Racial and Ethnic Disparities in Health Care Access and Utilization Under the Affordable Care Act

Health reform under the patient protection and Affordable Care Act: characteristics of exchange-based health insurance enrollees

The Affordable Care Act (ACA) reformed and expanded healthcare coverage with an exchange-based health insurance program. While millions of Americans have benefited from enrollment in ACA marketplace insurance plans, many individuals are likely to be affected by potential future policy changes. Since few studies on the features of marketplace enrollees exist, we adopted a retrospective, cross-sectional study design using 2016 National Health Interview data to identify sociodemographic and health characteristics of enrollees, comparing them to those without insurance. Chi-square tests and logistic regression examined factors associated with enrollees. Adults with multiple chronic diseases (AOR = 1.90, 95% CI = 1.44, 2.50), a history of smoking (AOR = 2.44, 95% CI = 1.82, 3.26), females, married, age 50-64 years, higher educational attainment, and retirees (AOR = 1.86, 95% CI = 1.06, 3.27) were more likely to be enrollees. Since enrollees are largely higher risk individuals with greater healthcare needs, policies that modify the ACA should take these factors into account to reduce potential adverse impacts on enrollees.

Recent Changes in Health Insurance Coverage for Urban and Rural Veterans: Evidence from the First Year of the Affordable Care Act

Introduction

Prior to the Affordable Care Act, as many as 1.3 million veterans lacked health insurance. With the passage of the Affordable Care Act, veterans now have new pathways to coverage through Medicaid expansion in those states that chose to expand Medicaid and through private coverage options offered through the Health Insurance Marketplace. We examined the impact of the ACA on health insurance coverage for veterans in expansion and non-expansion states and for urban and rural veterans.

Methods

We examined changes in veterans' health insurance coverage following the first year of the ACA, focusing on whether they lived in an urban or rural area and whether they live in a Medicaid expansion state. We used data on approximately 200,000 non-elderly community-dwelling veterans, obtained from the 2013-2014 American Community Survey and estimated differences in the adjusted probability of being uninsured between 2013 and 2014 for both urban and rural areas. Adjusted probabilities were computed by fitting logistic regressions controlling for age, gender, race, marital status, poverty status, education, and employment.

Results

There were an estimated 10.1 million U.S. non-elderly veterans in 2013; 82% lived in predominantly urban areas (8.3 million), and the remaining 18% (1.8 million) lived in predominately rural areas. Most veterans lived in the South (43.6%), and rural veterans were more likely to be Southerners than their urban counterparts. On every marker of economic well-being, rural veterans fared worse than urban veterans. They had a statistically significant higher chance of having incomes below 138% of FPG (20.0% versus 17.0%), of being out of the labor force (29.1% versus 23.0%), and of having no more than a high school education (39.6% versus 28.8%). Rural veterans were also more likely to experience at least one functional limitation. Overall, veterans in Medicaid expansion states experienced a significantly larger increase in insurance compared to veterans living in non-expansion states. For rural veterans in Medicaid expansion states, the increase in insurance was 3.5 percentage points, compared with 1.2 percentage points in non-expansion states.

Conclusion

Our analysis found a substantial 24% relative decline in the rate of uninsurance for U.S. Veterans, from 9.3 to 7.1% between 2013 and 2014. We found that coverage gains in rural areas were due to gains in Medicaid and individual market coverage. Residence in a Medicaid expansion state was particularly influential for rural veterans - the increase in the insured rate was three times larger in Medicaid expansion states versus non-expansion states. The ACA has had a positive and significant impact on the ability of U.S. Veterans to obtain health insurance coverage specifically for low-income veterans living in rural areas. The poverty rate among Veterans is rising and is particularly an issue for the more recent Gulf War veterans. Providing affordable and accessible health insurance options is part of our commitment to those who have served our country. Our analysis also presents yet another reason for the 17 non-expansion states to consider a Medicaid expansion.

Heterogeneity in the costs of medical care among people living with HIV/AIDS in the United States

OBJECTIVE

The costs of medical care for people with HIV/AIDS (PWH) vary substantially across demographic groups, stages of disease progression and regionally across the United States. We aimed to estimate medical costs for PWH and examine the heterogeneity in costs within key patient groups typically distinguished in cost-effectiveness analyses.

DESIGN

Retrospective cohort study using health administrative databases for diagnosed PWH in care at 17 HIV Research Network sites across the United States.

METHODS

We estimated mean quarterly costs for key patient groups using multivariable generalized linear mixed effects models. We used quantile regression to highlight differences in the effect of covariates within each patient group (difference between covariate estimates at the mean versus the 90th percentile of quarterly costs), identifying covariates with a larger effect among the highest cost PWH, or generating greater uncertainty in mean cost estimates.

RESULTS

Our sample included 40 022 patients with a median age of 39 years. Mean quarterly costs were highest for people who inject drugs with advanced disease progression and for PWH on antiretroviral treatment (ART). Within patient groups, we found the most heterogeneity at different levels of resource use for PWH on ART and PWH off ART with CD4 cell counts less than 200 cells/μl, people who inject drugs, as well as PWH in the South.

CONCLUSION

The study quantifies heterogeneity in costs both across and within key PWH patient groups. Our results highlight the need for sensitivity analysis on cost estimates and may inform decisions on model structure in cost-effectiveness analyses on HIV/AIDS treatment and prevention strategies.

Thriving in today's health care environment: strategies for social work leadership in population health

The current healthcare environment challenges social workers to balance multiple constituencies - organizational, payer-related, and professional - and convey the value-added nature of clinical work with patients and families. As healthcare systems move towards population health, leadership opportunities abound. This article provides an historical overview of healthcare transformation and its impact on social work practice, and describes strategies implemented to bolster the clinical focus and organizational responsiveness of Mount Sinai Health System care management staff. The training and supervisory approaches offered make possible relatable and synergistic connections between clinical practice and organizational imperatives to decrease unnecessary utilization and healthcare costs.

A retrospective evaluation of the impact of patient ethnicity on the use of epidural analgesia or blood transfusions in children undergoing major oncologic surgery

Background

The impact of patient ethnicity on healthcare delivery is well documented. In this study of children who had undergone open abdominal or pelvic surgery for tumor resection, we sought to compare the use of epidural analgesia or intraoperative blood transfusions between Caucasian and non-Caucasian children.

Methods

A retrospective study of 139 children was performed. Logistic regression models were used to evaluate the association between the specified perioperative factors and patient ethnicity.

Results

The average age (standard deviation) was 11 years (± 5), 50% were female, and 58% were Caucasian. Compared to Caucasian children, non-Caucasian children were younger (difference in mean, − 2.6 years; 95% confidence interval [− 4.3, − 0.9], p = 0.003), underwent shorter procedures (difference in mean anesthesia minutes, − 134; 95% confidence interval [−  230, − 39], p = 0.006), and had a lower proportion of patients who received epidural analgesia (66% versus 81%, p = 0.042) or blood transfusions (48% versus 65%, p = 0.039). In the adjusted model, patient ethnicity was not associated with the receipt of epidural analgesia (odds ratio 0.53, 95% confidence interval [0.23, 1.21], p = 0.132) or blood transfusions (odds ratio 0.77, 95% confidence interval [0.29, 2.04], p = 0.600). The use of epidural analgesia or blood transfusions was associated with abnormal coagulation factors (odds ratio 0.32, 95% confidence interval [0.14, 0.71], p = 0.005) and the duration of surgery (odds ratio 1.007, 95% confidence interval [1.005, 1.009], p < 0.001), respectively.

Conclusion

In this study of children who had undergone major oncologic surgery, the use of epidural analgesia or blood transfusions was not associated with patient ethnicity.

Access-To-Care Differences Between Mexican-Heritage And Other Latinos In California After The Affordable Care Act

We examined changes in health insurance coverage and access to and use of health care among adult (ages 18-64) Latinos in the US before (2007-13) and after (2014-16) implementation of the main provisions of the Affordable Care Act. Data from the California Health Interview Survey were used to compare respondents in the two periods. We used multivariable and decomposition regression analyses to investigate the role of documentation status in access disparities between Mexicans and other Latinos in California. Our findings show that after the implementation of these provisions in California, insurance coverage increased for US- and foreign-born Latinos, including undocumented Latinos. Our decomposition analyses show that after implementation, disparities between Mexicans and other Latinos declined with respect to having coverage and a usual source of care. Without the implementation of these provisions in 2014, these disparities would have been 5.76 percent and 0.31 percent larger, respectively. In contrast, legal documentation status was positively associated with disparities between Mexicans and other Latinos in having coverage and physician visits. If Mexican Latinos had had the same share of undocumented immigrants as other Latinos, disparities in health insurance coverage would have declined by 24.17 percent.

Differences in hospitalizations, emergency room admissions, and outpatient visits among Mexican-American Medicare beneficiaries

BACKGROUND

Few studies have investigated the healthcare utilization of Mexican-American Medicare beneficiaries. We used survey data that has been linked with Medicare claims records to describe the healthcare utilization of Mexican-American Medicare beneficiaries, determine common reasons for hospitalizations, and identify characteristics associated with healthcare utilization.

METHODS

Data came from wave five (2004/05) of the Hispanic Established Populations for the Epidemiological Study of the Elderly. The final sample included 1187 participants aged ≥75 who were followed for two-years (eight-quarters). Generalized estimating equations were used to estimate the probability of ≥1 hospitalization, emergency room (ER) admissions, and outpatient visits.

RESULTS

The percentage of beneficiaries who had ≥1 hospitalizations, ER admissions, and outpatient visits for each quarter ranged from 10.12-12.59%, 14.15-19.03%, and 76.61-80.68%, respectively. Twenty-three percent of hospital discharges were for circulatory conditions and 17% were for respiratory conditions. Hospitalizations for heart failure and simple pneumonia were most common. Older age was associated with significantly higher odds for ER admissions (OR = 1.49, 95% CI = 1.21-1.84) but lower odds for outpatient visits (OR = 0.74, 95% CI = 0.57-0.96). Spanish language and female gender were associated with significantly higher odds for hospitalizations (OR = 1.53, 95% CI = 1.14-2.06) and outpatient visits (OR = 1.82, 95% CI = 1.43-2.33), respectively. Having a middle-school or higher level of education was associated with significantly lower odds for ER admissions (OR = 0.71, 95% CI = 0.56-0.91). Participants who were deceased within two-years had significantly higher odds for hospitalizations (OR = 6.15, 95% CI = 4.79-7.89) and ER admissions (OR = 3.63, 95% CI = 2.88-4.57) than participants who survived at least three-years.

CONCLUSION

We observed high healthcare utilization among Mexican-American Medicare beneficiaries. Forty percent of all hospitalizations were for circulatory and respiratory conditions with hospitalizations for heart failure and pneumonia being the most common. Older age, gender, education, language, and mortality were all associated with healthcare utilization. Continued research is needed to identify patterns and clusters of social determinants and health characteristics associated with healthcare utilization and outcomes in older Mexican-Americans.

Changes in hospital service demand, cost, and patient illness severity following health reform

OBJECTIVE

To estimate the effects of the health insurance exchange and Medicaid coverage expansions on hospital inpatient and emergency department (ED) utilization rates, cost, and patient illness severity, and also to test the association between changes in outcomes and the size of the uninsured population eligible for coverage in states.

DATA SOURCES

Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases, 2011-2015, Nielsen Demographic Data, and the American Community Survey.

STUDY DESIGN

Retrospective study using fixed-effects regression to estimate the effects in expansion and nonexpansion states by age/sex demographic groups.

FINDINGS

In Medicaid expansion states, rates of uninsured inpatient discharges and ED visits fell sharply in many demographic groups. For example, uninsured inpatient discharge rates across groups, except young females, decreased by ≥39 percent per capita on average in expansion states. In nonexpansion states, uninsured utilization rates remained unchanged or increased slightly (0-9.2 percent). Changes in all-payer and private insurance rates were more muted. Changes in inpatient costs per discharge were negative, and all-payer inpatient costs per discharge declined <6 percent in most age/sex groups. The size of the uninsured population eligible for coverage was strongly associated with changes in outcomes. For example, among males aged 35-54 years in expansion states, there was a 0.793 percent decrease in the uninsured discharge rate per unit increase in the coverage expansion ratio (the ratio of the size of the population eligible for coverage to the size of the previously covered population within an age/sex/payer/geographic group).

CONCLUSIONS

Significant shifts in cost per discharge and patient severity were consistent with selective take-up of insurance. The "treatment intensity" of expansions may be useful for anticipating future effects.

Coping While Black: Chronic Illness, Mastery, and the Black-White Health Paradox

Prior research indicates that there is a black-white paradox in the relationship between physical health and mental health among American adults. However, none have considered black-white differences in psychosocial coping and depressive symptoms during the transitional stages from health to chronic illness. Using a nationally representative sample of chronically ill adults from the American Changing Lives study, this study builds on literature on chronic illness and the black-white paradox to examine if (1) growth in depressive symptoms across 16 years differs for black and white adults as they transition from healthy to chronically ill and (2) if the protective coping resource, mastery, provides an equal benefit to black and white chronically ill adults during that transition. Findings indicate that among chronically ill adults, not only do black-white disparities exist in how much mastery each group possesses, but that mastery's utility as a protective resource against depressive symptoms differs by race, with black ill adults experiencing a poorer return on their mastery than white adults. Moreover, findings that black adults maintain the same level of depressive symptoms as white adults despite this mastery disadvantage provide additional support for Minorities' Diminishing Returns Theory and some support for an emerging theory of collective resilience with regard to black American mental health.

Health Insurance Coverage Among U.S. Workers: Differences by Work Arrangements in 2010 and 2015

INTRODUCTION

For most Americans, health insurance is obtained through employers. Health insurance coverage can lead to better health outcomes, yet disparities in coverage exist among workers with different sociodemographic and job characteristics. This study compared uninsured rates among workers with different work arrangements.

METHODS

Data from the 2010 and 2015 National Health Interview Survey-Occupational Health Supplements were used to capture a representative sample of the U.S. civilian, non-institutionalized population. Associations between work arrangement and lack of health insurance were analyzed, adjusting for covariates. Analyses were performed during 2016-2018.

RESULTS

The percentage of workers aged 18-64years without health insurance coverage decreased significantly by 6.8% among workers in all work arrangement categories between 2010 and 2015. However, workers in nonstandard work arrangements were still more likely than standard workers to have no health insurance coverage. In 2015, for workers to have no health insurance the ORs were 4.92 (95% CI=3.91, 6.17) in independent, 2.87 (95% CI=2.00, 4.12) in temporary or contract, and 2.79 (95% CI=0.34, 0.41) in other work arrangements. Standard full-time workers in small establishments and standard part-time workers were also more likely to have no health insurance coverage (OR=2.74, 95% CI=2.27, 3.31, and OR=1.65, 95% CI=1.25, 2.18, respectively).

CONCLUSIONS

Important disparities in health insurance coverage among workers with different work arrangements existed in 2010 and persisted in 2015. Further research is needed to monitor coverage trends among workers.

The “Undeserving Poor,” Racial Bias, and Medicaid Coverage of African Americans

The Affordable Care Act’s Medicaid expansion increased coverage especially for the “undeserving poor”—nondisabled, nonelderly adults, who disproportionately are African American. However, African Americans benefited comparably less than other groups from Medicaid expansion because they disproportionately reside in states that rejected Medicaid expansion. Psychological and other social science research establishes that disapproval of providing “welfare” to “undeserving poor” is closely aligned with racial bias, and that these sentiments partly motivate public disapproval of policies such as Medicaid for nondisabled, nonelderly adults. It is important to clarify and acknowledge this barrier for a realistic perspective on obstacles to keeping and expanding Medicaid coverage.

Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map

BACKGROUND

Continued racial/ethnic health disparities were recently described as "the most serious and shameful health care issue of our time." Although the 2014 US Affordable Care Act-mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types.

OBJECTIVES

To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA.

SEARCH METHODS

Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities.

SELECTION CRITERIA

We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review).

DATA COLLECTION AND ANALYSIS

Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by clinical area. For areas with multiple studies in the same population and outcome, we pooled their reported hazard ratios (HRs) using random effects models (StatsDirect version 2.8.0; StatsDirect Ltd., Altrincham, England). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: odds ratio or HR of mortality for racial/ethnic minority group versus Whites, clinical area, strength of evidence, statistical significance, and racial group.

MAIN RESULTS

From 2840 citations, we included 25 studies. Studies were large (n ≥ 10 000) and involved nationally representative cohorts, and the majority were of fair quality. Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans. However, we found modest mortality disparities (HR or OR = 1.07, 1.52) for Black veterans with stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, or stroke; for American Indian and Alaska Native veterans undergoing noncardiac major surgery; and for Hispanic veterans with HIV or traumatic brain injury (most low strength).

AUTHOR'S CONCLUSIONS

Although the VHA's equal access health care system has reduced many racial/ethnic mortality disparities present in the private sector, our review identified mortality disparities that have persisted mainly for Black veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, we could not draw strong conclusions about this evidence. More disparities research is needed for American Indian and Alaska Native, Asian, and Hispanic veterans overall and for more of the largest life expectancy gaps. Public Health Implications. Because of the relatively high prevalence of diabetes in Black veterans, further research to better understand and reduce this mortality disparity may be prioritized as having the greatest potential impact. However, other mortality disparities affect thousands of veterans and cannot be ignored.

A Bayesian spatio-temporal analysis on racial disparities in hypertensive disorders of pregnancy in Florida, 2005-2014

Disparities in hypertensive disorders of pregnancy (HDP) exist among racial and ethnic groups in the US. However, little is known about spatio-temporal variations in HDP disparities. We used a Bayesian hierarchical regression approach to investigate spatio-temporal variations in HDP disparities from 2005 to 2014. County-level variation was firstly examined, followed by census tract-level variation assessment in counties where high HDP disparities were observed. A significant disadvantage in HDP was revealed for African Americans in Florida overall (Odds Ratio: 1.27, 95% Confidence Interval: 1.25, 1.29), with significant spatial variations. The greatest HDP disparities between African Americans and non-African Americans occurred in North Central Florida counties (the Big Bend region of Florida), with consistent patterns from 2005 to 2014. Analyses at census tract-level further revealed significant neighborhood disparities within these counties. Findings from this study provide important information for public health agencies and policymakers to reduce HDP disparities at the population level.

Emergency Department Utilization among Underserved African American Older Adults in South Los Angeles

Objectives: Using the Andersen’s Behavioral Model of Health Services Use, we explored social, behavioral, and health factors that are associated with emergency department (ED) utilization among underserved African American (AA) older adults in one of the most economically disadvantaged urban areas in South Los Angeles, California. Methods: This cross-sectional study recruited a convenience sample of 609 non-institutionalized AA older adults (age ≥ 65 years) from South Los Angeles, California. Participants were interviewed for demographic factors, self-rated health, chronic medication conditions (CMCs), pain, depressive symptoms, access to care, and continuity of care. Outcomes included 1 or 2+ ED visits in the last 12 months. Polynomial regression was used for data analysis. Results: Almost 41% of participants were treated at an ED during the last 12 months. In all, 27% of participants attended an ED once and 14% two or more times. Half of those with 6+ chronic conditions reported being treated at an ED once; one quarter at least twice. Factors that predicted no ED visit were male gender (OR = 0.50, 95% CI = 0.29–0.85), higher continuity of medical care (OR = 1.55, 95% CI = 1.04–2.31), individuals with two CMCs or less (OR = 2.61 (1.03–6.59), second tertile of pain severity (OR = 2.80, 95% CI = 1.36–5.73). Factors that predicted only one ED visit were male gender (OR = 0.45, 95% CI = 0.25–0.82), higher continuity of medical care (OR = 1.39, 95% CI = 1.01–2.15) and second tertile of pain severity (OR = 2.42, 95% CI = 1.13–5.19). Conclusions: This study documented that a lack of continuity of care for individuals with multiple chronic conditions leads to a higher rate of ED presentations. The results are significant given that ED visits may contribute to health disparities among AA older adults. Future research should examine whether case management decreases ED utilization among underserved AA older adults with multiple chronic conditions and/or severe pain. To explore the generalizability of these findings, the study should be repeated in other settings.

Assessment of Racial/Ethnic and Income Disparities in the Prescription of Opioids and Other Controlled Medications in California

Importance

Most drug epidemics in the United States have disproportionately affected nonwhite communities. Notably, the current opioid epidemic is heavily concentrated among low-income white communities, and the roots of this racial/ethnic phenomenon have not been adequately explained.

Objective

To examine the degree to which differential exposure to opioids via the health care system by race/ethnicity and income could be driving the observed social gradient of the current opioid epidemic, as well as to compare the trends in the prevalence of prescription opioids with those observed for stimulants and benzodiazepines.

Design, Setting, and Participants

This population-based study used 2011 through 2015 records from California's prescription drug monitoring program (Controlled Substance Utilization Review and Evaluation System), which longitudinally tracks all patients receiving controlled substance prescriptions in the state and contained unique records for 29.7 million individuals who received such a prescription from 2011 to 2015. Data were analyzed between January and May 2018.

Exposures

A total of 1760 zip code tabulation areas (ZCTAs) in California, with associated racial/ethnic composition and per capita income.

Main Outcomes and Measures

The percentage of individuals receiving at least 1 prescription each year was calculated for opioids, benzodiazepines, and stimulants.

Results

A nearly 300% difference in opioid prescription prevalence across the race/ethnicity-income gradient was observed in California, with 44.2% of adults in the quintile of ZCTAs with the lowest-income/highest proportion-white population receiving at least 1 opioid prescription each year compared with 16.1% in the quintile with the highest-income/lowest proportion-white population and 23.6% of all individuals 15 years or older. Stimulant prescriptions were highly concentrated in mostly white high-income areas, with a prevalence of 3.8% among individuals in the quintile with the highest-income/highest proportion-white population and a prevalence of 0.6% in the quintile with the lowest-income/lowest proportion-white population. Benzodiazepine prescriptions did not have an income gradient but were concentrated in mostly white areas, with 15.7% of adults in the quintile of ZCTAs with the highest proportion-white population receiving at least 1 prescription each year compared with 7.0% among the quintile with the lowest proportion-white population.

Conclusions and Relevance

The race/ethnicity and income pattern of opioid overdoses mirrored prescription rates, suggesting that differential exposure to opioids via the health care system may have induced the large, observed racial/ethnic gradient in the opioid epidemic. Across drug categories, controlled medications were much more likely to be prescribed to individuals living in majority-white areas. These discrepancies may have shielded nonwhite communities from the brunt of the prescription opioid epidemic but also represent disparities in treatment and access to all medications.

Divergent Discourse in Disproportionality Research: A Response to Kauffman and Anastasiou (2019)

This article is in response to Kauffman and Anastasiou, wherein the authors initiate discussion regarding the cultural politics within special education identification and placement, particularly surrounding the issue of disproportionality. In this article, we identified four points of discussion regarding societal implications of disproportionality; the roles of (a) divergent ideologies; (b) access and advantage; (c) adult, adolescent, and child behavior; and (d) methodology in the debate on disproportionality in special education identification and placement. Furthermore, we highlight the problems with focusing too heavily on either one of these roles, without proposing viable prevention and intervention efforts to eliminate discriminatory identification and placement in the future. We encourage further discourse in the field that will lead to sound policy and improved practices within and for schools.

Impact of a Social Worker in a Glaucoma Eye Care Service: A Prospective Study

The purpose of this study was to evaluate the effects of a six-month social worker intervention for participants with a glaucoma-related diagnosis in an urban ophthalmic setting (N = 40). The social worker assessed common barriers to eye care, helping participants with transportation, access to low-vision resources, and supportive counseling. The Distress Thermometer, Patient Health Questionnaire-9, and a satisfaction survey were administered to determine the effect of the social worker intervention and participants' overall impressions of the social worker. The most common barrier to eye care was emotional distress (77.5 percent). There was a significant decrease in the number of participants with symptoms of major and moderate depression. Fourteen participants experienced a clinically relevant decrease in depression, 37 participants felt that the social worker's support addressed their issues, and 29 participants thought it helped them in managing their glaucoma. This study provides evidence that a social work intervention may improve care coordination and management of individuals afflicted with vision impairment due to glaucoma and other ocular diseases.

Health Care Utilization of Opioid Overdose Decedents with No Opioid Analgesic Prescription History

Opioid overprescribing is a major driver of the current opioid overdose epidemic. However, annual opioid prescribing in the USA dropped from 782 to 640 morphine milligram equivalents per capita between 2010 and 2015, while opioid overdose deaths increased by 63%. To better understand the role of prescription opioids and health care utilization prior to opioid-related overdose, we analyzed the death records of decedents who died of an opioid overdose in Illinois in 2016 and linked to any existing controlled substance monitoring program (CSMP) and emergency department (ED) or hospital discharge records. We found that of the 1893 opioid-related overdoses, 573 (30.2%) decedents had not filled an opioid analgesic prescription within the 6 years prior to death. Decedents without an opioid prescription were more likely to be black (33.3% vs 20.2%, p < .001), Hispanic (16.3% vs 8.8%, p < .001), and Chicago residents (46.8% vs 25.6%, p < .001) than decedents with at least one filled opioid prescription. Decedents who did not fill an opioid prescription were less likely to die of an overdose involving prescribed opioids (7.3% vs 19.5%, p < .001) and more likely to fatally overdose on heroin (63% vs 50.4%, p < .001) or fentanyl/fentanyl analogues (50.3% vs 41.8%, p = .001). Between 2012 and the time of death, decedents without an opioid prescription had fewer emergency department admissions (2.5 ± 4.2 vs 10.6 ± 15.8, p < .001), were less likely to receive an opioid use disorder diagnosis (41.3% vs 47.5%, p = .052), and were less likely to be prescribed buprenorphine for opioid use disorder treatment (3.3% vs 8.6%, p < .001). Public health interventions have often focused on opioid prescribing and the use of CSMPs as the core preventive measures to address the opioid crisis. We identified a subset of individuals in Illinois who may not be impacted by such interventions. Additional research is needed to understand what strategies may be successful among high-risk populations that have limited opioid analgesic prescription history and low health care utilization.

Socioeconomic Disparities in the Acute Management of Stone Disease in the United States

INTRODUCTION

Patients admitted to the hospital with an acute, noninfected episode of urolithiasis are candidates for medical expulsive therapy, ureteral stent placement, or upfront ureteroscopy (URS). We sought to assess socioeconomic factors influencing treatment decisions in managing urolithiasis and to determine differences in outcomes based on treatment modality.

MATERIALS AND METHODS

The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database for California from 2007 to 2011 and for Florida from 2009 to 2014 were utilized. Patients who were admitted to the hospital with a primary diagnosis of kidney or ureteral stone were identified. The initial treatment modality utilized was assessed and factors that influenced that decision were analyzed. Multivariate logistic regression model was fit to determine factors independently associated with upfront URS. Lastly, outcomes of noninfected patients who underwent stent alone vs URS were compared.

RESULTS

We identified 146,199 patients who had an inpatient admission with urolithiasis. Overall, 45% of patients had no intervention at the time of their evaluation. Of the 55% of patients who underwent surgical intervention, 42% underwent stent alone, 44% underwent upfront URS, 1% had a PCN tube placement, 8% underwent extracorporeal shockwave lithotripsy, while 5% underwent PCNL. On multivariate logistic regression model, minorities, younger patients, publicly uninsured patients, more comorbid patients, those admitted on the weekends, and those admitted to an academic institution had significantly lower odds of undergoing upfront URS. Secondary analysis demonstrated clinical and economic advantages of upfront URS vs stent alone in eligible patients.

CONCLUSION

Upfront URS is an overlooked procedure that has clinical and cost-saving implications. Unfortunately, minorities, publicly insured patients, and those admitted on the weekend are less likely to undergo upfront URS, a disparity that should be addressed by urologist.

Effect of the Affordable Care Act on breast cancer presentation at a safety net hospital

INTRODUCTION

The Affordable Care Act (ACA) mandated the expansion of Medicaid in order to increase access to health care services. We examined the effect of the ACA on breast cancer screening and diagnosis at a Los Angeles safety net hospital.

METHODS

We performed a retrospective review of breast cancer patients treated at our institution. We compared two cohorts: patients diagnosed with breast cancer in the years 2011-2012 (pre-ACA) vs. 2015-2016 (post-ACA).

RESULTS

There were no differences in number of screening mammograms performed, age at diagnosis, mammography-detected cancers, or clinical stage at diagnosis. There was a significant decrease in the number of patients who reported as self-pay (34% vs. 6%, p < 0.0001).

CONCLUSION

In the 2-year period following ACA implementation, there was limited impact on breast cancer presentation at a safety-net hospital. Long-term follow-up across different healthcare systems is necessary to fully evaluate the global impact of the ACA on breast cancer care.

Inequalities in Young Adult Health Insurance Coverage Post-federal Health Reform

BACKGROUND

Uninsurance for young adults (YAs) was greatly reduced by the Affordable Care Act (ACA). However, reforms may not be equally beneficial for all YAs and certain policies may exacerbate, rather than resolve, pre-existing disparities.

OBJECTIVE

To investigate inequalities in YAs' insurance coverage pre- (2000-2010) and post-federal health reforms (dependent coverage expansion, 2010-2013, and Medicaid/Marketplace expansions, 2014-2016), among a nationally representative sample.

DESIGN

A difference-in-differences estimator (controlling for sociodemographics) was used to determine the effects of the ACA for young adults (ages 19-25) compared to adolescents (ages 13-18) and older YA (ages 26-30) counterparts; triple-difference estimators quantified differential policy effects by sociodemographics.

PARTICIPANTS

Three hundred eighty-seven thousand six hundred thirty-five participants in the 2000-2016 National Health Interview Survey.

MAIN MEASURES

Respondents reported their health insurance coverage types during the last 12 months, reasons uninsured, and detailed sociodemographics.

KEY RESULTS

An adjusted difference-in-differences estimator quantified a 12.3 percentage point increase (p < 0.0001) in full-year coverage post-ACA for YAs compared to older counterparts, driven by increases in employer-sponsored private insurance while younger and older youth saw larger gains in Medicaid coverage. Triple-difference estimators identified subgroups experiencing less beneficial dependent coverage expansion effects, including females, lower socioeconomic status, non-citizens, non-English speakers, and several racial/ethnic minority groups. Later ACA reforms (Marketplace/Medicaid expansions) mitigated many of these widening disparities.

CONCLUSION

While the ACA significantly impacted YA insurance coverage, these gains were not of equal magnitude for all YAs and disparities remain. As such, more work needs to be done to ensure optimal and equitable access to high-quality, affordable insurance for all YAs.

Cardiovascular disease in racial/ethnic minority populations: illness burden and overview of community-based interventions

Cardiovascular disease, the leading cause of death in the USA, poses a unique and multilateral burden to racial/ethnic minorities. The admixture of comorbid conditions, structural barriers, and psychosocial standing complicates the prevention, diagnosis, and management of cardiovascular disease in racial/ethnic minority populations and requires newer approaches to reduce existing disparities. A discussion of the cardiovascular disease risk burden is presented, along with an overview of multi-stratified considerations for improving racial/ethnic minority cardiovascular health via community engagement.

Medicaid enrollment among previously uninsured Americans and associated outcomes by race/ethnicity-United States, 2008-2014

Objectives

To examine the person‐level impact of Medicaid enrollment on costs, utilization, access, and health across previously uninsured racial/ethnic groups.

Data Source

Medical Expenditure Panel Survey, 2008‐2014.

Study Design

We pooled multiple 2‐year waves of data to examine the direct impact of Medicaid enrollment among uninsured Americans. We compared changes in outcomes among nonpregnant, uninsured individuals who gained Medicaid (N = 963) to those who remained uninsured (N = 9784) using a difference‐in‐differences analysis.

Principal Findings

Medicaid enrollment was associated with significant increases in total health care costs and total prescription drug costs and a significant decrease in out‐of‐pocket costs. Among those who gained Medicaid, prescription drug use increased significantly relative to those who remained uninsured. Medicaid enrollment was also associated with a significant increase in reporting a usual source of care, a decrease in foregone care, and significant improvements in severe psychological distress. Changes in total prescription drug costs and total prescription drug fills differed significantly across each racial/ethnic group.

Conclusions

Among a national sample of uninsured individuals, Medicaid enrollment was associated with substantial favorable changes in out‐of‐pocket costs, prescription drug use, and access to care. Our findings suggest Medicaid is an important tool to reduce insurance‐related disparities among Americans.

Preinjury employment status as a risk factor for symptomatology and disability in mild traumatic brain injury: A TRACK-TBI analysis

BACKGROUND

Preinjury employment status may contribute to disparity, injury risk, and recovery patterns following mild traumatic brain injury (MTBI).

OBJECTIVE

To characterize associations between preinjury unemployment, prior comorbidities, and outcomes following MTBI.

METHODS

MTBI patients from TRACK-TBI Pilot with complete six-month outcomes were extracted. Preinjury unemployment, comorbidities, injury factors, and intracranial pathology were considered. Multivariable regression was performed for employment and outcomes, correcting for demographic and injury factors. Mean-differences (B) and 95% CIs are reported. Statistical significance was assessed at p < 0.05.

RESULTS

162 MTBI patients were aged 39.8±15.4-years and 24.6% -unemployed. Unemployed patients demonstrated increased psychiatric comorbidities (45.0% -vs.- 23.8%; p = 0.010), drug use (52.5% -vs.- 21.3%; p < 0.001), smoking (62.5% -vs.- 27.0%; p < 0.001), prior TBI (78.4% -vs.- 55.0%; p = 0.012), and lower education (15.0% -vs.- 45.1% college degree; p = 0.003). On multivariable analysis, unemployment associated with decreased six-month functional outcome (Glasgow Outcome Scale-Extended: B = - 0.50, 95% CI [- 0.88, - 0.11]), increased psychiatric disturbance (Brief Symptom Inventory-18: B = 6.22 [2.33, 10.10]), postconcussional symptoms (Rivermead Questionnaire: B = 4.91 [0.38, 9.44]), and post-traumatic stress disorder (PTSD Checklist-Civilian: B = 5.99 [0.76, 11.22]). No differences were observed for cognitive measures or satisfaction with life.

CONCLUSIONS

Unemployed patients are at risk for preinjury psychosocial comorbidities, poorer six-month functional recovery and increased psychiatric/postconcussional/PTSD symptoms. Resource allocation and return precautions should be implemented to mitigate and/or prevent the decline of at-risk patients.

The association between symptoms of generalized anxiety disorder and appointment adherence, overnight hospitalization, and emergency department/urgent care visits among adults living with HIV enrolled in care

This study examined the association between generalized anxiety disorder (GAD) symptoms and healthcare utilization (HCU) among 801 people living with HIV (PLWH). Participants recruited from community health centers in Florida completed questionnaires assessing demographics, substance use, symptoms of GAD and depression, and HCU. Adjusted binary and multinomial logistic regressions assessed the association between moderate-severe GAD symptoms and past 6-month missed HIV-care appointments, overnight hospitalization, and emergency department (ED)/urgent care visits. Participants reporting moderate-severe GAD symptoms had a greater odds of missing an HIV-care appointment (AOR 2.03, 95% CI 1.28-3.24, p = 0.003), spending 2 (AOR 4.35, 95% CI 2.18-8.69, p < 0.001) or 3+ (AOR 2.79, 95% CI 1.20-6.45, p = 0.016) nights in the hospital, and visiting an ED/urgent care facility 2 (AOR 2.63, 95% CI 1.39-4.96, p = 0.003) or 3+ (AOR 2.59, 95% CI 1.27-5.26 p = 0.008) times compared to participants reporting none-mild anxiety. Depression was associated with fewer ED/urgent care visits and overnight hospitalizations, while no association was found with missed primary care appointments. The role of anxiety in illness management remains understudied among PLWH. Anxiety identification and the development of interventions for anxiety among PLWH may have important consequences for healthcare cost saving, patient retention in care, and HIV-disease management.

Palliative Care Consultation Trends Among Hospitalized Patients With Advanced Cancer in the United States, 2005 to 2014

Background:

Although palliative care services are increasing in the United States, disparities exist in access and utilization. Hence, we explored these factors in hospitalized patients with advanced cancers using the National Inpatient Sample (NIS).

Methods:

This was a retrospective analysis of NIS data, 2005 to 2014, and included patients ≥18 years with advanced cancers with and without palliative care consultations. Both χ2 and independent t tests were used for categorical and continuous variables. Multivariate logistic regressions were used for identifying factors associated with palliative care consultations.

Results:

Palliative care consultations were recorded in 9.9% of 4 732 172 weighted advanced cancer hospitalizations and increased from 3.0% to 15.5% during 2005 to 2014 (relative increase, 172.2%, Ptrend < .01). Factors associated with higher palliative care consultations were increasing age, ≥80 years (odds ratio [OR]: 1.47; 95% confidence interval [CI]: 1.38-1.56); black race (OR: 1.21; 95% CI: 1.14-1.28); private insurance coverage (OR: 1.10; 95% CI: 1.02-1.18); West region (OR: 1.15; 95% CI: 1.01-1.33); large hospitals (OR: 1.19; 95% CI: 1.02-1.34); high income (OR: 1.08; 95% CI: 1.08-1.17); do-not-resuscitate (dying patients) status (OR: 10.55; 95% CI: 10.14-10.99); and in-hospital radiotherapy (OR: 1.13; 95% CI: 1.06-1.21). Palliative care consultations were lower in patients with chemotherapy (OR: 0.71; 95% CI: 0.60-0.84).

Conclusion:

Many demographic, socioeconomic, health-care, and geographic disparities were identified in palliative care consultations. Additionally, palliative care resources were underutilized by hospitalized patients with advanced cancers and commonly utilized by patients who are dying. Health-care providers and policy makers should focus on these disparities in order to improve palliative care use.

Multi-Site Evaluation of Community-Based Efforts to Improve Engagement in HIV Care Among Populations Disproportionately Affected by HIV in the United States

This study assesses effects of a community-based intervention across seven sites in the United States on HIV care utilization and study retention, among people living with HIV (PLWH). A two-armed study was conducted from 2013 to 2016 in each of seven community-based agencies across the United States. Each site conducted interventions involving community engagement approaches in the form of case management or patient navigation. Control conditions were standard of care involving referral to HIV clinical care. Participants (N = 583) were adults reporting erratic or no HIV care in the past 6 months. Longitudinal survey data on demographics, behavioral risks, and HIV care were collected from participants at baseline, before service delivery, and at 6-month follow-up. Unadjusted and adjusted generalized linear mixed models were used to assess the intervention effects on HIV care utilization and study retention. Participants were majority black (75.5%), cisgender male (55.1%), and heterosexual (55.4%). No significant intervention effect was observed on HIV care utilization, although both groups improved significantly over time [adjusted odds ratio (AOR): 2.09, 95% confidence interval (CI): 1.30-3.37]. Intervention participants were more likely to be retained in the study (AOR: 1.50, 95% CI: 1.03-2.20). Community intervention did not affect HIV care utilization more than standard of care, but intervention participants were more likely to be retained in the study, suggesting that such approaches support relationship building in ways that can facilitate follow-up of socially vulnerable PLWH. More research is needed to understand how such community efforts can support better HIV care utilization in these populations.

Examining EMTALA in the era of the patient protection and Affordable Care Act

Background

Little is known regarding the characteristics of hospitals that violate the Emergency Medical Treatment and Labor Act (EMTALA). This study addresses this gap by examining EMTALA settlements from violating hospitals and places these descriptive results within the current debate surrounding the Patient Protection and Affordable Care Act (ACA).

Methods

We conducted a content analysis of all EMTALA Violations that resulted in civil monetary penalty settlements from 2002–2015 and created a dataset describing the nature of each settlement. These data were then matched with Thomson Healthcare hospital data. We then present descriptive statistics of each settlement over time, plot settlements by type of violation, and provide the geographic distribution of settlements.

Results

Settlements resulting from EMTALA violations decreased from a high of 46 in 2002 to a low of 6 in 2015, a decline of 87%. Settlements resulting from violations most commonly occurred for failure to screen and failure to stabilize patients in need of emergency care. Settlements were most common in hospitals in the South (48%) and in urban areas (74%). Among Disproportionate Share Hospitals (DSH) with a violation, the majority (62%) were located in the South or in urban areas (65%). Violating hospitals incurred annual settlements of $31,734 on average, for a total $5,299,500 over the study period.

Conclusions

EMTALA settlements declined prior to and after the implementation of the ACA and were most common in the South and in urban areas. EMTALA's status as an unfunded mandate, scheduled cuts to DSH payments and efforts to repeal the ACA threaten the financial viability of safety-net hospitals and could result in an increase of EMTALA violations. Policymakers should be cognizant of the interplay between the ACA and complementary laws, such as EMTALA, when considering changes to the law.

Racial Discrimination in Health Care and Utilization of Health Care: a Cross-sectional Study of California Adults

BACKGROUND

Racial and ethnic discrimination in health care have been associated with suboptimal use of health care. However, limited research has examined how facets of health care utilization influence, and are influenced by, discrimination.

OBJECTIVE

This study aimed to determine if type of insurance coverage and location of usual source of care used were associated with perceptions of racial or ethnic discrimination in health care. Additionally, this study examined if perceived racial or ethnic discrimination influenced delaying or forgoing prescriptions or medical care.

DESIGN

Data from the 2015-2016 California Health Interview Survey were used. Logistic regression models estimated odds of perceiving racial or ethnic discrimination from insurance type and location of usual source of care. Logistic regression models estimated odds of delaying or forgoing medical care or prescriptions.

PARTICIPANTS

Responses for 39,171 adults aged 18 and over were used.

MAIN MEASURES

Key health care utilization variables were as follows: current insurance coverage, location of usual source of care, delaying or forgoing medical care, and delaying or forgoing prescriptions. We examined if these effects differed by race. Ever experiencing racial or ethnic discrimination in the health care setting functioned as a dependent and independent variable in analyses.

KEY RESULTS

When insurance type and location of care were included in the same model, only the former was associated with perceived discrimination. Specifically, those with Medicaid had 66% higher odds of perceiving discrimination, relative to those with employer-sponsored coverage (AOR = 1.66; 95% CI 1.11, 2.47). Race did not moderate the impact of discrimination. Perceived discrimination was associated with higher odds of delaying or forgoing both prescriptions (AOR = 1.97; 95% CI 1.26, 3.09) and medical care (AOR = 1.84; 95% CI 1.31, 2.59).

CONCLUSIONS

Health care providers have an opportunity to improve the experiences of their patients, particularly those with publicly sponsored coverage.

Geographic Variability in Discharge Setting and Outpatient Postacute Physical Therapy After Total Knee Arthroplasty: A Retrospective Cohort Study

BACKGROUND

Despite the frequency of total knee arthroplasty (TKA) in the Medicare population, little is known about the use of postacute physical therapy among those discharged to home.

OBJECTIVE

The objectives of this study were to explore factors associated with geographic variability in discharge disposition and outpatient physical therapy utilization for Medicare patients after TKA discharged to home/self-care.

DESIGN

The design of the study was a retrospective cohort study.

METHODS

Medicare patients with TKA discharged alive from July 1, 2010, to June 30, 2011, with discharge disposition to home/self-care (HSC), home health agency (HHA), inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF) were selected. Geography was measured with Census region. Outpatient physical therapy utilization was calculated from Medicare Part B claims. Odds ratios for discharge disposition and adjusted means for physical therapy utilization variables by Census region were calculated, accounting for county-clustered data and adjusting for demographics, clinical, and environmental characteristics.

RESULTS

There was significant variation with discharge destination by Census region among 18,278 patients. With discharge disposition analysis, the patients from the West region who were discharged home were the referent group. The patients from the South and Northeast regions had higher odds for discharge to HHAs (adjusted odds ratio [95% CI = 1.80 [1.48-2.19] and 2.20 [1.70-2.84]), SNFs (1.34 [1.08-1.66] and 4.42 [3.38-5.79]), and IRFs (2.36 [1.80-3.09] and 8.83 [6.41-12.18]). For those discharged to HSC, 40.4% received outpatient physical therapy within 4 weeks. Significant differences were found with time to first physical therapy visit (Midwest <South <[West = Northeast]) and length of therapy episode, but not with the number of therapy visits by geographic region.

CONCLUSIONS

Geographic region was associated with discharge setting, postacute physical therapy, and outpatient therapy utilization in Medicare beneficiaries after TKA. Differences in outcomes of outpatient therapy should be assessed to better describe the impact of geographic variation in care.

Higher Predictive Value Positive for MMA Than ACA MTM Eligibility Criteria Among Racial and Ethnic Minorities: An Observational Study

The objective of this study was to examine positive predictive value (PPV) of medication therapy management (MTM) eligibility criteria under Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial and ethnic groups. The study analyzed Medicare data (2012-2013) for 2 213 594 beneficiaries. Medication utilization issues were determined based on medication utilization measures mostly developed by Pharmacy Quality Alliance. MMA was associated with higher PPV than ACA in identifying individuals with medication utilization issues among non-Hispanic blacks (blacks) and Hispanics than non-Hispanic whites (whites). For example, odds ratio for having medication utilization issues to whites when examining MMA in 2013 and ACA were 1.09 (95% confidence interval [CI] = 1.04-1.15) among blacks, and 1.17 (95% CI = 1.10-1.24) among Hispanics, in the main analysis. Therefore, MMA was associated with 9% and 17% higher PPV than ACA in identifying patients with medication utilization issues among blacks and Hispanics, respectively, than whites.

Odds of talking to healthcare providers as the initial source of healthcare information: updated cross-sectional results from the Health Information National Trends Survey (HINTS)

BACKGROUND

People use a variety of means to find health information, including searching the Internet, seeking print sources, and talking to healthcare providers, family members, and friends. Doctors are considered the most trusted source of health information, but people may be underutilizing them in favor of searching the Internet.

METHODS

A multinomial logistic regression of cross-sectional data from Cycle 4 of the Health Information National Trends Survey (HINTS) was conducted. Independent variables included gender, age, rurality, cancer history, general health, income, race, education level, insurance status, veteran status, Internet use, and data year; the dependent variable was the first chosen source of health information.

RESULTS

The most frequent initial source of health information was the Internet, and the second most frequent was healthcare providers. There were significant differences in odds of using healthcare providers as the first source of health information. Those likely to use doctors as their initial source of health information were older adults, black adults, adults with health insurance, those who do not use the Internet, and adults who do not have a college degree.

CONCLUSIONS

People who use healthcare providers as the first source of health information may have better access to health care and be those less likely to use the Internet. Doctors may have to provide more information to those who do not use the internet and spend time verifying information for those who do use health information from the internet.

Lower barriers to primary care after the implementation of the Affordable Care Act in the United States of America

OBJECTIVE

To examine short-term changes in perceived barriers to access to primary care before and after implementation of the Affordable Care Act (ACA) among adults in the United States of America.

METHODS

The ACA was approved in 2010. We used the National Health Interview Survey (NHIS) for the years 2011-2014 to compare the main reported problems in accessing primary care among adult respondents in 2011-2013 (before implementation of mandatory ACA health insurance for individuals) and in 2014 (after that implementation). A multivariate logistic stepwise regression analysis was used to identify trends with primary care barriers.

RESULTS

We found that from 2010 through 2014, individuals were progressively less likely to report challenges to accessing care, such as having trouble finding a provider, getting accepted as new patients, and health care providers not accepting their health insurance. In addition, adults were less likely to report inconveniences linked to waiting times for an appointment and with provider's office hours.

CONCLUSIONS

Informing policymakers, providers, and system administrators about the short-term changes in perceived barriers to care offers a baseline for evaluating policies and programs linked to implementing the ACA, as well as assessing how prepared primary care networks were for the influx of newly insured patients. Nevertheless, the abolition of the ACA health insurance mandate through legislation approved in December 2017 has put into question whether patients' perceptions of improved access to care will be sustained in the future.

Using Geosocial Networking Apps to Understand the Spatial Distribution of Gay and Bisexual Men: Pilot Study

BACKGROUND

While services tailored for gay, bisexual, and other men who have sex with men (gbMSM) may provide support for this vulnerable population, planning access to these services can be difficult due to the unknown spatial distribution of gbMSM outside of gay-centered neighborhoods. This is particularly true since the emergence of geosocial networking apps, which have become a widely used venue for meeting sexual partners.

OBJECTIVE

The goal of our research was to estimate the spatial density of app users across Metro Vancouver and identify the independent and adjusted neighborhood-level factors that predict app user density.

METHODS

This pilot study used a popular geosocial networking app to estimate the spatial density of app users across rural and urban Metro Vancouver. Multiple Poisson regression models were then constructed to model the relationship between app user density and areal population-weighted neighbourhood-level factors from the 2016 Canadian Census and National Household Survey.

RESULTS

A total of 2021 app user profiles were counted within 1 mile of 263 sampling locations. In a multivariate model controlling for time of day, app user density was associated with several dissemination area-level characteristics, including population density (per 100; incidence rate ratio [IRR] 1.03, 95% CI 1.02-1.04), average household size (IRR 0.26, 95% CI 0.11-0.62), average age of males (IRR 0.93, 95% CI 0.88-0.98), median income of males (IRR 0.96, 95% CI 0.92-0.99), proportion of males who were not married (IRR 1.08, 95% CI 1.02-1.13), proportion of males with a postsecondary education (IRR 1.06, 95% CI 1.03-1.10), proportion of males who are immigrants (IRR 1.04, 95% CI 1.004-1.07), and proportion of males living below the low-income cutoff level (IRR 0.93, 95% CI 0.89-0.98).

CONCLUSIONS

This pilot study demonstrates how the combination of geosocial networking apps and administrative datasets might help care providers, planners, and community leaders target online and offline interventions for gbMSM who use apps.

Diabetes mortality rates among African Americans: A descriptive analysis pre and post Medicaid expansion

Background

Compared with other racial and ethnic groups, African Americans are disproportionately burdened by high rates of deaths due to diabetes. Insurance coverage and access to primary care are critical for prevention and chronic disease management.

Purpose

To examine the difference in age-adjusted diabetes mortality rates in African Americans before and after Medicaid expansion.

Methods

Using ICD-10 Cause List E10–E14, age-adjusted diabetes mortality rates among African Americans were extracted from the Centers for Disease Control and Prevention's Compressed Mortality File. Sufficient and reliable data were available for 36 states and the District of Columbia. With a 95% confidence interval, two periods were analyzed: pre-Medicaid expansion - years 2008, 2009, 2010 and post-Medicaid expansion - years 2014, 2015, 2016. Three-year means for both periods were calculated for each state. Differences for each state are presented and contextualized as a state that opted in or out of expanding Medicaid coverage.

Results

There was a slight reduction in diabetes mortality in African Americans (41.14/100,000 pre-expansion and 38.94/100,000 post-expansion). We found variability across states – regardless of expansion status. Differences in rates ranged from a decrease of 15.43/100,000 to an increase of 9.53/100,000. Out of all states that met our criteria, 24 states expanded coverage; age-adjusted diabetes death rates declined in 16 of those states. There were also reductions in eight states that did not expand coverage.

Conclusion

Future research is needed to explore if Medicaid expansion is associated with reductions in diabetes mortality in the African American community.

•

There was a reduction in mean age-adjusted diabetes mortality rates in 24 states after Medicaid expansion.

•

Mean mortality reductions were observed in regions of the country with a high prevalence of diabetes.

•

Mixed findings suggest age-adjusted diabetes mortality reductions in states regardless of Medicaid expansion.

Pancreatic Cancer Related Health Disparities: A Commentary

We summarize the risk factors that may significantly contribute to racial disparities in pancreatic cancer, which is now the third leading cause of cancer deaths and projected to be second around 2030 in 12 years. For decades, the incidence rate of pancreatic cancer among Blacks has been 30% to 70% higher than other racial groups in the United States and the 5-year survival rate is approximately 5%. Diabetes and obesity have been identified as potentially predisposing factors to pancreatic cancer and both are more common among Blacks. Smoking continues to be one of the most important risk factors for pancreatic cancer and smoking rates are higher among Blacks compared to other racial groups. The overall risk of pancreatic cancer due to changes in DNA is thought to be the same for most racial groups; however, DNA methylation levels have been observed to be significantly different between Blacks and Whites. This finding may underlie the racial disparities in pancreatic cancer. Identification and prevention of these factors may be effective strategies to reduce the high incidence and mortality rates for pancreatic cancer among Blacks.

Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation

BACKGROUND AND OBJECTIVES

Before 2014, low-income individuals in the United States with non-dialysis-dependent CKD had fewer options to attain health insurance, limiting their opportunities to be preemptively wait-listed for kidney transplantation. We examined whether expanding Medicaid under the Affordable Care Act was associated with differences in the number of individuals who were pre-emptively wait-listed with Medicaid coverage.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the United Network of Organ Sharing database, we performed a retrospective observational study of adults (age≥18 years) listed for kidney transplantation before dialysis dependence between January 1, 2011-December 31, 2013 (pre-Medicaid expansion) and January 1, 2014-December 31, 2016 (post-Medicaid expansion). In multinomial logistic regression models, we compared trends in insurance types used for pre-emptive wait-listing in states that did and did not expand Medicaid with a difference-in-differences approach.

RESULTS

States that fully implemented Medicaid expansion on January 1, 2014 ("expansion states," n=24 and the District of Columbia) had a 59% relative increase in Medicaid-covered pre-emptive listings from the pre-expansion to postexpansion period (from 1094 to 1737 listings), compared with an 8.8% relative increase (from 330 to 359 listings) among 19 Medicaid nonexpansion states (P<0.001). From the pre- to postexpansion period, the adjusted proportion of listings with Medicaid coverage decreased by 0.3 percentage points among nonexpansion states (from 4.0% to 3.7%, P=0.09), and increased by 3.0 percentage points among expansion states (from 7.0% to 10.0%, P<0.001). Medicaid expansion was associated with absolute increases in Medicaid coverage by 1.4 percentage points among white listings, 4.0 percentage points among black listings, 5.9 percentage points among Hispanic listings, and 5.3 percentage points among other listings (P<0.001 for all comparisons).

CONCLUSIONS

Medicaid expansion was associated with an increase in the proportion of new pre-emptive listings for kidney transplantation with Medicaid coverage, with larger increases in Medicaid coverage among racial and ethnic minority listings than among white listings.