Travel time, availability of emergency obstetric care, and perceived quality of care associated with maternal healthcare utilisation in Afghanistan: A multilevel analysis

Limited understanding of factors such as travel time, availability of emergency obstetric care (EmOC), and satisfaction/perceived quality of care on the utilisation of maternal health services exists in fragile and conflict-affect settings. We examined these key factors on three utilisation outcomes: at least one skilled antenatal care (ANC) visit, in-facility delivery, and bypassing the nearest public facility for childbirth in Afghanistan from 2010 to 2015. We used three-level multilevel mixed effects logistic regression models to assess the relationships between women's and their nearest public facilities' characteristics and outcomes. The nearest facility score for satisfaction/perceived quality was associated with having at least one skilled ANC visit (AOR: 2.02, 95% CI: 1.21, 3.36). Women whose nearest facility provided EmOC had a higher odds of in-facility childbirth compared to women whose nearest facility did not (AOR: 1.24, 95% CI: 1.04, 1.48). Nearest hospital travel time (AOR: 0.95, 95% CI: 0.93, 0.98) and nearest facility satisfaction/perceived quality (AOR: 0.34, 95% CI: 0.14, 0.82) were associated with lower odds of women bypassing their nearest facility. Afghanistan has made progress in expanding access to maternal healthcare services during the ongoing conflict. Addressing key barriers is essential to ensure that women have access to life-saving services.

Changes in chronic medication adherence in older adults with cancer versus matched cancer-free cohorts

OBJECTIVES

A cancer diagnosis can influence medication adherence for chronic conditions by shifting care priorities or reinforcing disease prevention. This study describes changes in adherence to medications for treating three common chronic conditions - diabetes, hyperlipidemia, and hypertension - among older adults newly diagnosed with non-metastatic breast, colorectal, lung, or prostate cancer.

METHODS

We identified Medicare beneficiaries aged ≥66 years newly diagnosed with cancer and using medication for at least one chronic condition, and similar cohorts of matched individuals without cancer. To assess medication adherence, proportion of days covered (PDC) was measured in six-month windows starting six-months before through 24 months following cancer diagnosis or matched index date. Generalized estimating equations were used to estimate difference-in-differences (DID) comparing changes in PDCs across cohorts using the pre-diagnosis window as the referent. Analyses were run separately for each cancer type-chronic condition combination.

RESULTS

Across cancer types and non-cancer cohorts, adherence was highest for anti-hypertensives (90-92%) and lowest for statins (77-79%). In older adults with colorectal and lung cancer, adherence to anti-diabetics and statins declined post-diagnosis compared with the matched non-cancer cohorts, with estimates ranging from a DID of -2 to -4%. In older adults with breast and prostate cancer cohorts, changes in adherence for all medications were similar to non-cancer cohorts.

CONCLUSION

Our findings highlight variation in medication adherence by cancer type and chronic condition. As many older adults with early stage cancer eventually die from non-cancer causes, it is imperative that cancer survivorship interventions emphasize medication adherence for other chronic conditions.

The Direct Clinic-Level Cost of the Implementation and Use of a Protocol to Assess and Address Social Needs in Diverse Community Health Center Primary Care Clinical Settings

PURPOSE

Social determinants of health, including food insecurity, housing instability, social isolation, and unemployment are important drivers of health outcomes and utilization. To inform implementation of social needs screening and response protocols, there is a need to identify the associated costs in routine primary care encounters.

METHODS

We interviewed key stakeholders in four diverse community health centers that had adopted a widely used social needs screening and response protocol. We evaluated costs using an activity-based costing tool across both the initial implementation phase and ongoing maintenance phase.

RESULTS

Clinic costs were associated with workforce development, planning, and electronic health record integration. These initial implementation costs varied by site ($6,644-$49,087). On a per-patient basis, ongoing maintenance costs ranged from $9.76 to $47.98.

CONCLUSION

Our findings can aid in designing reimbursement mechanisms tied to social needs screening and response to accelerate translational efforts and promote health equity.

Treatment selection and medication adherence for stable angina: The role of area-based health literacy

RATIONALE, AIMS, AND OBJECTIVES

Clinical studies show equivalent health outcomes from interventional procedures and treatment with medication only for stable angina patients. However, patients may be subject to overuse or access barriers for interventional procedures and may exhibit suboptimal adherence to medications. Our objective is to evaluate whether community-level health literacy is associated with treatment selection and medication adherence patterns.

METHOD

The sample included Medicare fee-for-service beneficiaries (20% random sample) with stable angina in 2007-2013. We used an area-level health literacy variable because of the lack of an individual measure in claims. We measured the association between (a) area-based health literacy with treatment selection (medication only, percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) surgery) and (b) area-based health literacy with medication adherence. We controlled for other factors including demographics, co-morbidity burden, dual eligibility, and area deprivation index.

RESULTS

We identified 8300 patients of whom 8.7% lived in a low health literacy area. Overall, 56% of patients received medication only, 28% received PCI, and 15% received CABG. Patients in low health literacy areas were less likely to receive CABG (-3.5 percentage points; 95% CI, -6.8 to -0.3) than were patients in high health literacy areas, but the significance was sensitive to specification. Overall, 81.5% and 71.5% of patients were adherent to antianginals and statins, respectively. Living in low health literacy areas was associated with lower adherence to antianginals (-3.3 percentage points; 95% CI, -6.1 to -0.6) but not statins.

CONCLUSIONS

Low area-based health literacy was associated with being less likely to receive CABG and lower adherence, but the differences between low and high health literacy areas were small and sensitive to model specification. Individual factors such as dual eligibility status and race/ethnicity had stronger associations with outcomes than had area-based health literacy, suggesting that this area-based measure was inadequate to account for social determinants in this study.

Cost-effectiveness of Interventions to Increase HPV Vaccine Uptake

OBJECTIVES

We sought to prioritize interventions for increasing human papillomavirus (HPV) vaccination coverage based on cost-effectiveness from a US state perspective to inform decisions by policy makers.

METHODS

We developed a dynamic simulation model of HPV transmission and progression scaled to a medium-sized US state (5 million individuals). We modeled outcomes over 50 years comparing no intervention to a one-year implementation of centralized reminder and recall for HPV vaccination, school-located HPV vaccination, or quality improvement (QI) visits to primary care clinics. We used probabilistic sensitivity analysis to assess a range of plausible outcomes associated with each intervention. Cost-effectiveness was evaluated relative to a conservative willingness-to-pay threshold; $50 000 per quality-adjusted life-year (QALY) .

RESULTS

All interventions were cost-effective, relative to no intervention. QI visits had the lowest cost and cost per QALY gained ($1538 versus no intervention). Statewide implementation of centralized reminder and recall cost $28 289 per QALY gained versus QI visits. School-located vaccination had the highest cost but was cost-effective at $18 337 per QALY gained versus QI visits. Scaling to the US population, interventions could avert 3000 to 14 000 future HPV cancers. When varying intervention cost and impact over feasible ranges, interventions were typically preferred to no intervention, but cost-effectiveness varied between intervention strategies.

CONCLUSIONS

Three interventions for increasing HPV vaccine coverage were cost-effective and offered substantial health benefits. Policy makers seeking to increase HPV vaccination should, at minimum, dedicate additional funding for QI visits, which are consistently effective at low cost and may additionally consider more resource-intensive interventions (reminder and recall or school-located vaccination).

A controlled trial of dissemination and implementation of a cardiovascular risk reduction strategy in small primary care practices

OBJECTIVE

To assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk-stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices.

STUDY SETTING

A total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018.

STUDY DESIGN

We performed a stepped-wedge, stratified, cluster randomized trial of a one-year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of risk-stratified adults, aged 40-79 years and their unmet treatment opportunities. The primary outcome was change in 10-Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3 months postintervention.

DATA COLLECTION/ EXTRACTION METHODS

Data extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry.

PRINCIPLE FINDINGS

ASCVD risk scores were assessed on 437 556 patients and 146 826 had a calculated 10-year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD ± 12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped-wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65 years, low-income (<$40 000), and Black race (P < .001 for all variables) were each associated with greater risk reductions.

CONCLUSION

A risk-stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10-year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under-resourced practices. Registration: ClinicalTrials.Gov 15-0479.

Development of a personalized follow-up care algorithm for Medicare breast cancer survivors

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Background: The rapidly growing number of cancer survivors in the US have substantial healthcare needs requiring surveillance and care for the late and long-term effects of cancer treatment and comorbidities. Lacking a clear system of care, experts recommend a personalized approach to survivorship care. The objective of this study was to test a clinical prediction algorithm to distinguish low-complexity breast cancer survivors who may be suited to self-manage their survivorship care and be followed by their primary care provider (PCP) from survivors who require specialty care. Methods: We used the Surveillance and Epidemiology End Results (SEER) registry – Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data to identify women diagnosed with stage 0-3 breast cancer between 2003 and 2011. Cross-validated random forest machine learning models separately estimated survivors’ independent risk of all-cause death, cancer-specific death, recurrence, or severe late effects within 3 years following treatment completion. The absence of these outcomes identified survivors as potentially eligible for self-management and PCP care. Predictors included measures of baseline health status and health care utilization, patient socio-demographic characteristics, cancer characteristics, and financial burden. Results: Among the 4,516 survivors in the primary cohort, 82% were white, and the mean (SD) age was 75.1 (7.8) years. Almost 50% were diagnosed with Stage I breast cancer, followed by 25.2% with Stage 2, 19.3% with Stage 0, and 5.6% with Stage III. Within the 3-year follow-up period, 372 (8.2%) survivors died (111 or 2.5% from cancer), 665 (14.7%) experienced recurrence, and 488 (10.8%) were hospitalized due to severe late effects. Predicting all-cause death resulted in 91.9% out-of-sample accuracy, a 37.6% improvement over an uninformed model. Important predictors across outcomes included age, geographic region, diagnosis year, financial burden, comorbidities, and cancer stage. Conclusions: Survivors requiring specialty care are characterized by higher comorbidity, lower educational attainment, and advanced age, suggesting that, in addition to cancer characteristics, personalized care pathways developed in response to our findings must account for social and contextual factors as well.

The association between the supply of select nonpharmacologic providers for pain and use of nonpharmacologic pain management services and initial opioid prescribing patterns for Medicare beneficiaries with persistent musculoskeletal pain

OBJECTIVE

To test the relationship between the supply of select nonpharmacologic providers (physical therapy (PT) and mental health (MH)) and use of nonpharmacologic services among older adults with a persistent musculoskeletal pain (MSP) episode.

DATA SOURCES/STUDY SETTING

Claims data from a 5 percent random sample of Medicare beneficiaries enrolled fee-for-service (2007-2014) and the Area Health Resource File (AHRF).

STUDY DESIGN

This retrospective study used generalized estimating equations to estimate the association between the county nonpharmacologic provider supply and individual service use with opioid prescriptions filled during Phase 1 (first three months of an episode) and Phase 2 (three months following Phase 1).

DATA COLLECTION/EXTRACTION METHODS

We identified beneficiaries (>65 years) with ≥2 MSP diagnoses ≥90 days apart and no opioid prescription six months before the first pain diagnosis (N = 69 456). Beneficiaries' county characteristics were assigned using the AHRF.

PRINCIPAL FINDINGS

About 13.9 percent of beneficiaries used PT, 1.8 percent used MH services, and 10.7 percent had an opioid prescription during the first three months of a persistent MSP episode. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT/10 000 people/county [aOR: 0.98, 95% CI: 0.97-1.00] was associated with lower odds of filling an opioid prescription in Phase 1. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT use in Phase 1 [aOR: 0.62, 95% CI: 0.58-0.67] were associated with lower odds of filling an opioid prescription in Phase 2. The associations between the supply of providers and nonpharmacologic service use in Phase 1 and Phase 1 opioid prescriptions significantly differed by metropolitan and rural counties (P-value: .019).

CONCLUSIONS

Limited access to nonpharmacologic services is associated with opioid prescriptions at the onset of a persistent MSP episode. Initiating PT at the onset of an episode may reduce future opioid use. Strategies for engaging beneficiaries in nonpharmacologic services should be tailored for metropolitan and rural counties.

National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility

In Afghanistan, the risk of maternal death is among the highest in the world, with wide variation across the country. One explanation may be wide geographic disparities in access and use of maternal health care services. This study describes the spatial distribution of public facilities providing maternal health care in Afghanistan, specifically emergency obstetric care (EmOC), and the differences in travel time estimates using different transportation modes from 2010 to 2015 at the national and subnational levels. We conducted mapping and spatial analyses to measure the proportion of pregnant women able to access any EmOC health facility within 2 h by foot, animal, motor vehicle and a combination of transport modes. In 2015, adequate coverage of active public health facilities within 2 h of travel time was 36.6% by foot and 71.2% by a combination of transport modes. We found an 8.3% and 63.2% increase in access to EmOC facilities within 2 h of travel time by a combination of transport modes and by foot only, respectively, by 2015. Access to a combination of transportation options such as motor vehicles and animals may benefit pregnant women in reaching health facilities efficiently. Afghanistan made impressive gains in maternal healthcare access; despite these improvements, large disparities remain in geographic access by province and overall access to facilities is still poor.

Productivity costs associated with metastatic breast cancer in younger, midlife, and older women

BACKGROUND

The objective of the current study was to estimate productivity costs due to metastatic breast cancer (mBC) via productive time lost among survivors and potential life-years lost from premature mortality among 3 age groups: younger (aged 18-44 years), midlife (aged 45-64 years), and older (aged ≥65 years) women.

METHODS

The authors estimated the number of work and home productivity days missed due to mBC by age group using data from the 2000 to 2016 National Health Interview Survey. Years of potential life lost (YPLL) due to mBC were calculated for each age group using 2015 National Vital Statistics System data. The authors valued both sources of lost productivity time using the Current Population Survey and prior studies.

RESULTS

The per-woman value of lost productive days (work and home) due to mBC ranged from $680 for older women to $5169 for younger women. In 2015, the value of lost work and home productivity days associated with mBC nationally was $67 million for younger women, $246 million for midlife women, and $66 million for older women. YPLL were highest among midlife women (403,786 life-years), followed by older women (248,522 life-years) and younger women (95,943 life-years). Midlife women were found to have the highest market value of YPLL ($4.1 billion), followed by younger women ($1.6 billion) and older women ($527 million).

CONCLUSIONS

The results of the current study demonstrated that mBC generates a high economic burden through lost productivity, especially among midlife women.

Insurance instability and use of emergency and office-based care after gaining coverage: An observational cohort study

Background

The Affordable Care Act led to improvements in reporting a usual source of care, but it is unclear whether patients are changing their usual source of care in response to coverage gains. We assess whether prior insurance instability is associated with changes in use of emergency and office-based care after the Marketplace and Medicaid expansion were introduced.

Methods

Our study draws from the 2013–14 Medical Expenditure Panel Survey, identifying a cohort of non-elderly adults with full-year health insurance coverage in 2014. We use linear and multinomial logistic regression to assess the relationship between insurance instability prior to 2014 (uninsured for 1–11 months, ≥12 months) and person-level changes in use of health care after gaining coverage (change in ED and office visits from 2013 to 2014) with continuously insured individuals serving as a comparison group.

Results

Being uninsured for at least one year prior to gaining full-year coverage in 2014 was associated with a 33% increase in ED visits (0.06 visits, p<0.01) and a 47% increase in office visits (1.10 visits, p<0.01), driven by those gaining public coverage. We found no evidence of substitution across settings in the short term, often a stated goal of expansion.

Conclusion

The long-term uninsured may have substantial health needs and pent-up demand for health care, seeing more physicians across multiple settings in the year after gaining coverage as they seek to get unmanaged conditions under control. Closing the gap in primary care use between the previously uninsured and those with health insurance coverage may help improve long-term health outcomes.

Influence of Treating Facility, Provider Volume, and Patient-Sharing on Survival of Patients With Multiple Myeloma

BACKGROUND

Population-based studies suggest that patients with multiple myeloma (MM) have better outcomes when treated at high-volume facilities, but the relative contribution of provider expertise and hospital resources to improved outcomes is unknown. This study explored how treating facility, individual provider volume, and patient-sharing between MM specialists and community providers influenced outcomes for patients with MM.

PATIENTS AND METHODS

A state cancer registry linked to public and private insurance claims was used to identify a cohort of patients diagnosed with MM in 2006 through 2012. Three multivariable Cox models were used to examine how the following factors impacted overall survival: (1) evaluation at an NCI-designated Comprehensive Cancer Center (NCICCC), (2) the primary oncologist's volume of patients with MM, and (3) patient-sharing between MM specialists and community oncologists.

RESULTS

A total of 1,029 patients diagnosed with MM in 2006 through 2012 were identified. Patients who were not evaluated at an NCICCC had an increased risk of mortality compared with those evaluated at an NCICCC (hazard ratio [HR], 1.50; 95% CI, 1.21-1.86; P<.001). Compared with patients treated by NCICCC MM specialists, those treated by both low-volume community providers (HR, 1.47; 95% CI, 1.14-1.90; P<.01) and high-volume community providers (HR, 1.29; 95% CI, 1.04-1.61; P<.05) had a higher risk of mortality. No difference in mortality was seen between patients treated by NCICCC MM specialists and those treated by the highest-volume community oncologists in the ninth and tenth deciles (HR, 1.08; 95% CI, 0.84-1.37; P=.5591). Patients treated by community oncologists had a higher risk of mortality regardless of patient-sharing compared with patients treated by MM specialists (eg, community oncologist with a history of sharing vs NCICCC MM specialist: HR, 1.49; 95% CI, 1.10-2.02; P<.05).

CONCLUSIONS

Findings of this study add to the accumulating evidence showing that patients with MM benefit from care at high-volume facilities, and suggest that similar outcomes can be achieved by the highest-volume providers in the community.

Changes in chronic medication adherence, costs, and health care use after a cancer diagnosis among low-income patients and the role of patient-centered medical homes

BACKGROUND

Approximately 40% of patients with cancer also have another chronic medical condition. Patient-centered medical homes (PCMHs) have improved outcomes among patients with multiple chronic comorbidities. The authors first evaluated the impact of a cancer diagnosis on chronic medication adherence among patients with Medicaid coverage and, second, whether PCMHs influenced outcomes among patients with cancer.

METHODS

Using linked 2004 to 2010 North Carolina cancer registry and claims data, the authors included Medicaid enrollees who were diagnosed with breast, colorectal, or lung cancer who had hyperlipidemia, hypertension, and/or diabetes mellitus. Using difference-in-difference methods, the authors examined adherence to chronic disease medications as measured by the change in the percentage of days covered over time among patients with and without cancer. The authors then further evaluated whether PCMH enrollment modified the observed differences between those patients with and without cancer using a differences-in-differences-in-differences approach. The authors examined changes in health care expenditures and use as secondary outcomes.

RESULTS

Patients newly diagnosed with cancer who had hyperlipidemia experienced a 7-percentage point to 11-percentage point decrease in the percentage of days covered compared with patients without cancer. Patients with cancer also experienced significant increases in medical expenditures and hospitalizations compared with noncancer controls. Changes in medication adherence over time between patients with and without cancer were not determined to be statistically significantly different by PCMH status. Some PCMH patients with cancer experienced smaller increases in expenditures (diabetes) and emergency department use (hyperlipidemia) but larger increases in their inpatient hospitalization rates (hypertension) compared with non-PCMH patients with cancer relative to patients without cancer.

CONCLUSIONS

PCMHs were not found to be associated with improvements in chronic disease medication adherence, but were associated with lower costs and emergency department visits among some low-income patients with cancer.

Are Rates of Methicillin-Resistant Staphylococcus aureus and Clostridioides difficile Associated With Quality and Clinical Outcomes in US Acute Care Hospitals?

The purpose of this study was to examine the association between rates of methicillin-resistant Staphylococcus aureus (MRSA)/Clostridioides difficile and quality and clinical outcomes in US acute care hospitals. The population was all Medicare-certified US acute care hospitals with MRSA/C difficile standardized infection ratio (SIR) data available from 2013 to 2017. Hospital-level data from the Centers for Medicare & Medicaid Services were used to estimate hospital and time fixed effects models for 30-day hospital readmissions, length of stay, 30-day mortality, and days in the intensive care unit. The key explanatory variables were SIR for MRSA and C difficile. No association was found between MRSA or C difficile rates and any of the 4 outcomes. The null results add to the mixed evidence in the field, but there are likely residual confounding factors. Future research should use larger samples of patient-level data and appropriate methods to provide evidence to guide efforts to tackle antimicrobial resistance.

Medical costs associated with metastatic breast cancer in younger, midlife, and older women

PURPOSE

We estimated average medical costs due to metastatic breast cancer (mBC) among younger (aged 18-44), midlife (aged 45-64), and older women (aged 65 and older) by phase of care: initial, continuing, and terminal.

METHODS

We used 2003-2014 North Carolina cancer registry data linked with administrative claims from public and private payers. We developed a claims-based algorithm to identify breast cancer patients who progressed to metastatic disease. We matched breast cancer patients (mBC and earlier stage) to non-cancer patients on age group, county of residence, and insurance plan. Outcomes were average monthly medical expenditures and expected medical expenditures by phase. We used regression to estimate excess costs attributed to mBC as the difference in mean payments between patients with mBC (N = 4806) and patients with each earlier-stage breast cancer (stage 1, stage 2, stage 3, and unknown stage; N = 21,772) and non-cancer controls (N = 109,631) by treatment phase and age group.

RESULTS

Adjusted monthly costs for women with mBC were significantly higher than for women with earlier-stage breast cancer and non-cancer controls for all age groups and treatment phases except the initial treatment among women with stage 3 breast cancer at diagnosis. The largest expected total costs were for women aged 18-44 with mBC during the continuing phase ($209,961 95% Confidence Interval $165,736-254,186).

CONCLUSIONS

We found substantial excess costs for mBC among younger women and during the continuing and terminal phases of survivorship. It is important to assess whether this care is high value for these women.

The Affordable Care Act and Ethnic Disparities in Colorectal Cancer Screening

INTRODUCTION

Cost sharing can deter the use of health services and act as a potential contributor to racial/ethnic disparities in cancer. The Affordable Care Act required most health plans to cover, without cost sharing, preventive services, including colorectal cancer screening. Population-based data were used to estimate the impact of the Affordable Care Act's cost-sharing provision (together with other Affordable Care Act provisions targeting preventive care) on ethnic disparities in colorectal cancer screening, comparing Hispanics with non-Hispanics.

METHODS

An interrupted time series quasi-experimental analysis was used to examine ethnic differences in colorectal cancer screening pre- and post-implementation of the Affordable Care Act (analysis performed in 2018). The study cohort included insured individuals aged 50-64 years who participated in the Medical Expenditure Panel Survey from 2007 through 2015 (n=44,343).

RESULTS

During the pre-Affordable Care Act period, screening rates decreased annually for non-Hispanics by -0.38 per 100 adults per year (95% CI= -0.55, -0.22) but remained level for Hispanics (annual trend per 100 adults: 0.01, 95% CI= -0.34, 0.35). After cost sharing was eliminated in 2011, colorectal cancer screening rates increased for both Hispanics (by 1.29 per 100 adults, 95% CI=0.69, 1.89) and non-Hispanics (by 0.58 per 100 adults, 95% CI=0.18, 0.99). The difference in trend increases between Hispanics and non-Hispanics was not statistically significant (0.70%, 95% CI= -0.24, 1.64).

CONCLUSIONS

These findings suggest that Affordable Care Act implementation resulted in increased colorectal cancer screening; however, the effect of the law was not significantly different between Hispanics and non-Hispanics. These results provide indications that more needs to be done to reduce racial/ethnic disparities in colorectal cancer screening.

Hospitalization after Adolescent and Young Adult (AYA) Cancer: A Population-Based Study in Utah

BACKGROUND

Adolescents and young adults (AYA, age 15-39 years) with cancer may be at elevated risk for late morbidity following their cancer treatment, but few studies have quantified the excess burden of severe disease in this population. Using population-based data from Utah, we examined the risk of inpatient hospitalizations among AYA cancer survivors compared with their siblings and the general population.

METHODS

Survivors of AYA cancer who were ≥2 years from diagnosis and diagnosed from 1994 to 2015 (N = 6,330), their siblings (N = 12,924), and an age- and sex-matched comparison cohort (N = 18,171) were identified using the Utah Population Database (UPDB). Hospitalizations from 1996 to 2017 were identified from statewide discharge records in the UPDB. We estimated multivariable-adjusted hazard ratios (HR) for first hospitalization and rate ratios (RR) for total hospitalizations for survivors relative to the matched comparison cohort and siblings.

RESULTS

Overall, the risk of a first hospitalization was higher among AYA cancer survivors than the matched population-based cohort [HR = 1.93; 95% confidence interval (CI), 1.81-2.06]. Risk was most elevated for survivors of leukemia (HR = 4.76), central nervous system tumors (HR = 3.45), colorectal cancers (HR = 2.83), non-Hodgkin lymphoma (HR = 2.76), and breast cancer (HR = 2.37). The rate of total hospitalizations was also increased among survivors relative to the comparison cohort (RR = 2.05; 95% CI, 1.95-2.14). Patterns were generally similar in analyses comparing survivors to their siblings.

CONCLUSIONS

AYA cancer survivors have a higher burden of inpatient hospitalization than their siblings and the general population.

IMPACT

Results indicate the importance of long-term, risk-based follow-up care to prevent and treat severe morbidities after cancer treatment.

Total Medicare Costs Associated With Diagnosis and Treatment of Prostate Cancer in Elderly Men

Importance

Localized prostate cancer diagnosis and treatment among elderly men who are not likely to benefit represents a potential source of low-value health care services.

Objective

To quantify the costs to the Medicare program associated with detection and treatment of prostate cancer among elderly men in the United States.

Design, Setting, and Participants

This nationwide, population-based, retrospective cohort study uses the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to identify men 70 years or older diagnosed with localized prostate cancer between 2004 and 2007 and to ascertain Medicare costs associated with diagnosis and workup, treatment, follow-up, and morbidity management of the disease. National Medicare costs were estimated using per-person costs, stage-adjusted prostate cancer incidence rates by age from SEER 2007 through 2011, and 2010 Census population estimates by age.

Main Outcomes and Measures

Estimated costs to the Medicare program overall, and in each (mutually exclusive) category related to diagnosis and workup, treatment, follow-up, and morbidity management.

Results

This nationwide, population-based, retrospective cohort study included 49 692 men with nonmetastatic prostate cancer from the SEER-Medicare database (all participants were 70 years or older; 25 981 [52.3%] were 76 years or older). The median per-patient cost within 3 years after prostate cancer diagnosis was $14 453 (interquartile range [IQR], $4887-$27 899). The majority of this cost was attributable to treatment costs (median, $10 558; IQR, $1990-$23 718). Patients with a Gleason score of 6 or lower who pursued initial conservative management (no treatment within 12 months of diagnosis) had a 3-year median total cost of $1914 per patient. The estimated total 3-year cost to the Medicare program associated with the annual detection of prostate cancer in men 70 years or older is approximately $1.2 billion. Increasing active surveillance use in those with Gleason score of 6 or lower could reduce this cost by $320 million.

Conclusions and Relevance

There is substantial cost to the Medicare program associated with the diagnosis and treatment of localized prostate cancer among elderly men in the United States, despite the fact that these men are unlikely to die of prostate cancer. The majority of costs are related to treatment. Reducing provision of low-value health care services among this patient population could result in significant health care savings.

The impact of basic vs. enhanced Go NAPSACC on child care centers' healthy eating and physical activity practices: protocol for a type 3 hybrid effectiveness-implementation cluster-randomized trial

BACKGROUND

To prevent childhood obesity and promote healthy development, health authorities recommend that child care programs use the evidence-based practices that foster healthy eating and physical habits in children. Go NAPSACC is an intervention shown to improve use of these recommended practices, but it is known to encounter barriers that limit its impact and widespread use.

METHODS

This study will use a type 3 hybrid effectiveness-implementation cluster-randomized trial to compare effectiveness and implementation outcomes achieved from Go NAPSACC delivered with a basic or enhanced implementation approach. Participants will include approximately 25 coaches from Child Care Aware of Kentucky (serving four geographic regions), 97 child care centers with a director and teacher from each and two cross-sectional samples of 485 3-4-year-old children (one recruitment at baseline, another at follow-up). Coaches will be randomly assigned to deliver Go NAPSACC using either the basic or enhanced implementation approach. "Basic Go NAPSACC" represents the traditional way of delivering Go NAPSACC. "Enhanced Go NAPSACC" incorporates preparatory and support activities before and during their Go NAPSACC work, which are guided by the Quality Implementation Framework and the Consolidated Framework for Implementation Research. Data will be collected primarily at baseline and post-intervention, with select measures continuing through 6, 12, and 24 months post-intervention. Guided largely by RE-AIM, outcomes will assess change in centers' use of evidence-based nutrition and physical activity practices (primary, measured via observation); centers' adoption, implementation, and maintenance of the Go NAPSACC program (assessed via website use); center directors', teachers', and coaches' perceptions of contextual factors (assessed via self-report surveys); children's eating and physical activity behaviors at child care (measured via observation and accelerometers); and cost-effectiveness (assessed via logs and expense tracking). The hypotheses anticipate that "Enhanced Go NAPSACC" will have greater effects than "Basic Go NAPSACC."

DISCUSSION

This study incorporates many lessons gleaned from the growing implementation science field, but also offers opportunities to address the field's research priorities, including applying a systematic method to tailor implementation strategies, examining the processes and mechanisms through which implementation strategies produce their effects, and conducting an economic evaluation of implementation strategies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03938103, Registered April 8, 2019.

Comparing Shared Patient Networks Across Payers

BACKGROUND

Measuring care coordination in administrative data facilitates important research to improve care quality.

OBJECTIVE

To compare shared patient networks constructed from administrative claims data across multiple payers.

DESIGN

Social network analysis of pooled cross sections of physicians treating prevalent colorectal cancer patients between 2003 and 2013.

PARTICIPANTS

Surgeons, medical oncologists, and radiation oncologists identified from North Carolina Central Cancer Registry data linked to Medicare claims (N = 1735) and private insurance claims (N = 1321).

MAIN MEASURES

Provider-level measures included the number of patients treated, the number of providers with whom they share patients (by specialty), the extent of patient sharing with each specialty, and network centrality. Network-level measures included the number of providers and shared patients, the density of shared-patient relationships among providers, and the size and composition of clusters of providers with a high level of patient sharing.

RESULTS

For 24.5% of providers, total patient volume rank differed by at least one quintile group between payers. Medicare claims missed 14.6% of all shared patient relationships between providers, but captured a greater number of patient-sharing relationships per provider compared with the private insurance database, even after controlling for the total number of patients (27.242 vs 26.044, p < 0.001). Providers in the private network shared a higher fraction of patients with other providers (0.226 vs 0.127, p < 0.001) compared to the Medicare network. Clustering coefficients for providers, weighted betweenness, and eigenvector centrality varied greatly across payers. Network differences led to some clusters of providers that existed in the combined network not being detected in Medicare alone.

CONCLUSION

Many features of shared patient networks constructed from a single-payer database differed from similar networks constructed from other payers' data. Depending on a study's goals, shortcomings of single-payer networks should be considered when using claims data to draw conclusions about provider behavior.

The effect of medical home enrollment on cardiometabolic medication adherence among Medicaid-insured cancer patients

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Background: Medical homes, developed to increase care coordination among vulnerable patient populations, have been successful in improving outcomes of patients with multiple chronic comorbidities, but have not been evaluated among cancer survivors. We determined the impact of medical home enrollment on adherence to anti-diabetics, anti-lipidemics, and anti-hypertensives among Medicaid patients diagnosed with non-metastatic breast, colorectal, or lung cancer. Methods: Using linked cancer registry and claims data from North Carolina, we included Medicaid-insured adults diagnosed from 2004-2012 with breast, colorectal, or lung cancer who had at least one cardiometabolic condition (i.e., hyperlipidemia, hypertension, and diabetes mellitus). For each cardiometabolic condition, we measured medication adherence using ambulatory proportion of days covered (PDC). We examined the impact of medical home enrollment on PDC across the phases of cancer care (i.e., pre-cancer diagnosis, treatment, and survivorship phases) using a differences-in-differences model. All models adjusted for age, sex, race/ethnicity, dual enrollment, cancer type, comorbidity index, and number of cardiometabolic conditions. Results: We included, respectively, 765, 1079, and 1634 cancer patients with diabetes, hyperlipidemia, and hypertension. Overall, adherence to anti-lipidemics was lower than adherence to anti-diabetics and anti-hypertensives. In the pre-diagnosis phase, mean PDC across all cardiometabolic conditions was slightly lower for cancer patients enrolled in a medical home than those not enrolled in a medical home. However, medication adherence improved 3-5% in the treatment phase and 7% in the survivorship phase for cancer patients in a medical home compared to cancer patients not in a medical home during the pre-diagnosis phase. Conclusions: These results provide evidence that enrollment in a medical home can improve medication adherence, even among vulnerable cancer patients with complex health needs. The medical home model is an effective healthcare system intervention through which to provide better care coordination and improve patient outcomes.