Objective: To examine care system choices for Veterans dually-eligible for VA and Medicare FFS following changes in VA eligibility policy, which expanded availability of VA health care services. Conclusions:Veterans newly eligible for VA healthcare services, particularly those with the highest risk scores, had higher odds of dual system use compared to earlier eligibles. Providers should ensure coordination of care for Veterans who may be receiving care from multiple sources. Provisions of the Patient Protection and Affordable Care Act may help to ensure care coordination for persons receiving care from multiple systems.

Recent research suggests living in an economically disadvantaged neighborhood is associated with decreased likelihood of undergoing mammography and increased risk of late-stage breast cancer diagnosis. Long distances and travel times to facilities offering low-or no-fee mammography may be important barriers to adherence to mammography screening recommendations for women living in economically disadvantaged urban neighborhoods, in which African-Americans are disproportionately represented. The purpose of this study was to examine whether the spatial distribution of facilities providing low-or no-fee screening mammography in Chicago, Illinois, is equitable on the basis of neighborhood socioeconomic and racial characteristics. We found that distance and travel times via automobile and public transportation to facilities generally decrease as neighborhood poverty increases. However, we also found that the strength of the association between neighborhood poverty level and two of the spatial accessibility measures-distance and public transportation travel time-is less strong in African-American neighborhoods. Among neighborhoods with the greatest need for facilities (i.e., neighborhoods with the highest proportions of residents in poverty), African-American neighborhoods have longer travel distances and public transportation travel times than neighborhoods with proportionately fewer African-American residents. Thus, it appears that the spatial accessibility of low-and no-fee mammography services is inequitable in Chicago. In view of persistent social disparities in health such as breast cancer outcomes, these findings suggest it is important for researchers to examine the spatial distribution of health resources by both the socioeconomic and racial characteristics of urban neighborhoods.

The distributions of medical costs are often skewed to the right because small numbers of patients use large amounts of health care resources. Using data from a study of colon cancer costs, we show, by example, the impact and magnitude of outliers and influential observations on health care costs and compared the effects of statistical costing methods for addressing the disproportionate influence of outliers and influential observations. We used data from a retrospective cohort study of 3,842 elderly veterans with colon cancer who were enrolled in and used health care from, both the Department of Veterans Affairs and Medicare in 1999–2004. After calculating the average colon cancer episode cost and distribution for the full cohort, we used box-plot methods, Winsorization, DFBETAs, and Cook's distance to identify and assess or adjust the outlying and/or influential observations. The number of observations identified as outlying and/or influential ranged from 13 when the predicted DFBETA measurement was greater than 0.15 and the observation was a qualified box-plot outlier to 384 cases using the Winsorization method at the 5th and 95th percentiles. Average costs of colon cancer episodes using these methods were similar. The method of choice from the results of this particular analysis can be conditionally based on whether the purpose is to control only for influential observations or to simultaneously control for outliers and influential observations. Understanding how estimates could change with each approach is important in assessing the impact of a particular method on the results.

In the United States, despite substantial investment in public health initiatives to promote early detection of breast cancer through screening mammography, the proportion of female breast cancers that have advanced beyond the localized stage by the time of diagnosis remains high. Our objective in this exploratory study was to investigate whether stage of breast cancer at diagnosis among Chicago residents is associated with characteristics of the neighborhoods in which proximate mammography facilities are located. Those characteristics may influence likelihood of utilizing the service routinely and partly explain differences in stage at diagnosis. We used a retrospective cohort design and combined 3 years of data from the Illinois State Cancer Registry (ISCR) with information on locations of mammography facilities, public transportation service, crime, and area demographic and economic characteristics. Using a Geographic Information System (GIS), we identified the five facilities located nearest to each case's residence. Estimates of the association between characteristics of mammography facility locations and breast cancer stage at diagnosis were obtained using the partial proportional odds regression model. We found that the number of homicides in areas in which the nearest mammography facilities were located was associated with increased odds of later stage diagnosis. This effect was independent of age, race, and residential area education and income. We found no effect on stage of distance, public transportation service, or measures of neighborhood social similarity. The "spatial dynamics" of health may involve geographies beyond the immediate neighborhood. The results of our study suggest that areas in which the nearest mammography facilities are located may be one such geography. We hope that this study will spark research interest in the impact of health service locations on utilization.

The Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) represents an unprecedented collaboration across diverse healthcare institutions including private, county, and state hospitals and health systems, a consortium of Federally Qualified Health Centers, and two Department of Veterans Affairs hospitals. CAPriCORN builds on the strengths of our institutions to develop a cross-cutting infrastructure for sustainable and patient-centered comparative effectiveness research in Chicago. Unique aspects include collaboration with the University HealthSystem Consortium to aggregate data across sites, a centralized communication center to integrate patient recruitment with the data infrastructure, and a centralized institutional review board to ensure a strong and efficient human subject protection program. With coordination by the Chicago Community Trust and the Illinois Medical District Commission, CAPriCORN will model how healthcare institutions can overcome barriers of data integration, marketplace competition, and care fragmentation to develop, test, and implement strategies to improve care for diverse populations and reduce health disparities.