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Research Studies is a monthly compilation of research articles funded by AHRQ or authored by AHRQ researchers and recently published in journals or newsletters.
Results1 to 25 of 8558 Research Studies Displayed
Ghaferi AA, Wells EE
Improving postoperative rescue through a multifaceted approach.
Through structured engagement of clinical champions, the authors present rescue improvement tools that may decrease rates of secondary and tertiary complications and enhance staff culture, confidence, and competence. They indicate that their interventions lay the groundwork for the further development, testing, and implementation of larger scale rescue-focused initiatives.
Citation: Ghaferi AA, Wells EE . Improving postoperative rescue through a multifaceted approach. Surg Clin North Am 2021 Feb;101(1):71-80. doi: 10.1016/j.suc.2020.09.004..
Keywords: Surgery, Adverse Events, Patient Safety, Hospitals
Rhoten BA, Sellers JI, Baraff B
A qualitative examination of patient priorities and preferences during treatment decision-making for recurrent head and neck cancer.
Patients with recurrent head and neck cancer (HNC) may feel overwhelmed at the prospect of having to consider treatment options particularly if they recently completed treatment for their primary disease or when they have no options that may lead to long-term survival. The purpose of this study was to examine patient priorities and preferences during treatment decision-making for recurrent HNC.
Citation: Rhoten BA, Sellers JI, Baraff B . A qualitative examination of patient priorities and preferences during treatment decision-making for recurrent head and neck cancer. Support Care Cancer 2021 Jan;29(1):377-85. doi: 10.1007/s00520-020-05488-9..
Keywords: Cancer, Decision Making, Quality of Life
Holden RJ, Abebe E
Medication transitions: vulnerable periods of change in need of human factors and ergonomics.
The authors present a novel view of transitions from the lens of patient ergonomics which posits that patients and other nonprofessionals experience many changes during patient work transitions toward health-related goals. Medication transitions are particularly vulnerable. Two cases of medication transitions; new and medication deprescribing are described in which the patient work lens reveals many accompanying changes, vulnerabilities, and opportunities for human factors and ergonomics.
Citation: Holden RJ, Abebe E . Medication transitions: vulnerable periods of change in need of human factors and ergonomics. Appl Ergon 2021 Jan;90:103279. doi: 10.1016/j.apergo.2020.103279..
Keywords: Medication, Medication: Safety, Patient and Family Engagement, Transitions of Care, Patient Safety
Ali MM, McClellan C, West KD
AHRQ Author: McClellan C
Medical marijuana laws, marijuana use, and opioid-related outcomes among women in the United States.
This study examined whether state medical marijuana laws (MMLs) was associated with lower levels of opioid-related outcomes. Data was drawn from the 2002-2014 National Survey on Drug Use and Health to compare opioid misuse in states with and without MMLs among all women, pregnant women, and parenting women. It also invested the impact of MMLs on marijuana use and marijuana use disorder. There was found to be no association of MMLs with opioid misuse, opioid misuse initiation, or opioid use disorder among all women, pregnant women and parenting women. However there was a positive correlation with marijuana use and marijuana use disorder among all women and women with children. MMLs were also associated with an increase in the frequency of opioid misuse in pregnant women and a decrease in the frequency of opioid misuse for parenting women.
Citation: Ali MM, McClellan C, West KD . Medical marijuana laws, marijuana use, and opioid-related outcomes among women in the United States. Womens Health Issues 2021 Jan-Feb;31(1):24-30. doi: 10.1016/j.whi.2020.09.003..
Keywords: Women, Opioids, Substance Abuse, Medication, Policy, Practice Patterns
Iribarren S, Lentz C, Sheinfil AZ
Using an HIV self-test kit to test a partner: attitudes and preferences among high-risk populations.
Researchers explored attitudes and preferences among HIV-negative men who have sex with men and HIV-negative transgender women using an HIV self-testing (HIVST) kit to test partners. They found that most preferred gum swab over fingerprick tests, but would prefer a blood test if it gave results for other sexually transmitted infections (STIs). They concluded that efforts to improve HIVST uptake should focus on incorporating testing for other STIs, reducing test kit size, and reducing cost.
Citation: Iribarren S, Lentz C, Sheinfil AZ . Using an HIV self-test kit to test a partner: attitudes and preferences among high-risk populations. AIDS Behav 2020 Nov;24(11):3232-43. doi: 10.1007/s10461-020-02885-3..
Keywords: Human Immunodeficiency Virus (HIV), Diagnostic Safety and Quality, Infectious Diseases, Prevention
Perioperative management of aneurysmal subarachnoid hemorrhage.
This article discusses aneurysmal subarachnoid hemorrhage, an acute neurologic emergency. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. The author indicates that prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. The author also notes that data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist.
Citation: Sharma D . Perioperative management of aneurysmal subarachnoid hemorrhage. Anesthesiology 2020 Dec;133(6):1283-305. doi: 10.1097/aln.0000000000003558..
Keywords: Cardiovascular Conditions, Neurological Disorders, Surgery, Care Management
Savitz ST, Bailey SC, Dusetzina SB
Treatment selection and medication adherence for stable angina: the role of area-based health literacy.
Clinical studies show equivalent health outcomes from interventional procedures and treatment with medication only for stable angina patients. However, patients may be subject to overuse or access barriers for interventional procedures and may exhibit suboptimal adherence to medications. The objective of the study was to evaluate whether community-level health literacy was associated with treatment selection and medication adherence patterns.
Citation: Savitz ST, Bailey SC, Dusetzina SB . Treatment selection and medication adherence for stable angina: the role of area-based health literacy. J Eval Clin Pract 2020 Dec;26(6):1711-21. doi: 10.1111/jep.13341..
Keywords: Medication, Patient Adherence/Compliance, Health Literacy, Heart Disease and Health, Cardiovascular Conditions
Sangal RB, Fodeh S, Taylor A
Identification of patients with nontraumatic intracranial hemorrhage using administrative claims data.
Nontraumatic intracranial hemorrhage (ICH) is a neurological emergency of research interest; however, unlike ischemic stroke, has not been well studied in large datasets due to the lack of an established administrative claims-based definition. In this study, the investigators aimed to evaluate both explicit diagnosis codes and machine learning methods to create a claims-based definition for this clinical phenotype.
Citation: Sangal RB, Fodeh S, Taylor A . Identification of patients with nontraumatic intracranial hemorrhage using administrative claims data. J Stroke Cerebrovasc Dis 2020 Dec;29(12):105306. doi: 10.1016/j.jstrokecerebrovasdis.2020.105306..
Keywords: Cardiovascular Conditions, Neurological Disorders, Diagnosis, Data
Radovic A, Odenthal K, Flores AT
Prescribing technology to increase uptake of depression treatment in primary care: a pre-implementation focus group study of SOVA (Supporting Our Valued Adolescents).
Supporting Our Valued Adolescents (SOVA) is a web-based technology intervention designed to increase depression and anxiety treatment uptake by adolescents in the context of an anonymous peer community with an accompanying website for parents. With a goal of informing the design of a hybrid effectiveness-implementation randomized controlled trial, we conducted a pre-implementation study in two primary care practices to guide implementation strategy development. We conducted focus groups with primary care providers (PCPs) at three different timepoints with PCPs (14 total) from two community practices.
Citation: Radovic A, Odenthal K, Flores AT . Prescribing technology to increase uptake of depression treatment in primary care: a pre-implementation focus group study of SOVA (Supporting Our Valued Adolescents). J Clin Psychol Med Settings 2020 Dec;27(4):766-82. doi: 10.1007/s10880-019-09669-5.
Keywords: Children/Adolescents, Depression, Anxiety, Mental Health, Primary Care, Health Information Technology (HIT), Implementation
Reisz PA, Laviana AA, Zhao Z
Assessing the quality of surgical care for clinically localized prostate cancer: results from the CEASAR study.
Prior studies suggest that nationally endorsed quality measures for prostate cancer care are not linked closely with outcomes. Using a prospective, population based cohort the investigators measured clinically relevant variation in structure, process and outcome measures in men undergoing radical prostatectomy. The authors did not identify and meaningful variation in quality of care across racial groups, age groups and surgeon volume strata, in this cohort, suggesting that men were receiving comparable quality of care across these strata.
Citation: Reisz PA, Laviana AA, Zhao Z . Assessing the quality of surgical care for clinically localized prostate cancer: results from the CEASAR study. J Urol 2020 Dec;204(6):1236-41. doi: 10.1097/ju.0000000000001198..
Keywords: Surgery, Cancer: Prostate Cancer, Cancer, Quality of Care, Quality of Life, Patient-Centered Outcomes Research, Comparative Effectiveness, Evidence-based Practice
O'Leary KJ, Manojlovich M, Johnson JK
A multisite study of interprofessional teamwork and collaboration on general medical services.
This multisite study of four mid-sized hospitals measured teamwork climate of nurses, nurse assistants, and physicians working on general medical services. Teamwork climate scores for 380 participants (80 hospitalists, 13 resident physicians, 193 nurses, and 94 nurses) were measured using the Safety Attitudes Questionnaire. Hospitalists had the highest median teamwork climate score and nurses had the lowest, but it was not a statistically significant difference. A higher percentage of hospitalists (63.3%) rated the quality of collaboration with nurses as high or very high, but only 48.7% of nurses rated the collaboration with hospitalists as high or very high. There were significant differences in perceptions of teamwork climate across sites and across professional categories.
Citation: O'Leary KJ, Manojlovich M, Johnson JK . A multisite study of interprofessional teamwork and collaboration on general medical services. Jt Comm J Qual Patient Saf 2020 Dec;46(12):667-72. doi: 10.1016/j.jcjq.2020.09.009..
Keywords: Teams, Hospitals, Patient Safety, Provider: Clinician, Provider: Physician, Provider: Nurse, Provider
Hudson JL, Moriya AS
AHRQ Author: Hudson JL
The role of marketplace policy on welcome mat effects for children eligible for Medicaid or the Children's Health Insurance Program.
This study examined the role of marketplace policy on “welcome mat” effects for children eligible for Medicaid or the Children’s Health Insurance Program (CHIP). Data from the American Community Survey from 2013-2018 was used to estimate the relationship between Marketplace policy and increases in Medicaid/CHIP coverage among pre-ACA eligible children after the implementation of the Affordable Care Act (ACA). The sample included non-disabled citizen children ages 0-18 at 139-250% federal poverty level who were Medicaid/CHIP-eligible before and after implementation of the ACA. Marketplace policies and enrollment were compared in expansion states versus non-expansion states. Public coverage did increase more in states that empowered their Marketplace to enroll publicly-eligible applicants directly into Medicaid/CHIP. This was driven by enrollment policy, not by choice of state-based versus federal-based Marketplaces. Welcome mats were largest in expansion states and increases ranged from 9 to 13 percentage points in enrollment.
Citation: Hudson JL, Moriya AS . The role of marketplace policy on welcome mat effects for children eligible for Medicaid or the Children's Health Insurance Program. Inquiry 2020 Jan-Dec;57:46958020952920. doi: 10.1177/0046958020952920..
Keywords: Children/Adolescents, Children's Health Insurance Program (CHIP), Medicaid, Health Insurance, Policy, Uninsured, Access to Care
Hu QL, Grant MC, Hornor MA
Technical evidence review for emergency major abdominal operation conducted for the Agency for Healthcare Research and Quality Safety program for improving surgical care and recovery.
This technical evidence review focuses on the use of enhanced recovery pathways (ERPs) for emergency major abdominal surgery conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR). This national ERP initiative is funded by AHRQ and implemented in 2017 through a collaboration with American College of Surgeons, and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality. Five common emergency general surgery (EGS) procedures were focused on: perforated peptic ulcer repair, colectomy, lysis of adhesions, small bowel resection, and exploratory laparotomy. The authors identified seventeen candidate components for emergency major abdominal ERP. The components span the continuum of care from preoperative setting to hospital discharge. For every component they conducted a systematic literature review to find relevant studies. Each component was examined for rationale, evidence, and summary and recommendations. Many were supported by evidence and guidelines specific to their particular operation. Key gaps in literature were highlighted, specifically lack of evidence specific to these operations across many ERP processes.
Citation: Hu QL, Grant MC, Hornor MA . Technical evidence review for emergency major abdominal operation conducted for the Agency for Healthcare Research and Quality Safety program for improving surgical care and recovery. J Am Coll Surg 2020 Dec;231(6):743-64.e5. doi: 10.1016/j.jamcollsurg.2020.08.772..
Keywords: Evidence-based Practice, Surgery, Patient Safety, Quality Improvement, Quality of Care, Patient-Centered Outcomes Research
Hong MR, Lei D, Yousaf M
A real-world study of the longitudinal course of adult atopic dermatitis severity in clinical practice.
This study examined the longitudinal course of adult atopic dermatitis (AD) severity in clinical practice. Dermatology patients were assessed at approximately 6,12, 18, and 24 months by the scoring systems Eczema Area and Severity Index (EASI) and objective-Scoring Atopic Dermatitis (objective-SCORAD). At any visit, 36.2% of cases were scored as moderate, and 18.2% were severe. Among those patients, 25% and 18.6% continued to have moderate or severe scores at 1 or more follow-up visits for EASI, and 22.6% and 24.5% moderate or severe objective-SCORAD scores respectively. Many patients had fluctuating severity scores over time and a minority had persistently moderate or severe lesions over time, and most of those patients were unable to achieve persistent lesional clearance.
Citation: Hong MR, Lei D, Yousaf M . A real-world study of the longitudinal course of adult atopic dermatitis severity in clinical practice. Ann Allergy Asthma Immunol 2020 Dec;125(6):686-92.e3. doi: 10.1016/j.anai.2020.07.005.
Keywords: Skin Conditions, Patient-Centered Outcomes Research, Evidence-based Practice
Griffey RT, Schneider RM, Sharp BR
Description and yield of current quality and safety review in selected US academic emergency departments.
This study examined the impact of current quality and safety reviews used in US academic emergency departments (EDs). The authors hypothesized that current protocols are decades old and inefficient with low yield for identifying patient harm. They conducted a prospective observational study at five academic EDs for a 12-month procedure. Sites used the Institute for Healthcare Improvement’s definition in defining an adverse event and a modified National Coordinating Council for Medication Error Reporting and Prevention (MERP) Index for severity grading of events. They reviewed a total of 4735 cases and identified 381 events, of which 287 were near-misses, and 94 had adverse events (AEs). The overall AE rate was 1.99% (1.24-3.47%) across all sites. Quality concern rate (events without harms) was 6.06% (5.42-6.78%). Forty-seven percent of cases used 72 hour returns as their referral source but with only a 0.81% yield in identifying harm. Other referral sources also had similar low yields. External referrals in the 94 AE cases accounted for 41.49% of cases. The authors concluded that new approaches to quality and safety review in the ED are needed to optimize yield and efficiency for identifying harms and areas for improvement.
Citation: Griffey RT, Schneider RM, Sharp BR . Description and yield of current quality and safety review in selected US academic emergency departments. J Patient Saf 2020 Dec;16(4):e245-e49. doi: 10.1097/pts.0000000000000379..
Keywords: Emergency Department, Patient Safety, Quality Improvement, Quality of Care, Provider Performance
Feldman AG, Marsh R, Kempe A
Barriers to pretransplant immunization: a qualitative interview study of pediatric solid organ transplant stakeholders.
Investigators described the experiences and beliefs of pediatric transplant stakeholders regarding factors that contribute to low pre-transplant immunization rates. Five central themes emerged: gaps in knowledge about timing and safety of pre-transplant immunizations; lack of communication, coordination, and follow-up between team members; lack of centralized immunization records; subspecialty clinics functioning as the medical home for transplant candidates, but not able to provide all needed immunizations; and differences between organ type in prioritization and completion of pre-transplant immunization. The authors recommended new tools to overcome these barriers and to increase immunization rates in transplant candidates.
Citation: Feldman AG, Marsh R, Kempe A . Barriers to pretransplant immunization: a qualitative interview study of pediatric solid organ transplant stakeholders. J Pediatr 2020 Dec;227:60-68. doi: 10.1016/j.jpeds.2020.07.038..
Keywords: Children/Adolescents, Transplantation, Surgery, Healthcare Delivery, Healthcare Utilization
Daniel VT, Francalancia S, Amir NS
Upper gastrointestinal perforations: a possible danger of antibiotic overuse.
Investigators conducted a retrospective case-control study to examine the relationship between antibiotic exposure and upper gastrointestinal (UGI) perforations in a national sample. A 5% random sample of Medicare were queried to identify patients at least 65 years old who were hospitalized with stomach or small intestine UGI perforations using International Classification of Diseases diagnosis codes; Cases with UGI perforations were matched with 4 controls based on age and sex. The investigators concluded that recent outpatient antibiotic use, in particular in the preceding 30 days, is associated with UGI perforation among Medicare beneficiaries. They recommended minimizing exposure to antibiotics in the outpatient setting.
Citation: Daniel VT, Francalancia S, Amir NS . Upper gastrointestinal perforations: a possible danger of antibiotic overuse. J Gastrointest Surg 2020 Dec;24(12):2730-36. doi: 10.1007/s11605-019-04473-w..
Keywords: Digestive Disease and Health, Antimicrobial Stewardship, Antibiotics, Medication, Adverse Drug Events (ADE), Adverse Events
Caram MEV, Oerline MK, Dusetzina S
Adherence and out-of-pocket costs among Medicare beneficiaries who are prescribed oral targeted therapies for advanced prostate cancer.
The authors investigated coping and material measures of the financial hardship of abiraterone and enzalutamide among patients with advanced prostate cancer with Medicare Part D coverage. They found substantial variations in the adherence rate and out-of-pocket payments, with sociodemographic patient and regional factors found to be associated with both aspects.
Citation: Caram MEV, Oerline MK, Dusetzina S . Adherence and out-of-pocket costs among Medicare beneficiaries who are prescribed oral targeted therapies for advanced prostate cancer. Cancer 2020 Dec 1;126(23):5050-59. doi: 10.1002/cncr.33176..
Keywords: Patient Adherence/Compliance, Medicare, Cancer: Prostate Cancer, Cancer, Medication, Healthcare Costs
Byrnes ME, Varlamos CJ, Rivard SJ
"You're used to being the one that can fix things…": a qualitative snapshot of colorectal surgeons during COVID-19.
This viewpoint article reflects the narratives of 58 colorectal surgeons who engaged in an in-depth qualitative interview during the COVID-19 shutdown of elective surgeries. The goal for reporting these findings is to offer a snapshot of surgeon perspectives on the delays of elective surgeries and to give voice to surgeons who were unable to perform most or all their duties as a surgeon.
AHRQ-funded; HS025365; HS000053.
Citation: Byrnes ME, Varlamos CJ, Rivard SJ . "You're used to being the one that can fix things…": a qualitative snapshot of colorectal surgeons during COVID-19. Dis Colon Rectum 2020 Dec;63(12):1575-78. doi: 10.1097/dcr.0000000000001818..
Keywords: Surgery, Provider: Physician, Provider, Infectious Diseases, Public Health
Barry CL, Han H, Presskreischer R
Public support for social safety-net policies for COVID-19 in the United States, April 2020.
Researchers examined public support for health insurance, income support, and unemployment policies during the initial phase of disease transmission and economic distress following the COVID-19 outbreak and assessed varying public support based on beliefs about the role of government. They fielded a nationally representative survey of US adults from April 7-13, 2020. Their results indicate that, during the initial phase of the COVID-19 pandemic in early April 2020, most US adults favored a range of safety-net policies to ameliorate its negative health and economic consequences, with public support being the highest among those favoring a stronger governmental role in society.
Citation: Barry CL, Han H, Presskreischer R . Public support for social safety-net policies for COVID-19 in the United States, April 2020. Am J Public Health 2020 Dec;110(12):1811-13. doi: 10.2105/ajph.2020.305919..
Keywords: Public Health, Policy
Bajaj JS, Duarte-Rojo A, Xie JJ
Minimal hepatic encephalopathy and mild cognitive impairment worsen quality of life in elderly patients with cirrhosis.
Researchers investigated the performance of elderly patients with cirrhosis on tests for minimal hepatic encephalopathy (MHE) and predementia mild cognitive impairment (MCI) and their effects on quality of life (QOL). They found that, in a multicenter study of elderly patients with cirrhosis and controls, the presence of MHE, regardless of MCI, was associated with poor cognition and QOL. They created adjusted norms that defined the high sensitivity of EncephalApp for the detection of MHE in older individuals and validated it in a separate cohort.
Citation: Bajaj JS, Duarte-Rojo A, Xie JJ . Minimal hepatic encephalopathy and mild cognitive impairment worsen quality of life in elderly patients with cirrhosis. Clin Gastroenterol Hepatol 2020 Dec;18(13):3008-16.e2. doi: 10.1016/j.cgh.2020.03.033..
Keywords: Elderly, Chronic Conditions, Quality of Life, Dementia, Neurological Disorders
Short MN, Ho V
Weighing the effects of vertical integration versus market concentration on hospital quality.
Provider organizations are increasing in complexity, as hospitals acquire physician practices and physician organizations grow in size. At the same time, hospitals are merging with each other to improve bargaining power with insurers. In this study, the investigators analyzed 29 quality measures reported to the Center for Medicare and Medicaid Services' Hospital Compare database for 2008 to 2015 to test whether vertical integration between hospitals and physicians or increases in hospital market concentration influenced patient outcomes.
Citation: Short MN, Ho V . Weighing the effects of vertical integration versus market concentration on hospital quality. Med Care Res Rev 2020 Dec;77(6):538-48. doi: 10.1177/1077558719828938.
Keywords: Consumer Assessment of Healthcare Providers and Systems (CAHPS), Quality of Care, Patient Experience, Hospitals, Medicare, Provider Performance, Healthcare Systems
Nazareno J, Zhang W, Silver B
Home health utilization in assisted living settings.
The authors explored the growth in the delivery of home health agency (HHA) services to Medicare beneficiaries in assisted living (AL) compared with other home settings between 2012 and 2014. Their findings suggested that there was a slight growth in the share of HHA services being delivered in AL. HHA recipients in AL were more likely to have cognitive and activities of daily living impairments than those receiving HHA services in other settings. This study is among the first of those to examine HHA utilization in AL.
Citation: Nazareno J, Zhang W, Silver B . Home health utilization in assisted living settings. Med Care Res Rev 2020 Dec;77(6):620-29. doi: 10.1177/1077558719835049..
Keywords: Elderly, Home Healthcare, Medicare, Healthcare Utilization
Henke RM, Karaca Z, Gibson TB
Medicaid Accountable Care Organizations and childbirth outcomes.
This study examined the impact of Accountable Care Organizations (ACOs) to childbirth outcomes. States that use Medicaid ACOs were compared with states that had not adopted ACO. Using HCUP data, the relationship between Medicaid ACO adoption and neonatal and maternal outcomes, and cost per birth was examined. Medicaid ACO implementation was associated with a moderate reduction in hospital costs per birth and decreased cesarean section rates with results varying by state. There was no association with other birth outcomes, including infant inpatient mortality, low birthweight, neonatal intensive care unit utilization and severe maternal morbidity.
AHRQ-authored; AHRQ-funded; 290201300002C.
Citation: Henke RM, Karaca Z, Gibson TB . Medicaid Accountable Care Organizations and childbirth outcomes. Med Care Res Rev 2020 Dec;77(6):559-73. doi: 10.1177/1077558718823132..
Keywords: Healthcare Cost and Utilization Project (HCUP), Medicaid, Managed Care, Health Insurance, Labor and Delivery, Pregnancy, Women, Outcomes, Healthcare Costs
Everson J, Adler-Milstein J, Ryan AM
Hospitals strengthened relationships with close partners after joining accountable care organizations.
This study tested the hypothesis that hospitals participating in Medicare Accountable Care Organizations (ACOs) try to influence where their patients receive care in order to achieve quality and cost containment goals. The authors studied hospitals participating in ACO from 2010 to 2014. ACO hospitals shared patients 4.4% more than non-ACO hospitals. This occurred disproportionately at hospitals that already shared a high proportion of their patients prior to participation and among hospitals in ACOs characterized as physician-hospital collaborations.
AHRQ-funded; HS024525; HS024728.
Citation: Everson J, Adler-Milstein J, Ryan AM . Hospitals strengthened relationships with close partners after joining accountable care organizations. Med Care Res Rev 2020 Dec;77(6):549-58. doi: 10.1177/1077558718818336..
Keywords: Hospitals, Medicare, Policy, Managed Care, Health Insurance