate ratios (IRR)=0.69, P<0.05], the number of FQHC look-alike sites per 10,000 uninsured individuals (IRR=0.46, P<0.05), Medicaid beneficiary payments (IRR=0.9998, P<0.05), and Medicaid eligibility levels (IRR=0.998, P<0.10) are negatively associated with the number of free clinics. Thus, free clinics seem to respond to particular gaps left by safety-net providers and Medicaid but do not seem to respond to direct need.
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Increasing patient-provider sex and race/ethnicity concordance has been proposed to improve healthcare and help mitigate health disparities, but the relationship between concordance and health outcomes remains unclear. ⋯ Little evidence of clinical benefit resulting from sex or race/ethnicity concordance was found. Greater matching of patients and providers by sex and race/ethnicity is unlikely to mitigate health disparities.