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Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation (2005)

Chapter: Appendix B: Annotated Bibliography

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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
×
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
×
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Suggested Citation:"Appendix B: Annotated Bibliography." National Academies of Sciences, Engineering, and Medicine. 2005. Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22055.
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Final Report B-1 Appendix B: Annotated Bibliography Ahmed, S.M., Lemkau, J.P., Nealeigh, N., Mann, B., Barriers to Healthcare Access in a Non- Elderly Urban Poor American Population, Health and Social Care in the Community, 9:445-53, 2001. This study focuses on urban poor under age 65 in Dayton, Ohio, considering barriers between working and non-working poor to healthcare access. Interviews were conducted door-to-door, enabling patients without telephones to participate. 16% of respondents reported finding transportation for medical care was “hard”; an additional 15% reported “very hard”. People reporting transportation barriers were more likely to have no phone in the home, live below the poverty level and be nonworking. The number one reason patients did not access care was because they were unaware of programs available to them for free or at reduced rates. Table 3 shows that in regression analysis the odds a person will have difficulty finding transportation increases with poverty status, female gender, no health insurance. The strongest predictor of transportation difficulty is having no phone in the home (OR 4.40). Altarum, Healthcare Management Model, V. 2.0.4, January 24, 2002. The Healthcare Management Model, created by Altarum, simulates various health experiences and predicts service and material requirements.

Final Report B-2 American Public Transportation Association, Americans in Transit, 1992. http://www.apta.com/research/stats/ridershp/income.cfm Americans in Transit study is an older survey of public transit officials to determine rider statistics. Results on income and trip purpose are shown in Tables 13 and 15. American Public Transportation Association, Mobility for America’s Small Urban and Rural Communities, 2003. http://www.apta.com/research/info/online/ This is a brochure publication created by APTA and the Public Transportation Partnership for Tomorrow as part of the Benefits of Public Transportation series. The brochure uses research by Cambridge Systematics, Inc to educate consumers and decision-makers about the supply and demand of public transportation in small urban and rural areas. The following are highlights: • 41% have no access to transit; • Another 25% live in areas with below-average transit services; • Americans in the lowest 20% income bracket, many of whom live in rural settings, spend about 42% of their total annual incomes on transportation compared to middle income Americans who spend under 22%; • Small urban and rural America is now home to 56 million residents in 2,303 non- metropolitan counties, as well as 35 million more residents living in rural settings on the fringes of metropolitan areas.

Final Report B-3 The report also profiles two communities that increased access to healthcare through public transportation: Mitchell, South Dakota area (pop. 14,558) created public transportation alternatives that expanded access for medical treatment and reduced healthcare costs by reducing in-patient medical treatment and the costs of 911 responses and the use of Emergency Medical Services; North Carolina’s 100 counties coordinate human service and general public transportation services by requiring joint plans for state funding. American Public Transportation Association, The Route to Better Health, 2003. http://www.apta.com/research/info/online/ This is a brochure publication created by APTA and the Public Transportation Partnership for Tomorrow as part of the Benefits of Public Transportation series. This report mainly addresses the environmental and public health benefits of a public transportation system. The medical access issue is addressed as a problem mainly among low income and minority populations. Key highlights: • As many as four million children in families with incomes under $50,000 a year miss essential doctor appointments because of inadequate transportation; • In Cincinnati, 60 percent of the patients using Good Samaritan Hospital’s clinics use public transportation to access the clinics; • Tri-Met in Portland, OR, carries 65 percent of non-emergency Medicaid trips; • The Metropolitan Tulsa Transit Authority (MTTA) coordinates Medicaid transportation statewide, handling 400 calls a day; • The Rhode Island Public Transit Authority (RIPTA) also coordinates Medicaid transportation statewide, using existing bus routes for 98 percent of the trips. American Public Transportation Association, Transit Resource Guide, No. 3, Revised April 2004. http://www.apta.com/research/info/briefings/documents/brief3.pdf A handout intended to educate seniors who may be encountering transportation barriers. Resources include a Census Bureau brief on the 65 years and older demographic, a study by the Brookings Institute on services for older Americans, and several reports on travel trends among older Americans, along with public transportation services that target older travelers. The document ends with profiles of communities that have strong public transit programs for seniors. Anderson, G., Knickman, J.R., Changing the Chronic Care System to Meet People’s Needs, Health Affairs, 20(6): 146-160, November/December 2001. A profile of the healthcare system from the perspective of the 128 million patients with a disability, chronic disease and/or functional limitation. Chronic illness accounted for 75% of healthcare costs in 2000. The current system limits coordination between the various providers managing chronic conditions, which presents problems with insurance and increases the likelihood of medical errors. Additional challenges exist when patients require professional long- term care that is cost-prohibitive.

Final Report B-4 Anderson, G., The Cost and Prevalence of Chronic Conditions are Increasing. A Response is Overdue, Expert Voices, Issue 4, January 2002. This is a summary article on the prevalence and cost of chronic diseases in America and the trends over time and age groups. Citations include MEPS data and a Harris Poll. Public perceptions are presented as concerned. Ashman, J.J., Conviser R., Pounds, M.B., Associations Between HIV-positive Individuals’ Receipt of Ancillary Services and Medical Care Receipt and Retention, AIDS Care, 14: S109- S118, 2002. This article uses data on AIDS and HIV patients who obtained safety-net services cities or states participating in the Health Resources and Services Administration’s Client Demonstration Project from January 1997 to the end of 1998. The focus of the research is on the relationship between providing support services (including transportation) and patient attendance in primary care. 28%

Final Report B-5 of the AIDS patients surveyed used the transportation service offered. Table 5 shows the relationship between receiving ancillary services and retention in primary care. Aved, B. M., Irwin, M. M., Cummings, L.S., Barriers to Prenatal Care for Low-Income Women, Western Journal of Medicine, 158:493-8, 1993. This research article studies women enrolled in Medi-Cal (California’s Medicaid program) admitted into one of eight Sacramento-area emergency rooms to give birth from April to May 1991, without a physician on record. Of the 69 women who listed “no doctor” upon giving birth, 29% never tried to obtain doctor’s services because of transportation issues. Women who did seek services but failed to secure care cited transportation issues as the second most important factor preventing them from having a doctor. Distance to doctor’s office and the cost of transportation were also factors cited as barriers to care. The article also surveyed reasons that physicians rejected Medi-Cal patients. The perception of low patient compliance both to appointments and instructions were cited as the second highest reason to reject Medi-Cal patients. Table 2 shows the experiences of the women studied and their use of prenatal care.

Final Report B-6 Bailey, L., Aging Americans: Stranded Without Options, Surface Transportation Policy Project, April 2004. http://www.transact.org/report.asp?id=232 This is a policy brief on transportation options for older Americans. Much of the data is derived from the 2001 National Household Travel Survey. Highlights from the Executive Summary include: • More than one in five (21%) Americans ages 65 and older do not drive. Some reasons include: • Declining health, eyesight, physical or mental abilities; • Concern over safety (self-regulation); • No car or no access to a car; • Personal preference. • More than 50% of non-drivers age 65 and older - or 3.6 million Americans stay home on any given day partially because they lack transportation options. The following populations are more heavily affected:

Final Report B-7 • Rural communities and sprawling suburbs; • Households with no car; • Older African-Americans, Latinos and Asian-Americans. • Older non-drivers have a decreased ability to participate in the community and the economy. Compared with older drivers, older non-drivers in the United States make: • 15% fewer trips to the doctor; • 59% fewer shopping trips and visits to restaurants; • 65% fewer trips for social, family and religious activities. • Public transportation trips by older non-drivers totaled an estimated 310 million in 2001; • Older minority populations account for a significant share of these trips, with older African-Americans and Latinos more than twice as likely to use public transportation as their white counterparts. • More livable communities have lower rates of staying home, and higher rates of public transportation use and walking among non-drivers aged 65 and over. • 61% of older non-drivers stay home on a given day in more spread-out areas, as compared to 43% in denser areas; • More than half of older non-drivers use public transportation occasionally in denser areas, as compared to 1 in 20 in more spread-out areas; • One in three older non-drivers walks on a given day in denser areas, as compared to 1 in 14 in more spread-out areas.

Final Report B-8 Baren, J., Shofer, F.S., Ivey, B., Reinhard, S., DeGeus, J., Stahmer, S.A., Panettieri R, Hollander, J.E., A Randomized, Controlled Trial of a Simple Emergency Department Intervention to Improve the Rate of Primary Care Follow-up for Patients With Acute Asthma Exacerbations, Annals of Emergency Medicine, 38: 115-122, 2001. Study of whether an intervention in the emergency department impacts the rate of follow-up over a 4-week window with primary care physicians (PCP) for patients aged 16-45 who enters the emergency department for asthma. The study is a randomized, controlled trial in a university emergency department comparing usual care to an intervention that includes a sample of medicine, a transportation voucher and a phone call reminder to schedule an appointment with the PCP. Sample size was 192 over 8 months, with 93% patients completing follow-up. In both control and intervention groups only 53% of patients had their own car, as shown in Table 2 (abbreviated from original document). Those receiving the intervention were significantly more likely to see the PCP, as shown in Table 4; however transportation itself was not a significant predictor of follow-up attendance.

Final Report B-9 Bayliss, E.A., Steiner, J.F., Fernald, D.H., Crane, L.A., Main, D.S., Descriptions of Barriers to Self-Care by Persons with Comorbid Chronic Diseases, Annals of Family Medicine, 1:15-21, 2003. This article presents the results of interviews with 16 patients with at least 2 comorbid chronic diseases in urban areas to determine the barriers to self-care. Although this study has good background information on the prevalence of comorbidities, nothing transportation specific is discussed. Of the 125 million Americans suffering chronic conditions, 60 million have more than one chronic condition. Comorbidity is age dependent, such that 69% of Americans 65 and older have 2 or more chronic conditions. On average, Americans over age 60 have 2.2 chronic conditions.

Final Report B-10 Beland, F., Lemay A., Boucher, M., Patterns of Visits to Hospital-Based Emergency Rooms, Social Science Medicine, 47: 165-179, 1998. This article attempts to understand the patterns of emergency room (ER) visits by assessing the utilization patterns in the one hospital emergency room (311 beds) in Laval, Quebec, an urban area near the metropolis of Montreal. The 14,045 visits sampled from 1981, 1988, 1986, and 1990 were divided into 4 categories: urgent care only available at a hospital, urgent care available at a hospital and other settings, non-urgent care available only at a hospital, and non- urgent care available at a hospital and other settings. These visits are utilized differently by different generations of patients and by patients grouped in other ways- i.e., low income, young and male, etc. These patterns of utilization may be useful in assessing how many emergency visits could be avoided through more regular care. Bender, B., Milgrom, H., Rand, C., Nonadherence in asthmatic patients: is there a solution to the problem? Annals of Allergy, Asthma and Immunology, 79:177-186, 1997. This meta-analysis on patient compliance with asthma treatment reveals that patients only take 50% of medications they are prescribed. This range is 40-70% nonadherence. Benway, C.B., Hamrin, V., McMahon, T.J., Initial Appointment Nonattendance in Child and Family Mental Health Clinics, American Journal of Orthopsychiatry, 73:419-428, 2003. This article is something of a literature review on the reasons that patients miss mental health appointments and the efficacy of various interventions intended to increase attendance. The authors found no consistency and some contradictions for reasons that appointments are missed and although there were reports of effective interventions, they were not related to the reasons patients miss appointments. Transportation is discussed, briefly. Table 2 shows the results of the literature review.

Final Report B-11 Bishaw, A., Iceland, J., Poverty: 1999, Census 2000 Brief, 2003. www.census.gov This is a Census 2000 Brief produced by the U.S. Census Bureau in the Department of Commerce on poverty according to the 2000 Census survey of families and their incomes in 1999. The report characterizes the current level and burden of poverty based on age, geography, race/ethnicity, and family type. Block, B., Branham, R.A., Efforts to Improve the Follow-Up of Patients with Abnormal Papanicolaou Test Results, Journal of the American Board of Family Practitioners, 11: 1-11, 1998. This is a study of the impact on follow-up of patients from 1994-1996 diagnosed with abnormal Pap tests in a family practice clinic in Pittsburgh, Pennsylvania. An intervention to increase follow-up wherein patients were supplied reminder and support services, including round trip coverage of taxi fare if a transportation barrier was expressed, increased attendance compared to pre-intervention attendance rates in 1990 and 1993. Transportation assistance was the most successful intervention reported. Bostock, L., Pathways of Disadvantage: Walking as a Mode of Transport Among Low-Income Mothers, Health and Social Care in the Community, 9:11–18, 2001. This is qualitative research of low-income mothers and their experiences without cars. The author interviewed 30 mothers on social security benefits in 1996, regarding their experiences without transportation. Many relayed stories of delaying healthcare because of limited access to transportation and the desire to “save up” rides from friends for emergencies only. Braveman, P. Marchi, K., Egerter, S., Pearl, M., Neuhaus J., Barriers to Timely Prenatal Care Among Women With Insurance: The Importance of Prepregnancy Factors, Obstetrics and Gynecology, 95:874-870, 2000. This is a subsample study of 100,000 postpartum women interviewed at one of 19 California hospitals between August 1994 and July 1995. The subsample of 3071 had public (MediCal) or private insurance throughout their pregnancy, was 18 or older, had family incomes at or below 200% poverty, and lived in California in their first trimester. Despite insurance coverage, 8% of pregnant women did not access available prenatal care in a timely manner due to transportation barriers as shown in Table 2.

Final Report B-12

Final Report B-13 Brown, D.M., Public Transportation on the Move in Rural America, Economic Research Services, Department of Agriculture, 2004. http://www.nal.usda.gov/ric/ricpubs/publictrans.htm This is a policy brief in response to 2004 Congressional reauthorization opportunities on the benefits of public transportation services in rural areas. Currently, public transit exists in 60% of all rural counties, with a total of 1200 systems. Rural public transit services benefit economic efficiency and reduce the impact of social inequality. Brown, E.R., Davidson, P.L., Yu, H., Wyn, R., Andersen, R.M., Becerra, L., Razack, N., Effects of Community Factors on Access to Ambulatory Care for Lower-Income Adults in Large Urban Communities, Inquiry, 41: 39-56, 2004. This study examines community factors and their effect on access to ambulatory care using data from low-income, non-elderly, urban residents in the 1995 and 1996 National Health Interview Surveys. The analysis determines the likelihood of visiting a physician over the last year based on individual and community variables.

Final Report B-14 Burkhardt, J.E., Hedrick, J.L., McGavock, A.T., Assessment of the Economic Impacts of Rural Public Transportation, TCRP Report 34, Transportation Research Board, 1998. This document provides guidance to decision makers and transit authorities on the economic impacts of rural public transportation, both in the costs of running a system and in the financial benefits created for a community. Each chapter focuses on a different aspect of the economic impacts associated with public transportation and rural areas, including a section on successful programs that have already been established. The 50% of all rural counties with transit systems

Final Report B-15 experienced an 11% average net economic growth compared to those counties without public transportation. This document provides a useful guide in assessing transportation costs and benefits. Burkhardt, J., Hamby, B., McGavock, A.T., Users' Manual for Assessing Service-Delivery Systems for Rural Passenger Transportation, TCRP Report 6, Transportation Research Board, 1995. According to the project description on the TRB website, this document serves to educate transit agencies interested in providing services to rural communities with a step-by-step process for implementing and evaluating the system. There are several case studies of cost efficient rural transit systems. Much of this work appears to be updated in the 1998 rural transportation report by the same author. Burkhardt, J., Koffman, D., Murray, G., Economic Benefits of Coordinating Human Service Transportation and Transit Services, TCRP Report 91, Transportation Research Board, 2003. The focus of this paper is on coordination of public transportation to lower overall costs and increase utilization. In discussing access, the executive summary cites examples of moving more Paratransit users onto fixed route lines and the cost savings associated with this transition. There is a set of examples of areas that used school buses during school hours to provide Paratransit services. Another savings in coordination comes from using human services agencies to coordinate Paratransit services and utilize volunteers/donations, or to open bids to Paratransit providers. The article is full of case studies and includes medical access specific information. The following figure appears in the executive summary.

Final Report B-16 Burkhardt, J., McGavock, A.T., Nelson, C.A., Improving Public Transit Options for Older Persons, TCRP Report 82, Transportation Research Board, 2002. This book focuses on public transportation and how the services rendered fit the demand from the senior population. The short run recommendations on meeting this demand include maintaining punctuality, coordination with older representatives and the addition of vehicles that support wheelchairs or stretchers to accommodate a range of abilities among older riders. The authors emphasize coordination and a consumer oriented approach that coordinates rides with a variety of ride and vehicle options to suit the older passenger. The two graphs printed below appear in the executive summary and reflect the current trends in utilization and demand for public transit users. The data is from the National Health Interview Survey of 1994. Burkhardt, J., McGavock, A., Researching the Health Care Benefit of Medicare Transportation, Community Transportation Association of America, Research, 2002. http://www.ctaa.org/ct/medical2002/research This report focuses on emergency transportation funded by Medicare. Medicare imposes severe restrictions on transportation that can be reimbursed, however many trips taken in an ambulance could be provided with less cost through Paratransit or public transportation, and would relieve the burden on emergency rooms to provide care. The report cites a GAO study that claimed 50% of ambulance trips were for non-emergency care, although more recent estimates claim only 10%, but the costs are still in the order of $250 million to $1.25 billion transportation dollars. Burt, C.W., and Schappert, S.M., Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States, 1999-2000, National Center for Health Statistics: Vital Health Statistics, 13:1-70, 2004. This report presents data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1999-2000 on all patient visits to physician offices, hospital outpatient departments, and hospital emergency departments based on patient characteristics and presenting condition. Visits to medical specialists were compared to 1993- 1994 data. In 1999-2000 there were 979 million visits, at a rate of 3.6 visits per person. Burton L. C., Anderson G. F., Kues, I. W., Using Electronic Health Records to Help Coordinate Care, The Milbank Quarterly, 82: 457-481, 2004.

Final Report B-17 A paper on multiple chronic health conditions and the higher utilization and medical error associated with these 60 million Americans. Electronic Health Records offer great potential in coordinating care and enhancing communication to reduce errors and lower utilization. The greatest burden stemming from this lack of easy and effective care coordination is for the 60 million Americans with multiple chronic conditions. Studies have found that people with multiple chronic conditions are more likely to be hospitalized, see a variety of physicians, take several prescription drugs, and be visited at home by health workers. For example, Medicare beneficiaries with five or more chronic conditions fill an average of 48 prescriptions, see 15 different doctors, and receive almost 16 home health visits during one year. Furthermore, the poor coordination of care has been associated with poor clinical outcomes such as unnecessary hospitalization, duplicate tests, conflicting clinical advice, and adverse drug reactions. One study showed that Medicare beneficiaries with four or more chronic conditions were 99 times more likely to have an unnecessary hospitalization during the year than was a beneficiary without a chronic condition… Because people with multiple chronic conditions represent 57 percent of healthcare spending, the potential for cost savings from better coordination of their care is obvious. Equally obvious are the problems associated with poor care coordination: unnecessary hospitalizations, unnecessary nursing home visits, duplicate tests, and adverse drug events. Canupp, K.C., Waites, K.B., DeVivo, M.J., Richards, J.S., Predicting Compliance With Annual Follow-up Evaluations in Persons With Spinal Cord Injury, Spinal Cord, 35: 314-319, 1997. This is a comparison study of 102 compliant and 61 noncompliant patients who suffered a spinal cord injury between 1977-1986. Noncompliance with follow-up evaluations was associated with access to transportation, as shown in Table 2. Card, D., Dobkin, C., Maestas, N., The Impact of Nearly Universal Coverage on Health Care Utilization and Health Evidence from Medicare, NBER Working Papers 10365, March 2004. This report shows that health care utilization goes up when Americans enroll in Medicare, often for elective procedures, but the rate of growth of mortality does not similarly change. The issues of access to transportation are not addressed (the word ‘transportation’ does not even appear), but this paper aids in the assessment of moral hazard that might accompany provision of a transportation benefit.

Final Report B-18 Clancy, C.M., Andresen, E.M., Meeting the Health Care Needs of Persons with Disabilities, Milbank Quarterly, 80: 381-391, 2002. This is a qualitative article on the challenges of patients with disabilities in accessing health care. Transportation is not addressed, but other access issues are. The various barriers to access discussed stem from offices and equipment designed for “able” patients as opposed to the disabled. Clayton, A.B., Ed., Older Road Users, The Role of Government and the Processions, Proceedings of a one-day conference held at the Royal Society of Arts, London, November 1993. An older compilation of research conducted in Britain and Europe regarding older drivers, public safety related to automobile accidents, and the demand for transportation. Cleemput, I., Katrien, K., DeGeest, S., A Review of the Literature on the Economics of Noncompliance. Room for Methodological Improvement, Health Policy, 59:65-94, 2002. This is a qualitative review of issues of noncompliance and the methodologies used to study it. Several articles on noncompliance in patient appointment attendance are referenced, providing a good source of additional material to assess the impact of transportation on missed appointments. Committee on Injury and Poison Prevention, School Bus Transportation of Children With Special Health Care Needs, Pediatrics, 108: 516-518, 2001. This is a review of the safety laws surrounding transportation for children with special needs in school buses. It addresses wheelchair access and issues for children with oxygen or tracheostomies, along with the obligations to provide staff with training and nurses onboard depending on the health needs of the child. Committee on Injury and Poison Prevention, Transporting Children With Special Health Care Needs, Pediatrics, 104: 988-992, 1999. This review of safety laws for providing transportation for children with special needs discusses wheelchair and seatbelt harnesses and how transportation needs must be included in planning medical care from a healthcare facility. Seat belt restraints and car seats for toddlers through teenagers are described in detail, as are the needs of children with tracheostomies. Community Transportation Association of America, Medicaid Transportation: Assuring Access to Health Care, A Primer for States, Health Plans, Providers and Advocates, Washington, DC, January 2001. This primer has federal and state information on Medicaid transportation services with specific state examples.

Final Report B-19 Community Transportation Association of America, Medical Transportation Tool Kit and Best Practices, Washington, DC, January 2001. This document contains step-by-step guidance on community transportation services designed to provide non-emergency medical transportation, either provided by state or community funding or through special local programs. The tool kit promises to: • Understand how community transportation can assist the need many patients have for transportation assistance to medical appointments, pharmacies, dialysis, chemotherapy and other treatments. • Understand how and when Medicaid pays for transportation for enrollees. • Discover new funding sources for NEMT. • Learn how to use transit or other existing transportation providers for patients. • Learn how to contract for transportation services. • Understand the issues behind transportation for medical employees. • Learn how other medical organizations and transportation providers are addressing their medical transportation needs. Conover, C.J., Whetten-Goldstein, K., The Impact of Ancillary Services on Primary Care Use and Outcomes for HIV/AIDS Patients with Public Insurance Coverage, AIDS Care, 14:S59-S71, 2002. This is a study of 377 adults, over age 18, eligible for public insurance, suffering AIDS or HIV, and seeing physicians in one of three academic hospitals in North Carolina, to determine the impact of support services on primary care utilization, and health outcomes. Transportation fell into the “other” catch-all ancillary service. Transportation problems are self-reported in 16.7% of all patients, as seen in Table 1. From the discussion: Difficulties in obtaining transportation (a) increased the total number of annual primary care visits; (b) consistently reduced the likelihood of receiving adequate primary care during the year, as noted above; and (c) had no significant effect on whether patients received any primary care. This effect is shown in Table 4.

Final Report B-20 Coughlin, J., Transportation And Older Persons: Perceptions and Preferences, A Report on Focus Groups, AARP Public Policy Institute, 2001. This report details the results of focus groups and interviews with non-institionalized adults over age 75 regarding their perceptions and preferences for transportation. The groups included subsets of suburban and urban nondrivers and suburban drivers. Respondents placed overwhelming preference for the private car as the ideal means of transportation. Urban drivers were most likely to use public transportation. Suburban residents did not know what services were available. Health features only in whether it caused respondents to delay or cancel trips. Public transport was considered unsafe and taxicabs too expensive. Crane, L.A., Kaplan, C.P., Bastani, R., Scrimshaw, S.C.M., Determinants of Adherence Among Health Department Patients Referred for a Mammogram, Women and Health, 24:43-64, 1996. This is a study of variables impacting adherence among women referred to get a mammogram. In the sample of 576 women over 50 from a federal community health department interviewed one year after a mammogram referral, 39% of non-adherent women experienced transportation barriers, compared to 27% of adherent women. Table 4 shows that transportation barriers predict non-adherence. TABLE 4: Predictors of Adherence: Stepwise Logistic Regressiona Predictors Beta Odds Ratio P value Transportation barrier -0.5650 0.57 .02 Fear of immigration authorities -1.3320 0.26 .008 Control over breast cancer 0.1144 1.12 .01 Self-rated health status 0.3064 1.36 .01 Age 60-64 0.6950 2.00 .008 Provider-patient communication -0.1027 0.90 .005 a All variables significantly related to adherence at the bivariate level were entered into a stepwise logistic regression procedure.

Final Report B-21 Daly, J., Sindone, A.P., Thompson, D.R., Hancock, K., Chang, E., Davidson, P., Barriers to Participation in and Adherence to Cardiac Rehabilitation Program: A Critical Literature Review, Progress in Cardiovascular Nursing, 17:8-17, 2002. This is a review of the literature on patients who do not attend cardiac rehabilitation programs. Distance and transportation are factors in missing appointments. Patients that miss appointments are older, female, have low education levels, have pessimistic perceptions about the benefits of cardiovascular rehabilitation, suffer angina, and get little physical activity during leisure time. The author review cautions that there are methodological weaknesses behind many of the conclusions. Damiano, P.C., Momany, E.T., Foster, N.S.J., McLeran H.T., Transportation of Rural Elders and Access to Health Care, University of Iowa Public Policy Center and US Dept of Transportation, June 1994. This is a profile of the demographics, demand for transportation, and current utilization patterns Iowans 75 and older residing in rural areas assessed through a telephone survey of 800 residents and 13 Area Agency on Aging directors and 16 transit managers. Figure 3-4 shows the trip purpose and mode utilized. Table 5-2 shows the funding potential as assessed by AAA and transit personnel for expansion of medical transit programs. Tables 6-4 and –5 focus on the medical care and transportation issues described by the elderly Iowan resident surveyed.

Final Report B-22

Final Report B-23

Final Report B-24 Davidson, P.L., Andersen, R.M., Wyn, R., Brown, E.R., A Framework for Evaluating Safety- Net and Other Community-Level Factors on Access for Low-Income Populations, Inquiry, 41: 21-38, 2004. This paper presents a policy-oriented framework for assessing individual and community level factors that impact access to safety net healthcare services. Community level factors and data sources are outlined below.

Final Report B-25

Final Report B-26 Davidson, R.A., Giancola, A., Gast, A., Ho, Janice, Waddell, R., Evaluation of Access, A Primary Care Program for Indigent Patients: Inpatient and Emergency Room Utilization, Journal of Community Health, 28: 59-64, 2003. This study assesses the impact on utilization given a free primary care program is made available to 91 low-income, chronically ill, Florida patients. In before and after implementation comparisons emergency room utilization and costs went down but inpatient admissions did not change. These results aid in determining moral hazard and the effects of providing care. DeJong, G., Palsbo, S.E., Beatty, P.W., National Rehabilitation Hospital Center for Health and Disability Research, The Organization and Financing of Health Services for Persons with Disabilities, Milbank Quarterly, 80:261-301, 2002. This is a qualitative review of the healthcare needs of the disabled. Transportation issues are described in some detail in regard to the limitations of public transit and the poor scheduling options using Paratransit. Legal information pertaining to the Olmstead case and the American Disability Act is also addressed. DeLia, D., Distributional Issues in the Analysis of Preventable Hospitalizations, Health Services Research, 38: 1761-1780. This study examines the impact of location on preventable hospitalizations, called ambulatory care sensitive admissions, based on zip codes and socioeconomic variables from the US Census and New York state hospital discharge data from 1990-1998. Figure 1 shows preventable hospitalizations by income, demonstrating that lower income patients experience higher ACS. This study addresses the burden of poverty and location on health.

Final Report B-27 Dewees, S., Transportation in Rural Communities: Strategies for Serving Welfare Participants and Low-Income Individuals, Rural Welfare Issue Brief, April 2000. This issue brief describes transportation challenges for low-income rural dwellers. Highlights of the problem: lack of private vehicle ownership; lack of access to public transportation; and long distances between jobs, childcare sites, and home. The brief includes examples of how strategies that address these needs have succeeded. Disease Management Association of America, www.dmaa.org This is a special interest group for healthcare professionals and the healthcare community to explore issues related to disease management. Research documents, conferences and other disease management resources are available. Drummond, M., Stoddart, G. and Torrance, G. Methods for the Economic Evaluation of Health Care Programmes, 1987. New York: Oxford University Press. This book details the various methods economists can evaluate healthcare programs. Cost effectiveness analysis is explained in detail. Ebbinghaus, S., Bahrainwala, A.H., Asthma Management by an Inpatient Asthma Care Team, Pediatric Nursing, 29: 177-182, 2003. This is a study of the efficacy of pediatric asthma case management intervention that includes arranging transportation for future appointments, and emphasizes moving patients off the emergency medical system for transit needs. Comparing costs and outcomes pre 1996, before the case management program (IAS) was implemented, and post 1996 showed that the patients in the program had better coordination of care between inpatient and outpatient programs, and reduced length of stay, as shown in Figure 1. Figure 3 shows the reduced readmission rates for patients in the intervention program.

Final Report B-28 Figure 1. Average Length of Stay for Asthma Inpatients by Service Figure 3. Readmission Rate for Asthma Inpatients by Service/Year ECONorthwest, Parsons Brinckerhoff Quade and Douglas, Inc, Estimating the Benefits and Costs of Public Transit Projects: A Guidebook for Practitioners CD ROM, TCRP Report 78, Transportation Research Board, 2002. This is a CD-ROM that includes both a guidebook and a tool to model the benefits and costs of public transit projects. Although medical transportation is not the focus, the information on costs associated with transportation programs is relevant. Evans, C., Tavakoli, M., Crawford, B., Use of Quality Adjusted Life Years and Life Years Gained as Benchmarks in Economic Evaluations: A Critical Appraisal, Health Care Management Science, 7:43-49, 2004. This research touches on the methodology of quality adjusted life years as a measure of cost effectiveness, and discusses ways to benchmark results. Flores, G., Abreu, M., Olivar, M.A., Kastner, B., Access Barriers to Health Care for Latino Children, Archives of Pediatric Adolescent Medicine, 152: 1119-1125, 1998.

Final Report B-29 This is a survey of 203 urban Latino parents bringing children into the Pediatric Latino Clinic at the Boston Medical Center from February 1996 to February 1997 regarding their children’s healthcare experiences prior to attending the Pediatric Latino Clinic. The single greatest barrier to access to care for Latino children is a language barrier; however transportation was cited as the greatest barrier by 6% of parents surveyed. 21% of respondents said transportation has been a barrier to accessing care in the past. Of the 42 parents citing transportation problems, 62% said they had no car. Flores, G., Abreu, M., Chaisson, C.E., Sun, D., Keeping Children Out of Hospitals: Parents’ and Physicians’ Perspectives on How Pediatric Hospitalizations for Ambulatory Care-Sensitive Conditions Can Be Avoided, Pediatrics, 112:1021–1030, 2003. This article researches the reasons children are hospitalized in cases that could be avoided and the leading causes of these avoidable hospitalization conditions (AHC). The study includes the opinions of parents, PCPs and inpatient attending physicians. Participants were under 18 and were admitted to the inpatient ward of Boston Medical Center from May 1997 through December 1998 with AHC for a total of 676 episodes. Parents responded to a questionnaire, while admitting (IAP) and primary care (PCP) physician interviews were face-to-face or over the telephone. Table 5 shows the results of a regression analysis on the factors related to AHC. According to PCPs, 0.7% of AHC is caused by parent or guardian transportation problems.

Final Report B-30 Friedhoff, S.G., Intensive Case Management of High-Risk Patients in a Family Medicine Residency Setting, Journal of the American Board of Family Practitioners, 12:264-269, 1999. From January to April, 1998, 19 high risk patients in a family medicine residency practice in Mount Holly, New Jersey, were moved into the case management intervention group. Case management included transportation coordination. The residency experienced considerable cost savings ($166,083) as a result of 51% fewer patient days and 46% hospital charges. The case management charges were only 16% of all charges incurred by the case managed patients. Friedman, J., Dinan, M.A., Masselink, L, Allsbrook, J., Bosworth, H., Bright, C., Oddone, E., McIntosh, M., Schulman, K., Weinfurt, K., Perceptions of Access and Barriers to Healthcare: A Survey of Durham County, NC, Duke Clinical Research Institute, November 2003. Based on a national Kaiser Family Foundation survey of access, this research focuses a very similar set of questions for Durham County, North Carolina. Using a telephone survey of residents and a targeted survey to PrimaHealth IPA Provider Network participants (1131 respondents), the authors studied access issues with a focus on the minority populations in Durham and perceptions of racism as a barrier to care. More detailed questions on transportation barriers are below.

Final Report B-31 Friedmann, P.D., Lemon, S.C., Stein, M.D., Transportation and Retention in Outpatient Drug Abuse Treatment Programs, Journal of Substance Abuse Treatment, 21:97-103, 2001. This is a study using data from the Drug Abuse Treatment Outcomes Study (sample size of 1144 patients in an outpatient methadone clinic and 2031 in an outpatient drug-free clinic) on the effects of transportation assistance to improve outpatient treatment retention for patients in drug abuse treatment programs. The provision of a car, van or contracted transportation service improved treatment retention, but vouchers or payment for public transportation did not. Gibson, M.J., Freiman, M., Gregory, S., Kassner, E., Kochera, A., Mullen, F., Pandya, S., Redfoot, D., Straight, A., Wright, B., Beyond 50.03: A Report to the Nation on Independent Living and Disability, AARP Public Policy Institute, 2003. This is a summary report of a survey administered to 1102 Americans over 50 with a disability. Demographic trends and disability rates are summarized as well as health care coverage and access. The majority of older Americans rely on a private car for transportation. The next most common form of transportation is through rides from friends and family- 8.5% of those 50 and older (over 6 million Americans). Older age, low income, and worse disability increases the rate of dependence on others for rides. 50% of those over 50 complain that depending on others for rides creates problems. 32% of Americans 65 and older with a disability report transportation barriers compared to 4% without disabilities. Despite Americans with Disabilities Act provisions that public transit support travelers with disabilities, very few of the elderly surveyed take advantage of these options. Gimotty, P.A., Burack, R.C., George, J.A., Delivering Preventive Health Services of Breast Cancer Control: A Longitudinal View of a Randomized Controlled Trial, Health Services Research, 37:63-83, 2002. This is a randomized controlled trial to evaluate physician reminders as a strategy to increase mammography. Data was collected from women over 40 who had not had breast cancer and had made a visit to the health department primary care clinic in Detroit, Michigan from May 1989 to April 1990. Transportation is not mentioned but other factors that account for missed preventive care are described, shown in Table 2.

Final Report B-32 Glick, H., Cook, J., Kinosian, B., Pitt, B., Bourassa, M.G., Pouleur, H. and Gerth W. 1995. “Costs and Effects of Enalapril Therapy in Patients with Symptomatic Heart Failure: An Economic Analysis of the SOLVD Treatment Trial,” Journal of Cardiac Failure 1: 371-81. This article presents the cost-effectiveness evaluation results stemming from primary data of the Studies of Left Ventricular Dysfunction (SOLVD) Treatment Trial. Therapy with enalapril during the approximate 48-month follow-up period in SOLVD resulted in a gain of 0.16 year of life and savings of dollars 718. During the patient’s lifetime, a survival benefit of 0.40 year, a cost per year of life saved of dollars 80, and a cost per quality-adjusted life year of dollars 115 with the use of enalapril were projected. Gold, M., Siegel, J., Russell, L., and Weinstein, M. eds., Cost-Effectiveness in Health and Medicine, 1996, New York: Oxford University Press. This book outlines cost-effectiveness analytical methods with a focus on healthcare and medical treatments. Greineder, D.K., Loane, K.C., Parks, P., A Randomized Controlled Trial of a Pediatric Asthma Outreach Program, Journal of Allergy and Clinical Immunology, 103: 436-430, 1999. This randomized controlled trial of a team case management approach to pediatric asthma care demonstrated that better management can reduce hospitalization rates by 75% compared to controls, emergency room visits by 57% and out-of-health-plan use by 71%. Asthma is the most prevalent chronic condition among children, with nearly 5 million children diagnosed.

Final Report B-33 Gresenz, C.R., Rogowski, J.A., Escarce, J.J., Health Care Markets, the Safety Net and Access to Care Among the Uninsured, 2004, Cambridge, MA: NBER Working Papers 10799. This article analyzes data on healthcare markets, utilization, and the uninsured using the Medical Expenditure Panel Survey. Guse, C.E., Richardson, L., Carle,M., Schmidt, K., The Effect of Exit-Interview Patient Education on No-Show Rates at a Family Practice Residency Clinic, Journal of the American Board of Family Practice, 16: 399-404, 2003. This is a study designed to assess the value of exit interviews as a means of reducing missed appointments in a family practice residency clinic in Milwaukee, Wisconsin. There were 146 patients in the intervention group who received an exit interview including clinic policies and patient education following first appointments. Patients who missed appointments or were in 4 clinic sessions not assigned to the intervention made up the 297 patients in the control group. Data from billing records and the 1999 Census were used to analyze socioeconomic variables. Part of the exit interview intervention included conversation/education about transportation. Missed appointments were associated with low income and noncommercial insurance. Table 3 shows the risk of non-attendance given various factors. Hasselblad, V., McCrory, D., Meta-Analytic Tools for Medical Decision Making: A Practical Guide, Medical Decision Making, 15:81-96, 1995. This paper provides a methodology for meta-analysis of medical research using actual examples. The methods include those for combining p-values, for analyzing general fixed-effects models, for analyzing contingency tables, and for analyzing count and continuous outcomes. Haynes, R., Geographical Access to Health Care, Access to Health Care, p.13-35, edited by M. Gulliford and M. Morgan, New York, 2003. This is a chapter in a book on access issues, published in Britain. The author describes geographic location and transportation issues in health care in general. Figure 2.1 provides a useful diagram of the complexity of this problem.

Final Report B-34 Health and Retirement Study, University of Michigan Institute for Social Research, http:/hrsonline.isr.umich.edu According to the website: The University of Michigan Health and Retirement Study (HRS) surveys more than 22,000 Americans over the age of 50 every two years. Supported by the National Institute on Aging (NIA U01AG09740), the study paints an emerging portrait of an aging America's physical and mental health, insurance coverage, financial status, family support systems, labor market status, and retirement planning. Hetzel L, Smith, A., The 65 Years and Over Population, 2000, Census 2000 Brief, 2001. This is a Census 2000 Brief produced by the U.S. Census Bureau in the Department of Commerce on the population in American aged 65 and older. The report characterizes the current rates and projections of age, life expectancy, income, disability status, geography, race/ethnicity, and family type. Hillemeier, M.M., Lynch, J., Harper, S., Casper, M., Measuring Contextual Characteristics for Community Health, Health Services Research, 38:1645-1718, 2003. Transportation is considered one of 12 dimensions in the study of how to measure community health, as seen in Figure 1, but the issues studied are public health related: injuries and death from motor vehicle accidents, safety in walking, and environmental factors like car pollution and congestion. Access to jobs is also addressed under the transportation dimension. Information on

Final Report B-35 access to public transportation by neighborhood was through the American Housing Survey. Information on spending and fare revenue for public transit systems was through the National Transit Database. Hixon, A.L., Chapman, R.W., Nuovo, J., Failure to Keep Clinic Appointments: Implications for Residency Education and Productivity, Family Medicine, 31: 627-630, 1999. This research examines the impact of missed appointments on health providers through a survey administered to all 486 family practice residencies in the U.S. on missed appointments. Of the 60% of clinics that respondent the average, estimated no-show rate was 21%. There was no statistically significant difference in no-show rates between clinics that used reminder systems or not. Hobson, J., Quiroz-Martinez, J., Roadblocks to Health: Transportation Barriers to Healthy Communities, Transportation for Healthy Communities Collaborative, 2002. www.transcoalition.org The research focuses on the health of fifteen low-income communities of color in Oakland, California, using geographic information systems (GIS) to study access and transportation barriers and a multi lingual survey of 699 residents. Highlights: Alameda County • Only 28% of the residents of Alameda County’s disadvantaged neighborhoods have transit access to a hospital, leaving over 160,000 residents without transit access. • African-American pedestrians in Alameda County are 2.5 times more likely than white pedestrians to be hit by a car and killed or hospitalized. Contra Costa County • Contra Costa County’s disadvantaged neighborhoods have the worst access of the three counties in this study: 20% of residents have transit access to a hospital, 33% have transit access to a community clinic, and 39% have walking access to a supermarket.

Final Report B-36 • In four of the county’s six neighborhoods, no residents have transit access to a hospital. • In Monument Corridor neighborhood in Concord, residents suffer from 0% transit access to hospitals and only 1% access to clinics, despite the presence of facilities nearby. • North Richmond residents have 0% access to hospitals and supermarkets. Santa Clara County • Of the three counties studied, Santa Clara County’s disadvantaged neighborhoods residents have the best transit access to hospitals and supermarkets. • Access to hospitals is threatened by the planned closure of the San Jose Medical Center, which would reduce transit access to a hospital from 42% to 0% for residents of downtown San Jose, and from 74% to 48% for residents of East San Jose. • Residents of suburban Gilroy suffer from poor transit access under all the measures in this report, including 0% access to clinics, 7% transit access to hospitals and 33% to supermarkets. Ide, B.A., Curry, M.A., Drobnies, B., Factors Related to the Keeping of Appointments by Indigent Clients, Journal of Health Care for the Poor and Underserved, 4:21-39, 1993. A comprehensive study of the clinic and client records from 1986-1987 at the University Medical Hospital in Lafayette, Louisiana, and a sub sample telephone survey of the factors predicting no- shows in an indigent population. Of the 213 in the sample, 155 had missed their last appointment, within the sub sample of 41, all had missed appointments. Results showed that patients living more than 20 miles from the source of care were twice as likely to miss an appointment. Lack of transportation was a leading cause for non-attendance as shown in Table 3.

Final Report B-37 Institute of Medicine, Unequal Treatment: What Healthcare Providers Need to Know about Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academy Press, 2002. This report addresses racial and ethnic disparities in healthcare with emphasis on how this impacts healthcare provider’s practices. A lack of awareness of disparities, subjective medicine, as opposed to “evidence-based medicine” and too few minority providers contribute to the problem. Irwin, C.E., Millstein, S.G., Ellen, J.M. Appointment-keeping Behavior in Adolescents: Factors Associated with Follow-Up Appointment Keeping, Pediatrics, 92:20-3, 1993. Interviews/questionnaires with 166 adolescent patients in a California general adolescent medical clinic found that 12.8% of patients failed to keep appointments because of transportation issues. Through the Health Belief Model, the number of perceived negative health outcomes if appointments were missed predicted patient appointment compliance. Parental involvement impacted initial appointment keeping but not follow-up appointment compliance. Javors, J. R., Bramble, J. E., Uncontrolled Chronic Disease: Patient Non-Compliance or Clinical Mismanagement? Disease Management, 6: 169-178, 2003. This evaluation of patient compliance in a population of chronically ill beneficiaries in a Midwestern company revealed that nearly all the patients were following doctor’s orders, but 50% did not have their conditions under control due to clinician behavior. Clinicians that followed national guidelines were highly correlated with patients who had their conditions under control. Patients who did not have their conditions under control had clinicians that were aware of the guidelines but did not agree or misunderstood them. Communication and administrative barriers were also cited as a reason for failure on the clinician’s part to adequately follow guidelines. Jefferson, T., Demicheli, V., Mugford, M., Elementary Economic Evaluation in Health Care, BMJ Publishing Group, London, 1996. This book presents various methods for evaluating the economics of healthcare, including cost of illness studies, healthcare financing and resource allocation, with case studies and real-life examples. Jorgensen, W.A., Pollvka, B.J., Lennie, T.A., Perceived Adherence to Prescribed or Recommended Standards of Care Among Adults with Diabetes, The Diabetes Educator, 28:989- 998, 2002. This is a survey administered to 264 diabetic adults receiving care at a health department clinic, and 111 patients in a non-profit healthcare agency to evaluate how diabetes patients perceived and adhered to the four standards of care: diet, exercise, weight and diabetes self-management education and whether barriers affected either perception or adherence. The most frequent reasons cited for missing appointments and not receiving appropriate care included transportation, as shown in Tables 4 and 5.

Final Report B-38 Karter, A.J., Parker, M.M., Moffet, H.H., Ahmed, A.T., Ferrara, A., Liu, J.Y., Selby, J.V., Missed Appointments and Poor Glycemic Control, An Opportunity to Identify High-Risk Diabetic Patients, Medical Care, 42:110-115, 2004. A study of missed appointments and glycemic control/diabetes self management in the 84,040 members of the Kaiser Permanente Northern California Diabetes Registry during 2000. Appointment keeping was measured as no missed, 1- 30% missed and more than 30% missed appointments in the calendar year. Transportation was not specifically measured but mentioned in the discussion. Highlights: The adjusted mean glycosylated hemoglobin (HbA1c ) among members who missed more than 30% of scheduled appointments was 0.70 to 0.79 points higher (P <0.0001) relative to those attending all appointments. Patients who missed more than 30% of their appointments were less likely to practice daily self-monitoring of blood glucose and to have poor oral medication refill adherence.

Final Report B-39 Kaye, H.S., Mobility Device Use in the United States, Report #14, National Institute on Disability and Rehabilitation Research, 2000. This report contains national information on current trends in disability and device use based on the results of the National Health Interview Survey. Table 9 shows the health conditions associated with mobility use, Table 14 shows the rates and types of mobility device use by age and insurance status.

Final Report B-40 Kenagy, G.P., Linsk, N.L., Bruce, D., Warnecke, R., Gordon, A., Wagaw, F., Densham, A., Service Utilization, Service Barriers, and Gender Among HIV-Positive Consumers in Primary Care, AIDS Patient Care and STDs, 17: 235-244, 2003. Study of AIDS/HIV primary care beneficiaries of the Ryan White CARE Act in Chicago to determine the utilization and barriers for primary care services. Of the 161 patients surveyed, 43% reported at least one unmet demand. The most common included transportation (16.8% total, 20.4% of men and 11.5% of women) as shown in Table 2.

Final Report B-41 Table 2. Percentage of Sample Unable to Obtain Services Because of Cost Kindig, D. et al., What New Knowledge Would Help Policymakers Better Balance Investments for Optimal Health Outcomes? Health Services Research, 38(6), Part II:1923-1937, December 2003 (A special supplement to HSR on the social determinants of health). A synthesis of factors which play a role in “producing” good health and a discussion of which factors deserve greater research activity. Twenty-five years after Grossman’s seminal work on the health production function, there is a growing scholarly and policy appreciation that producing health comes from much more than medical care, and that optimizing health outcomes requires a balanced investment strategy across all determinants… This article’s purpose is to stimulate research to produce knowledge about cross-sectoral relationships that might be useful to inform policymakers as they develop and implement policies for population health improvement. We do not here establish such relationships but reiterate and emphasize this residual gap between knowing that there are relationships and knowing exactly the order and weight these relationships take. We consider such sectors and factors to be medical care, public health, income and income maintenance, education, land use, air and water quality, agriculture and food processing, housing, social cohesion, political stability, and economic development. We define cross-sectoral to be explicit coordination or reallocation of resources in order to achieve a benefit in maintaining or improving health status for a population. Kolata, G., Annual Physical Checkup May Be an Empty Ritual, New York Times, August 12, 2003. Newspaper article on the value of physical check-ups every year. The concepts presented here bear on the benefits calculated for providing transit services for missed appointments.

Final Report B-42 Kulkarni, M., Fact Sheet: Medicaid Transportation Services, National Health Law Program, June 2000. http://www.healthlaw.org/pubs/200006FactSheet_trans.html This is a fact sheet on what the Medicaid program is required by law to provide Americans. Each state plan must ensure that Medicaid patients have necessary transportation to and from health services. Necessary can be defined according to the following: • Transportation to and from Medicaid-covered services; • The least expensive form available and appropriate for the client; • To the nearest qualified provider; and • No other transportation resource is available free of charge. • Transportation can be funded either as an administrative expense or as a medical service. Lamberth, E.R., Rothstein, E.P, Hipp, T.J., Souder, R.L., Kennedy, T. I., Faccenda, D.F., Casher, D., Kratz, R.T., Homeier, B.P., Rates of Missed Appointments Among Patients in a Private Practice: Medicaid Compared with Private Insurance, Archives of Pediatric and Adolescent Medicine, 156:86-7, 2002. Over 11-weeks appointments in a suburban/rural pediatric practice in Pennsylvania were evaluated for missed appointments and insurance status. Medicaid patients missed nearly twice as many appointments as privately insured patients.

Final Report B-43 Larson, S.L., Machlin, S.R., Nixon, A., Zodet, M., Health Care in Urban and Rural Areas, Combined Years 1998-2000. Agency for Healthcare Research and Quality, Rockville, MD. MEPS Chartbook, No.13, 2004. AHRQ Pub. No. 04-0050. This report compares healthcare access, use and costs between urban and rural areas using the metropolitan statistical areas (MSA) designations in the Medical Expenditure Panel Survey data from 1998-2000. More rural residents were elderly, female, and in poor health compared to urban residents. Rural residents had fewer visits than their urban counterparts- a difference that was especially true among elderly rural residents. Lavizzo-Mourey, R., Smith, V., Sims, R., Taylor, L., Hearing Loss: An Educational and Screening Program for African-American and Latino Elderly, Journal of the National Medical Association, 86:53-9, 1994. This is a study on African-American and Latino elderly to determine the effectiveness of culturally sensitive educational pamphlets and screenings. Of the 296 seniors screened, 174 had abnormal hearing but only 26% obtained further testing. The barriers to follow-up care included problems with finances, transportation and illness. LeSon, S., Gerswhin, M.E., Risk Factors for Asthmatic Patients Requiring Intubation. I. Observations in Children, Journal of Asthma, 32: 285-294, 1995. This is a study of risk factors for asthma intubation in young adults as potential predictors of death. The sample included all asthmatics 5-12 admitted over a 10-year period to UC Davis Medical Center. Despite comprehensive patient characteristics recorded, transportation was not directly mentioned. LeSon, S., Gerswhin, M.E., Risk Factors for Asthmatic Patients Requiring Intubation.III. Observations in Young Adults, Journal of Asthma, 33: 27-35, 1996. This is a study of risk factors for intubation in young adults as potential predictors of death. The sample included all asthmatics 20-34 admitted over a 10-year period to UC Davis Medical Center. Transportation is not a variable considered, however other risk factors that correlate with the transportation disadvantaged population are considered.

Final Report B-44 Lo, W., MacGovern, T., Bradford, J., Association of Ancillary Services With Primary Care Utilization and Retention for Patients With HIV/AIDS, AIDS Care, 14: S45-S57, 2002. A study of 999 patients of Boston’s Fenway Community Health Center from 1997 to 1998 to assess HIV and AIDS patients use of support services and subsequent utilization and primary care retention rates. 5.1% of patients needed transportation and 78.4% received it. Table 4 shows the association of transportation with primary care visits. Logisticare 2003b. Case Study: The Connecticut Medicaid NET. www.logisticare.com. Accessed 7/31/03. This is a commercial white paper on the experience of LogistiCare in providing coordination assistance to the various non-emergency medical transportation service providers in the state of Connecticut. Logisticare. 2003a. Case Study: State of Georgia Medicaid NET. www.logisticare.com. Accessed 7/31/03. This is a commercial white paper on the benefits of the coordination between LogistiCare and the Georgia Medicaid program to provide cost effective non-emergency medical transportation to Medicaid patients. Georgia reduced costs by 50% and increased services threefold. Longino, C.F. Jr., Taplin, I.M., How Does the Mobility of the Elderly Affect Health Care Delivery in the USA? Aging Clinical Experience and Research, 6: 399-409, 1994. This research is a qualitative study on how the demands mobile older Americans impact health care delivery, with a focus on migrant workers, veterans, and those transitioning into nursing homes or concentrating into rural areas for retirement.

Final Report B-45 Long, S.K., Coughlin, T.A., Kendall, S.J., Access to Care Among Disabled Adults on Medicaid, Health Care Financing Review; 23: 159-174, 2002. This article explores in more detail the access issues for disabled Medicaid beneficiaries based on disability subgroups among adult Social Security beneficiaries in New York City from 1999- 2000. Those with mental retardation/developmental disabilities and those with increased activities of daily living (ADL) limitations faced the greatest barrier to accessing care. Transportation is not directly addressed however vehicle needs can be extrapolated. Lovett, A., Haynes, R., Unnenberg, G.S., Gale, S., Car Travel Time and Accessibility by Bus to General Practitioner Services: a study using patient registers and GIS, Social Science & Medicine, 55: 97-111, 2002. Research in the Britain using geographic information systems (GIS) to evaluate accessibility of surgery clinics through public and private transit routes. Highlights: The results indicated that only 10% of residents faced a car journey of more than 10 min to a GP. Some 13% of the population could not reach general medical services by daily bus. For 5% of the population, the car journey to the nearest surgery was longer than 10 min and there was no suitable bus service each weekday. GIS may be a useful way to evaluate accessibility, especially for rural and low- income populations.

Final Report B-46 Luce, B. R., Zangwill, K. M., Palmer, C. S., Mendelman, P. M., Yan, L., Wolff, M. C., Cho, I., Marcy, S. M., Iacuzio, D., Belshe, R. B., Cost-Effectiveness Analysis of Intranasal Influenza Vaccine for the Prevention of Influenza in Healthy Children, Pediatrics, 108: 24-33, 2001 This cost effectiveness analysis focuses on children and shows that administration of the influenza vaccine on an individual basis was $30 for each day of illness avoided. The analysis was sensitive to the cost of the vaccine and its administration. If the study was done on a group basis, the vaccine was cost saving as long as the vaccine cost less than $28. Majeroni, B.A., Cowan, T., Osborne, J., Graham, R.P., Missed Appointments and Medicaid Managed Care, Archives of Family Medicine, 5:507-11, 1996. This retrospective cohort study of missed appointments in an 18-month period in an urban primary care practice studied the correlation between insurer, age, sex, race, ZIP code and diagnoses. Of all established patients, 48% missed one or more appointment. Medicaid managed care insured patients scheduled and missed more appointments than other insurances. Mark, D., Hlatky, M., Medical Economics and the Assessment of Value in Cardiovascular Medicine: Part I, Circulation 106: 516-20, 2002. This article presents a framework for analyzing advances in cardiovascular care through medical economics. A glossary on economic terms that apply to medical evaluations is included. The following methods are discussed as they pertain to comparisons of new technology to standard care. McClure, R.J., Newell, S.J., Edwards, S., Patient Characteristics Affecting Attendance At General Outpatient Clinics, Archives of Disease in Childhood, 74: 121-125, 1996. Results from a survey administered to parents of 359 children over 6-months at a general clinic in Leeds, England showed two distinct categories of attenders and non-attenders. 36% of non- attenders used a car, compared to 63% of attenders. Non-attenders also spent 8 minutes more than attenders getting to appointments. The parent’s perception of the severity of illness was not a factor in attendance, indicating that logistical and social factors are behind non-attendance. McCray, T., Delivering Healthy Babies: Transportation and Health Care Access, Planning Practice and Research 15: 17-29, 2000. This is a study of how transportation patterns and access impact prenatal care using data from Detroit, MI and South Africa. Infant mortality is greatly reduced by prenatal care, however

Final Report B-47 pregnant women are unlikely to access healthcare if transportation services are unavailable or unreliable. McCray, T., Promoting the Journey to Health: Healthcare Access and Transportation in Rural South Africa, University of Michigan, Ph.D. Dissertation, 2001. A precursor to McCray’s other article, this study analyzes data from South Africa that shows pregnant women’s access to healthcare is impacted by transportation resources, including safety at public transit stops and reliability of transit systems. McNeil, J., Americans with Disabilities: Current Population Reports – 1997, February 2001. This profile of Americans with disabilities from the 1997 Survey of Income and Program Participation documents the type and magnitude of disability in the United States in 1997. 27.9% of severely disabled adults live below the poverty line, compared to 8.3% of non-disabled adults. Additional statistics are shown below. Messeri, P.A., Abramson, D.M., Aidala, A.A., Lee, F., Lee, G., The Impact of Ancillary HIV Services on Engagement in Medical Care in New York City, AIDS Care, 14: S15-S29, 2002. Longitudinal data on 577 HIV positive adults in New York City was used to examine the effect of ancillary support services on the number of HIV patients entering and retaining medical care. Transportation was identified as a logistical need that could be addressed with advice/education on how to access rides or more practical help. Ancillary service provision was associated with increased entry and continuity, especially when the service provided met a documented need.

Final Report B-48 Milliman Care Guidelines, www.careguidelines.com This is a commercial product designed to support clinical healthcare providers by providing evidence-based practices at the point of care. The Care Guidelines cover inpatient and outpatient services, as well as home care, long-term care, and other specialty services. Mishan, E., Cost-Benefit Analysis, 4th Edition, Unwin Hyman, London, 1988. This textbook explains the methodology of cost-benefit analysis with case studies.

Final Report B-49 MMWR, Facilitating Influenza and Pneumococcal Vaccination Through Standing Orders Programs, Morbidity and Mortality Weekly Report, 52: 68-69, 2003. This is an update of the Advisory Committee on Immunization Practices (ACIP) recommendations on the use of the influenza and pneumococcal vaccines. Influenza can be relatively harmless but can cause hospitalizations and sometimes death in young children and the elderly, who are considered most at risk. The primary target groups recommended for annual vaccination are 1) persons at increased risk for influenza-related complications (e.g., those aged >65 years, children aged 6--23 months, pregnant women, and persons of any age with certain chronic medical conditions); 2) persons aged 50--64 years because this group has an elevated prevalence of certain chronic medical conditions; and 3) persons who live with or care for persons at high risk (e.g., health-care workers and household contacts who have frequent contact with persons at high risk and who can transmit influenza to those persons at high risk). The vaccine prevents influenza in 70-90% of adults under age 65. Efficacy results in children vary, with the lowest estimate at 30% of children protected against the virus. Among the elderly who are not in nursing homes, the vaccine protects against hospitalization for 30-70% of users. Cost effectiveness studies of the influenza vaccine estimated a cost of approximately $60-- $4,000/illness averted among healthy persons aged 18--64 years, depending on the cost of vaccination, the influenza attack rate, and vaccine effectiveness against influenza-like illness. Another cost-benefit economic model estimated an average annual savings of $13.66/person vaccinated. Among persons aged >65 years, vaccination resulted in a net savings per quality- adjusted life year (QALY) gained and resulted in costs of $23--$256/QALY among younger age groups. Additional studies of the relative cost-effectiveness and cost utility of influenza vaccination among children and among adults aged <65 years are needed and should be designed to account for year-to-year variations in influenza attack rates, illness severity, and vaccine efficacy when evaluating the long-term costs and benefits of annual vaccination. Table 2 shows vaccine coverage rates by age group according to 2002 NHIS data.

Final Report B-50 Moran, C.M., Hletko, P., Darden, P.M., Reigart, J.R., Transportation: A Barrier to Health Care for Rural Children? The eJournal of the South Carolina Medical Association, 99:261-268, 2003. This is a study of access to care in rural Georgetown County, South Carolina through the administration of a 42 question, multiple-choice questionnaire to 341 caretakers whose patients received care at two health care systems emergency rooms serving the county in 2000. Tables 2, 3 and 4 profile the transportation barriers existing within the various subpopulations of the sample and the associated health care utilization. Table 5 shows the association of belief in the health care system with emergency room visits.

Final Report B-51

Final Report B-52 Mulder, P.L., Shellenberger, S., Streiegel, R., Jumper-Thurman, P., Danda, C.E., Kenkel, M.B., Constantine, M.G., Sears, S.F.Jr., Kalodner, M., Hager, A., The Behavioral Health Care Needs of Rural Women, Report Of The Rural Women’s Work Group and the Committee on Rural Health Of the American Psychological Association, September 2000. www.apa.org/rural/ruralwomen.pdf. According to the executive summary, commonly cited barriers to treatment include low population density; geographical distance from large metropolitan areas; isolation; inclement weather; geographic barriers; dense social networks; patriarchal or traditionalist social structures; a culture of self-sufficiency; and fewer economic resources. Many families do not have telephones; many families do not have automobiles, and public transportation is almost never available in rural areas. Cost is consistently listed as the main deterrent to health care, including mental health services. Rural women are less likely to have health insurance than males because of the lack of employment opportunities and poverty. Rural residents are frequently unaware of the various entitlement programs available to them and the rural population struggles with a limited tax base to fund needed services, resulting in underfunding and understaffing of health care centers, further exacerbating the problem. National Asthma Education and Prevention Program, Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, National Institutes of Health, 1997. Publication No. 97-4051. Overview of asthma in children and adults including symptoms to track, goals for disease management and drugs that are approved and recommended for different stages of the disease. Nemet, G.F., Bailey, A.J., Distance and Health Care Utilization Among the Rural Elderly, Social Science and Medicine, 50:1197-1208, 2000. This research focuses on the distance from health care services and the impact on utilization among rural elderly in Vermont assessed through a mailed survey to 20 random elderly residents of Orleans County. Although there is some evidence that distance impacts utilization, the sample size is too small to draw a significant conclusion. Newacheck, P.W., Hung, Y.Y., Park, J., Brindis, C.D., Irwin, C.E.Jr, Disparities in Adolescent Health and Health Care: Does Socioeconomic Status Matter? Health Services Research, 38:1235-1252, 2003. A study using 1999-2000 NHIS data to analyze access for children aged 10-18. Transportation barriers are only mentioned in the conclusion, but this article characterizes access for a low- income population well. Results for medical information are shown in Figure 1, access issues are in Figure 3.

Final Report B-53

Final Report B-54 Nichol, K.L., Mallon, K. P., Mendelman, P. M., Cost Benefit of Influenza Vaccination in Healthy, Working Adults: an Economic Analysis Based on the Results of a Clinical Trial of Trivalent Live Attenuated Influenza Virus Vaccine, Vaccine, 21: 2207-2217, 2003. This cost benefit analysis of providing an influenza vaccine to healthy adults showed that the breakeven cost of the vaccine and its administration was $43 per person. Work missed as well as ineffective work time and visits to healthcare providers were calculated as part of the cost of contracting influenza. Nichol, K.L., Ten Year Durability and Success of an Organized Program to Increase Influenza and Pneumococcal Vaccination Rates Among High-Risk Adults, American Journal of Medicine, 105: 385-392, 1998. This is a ten-year study on the effectiveness of a vaccination program in the Veterans Affairs Medical Center of Minneapolis. Compliance rates with vaccines for influenza went from 58% to 84% over the study period. Rates were lowest among high risk patients under age 65. Northwest Research Group, Oregon's Mobility Needs: General Population Survey and Transportation Provider Survey Final Report, SPR 395, Oregon Department of Transportation, January 1999. This is a study of the mobility needs of Oregon residents, evaluated through telephone surveys with 578 mobility impaired residents and 129 mailed surveys to transit providers. Highlights for the mobility impaired in Oregon: • Mobility impairment has an 8% incidence rate; • 61% of trips were for medical appointments; • 16% reported no access to public transportation. • Transportation barriers were assessed for the mobility impaired and health population, as shown in Figure ES.1. Figure ES.2 shows the type of mobility impairment.

Final Report B-55 O’Connell, L., Grossardt, T., Siria, B., Marchand, S., McDorman, M., Efficiency Through Accountability: Some Lessons from Kentucky’s Improved Medicaid Transit Service, Journal of Transportation and Statistics, 5: 73-81, 2002. This is an evaluation of Kentucky’s 1998 reform of its Medicaid non-emergency medical transit program through interviews with transit providers and Medicaid beneficiaries. Through better accountability and efforts to increase efficiency, quality, customer satisfaction and cost control all improved. The number of trips increased by 58% while unit cost decreased by 18%. Figure 1 displays the accountability changes. Table 3 shows the changes before and after reform in the mode of transportation.

Final Report B-56 O’Day, B., Dautel, P., Scheer, J., Barriers to Healthcare for People with Mobility Impairments, Managed Care Quarterly 10:41-57, 2002. Fifty-seven working age disabled people discuss barriers to quality, access, and payment in focus groups and interviews. Specific disabilities discussed include spinal cord injury (SCI), multiple sclerosis (MS), cerebral palsy (CP) and arthritis. Transportation barriers include wheelchair users who need lift-equipped, regular route bus service or door-to-door Paratransit services, or medical transportation. Patients complained of the advance notice required to schedule Paratransit services and the unreliability of the Paratransit system. O’Day, B., Palsbo, S. E., Dhont, K., Scheer, J., Health Plan Selection Criteria by People with Impaired Mobility, Medical Care, 40:732-42, 2002. Observational study and qualitative analysis of structured focus groups discussing disability as a barrier to accessing care. Focus group disliked Paratransit. Ofman, J. J., Badamgarav, E., Henning, J. M., Knight, K., Gano, A. D. Jr., Levan, R. K, Gur- Arie, S., Richards, M. S., Hasselbad, V., Weingarten, S. R., Does Disease Management Improve Clinical and Economic Outcomes in Patients with Chronic Disease? A Systematic Review, American Journal of Medicine, 117: 182-92, 2004. This review of the literature on disease management and chronic disease conditions demonstrates the benefits possible through improved coordination of care and patient management. The most successful disease management programs focus on depression, hyperlipidemia, coronary artery disease, hypertension, and diabetes. Chronic obstructive pulmonary disease and chronic pain were the least effective. Information on cost savings was limited. Patient education was the most common disease management strategy. Olason, R.A., Accessible Raleigh Transportation: A Paratransit System Using Trip-by-Trip Eligibility Determination and Two-Tiered, User-Side Subsidy. Transportation Research Record, 1760: 121-134, 2001. This is a profile of the community funded, Paratransit service in Raleigh, North Carolina that provides non-emergency medical transportation to disabled patients unable to ride buses. Taxicab ordinances allowed the community to create a complementary service with wheelchair accessible vans and cars that meets the demands of disabled residents. Tiered subsidies ensure effective cost sharing that does not inhibit utilization. O’Malley, A.S., Mandelblatt, J., Delivery of Preventive Services for Low-Income Persons Over Age 50: A Comparison of Community Health Clinics to Private Doctor’s Offices, Journal of Community Health, 28:185-97, 2003. This study used 1998 National Health Interview Survey results to compare preventive care between patients in privately insured offices versus community health care clinics. Of patients over age 50 and <200% the poverty level, 14.3% reported transportation and/or time issues that delayed care in the past year, as opposed to 8.7% of all patients over 50 in the U.S. A higher number of patients over 50 and <200% of the poverty level did not get needed treatment in the past year because of cost barriers-18.8% as opposed to 7.5% of all patients over 50 in the U.S.

Final Report B-57 Pagano, A.M., How Effective is Computer-Assisted Scheduling and Dispatching in Para- transit? 1760, Paper No. 01-2290, Transportation Research Record 2001. A survey and follow-up telephone interview administered to 14 nation-wide transportation managers with computer-assisted scheduling and dispatching (CASD) systems implemented. Table 1 shows the descriptive data from the survey. Figure 2 shows how the functions of the CASD system are being used, revealing that half of managers do no use all the functions of the CASD. Table 3 shows how the CASD has improved Paratransit services, demonstrating efficiency gains in the majority of Paratransit areas.

Final Report B-58 Partnership for Solutions, Asthma: The Impact of Multiple Chronic Conditions, August 2004. www.partnershipforsolutions.org. This is a summary of the prevalence, cost and health burden of asthma by age group. Comorbid conditions are also included, shown in Table 1. Age Group Most Common Comorbidity (%) Second-Most Common Comorbidity (%) 0-17 Allergies (23%) Pre adult Disorders (5%) 18-34 Allergies (19%) Chronic Respiratory Infections (11%) 35-64 Hypertension (27%) Allergies (26%) 65-74 Hypertension (51%) Heart Disease (31%) 75+ Hypertension (54%) Heart Disease (34%) Partnership for Solutions, Chronic Conditions: Making the Case for Ongoing Care, December 2002. www.partnershipforsolutions.org. This chartbook on chronic conditions highlights prevalence, trends, cost and utilization data from several different sources. The patient and clinician perspectives are considered in regard to barriers to coordination of care and the unique role of caregivers is also explored. Women have more chronic conditions than men; older adults have more chronic conditions than younger people.

Final Report B-59

Final Report B-60

Final Report B-61 Paul, J., Hanna, J.B., Applying the Marketing Concept in Health Care: The No-Show Problem, Health Marketing Quarterly, 14:3-18, 1997. An economic analysis of missed appointments and how the marketing concept can effectively be applied. A survey was administered to 114 randomly selected patients over a two-week period in an urban, hospital-based internal medicine clinic, and then telephone interviews were conducted with 44 of the 66 patients who had missed appointments in the week following the written survey administration. 22.7% of patients interviewed via telephone missed appointments because of transportation. Past no-shows predicted future no-shows.

Final Report B-62 Phelps, K., Taylor, C., Kimmel, S., Nagel, R., Klein, W., Puczynski, S., Factors Associated with Emergency Department Utilization for Nonurgent Pediatric Problems, Archives of Family Medicine, 9: 1086-1092, 2000. This is a survey administered to caretakers who brought children into the emergency room (ER) for non-acute conditions. The sample size was 200, 82% of who were mothers, and 70% of who were single parents, surveyed in one of two urban hospitals. Caretakers who were taken to the ER as children and caretakers on Medicaid viewed the ER as the usual site of care. Being a single caretakers predicted non-urgent visits. 19% of subjects surveyed reported not having a car and using public transportation or walking. 20% of caretakers surveyed answered the question “Why did you bring your child to the ER today?” with “the emergency room is closer to my home than the doctor’s office”. Although transportation was assessed in the patient characteristics, it was not listed as a predictor of non-urgent ER use. Porter, V., Angels on the Web: Free Flight for Patients in Need, Medscape Infectious Diseases, 4, 2002. A description of an airline program that helps underserved populations, particularly children and those in remote settings, access health care. Pucher, J., Renne J.L, Socioeconomics of Urban Travel: Evidence from the 2001 NHTS, Transportation Quarterly, 57: 49-77, 2003. This is a report on the results of the 2001 National Household Travel Survey. Comparisons are made to previous NHTS survey results. Private car is the primary means of travel, consistent with past survey results. 2% of trips are made via public transit, 5% of trips for those in the lowest income categories. Low income and minority Americans account for 63% of those riding public transit. Pucher, J., Renne J.L., Urban-Rural Differences in Mobility and Mode Choice: Evidence from the 2001 NHTS, Rutgers University, April 2004. This paper compares urban and rural trip behavior using the National Household Travel Survey data from 2001. Mobility in rural areas is higher than in urban areas. Urban poor and minorities experience the greatest deficits in access and personal car ownership. Highlights: • Over 97% of rural households own at least one car vs. 92% of urban households; • 91% of trips are made by car in rural areas vs. 86% in urban areas. Table 3 shows vehicle ownership rates, Table 5 shows trip mode.

Final Report B-63 Rimmer, J.H., Silverman, K., Braunschweig, C., Quinn, L., Liu, Y., Feasibility of a Health Promotion Intervention for a Group of Predominantly African American Women With Type 2 Diabetes, The Diabetes Educator, 28:571-581, 2002. This is a study of the impact of a health promotion intervention on 30 African American urban women with type 2 diabetes and co morbidities. The patients attended a 12-week university based intervention to promote healthy behavior that included diet, nutrition, and behavior. Transportation to and from the site was provided free to each patient. Compliance was 72% and health outcomes were very good, as shown in Table 2.

Final Report B-64 Ritter, A.S., Straight, A., Evans, E., Understanding Senior Transportation: Report and Analysis of a Survey of Consumers 50+, AARP Public Policy Institute, April 2002. This is a report produced by the AARP Public Policy Institute that describes the transportation utilization and demand among Americans over 50. The results of a national telephone survey administered to 2422 adults 50 and over from October 1998 to January 1999 regarding their travel behavior, show that health and disability status greatly reduces mobility and that less than 5% of those surveyed relied on either walking, public transit, taxis, or community vans for mobility. Only 2% of those surveyed reported dissatisfaction with their mobility, and those with worse health or disabilities are more likely to fall into this category. Rittner, B., Kirk, A.B., Health Care and Public Transportation Use by Poor and Frail Elderly People, Social Work, 40:365-73, 1995.

Final Report B-65 Study on survey data of 1083 low-income, non-institutionalized elderly attending a daytime meal program in three south Florida metropolitan areas. Most of the elderly relied on public transportation to gain access to health services, which was a barrier to healthcare. Researchers rode the bus service used by the elderly studied and found the average trip was two hours each way. Each route had missing or late buses, lack of shelters, buses that were difficult to get on or off, dirty windows and occasional confrontations with other passengers. A primary reason public transportation posed a barrier is fear of victimization. Tables 4 and 5 show the impact of transportation access on health care utilization. Rosenbloom, S., The Mobility Needs of Older Americans: Implications for Transportation Reauthorization, The Brookings Institution Series on Transportation Reform, 2003. This policy brief encourages decision makers to consider the needs of the elderly population in regard to transportation and mobility over the next twenty years.

Final Report B-66 Rosenbloom, S., Transportation Needs of the Elderly Population, Clinics in Geriatric Medicine, 9:297-310, 1993. This article is a qualitative discussion of elderly dependence on the car as the primary means of transportation. As seniors become more disabled, driving decreases. The mileage driven also decreases with age. Public transit is not an adequate alternative in that there is environmental and land use barriers. There is a gap in service for elderly non-drivers and those eligible for Paratransit, and many elderly who are eligible do not register. Paratransit has so many restrictions that it is not a viable solution for many seniors without access to a car. The APTA in 1989 reported one-way Paratransit costs at $9.70. Sanmartin, C., Ng, E., Blackwell, D., Gentleman, J., Martinez, M., Simile, C., Joint Canada/ United States Survey of Health, 2002-03, Statistics Canada, Catalogue 82M0022-XIE, 2004. This is a comparison of national health data for the United States and Canada. The data is collected through a one-time telephone survey, with a sample of 3505 in Canada and 5183 in the United States. 13% of Americans and 11% of Canadians reported unmet health needs. Chart 3 shows mobility limitations by type of limitation, gender and residency. Scheer, J. Kroll, T., Neri, M.T., Beatty P, Access Barriers for Persons with Disabilities, Journal of Disability Policy Studies, 13:221-231, 2003. Qualitative interviews with 30 disabled people (multiple sclerosis, cerebral palsy and spinal cord injuries) to understand access barriers. Transportation is discussed along with other barriers to utilization of necessary care. Two main factors in the utilization of public transportation are that

Final Report B-67 conditions preclude use and that provider office and medical equipment vendors are not on transit routes. Paratransit services eliminate these problems but require advance scheduling, which is not practical if a patient requires immediate care. Interview respondents experienced Paratransit services that were late, failed to arrive at all, or arrived with the wrong equipment. Respondents who relied on private car transportation felt that office hours for providers did not always match the free time available in a driver’s work schedule. One man missed a PCP appointment for this reason and was later seen in the emergency room and required extensive follow up care. Schilling, L.M., Scatena, L., Steiner, J.F., Albertson, G.A., Cyran, L., Ware, L., Anderson, R.J., The Third Person in the Room: Frequency, Role, and Influence of Companions During Primary Care Medical Encounters, Journal of Family Practice, 51: 685-690, 2002. This is a study of 1294 patients in 1998 arriving at primary care appointment in the general internal medicine practice of the University of Colorado Health Sciences Center with a third party, to provide transportation or emotional support. Sometimes these patients are in the room during appointments. Results showed that patients that reported that if a companion was with them because they needed help with transportation then they were unlikely to sit in with the doctor, as shown in Table 2.

Final Report B-68 Schoen, C., Osborn, R., Huynh, P.T., Doty, M., Davis, K, Zapert, K., Peugh, J., Primary Care and Health System Performance: Adults’ Experiences in Five Countries, Health Affairs Web Exclusive, W487-503, 2004. This article compares the results of the 2004 Commonwealth Fund International Health Policy Survey on primary care experience of patients in the United States, United Kingdom, New Zealand, Australia, and Canada. The United States ranks worst in public opinion of the healthcare system; also for out of pocket patient costs. Access to care was also more difficult and infrequent in the United States compared to other countries.

Final Report B-69 Schweitzer, L., Valenzuela Jr., A., Environmental Injustice and Transportation: The Claims and the Evidence, Journal of Planning Literature, 18: 383, 2004. This article creates a framework for evaluating whether transportation policy has put poor and minority communities at a disadvantage through unjust environmental damage. Sherer, R., Stieglitz, K., Narra, J., Jasek, J., Green, L., Moore, B., Shott, S., Cohen, M., HIV Multidisciplinary Teams Work: Support Services Improve Access to and Retention in HIV Primary Care, AIDS Care, 14: S31-44, 2002. This is a study of support services and the impact on access to care using longitudinal data from the HIV Primary Care Center 1997-1998. Transportation was one of the four support services, along with mental health care, chemical dependency support, and case management. Each service improved access for any care, regular care, and patients with any service had more visits than patients with no services. Retention increased 15-18%. The best outcomes were for patients with access to all services.

Final Report B-70 Sipe, W.E.,Wei, M.C., Roth, E.J., Chi, G.W., Naidu, S.K., Samuels, R.C., Barriers to Access: A Transportation Survey in an Urban Pediatric Practice, General Pediatrics and Preventive Pediatrics: Miscellaneous - Poster Session I, 2004 Pediatric Academic Society’s Annual Meeting, May 2004. This poster discusses the results of a survey administered to patients of a hospital based urban pediatric clinic regarding their transportation options. Results: A total of 82 surveys were completed. A private car was used by 66% of patients, whereas 27% used some combination of bus and other public transportation. Average one-way trip time was 55 minutes (45 minutes by car, 81 minutes by bus), and 60% of respondents said that they had previously missed or been late to an appointment due to problems with transportation. Of patients arriving by private car (n=51), 27% reported missing an appointment at some time due to transportation difficulties, while 43% had arrived late. Of those patients using a bus for some point of their trip (n=22), 86% reported missing an appointment due to transportation difficulties and 95% had arrived late. Compared to those arriving by private car, patients arriving by bus or other mode of transportation were significantly more likely to have missed or been late for appointments, and had longer trip times (p<0.007 for all). The average cost for those arriving by car was $7.71. Smith, C.M., Yawn, P.B., Factors Associated with Appointment Keeping in a Family Practice Residency Clinic, Journal of Family Practice, 38:25-9, 1994. Study on Midwestern urban family practice residency clinic patient records between April and June of 1991 revealed that appointment keeping rates were higher among older, white or Asian patients, private or managed care insured patients, and those who had appointments scheduled the day they called the clinic. Smith, S.R., Highstein, G.R., Jaffe, D.M., Fisher, E.B. Jr., Strunk, R.C., Parental Impressions of the Benefits (Pros) and Barriers (Cons) of Follow-up Care After an Acute Emergency Department Visit for Children With Asthma, Pediatrics, 110:323–330, 2002. Parents of low-income, urban asthma patients rated 41 items as pros or cons to bringing their children into a primary care physician after an emergency room episode. 147 parents interviewed in the ER filled out the form and 24 items were considered highly associated with whether a parent would bring a patient in for follow up. One of the cons was “I have to find transportation”. The list of pros and cons are in Table 2.

Final Report B-71 Specht, E.M., Bourguet, C.C., Predictors of Nonattendance at the First Newborn Health Supervision Visit, Clinical Pediatrics, 33: 273-279, 1994. 319 infant notes from the Continuity Care Clinic in Ohio showed relative risk of nonattendance at the first newborn visit was highest for multiparous mothers, women with no telephone, and unmarried teen mothers. 27.9% of newborns in this low-income population did not attend their first health visit.

Final Report B-72 State of Illinois, Office of Inspector General, Non-Emergency Medical Transportation Reviews, 99-0269, December 1999. This document reviews the non-emergency medical transportation services in the state of Illinois. From 1997-1999 expenditures for NEMT increased by 24.9% and 60 out of 64 providers had discrepancies in claims. The report recommends increased monitoring and accountability to prevent fraudulent claims or poorly rendered services. Stefl, G., Newsom, M., Medicaid Non-Emergency Transportation: National Survey 2002-2003, National Consortium of the Coordination of Human Services Transportation, December 2003. http://www.ctaa.org/ntrc/hrt.asp#rep This report analyzes the results of a survey of non-emergency medical transportation providers administered to each state in 2002. Half of all states report NEMT expenditures are less than 1% of all Medicaid expenses. A majority of states are implementing cost containment measures on NEMT programs due to budget shortages. The federal government finances about 57% of all Medicaid costs. More than half of states reported coordination between state transit and Medicaid programs to save money and increase mobility. The report breaks down which states use what Medicaid categorization to fund NEMT. Straight, A., Gregory, S. R., Transportation: The Older Person’s Interest, AARP Public Policy Institute, March 2002. http://research.aarp.org/il/fs44r_transport.html This report echoes similar research by the AARP on travel behavior and service demand among seniors aged 65 and over. Highlights: • In 2000, 56 percent of elderly persons lived in suburban areas and 23 percent in rural areas, with the remaining 21 percent in central cities; • Whereas the number of people age 65 and older grew approximately 12 percent from 1990 to 2000, the number of licensed drivers age 65 and older grew 35 percent during the same period. Figure 1 shows the mode of trip for Americans 65 and older.

Final Report B-73 Thorpe, K. E., Florence, C. S., Joski, P., Which Medical Conditions Account for the Rise in Health Care Spending? Health Affairs-Web Exclusive, August 2004. W4-437. Growth in healthcare costs from 1987 to 2000 was examined to determine which conditions acted as cost drivers. Five medical conditions account for 31% of the growth in spending: heart disease, mental disorders, pulmonary disorders, cancer, and trauma. Some of this was due to increased prevalence (cerebrovascular diseases, pulmonary conditions and diabetes), other cost increases stemmed from rising costs of treatments (heart disease, hypertension). United States Census Bureau, Transit and Ground Transportation, Transportation and Warehousing Industry Series, 2002 Economic Census, April 2004. This is a report on economic data on transit and ground passenger transportation from the 2002 Census. Highlights: • The nation had 1,234 urban transit systems in 2002, up from 618 in 1997; • Revenues grew from $1.5 billion to $3.6 billion; • Urban transportation systems employed nearly 66,000 people in 2002, compared with 33,000 in 1997 • Between 1997 and 2002, revenues of the privately operated school and employee bus transportation industry grew from $4.4 billion to $5.9 billion; • This industry showed an increase of more than 24,000 jobs, for a total of nearly 176,000. United States Congressional Budget Office, An Analysis of the Literature on Disease Management Programs, October 13th, 2004. www.cbo.gov This is a meta-analysis by the Congressional Budget Office on the benefits of disease management programs and how they might apply to Medicare. Congestive heart failure, coronary artery disease and diabetes are examined specifically while other disease management programs are also considered. The conclusion of the literature review is that there is not significant proof that healthcare costs are reduced through disease management programs, especially in a Medicare population.

Final Report B-74 United States Department of Commerce, Office of Technology Assessment, Health Care in Rural America, Report Number OTA-H- 434, September 1990. This is an older report on both the access and barriers that exist for rural Americans in utilization of health care. The section on patient mobility uses 1988 Medicare data to show that only a few hospitals incur the majority of charges for rural Americans, suggesting that although the distance between the patient and health care provider can be very wide, the options closer to home are scarce. Less than 6% of hospitals provided 75% of Medicare services. In addition to few health care options, distance and transportation access are significant barriers, but mode of travel was not specifically considered. United States Department of Health and Human Services, Centers for Disease Control Fact Book 2000/2001, Washington DC, September 2000. The factbook presents the preventive activities the CDC engaged in from 2000 through 2001. United States Department of Health and Human Services, Healthy People, 2010, Washington DC, 2000.

Final Report B-75 The majority of health care providers use the Healthy People guidelines to set goals to bring the public health of the nation up. These goals are described in this publication and provide guidance on standards that healthy people should achieve in terms of utilization of care and health outcomes. United States Department of Health and Human Services, Office of the Inspector General, Controlling Medicaid Non-Emergency Transportation Costs, OEI-04-95-00140, 1997. This is a report on how to address the 10% average rise in state non-emergency medical transportation costs that occurred between 1990-1995. Case studies in six states revealed a variety of strategies to control costs by eliminating trips for unnecessary care, people who have alternative transportation, and fraudulent claims for trips not made. Brokers reduced costs, as did reducing the number of high cost vehicles. United States Department of Health and Human Services, Prevention Makes Common “Cents”, Washington DC, September 2003. This is a report on the rising costs of health care and the burden of preventable diseases. The following are high cost, chronic conditions that could be prevented, thereby reducing the high cost of health care. • Approximately 129 million U.S. adults are overweight or obese which costs this Nation anywhere from $69 billion to $117 billion per year. • In 2000, an estimated 17 million people (6.2 percent of the population) had diabetes, costing the U.S. approximately $132 billion. People with diabetes lost more than 8 days per year from work, accounting for 14 million disability days. • Heart disease and stroke are the first and third leading causes of death in the United States. In 2003 alone, 1.1 million Americans will have a heart attack. Cardiovascular diseases cost the Nation more than $300 billion each year. • Approximately 23 million adults and 9 million children have been diagnosed with asthma at some point within their lifetime, with costs near $14 billion per year. United States Department of Transportation and Health and Human Services, Coordinating Council on Access and Mobility, established 1986. United We Ride http://www.unitedweride.gov/ This website provides resources to those with mobility needs. Information on public transit and paratransit services are organized by location. Policy development and research associated with transportation and access to healthcare are presented. United States Department of Transportation, Bureau of Transportation Statistics, Freedom to Travel, BTS03-08, Washington DC, 2003. This is a survey of 5,000 disabled and non-disabled public transportation riders. Results showed that just over 1% of the US population is homebound, 1.9 million of whom are also disabled. 528,000 of disabled, homebound Americans experience transportation barriers.

Final Report B-76 United States Department of Transportation, Bureau of Transportation Statistics, Highlights of the 2001 National Household Travel Survey, BTS03-05, Washington DC, 2003. The National Household Travel Survey of is administered to 26,000 households regarding their travel behavior. 8% of US households report not having a car for daily use, while 88% of Americans over age 15 report driving. The majority of trips were made in a personal vehicle, but 9% of all trips were made walking, and 2% were in public transit, as shown in Figure 6. Figure 7 shows the purpose of trips. 8.6% of respondents reported a medical condition that limits travel. Because medical visits were included as personal business with several other variables, the number of trips for medical care could not be determined. United States Department of Transportation, Safe Mobility for a Maturing Society: Challenges and Opportunities, Washington DC, November 2003. This report addresses the needs of the population aged 65 and over and safety on highways, local roads, and in automobiles and in public transportation. After the aged 16-24 cohort, Americans 75 and over have the highest fatality rates on the road. The report is a consensus of focus groups, industry stakeholders, and community forum participants from around the country in creating a 10 year vision of the changes to roadway and public transportation safety that should come about to increase the mobility of the elderly population. United States General Accounting Office, CMS Did Not Control Rising Power Wheelchair Spending, GAO 04-716T, April 2004. This report shows that spending on power wheelchairs, the most expensive product in the durable medical equipment category that Medicare covers, rose by 450% from 1999-2003, despite a change of only 11% in all other Medicare spending. Although there is concern that vendors supplying power wheelchairs are cheating the system with unfairly high prices, the relevant information is on the number of Americans using wheelchairs that may require special modes of transportation.

Final Report B-77 United States General Accounting Office, Mass Transit: FTA Needs to Better Define and Assess Impact of Certain Policies on New Starts Program, GAO-04-748, June 2004. Report on how the FTA makes funding decisions. There is a good description of cost effectiveness as a criterion. United States General Accounting Office, Rural Ambulances: Medicare Fee Schedule Payments Could Be Better Targeted, GAO HEHS 00-115, July 2000. This report on rural ambulance providers shows that ambulance trips are often necessary to ensure equal access for Medicare beneficiaries. The report discusses revised pay scales to ensure equity in payments and to allow rural providers to maintain service. United States General Accounting Office, Supports for Low Income Families, States Serve a Broad Range of Families through a Complex and Changing System, GAO-04-256, January 2004. This report shows the types of government programs that provide support to low-income families. Most states subsidize public transportation for low-income families, described in Table 8. Almost all families take advantage of state subsidized public transit but in states that also offer discounted car repairs, less than half of low-income families take advantage of this service.

Final Report B-78

Final Report B-79 United States General Accounting Office, Transportation-Disadvantaged Populations: Some Coordination Efforts Among Programs Providing Transportation Services but Obstacles Persist, GAO-03-697, June 2003. This report discusses the federal programs that exist to provide transportation services. Transportation disadvantaged people are predominantly low-income, disabled, and/or elderly. Four national agencies, Transportation, Health and Human Services, Labor and Education provide transit programs, and coordination could reduce redundant services saving money, and could increase mobility for riders. In fiscal year 2001, 29 of the 62 federally funded transportation programs spent $2.4 billion dollars. The Coordinating Council on Access and Mobility is working toward coordination efforts in each state. Some obstacles to coordination include rules or limits specific to certain agencies, and a lack of financial incentives to increase coordination and communication about program availability to riders. United States General Accounting Office, Transportation-Disadvantaged Populations: Federal Agencies Are Taking Steps to Assist States and Local Agencies in Coordinating Transportation Services, GAO 04-420. February 2004.

Final Report B-80 This report follows-up on the 2003 Transportation Disadvantaged report by the GAO. Results showed positive coordination efforts, but obstacles still remained. The Department of Education lagged in strategic planning for coordination and, along with the Department of Labor, has not joined the Coordinated Council on Access and Mobility. All four agencies have launched independent initiatives, like the “United We Ride” program to increase coordination and dissemination of information to riders, but long-term funding remains unclear. United States Preventive Health Services Task Force, 1996. Williams and Wilkins, 2nd ed., 1996. This document provides guidance on preventive services to set up the missed care aspect of the benefit cost analysis. The majority of preventive services are recommended for people over age 50. Walker, R.B., Transportation-related Barriers to Medical Care: A Grant Supported Study of a Rural West Virginia County, TRB Economic Development Conference, May 2002. http://www.marshall.edu/ati/tech/PortlandConference/updatedPDFs/Portland_Walker.pdf This report is an assessment of rural healthcare access and the effect of public transportation in Lincoln County, West Virginia, a rural area with a population of 23,675. Highlights of transportation-related barriers to care: • 28.3% (75/266) walked or relied on someone to drive them to care; • 36.8% (98/266) needed someone else to take them outside the county; • Half had to pay for transportation to care; • More than half said they could afford $5.00 (typical cost was $6.00 to $10.00); • More than 10% could not pay for transportation to care. Lack of transportation resulted in: • Missed appointments (40.2%); • Inability to get to a pharmacy (27.8%). • Almost half (44.7%) reported that road conditions kept them from medical care • Only 4 of 266 patients rode the bus despite 8 stops a day at the health center. Wallace, R.R. 1997. “Paratransit Customer: Modeling Elements of Satisfaction with Service,” Transportation Research Record 1571: 59-66. Using demographic and other characteristics of paratransit customers in southeastern Michigan, along with paratransit service characteristics in the region, this paper develops a causal model of factors affecting customer satisfaction with paratransit service. Such models, which analyze the covariance structures of variables and factors hypothesized to exhibit causal relationships, aid in the gauging the potential impact of improving customer satisfaction through changes in paratransit operations and management. Furthermore, these models can suggest which elements of customer satisfaction are most affected by system changes. A key finding from the study is that characteristics specific to the customers themselves—such as personal mobility—contribute

Final Report B-81 substantially to overall customer satisfaction. In addition, the study also showed that transit system characteristics also contribute to overall customer satisfaction, especially to satisfaction with the trips-scheduling process, meaning that technological and other system enhancements have ample potential to improve customer satisfaction, but that this potential is limited in part by characteristics of the customers. The study also revealed that, for the system in question, the agency accommodated about 85 percent of trip requests and that riders were overwhelmingly female and older adults, traveling for a wide variety of trip purposes. Of these purposes, however, medical trips and shopping trips were the most common. Warner, K.E., Luce, B.R., Cost Benefit and Cost-Effectiveness Analysis in Health Care: Principles, Practice, and Potential, Health Administration Press, Ann Arbor, MI, 1982. This textbook covers cost benefit and cost effectiveness analyses with a focus of healthcare. Weingarten, N., Meyer, D.L., Schneid, J.A., Failed Appointments in Residency Practices: Who Misses Them and What Providers are Most Affected? Journal of the American Board of Family Practice, 10:407-11, 1997. This study focuses on patient billing information and appointment records over 36 sampled days during 1995 for a community-hospital-based family practice in New England. The missed appointment rate was 6.7%. Missing appointments was correlated with being between 17-30 years of age, Medicaid coverage, lack of health insurance, and appointments scheduled with first year residents or medical students. Transportation was not one of the variables studied. Weinick, R.M., Krauss, N.A., Racial/Ethnic Differences in Children’s Access to Care, American Journal of Public Health, 90: 1771-1774, 2000. This analysis of 1999 Medical Expenditure Panel Survey data explores racial and ethnic differences in access to care among children. 17.2% of Hispanic children had no usual source of care, as compared to 12.5% of black, 8.6% of Asian, and 6.0% of white/other children. Weinick, R.M., Zuvekas, S.H., Drilea, S.K., Access to Health Care-Sources and Barriers, 1996, MEPS Research Findings No. 3, AHCPR Pub. No. 98-0001, Agency for Health Care Policy and Research, 1997. This analysis of 1996 Medical Expenditure Panel Survey data focuses on access to health care. Transportation barriers are included in “other problems” and account for 20.7% of all respondents experiencing access barriers. Welch, G.H., Dangers in Early Detection, Washington Post, p. A23, July 1, 2004. This newspaper article suggests that more costs are incurred through early detection and preventive screening measures than are warranted for the benefits perceived. Early warning signs for diseases could mask conditions that resolve without medical care or initiate treatment for diseases that may worsen health conditions rather than improving them.

Final Report B-82 Wittenburg, D., Favreault, M., Safety Net or Tangled Web? An Overview of Programs and Services for Adults with Disabilities, Occasional Paper No. 68, The Urban Institute, 2004. This report addresses the needs of the adult disabled population and the government safety net programs that exist to meet these needs. Data from the 1999 National Survey of America’s Families is used to profile the health of low income adults aged 25-55 and the subsequent challenges they face. Highlights of findings: Of the 28.9 million low-income adults in the U.S., 23% report a work limitation, 25% report fair/poor health status, and 15% report poor mental health. The prevalence of these problems is even higher among those with income below the poverty level; over 30% of adults report work limitations and/or fair or poor health, and 23% report poor mental health. Each condition is about twice as prevalent in the low-income population as in the total adult population. The report than discusses the government programs that provide services to this population. Transportation is not directly covered. Yang, S., Tipnis, S., Saenz, C., Kelly, N., The Impact of an Intervention Utilizing Mass Transit on Access to a Medical Home for Low-Income, Minority Urban Children, General Pediatrics and Preventive Pediatrics: Parental Role Education - Poster Session I, 2004 Pediatric Academic Society’s Annual Meeting, May 2004. This poster demonstrates the effectiveness of a mass transit program that targets pediatric patients with transportation problems at risk for missing appointments among low-income families in the urban Texas Hospital Residents Primary Care Group Clinic. This randomized controlled trial offered caregivers an intervention of bus tokens and route information in addition to routine discharge instructions. In the 6-month follow-up, the 60 caregivers receiving the intervention did not have different missed appointment rates from the control group. Missed appointments within the intervention group were associated with the receipt of multiple intervention boosters (p<0.001) and a higher income level (p=0.003). Results: At baseline, 55% reported they used their own car to reach clinic, 72% had never used public transit to clinic, and 25% reported missing an appointment due to transportation. Yawn, B.P., Xia, Z., Edmonson, L., Jacobson, R.M., Jacobsen, S.J., Barriers to Immunization in a Relatively Affluent Community, Journal of the American Board of Family Practice, 13: 325- 332, 2000. A self reported transportation barrier was associated with under immunization in 20-month-old children in this survey of 596 parents in a family practice clinic in affluent Olmstead County, Minnesota. Table 3 shows the results of the perceived barriers and under immunization of children.

Final Report B-83 Table 3. Association Between Perceived Barriers and Underimmunization Univariate Analysis Overall Adjusted* Analysis Problem Odds Ratio (95% CI) Attributable Risk (95% CI) Odds Ratio (95% CI) Attributable Risk (95% CI) I had problems getting transportation 7.8 (1.9, 31.8) 4.9 (-0.7, 10.4) 4.7 (1.1, 20.8) 5.2 (0.1, 13.7) My child had been sick and I didn't take my child for shots 5.2 (2.3, 11.5) 12.5 (3.4, 21.4) 4.0 (1.7, 9.3) 12.1 (2.4, 21.8) I didn't know when the next shot was needed 2.8 (1.5, 5.3) 13.6 (2.9, 21.2) 2.8 (1.4, 5.4) 14.1 (2.4, 25.8) It was hard to remember the appointment 2.6 (1.0, 6.8) 5.2 (-1.6, 12.0) 2.7 (1.0, 7.4) 5.5 (-1.9, 13.0) I was afraid my child would have a reaction to the shot 2.3 (1.3, 4.2) 14.4 (2.5, 26.4) 2.5 (1.3, 4.6) 16.4 (3.6, 29.2) I didn't like the doctors or nurses at the clinic 3.1 (0.9, 10.1) 3. (-1.7, 9.3) 2.4 (0.7, 8.1) 3.5 (-3.0, 10.0) My doctor advised that my child not have shots at this time 3.1 (0.9, 10.1) 3.8 (-1.7, 9.3) 2.5 (0.7, 8.5) 3.6 (-2.1, 9.3) I found the clinic location was not convenient 2.6 (0.9, 7.3) 4.3 (-1.9, 10.5) 2.7 (0.9, 8.0) 4.6 (-2.0, 11.3) I had to pay too much for the shots 2.0 (0.9, 4.4) 6.4 (-2.0, 18.0) 1.1 (0.5, 2.7) 0.5 (-10.6, 11.6) I didn't want to put my child through the pain of shots 1.4 (0.7, 2.9) 4.0 (-5.1, 13.3) 1.1 (0.5, 2.5) 1.6 (-9.2, 12.3) I didn't want my child to get more than one shot at a time 1.6 (0.7, 4.1) 3.3 (-3.4, 10.0) 1.7 (0.7, 4.5) 4.1 (-3.9, 12.1) Any barriers listed above 2.5 (9.0, 49.4) 33.0 (15.2, 50.7) 2.1 (1.2, 3.6) 29.2 (9.0, 49.4) Note: Barriers are combined reported major and minor barriers. * Associations after adjusting for income and self-payment. Zogby International, Survey Reveals Millions of U.S. Children Unable to Access Health Care Due to Lack of Transportation, New York, 2001. http://www.childrenshealthfund.org/release071201.html The survey commissioned by the Children’s Health Fund and conducted by the polling firm Zogby International finds transportation is a major barrier to healthcare access for children. Poor and low-income families who live up to 50 miles away from medical facilities are hardest hit, but urban areas face problems also. 9% of children in families with incomes up to $50,000 miss essential medical appointments dues to lack of transportation, regardless of insurance. 59% of children enrolled in the states Children’s Health Insurance Program (SCHIP) do not know that Medicaid provides transportation; only one out of ten Medicaid families has used it. Zorc, J.J., Scarfone, R.J., Yuelin, L., Hong, T., Harmelin, M., Grunstein, L., Andre, J.B., Scheduled Follow-up After a Pediatric Emergency Department Visit for Asthma: A Randomized Trial, Pediatrics, 111:495–502, 2003. This is an evaluation of an intervention to schedule follow-up appointments immediately following an emergency room (ER) visit for asthma and the subsequent health effects and utilization patterns among 144 randomly assigned urban children (2-18 years of age) compared with a control group of 142 receiving no intervention. In the intervention group more children returned for follow up appointments (64% compared with 46%) there was no change in return ER visits, missed school, and asthma medication use at home. Only 24% of patients in the

Final Report B-84 intervention group had appointments scheduled during the ER visit. Transportation barriers were mentioned in the discussion. This is a good characterization of asthma in urban children.

Next: Appendix C: Cost-Effectiveness Analysis and QALYs »
Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation Get This Book
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TRB’s Transit Cooperative Research Program (TCRP) Web-Only Document 29: Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation (NEMT) examines the relative costs and benefits of providing transportation to non-emergency medical care for individuals who miss or delay healthcare appointments because of transportation issues. The report includes a spreadsheet to help local transportation and social service agencies conduct their own cost-benefit analyses of NEMT tailored to the local demographic and socio-economic environment. The executive summary of the report is available as Research Results Digest 75.

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