The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity

Building Power for Health: The Grassroots Politics of Sustaining and Strengthening Medicaid

CONTEXT

Notwithstanding an impressive corpus charting the politics of Medicaid, there is still much to learn about the contemporary politics of sustaining, expanding, and protecting the program. There is especially scant scholarly evidence on the significance and function of grassroots political actors (i.e., the communities and groups most directly affected by health policy). This article explores the role such groups play in the politics of Medicaid.

METHODS

This research is based on qualitative interviews with organizers and advocates working in the domain of health policy.

FINDINGS

The power of grassroots actors in Medicaid politics is constrained by political and structural forces, including philanthropic funding practices, racism, and partisan polarization. Nevertheless, when bottom-up actors effectively exercise power, their involvement in Medicaid politics can transform policy processes and outcomes.

CONCLUSIONS

Grassroots actors-those who are part of, represent, organize, or mobilize the people most affected by Medicaid policy-can play pivotal roles within Medicaid politics. Although they do not yet have sufficient political wherewithal to consistently advance transformational policy change, ongoing political processes suggest that they hold promise for being an increasingly important political force.

Enrollee, Plan, and State Characteristics Associated With Experience of Care Among Adults in Medicaid Managed Care

OBJECTIVE

To examine five enrollee-reported experience of care metrics and assess enrollee, plan, and state characteristics associated with higher care ratings.

STUDY SETTING AND DESIGN

We conducted a repeated cross-sectional study using multivariable linear probability models and predictors that captured various enrollee, plan, and state characteristics. We evaluated five enrollee-reported experience of care measures: being "always or usually" easy to get needed care (yes/no), having a personal doctor (yes/no), having timely access to a checkup or routine care (yes/no), having timely access to specialty care (yes/no), and healthcare rating (0-10).

DATA SOURCES AND ANALYTIC SAMPLE

We used enrollee-level data for adults aged 18-64 from the National Committee on Quality Assurance (NCQA) Adult Medicaid Managed Care Member Experience Survey in 2018 and 2020.

PRINCIPAL FINDINGS

The study included 94,296 adults enrolled in 172 Medicaid managed care plans in 38 states and who responded to the member experience survey. Enrollees from racially and ethnically minoritized groups reported significantly worse experiences of care than non-Hispanic White enrollees on all outcomes. Larger plan size was associated with a lower likelihood of timely access to checkups (-5.44 percentage points [PP] difference) but a higher likelihood of having a personal doctor (4.52 PP). Plan for-profit status was associated with a lower likelihood of having access to needed care (-2.24 PP) or having a personal doctor (-4.07 PP). Enrollees in states with Medicaid managed care quality incentives for improving consumer experience of care were significantly more likely to report timely access to specialty care (5.16 PP).

CONCLUSIONS

Enrollees from racially and ethnically minoritized groups with poor health status report worse access to care, with characteristics such as for-profit plan status and large plan size being associated with access to care. Strategies to improve care experiences may include targeted outreach, equity initiatives, and strengthening provider networks and availability.

Attributing Racial Differences in Care to Health Plan Performance or Selection

Importance

There is increased interest in public reporting of, and linking financial incentives to, the performance of organizations on health equity metrics, but variation across organizations could reflect differences in performance or selection bias.

Objective

To assess whether differences across health plans in sex- and age-adjusted racial disparities are associated with performance or selection bias.

Design, Setting, and Participants

This cross-sectional study leveraged a natural experiment, wherein a southern US state randomly assigned much of its Medicaid population to 1 of 5 plans after shifting to managed care in 2012. Enrollee-level administrative claims and enrollment data from 2011 to 2015 were obtained for self-identified Black and White enrollees. The analyses were limited to Black and White Medicaid enrollees because they accounted for the largest percentages of the population and could be compared with greater statistical power than other groups. Data were analyzed from June 2021 to September 2024.

Exposures

Plan enrollment via self-selection (observational population) vs random assignment (randomized population).

Main Outcomes and Measures

Annual counts of primary care visits, low-acuity emergency department visits, prescription drug fills, and total spending. For observational and randomized populations, models of each outcome were fit as a function of plan indicators, indicators for race, interactions between plan indicators and race, and age and sex. Models estimated the magnitude of racial differences within each plan and tested whether this magnitude varied across plans.

Results

Of 118 101 enrollees (mean [SD] age, 9.3 [7.5] years; 53.0% female; 61.4% non-Hispanic Black; and 38.6% non-Hispanic White), 70.2% were included in the randomized population, and 29.8% were included in the observational population. Within-plan differences in primary care visits, low-acuity emergency department visits, prescription drug use, and total spending between Black and White enrollees were large but did not vary substantially and were not statistically significantly different across plans in the randomized population, suggesting minimal effects of plans on racial differences in these measures. In contrast, in the observational population, racial differences varied substantially across plans (standard deviations 2-3 times greater than in the randomized population); this variation was statistically significant after adjustment for multiple testing, except for emergency department visits. Greater between-plan variation in racial differences in the observational population was only partially explained by sampling error. Stratifying by race did not bring observational estimates of plan effects meaningfully closer to randomized estimates.

Conclusions and Relevance

This cross-sectional study showed that selection bias may mischaracterize plans' relative performance on measures of health care disparities. It is critical to address disparities in Medicaid, but adjusting plan payments based on disparity measures may have unintended consequences.

Impact of sex differences on patients with neuroendocrine neoplasms during hospital admission

Background

Sex disparities are known modifiers of health and disease. In neuroendocrine neoplasms (NENs), sex-based differences have been observed in the epidemiology and treatment-related side effects.

Objectives

To examine sex differences in demographics, diagnoses present during hospital admission, comorbidities, and outcomes of hospital course among hospitalized patients with NENs.

Design

Retrospective analysis.

Methods

A descriptive analysis of sex differences was performed on patients with NENs discharged from U.S. community hospitals in 2019 from the National Inpatient Sample (NIS), Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality.

Results

A total of 7334 patients with NENs were identified; 4284 patients had primary NENs, and 3050 patients had metastatic NENs. In total, 48.7% were males and 51.3% were females. Distributions of race and ethnicity, and payer types differed by sex (p < 0.001 and p = 0.027, respectively). For race and ethnicity, there were more females in White, Black, and Native American races, and Hispanic ethnicity. For payer types, female predominance was seen with Medicare, Medicaid, private insurance, and self-pay groups. Sex differences were seen in diagnosis made during hospital stay. In all NENs, oral (p = 0.036) and neurologic (p < 0.001) diagnoses were more common in females; ascites (p = 0.002), dysphagia (p = 0.002), biliary ductal obstruction (p = 0.014), and jaundice (p = 0.048) were more common in males. In primary NENs, ascites (p < 0.001) was male predominant. In metastatic NENs, dysphagia (p = 0.003) and jaundice (p = 0.034) were male predominant, whereas females had more headaches (p < 0.001). Nausea and vomiting were female predominant in all NENs (p < 0.001), primary (p = 0.044), and metastatic (p < 0.001) NENs. For comorbidities, arthropathies (p < 0.001), depression (p < 0.001), hypothyroidism (p < 0.001), other thyroid disorders (p < 0.001), chronic pulmonary disease (p = 0.002), and obesity (p < 0.001) were female predominant.

Conclusion

There were sex differences in the race and ethnicity, payer types, diagnoses present during hospital admission, and comorbidities among the 2019 NIS hospital discharge sample of patients with NENs.

Factors Affecting Adherence in Allergic Disorders and Strategies for Improvement

Addressing patient adherence is a key element in ensuring positive health outcomes and improving health-related quality of life for patients with atopic and immunologic disorders. Understanding the complex etiologies of patient nonadherence and identifying real-world solutions is important for clinicians, patients, and systems to design and effect change. This review serves as an important resource for defining key issues related to patient nonadherence and outlines solutions, resources, knowledge gaps, and advocacy areas across five domains: health care access, financial considerations, socioenvironmental factors, health literacy, and psychosocial factors. To allow for more easily digestible and usable content, we describe solutions based on three macrolevels of focus: patient, clinician, and system. This review and interactive tool kit serve as an educational resource and call to action to improve equitable distribution of resources, institutional policies, patient-centered care, and practice guidelines for improving health outcomes for all patients with atopic and immunologic disorders.

Trends in Timely Access to High-Quality and Affordable Surgical Care in the United States

OBJECTIVE

To quantify recent trends in access to timely, high-quality, affordable surgical care in the US.

BACKGROUND

Insufficient access to surgical care remains an ongoing concern in the US. Previous attempts to understand and quantify barriers in access to surgical care in the US lack a comprehensive, policy-relevant lens.

METHODS

This observational cross-sectional study evaluates multiple domains of access to surgical care across the US from 2011-2015 and 2016-2020. Our stepwise model included timeliness (<60-minute drive time), quality (surgically capable hospital with ≥3 CMS stars), and affordability (neither uninsured nor underinsured) of access to surgical care using a novel combination of data from the American Hospital Association, Medicare claims, CMS's Five-Star Quality Rating System, the American Community Survey, and the Medical Expenditure Panel Survey.

RESULTS

The number of Americans lacking access to timely, high-quality, affordable surgical care increased from 97.7 million in 2010-2015 to 98.7 million in 2016-2020. Comparing these two periods, we found improvements in the number of Americans lacking access due to being uninsured (decrease from 38.5 to 26.5 million). However, these improvements were offset by increasing numbers of Americans for whom timeliness (increase from 9.5 to 14.1 million), quality (increase from 3.4 to 4.9 million), and underinsured status (increase from 46.3 to 53.1 million) increased as barriers to access. Multiple sensitivity analyses using alternative thresholds for each access domain demonstrated similar trends. Those with insufficient access to care tended to be more rural (6.7% vs. 2.0%, P<0.001), lower income (40.7% vs. 30.0%, P<0.001), and of Hispanic ethnicity (35.9% vs. 15.8%, P<0.001).

CONCLUSIONS

Nearly one-in-three Americans lack access to surgical care that is timely, high-quality, and affordable. This study identifies the multiple actionable drivers of access to surgical care that notably can each be addressed with specific policy interventions.

Sociodemographic Predictors of Keratoconus (Severity, Treatment, and Progression) in a Tertiary Center in New York City

PURPOSE

To identify sociodemographic factors as predictors of keratoconus severity, progression, disease outcomes, and appropriate management in a tertiary care ophthalmology institute in the New York City metropolitan area.

METHODS

This is a retrospective chart review. Patients with keratoconus presenting at a tertiary eye institute in an urban setting seen between 2015 and 2022 were included. Sociodemographic data including age, sex, race, ethnicity, income derived from zip code, insurance coverage, and preferred language were recorded. These sociodemographic factors were analyzed as possible predictors of keratoconus severity at presentation (Amsler-Krumeich grades III and IV): patients presenting with acute hydrops, patients receiving corneal cross-linking or corneal transplant, patients showing 1 or more diopters of increase of Kmax during their follow-up, and patients having longer time between the provider's recommendation of corneal cross-linking and the time of the procedure.

RESULTS

The retrospective review included 634 patients with a clinical diagnosis of keratoconus. Factors associated with severe keratoconus at presentation in the multivariate analysis were non-White ( P < 0.001), lowest income (Q1) ( P = 0.018), Q2 income ( P = 0.012), and having Medicaid/Medicare coverage ( P = 0.021). Medicaid/Medicare coverage was the only factor associated with acute hydrops ( P < 0.001), and younger age was the only factor associated with disease progression ( P < 0.001). Younger patients and patients with commercial insurance coverage were more likely to receive corneal collagen cross-linking ( P < 0.001 and P < 0.001, respectively), whereas patients with Medicaid/Medicare coverage, lowest income, and non-White race were more likely to receive corneal transplantation ( P = 0.012, P = 0.062, and P = 0.028, respectively). Medicaid/Medicare was the only factor associated with delay in receiving corneal collagen cross-linking ( P = 0.013).

CONCLUSIONS

Our study demonstrates that there are sociodemographic predictors of keratoconus disease severity, progression, and the type and the time of treatment the patients received. This confirms eye health disparities among patients with keratoconus.

Achieving Health Equity: Combatting the Disparities in American Access to Musculoskeletal Care : Disparities Exist in Every Aspect of Orthopaedic Care in the United States - Access to Outpatient Visits, Discretionary and Unplanned Surgical Care, and Postoperative Outcomes. What Can We Do?

PURPOSE OF REVIEW

Healthcare disparities influence multiple dimensions of orthopaedic care including access, burden and incidence of disease, and outcome in varying populations. These disparities impact healthcare at both the micro and macro scale of the healthcare experience from individual patient-physician relationships to reimbursement rates across the United States. This article provides a review of how healthcare disparities contribute to the landscape of orthopaedic care and specifically highlights how disparities affect outpatient visits, discretionary and unplanned surgical care, and postoperative outcomes.

RECENT FINDINGS

Current research demonstrates the widespread presence of healthcare disparities in the field of orthopaedics and gives both objective and subjective evidence confirming disparities' measurable influence. The disparities most highlighted by our review include differences in orthopaedic care based on insurance type and race. Currently disparities in orthopaedic care are deeply connected to patient insurance status and race. In the outpatient setting insurance significantly impacts access to care, travel burden, and utilization of services. The emergent setting is similarly influenced with measurable differences in lack of access to acute care, rates of inappropriate triage, and timeliness of care based on insurance status and race. Additionally, the postoperative period is not immune to disparities with likelihood of follow up, experience of catastrophic medical expenses, and postoperative outcomes also being affected. Addressing these disparities is a pressing need and may include solutions like wider expansion and acceptance of publicly funded insurance and the development of readily available and easily measurable metrics for healthcare equity and quality in vulnerable populations.

Incidence of prostate cancer in Medicaid beneficiaries with and without HIV in 2001-2015 in 14 states

Prostate cancer (PCa) incidence is reportedly lower in men with HIV compared to men without HIV for unknown reasons. We describe PCa incidence by HIV status in Medicaid beneficiaries, allowing for comparison of men with and without HIV who are similar with respect to socioeconomic characteristics and access to healthcare. Men (N = 15,167,636) aged 18-64 with ≥7 months of continuous enrollment during 2001-2015 in 14 US states were retained for analysis. Diagnoses of HIV and PCa were identified using non-drug claims. We estimated cause-specific (csHR) comparing incidence of PCa by HIV status, adjusted for age, race-ethnicity, state of residence, year of enrollment, and comorbid conditions, and stratified by age and race-ethnicity. Hazard of PCa was lower in men with HIV than men without HIV (csHR = 0.89; 95% CI: 0.80, 0.99), but varied by race-ethnicity, with similar observations among non-Hispanic Black (csHR = 0.79; 95% CI: 0.69, 0.91) and Hispanic (csHR = 0.85; 95% CI: 0.67, 1.09), but not non-Hispanic white men (csHR = 1.17; 95% CI: 0.91, 1.50). Findings were similar in models restricted to men aged 50-64 and 40-49, but not in men aged 18-39. Reported deficits in PCa incidence by HIV status may be restricted to specific groups defined by age and race ethnicity.

Medicaid status is independently predictive of increased complications, readmission, and mortality following primary total shoulder arthroplasty

BACKGROUND

In recent years, several studies have evaluated the effect of Medicaid insurance status on total shoulder arthroplasty (TSA) outcomes and have presented discordant findings. The purpose of this study is to determine if Medicaid status is an independent predictor of all-cause complications, readmission, revision, and mortality following elective primary TSA using a large, national administrative claims database.

METHODS

The Nationwide Readmissions Database was queried to identify patients who underwent elective primary TSA from 2016 to 2020. Patients were propensity score matched in a 1:1 proportion based on age, sex, and discharge weight, yielding 15,374 Medicaid cases and 15,448 control cases. Patient demographic and discharge information, preoperative comorbidities, and postoperative outcomes were compared with bivariate analysis. Binary logistic regression was performed to account for the influence of variables other than Medicaid status on postoperative outcomes.

RESULTS

Medicaid patients had higher rates of preoperative comorbidities, higher Charlson-Deyo Comorbidity Index scores, and lower household incomes than matched controls. Compared to controls, Medicaid patients undergoing TSA had higher odds of adverse clinical outcomes, including all-cause complications, readmission, and mortality within 180 days, along with other specific medical and implant-related complications including broken hardware, dislocation, prosthetic loosening, and surgical site infection. Medicaid status was independently predictive of increased rates of all-cause complications within 180 days, readmission within 180 days, dislocation, pneumonia, sepsis, and decreased rates of prosthetic loosening. Medicaid patients had an increased mean cost of $1396 and increased mean length of stay of 0.4 days.

CONCLUSION

Medicaid status was independently predictive of readmission, complications, and mortality within 180 days of primary TSA, as well as other specific medical and surgical complications. Medicaid patients experience higher admission costs and longer hospital stays compared to those with other insurance types. Medicaid status is a risk factor for adverse clinical outcomes, and orthopedic surgeons need to consider the multitude of disparities that Medicaid patients experience when determining surgical options, treatment plans, and hospital disposition.

Financial Health Among Louisiana Medicaid Enrollees

This cross-sectional study compares average credit scores and unpaid medical and nonmedical debts in collections among Black, Hispanic, and White adults with Medicaid coverage.

Person-Centered Care Planning for People Living With or at Risk for Multiple Chronic Conditions

Importance

The US has a growing population of people living with multiple chronic conditions (MCC), yet the health system is ill designed to meet their needs. Person-centered care planning (PCCP) is an approach to provide comprehensive care that is responsive to the individual to improve health outcomes and increase value.

Objective

To examine strategies used to provide PCCP for people living with or at risk for MCC, as well as facilitators and barriers to implementation.

Design, Setting, and Participants

This qualitative study uses thematic analysis of responses from a Request for Information (RFI) published in the Federal Register soliciting input on PCCP, posted by the Agency for Healthcare Research and Quality (AHRQ) in 2022. The RFI was available for public comment from September 16, 2022, to November 15, 2022. Responses were analyzed between January 2023 and February 2024. Respondents were individuals and organizations who identify as, provide care for, or seek to improve care for individuals living with or at risk for MCC. Some responses represent multiple individuals.

Main Outcomes and Measures

Qualitative themes and subthemes of the RFI responses, developed using thematic analysis through inductive and deductive coding of the open-text responses.

Results

There were a total of 58 respondents, including clinicians, researchers, patients, caregivers, and representatives from health care payer, practitioner, health system, advocacy, professional, and supporting nonprofit and industry organizations. Researchers identified 9 themes: (1) suboptimal quality of care; (2) person-centered, goal-concordant care; (3) multidisciplinary team-based care and care coordination; (4) prevention across the life course; (5) digital health solutions; (6) workflow; (7) education and self-management support; (8) payment; and (9) achieving community, health system, and payer goals.

Conclusions and Relevance

In this qualitative study of PCCP for people living with or at risk for MCC, challenges to widescale adoption of PCCP were identified along with strategies to address these challenges, including the alignment of payment, policy support, culture change, adoption of meaningful measures, and the need for evidence on strategies to scale and spread PCCP. Insights gained from this analysis can inform research priorities and implementation efforts to advance PCCP as an integral component of routine care.

Outcomes of Pressure Ulcer Injuries Classified by Race: A 10-Year Nationwide Analysis

OBJECTIVES

Pressure ulcer injuries (PIs) are ischemic changes to the skin caused by long-term pressure on bony prominences. This study aimed to investigate the prevalence of PIs and their effects on minority groups in the hospital setting in the United States.

METHODS

The National Inpatient Sample (NIS) from 2011 to 2020 was used to identify adults hospitalized in the United States who received a diagnosis of PI. International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes were used to select patients. An equal number of random records, stratified by year and without a diagnosis of PI, were selected to serve as controls. Records were analyzed for baseline characteristics using a chi-square test.

RESULTS

Adjusted odds ratios (ORs) of developing a pressure ulcer were calculated using multivariate logistic regression, a weighted total of 5,993,667 PI admissions were included in this study, and 5,993,667 non-PI admissions were included. PI patients were more likely than controls to be male (OR = 0.88; 95% confidence interval {CI}: 0.88, 0.89; p < 0.05). PI patients were more likely to be older than non-PI patients (75+ years; OR = 3.46; 95% CI: 3.38, 3.54; p < 0.05). PI patients were more likely to be on Medicare or Medicaid (OR = 1.94; 95% CI: 1.92, 1.97; p < 0.05) than private insurance. PI patients were far more likely to have a high Charlson Comorbidity Index (CCI) of 3+ (OR = 10.44; 95% CI: 10.18, 10.71; p < 0.05) than a lower CCI score. Compared to Whites, African Americans (OR = 1.49; 95% CI: 1.47, 1.51; p < 0.05) were at higher risk of PIs. Among PI patients, White patients had a lower risk of death compared to African Americans (OR = 1.09; 95% CI: 1.07, 1.11; p < 0.05). African Americans had lower rates of acute kidney injury (AKI) compared to Whites (OR = 0.88; 95% CI: 0.86, 0.91; p < 0.05). Compared to Whites, rates of sepsis were higher for African Americans (OR = 1.40; 95% CI: 1.38, 1.42; p < 0.05).

CONCLUSION

A racial discrepancy in pressure ulcer prevalence was shown in racial minorities, particularly African Americans. It is essential to address this difference in diagnosis to improve outcomes among racial minorities.

Letter: Enhancing cirrhosis management-The critical role of social workers in supporting NAFLD surveillance

This article is linked to Tran et al papers. To view these articles, visit https://doi.org/10.1111/apt.18024 and https://doi.org/10.1111/apt.18265

Using patient portals for large-scale recruitment of individuals underrepresented in biomedical research: an evaluation of engagement patterns throughout the patient portal recruitment process at a single site within the All of Us Research Program

OBJECTIVE

To evaluate the use of patient portal messaging to recruit individuals historically underrepresented in biomedical research (UBR) to the All of Us Research Program (AoURP) at a single recruitment site.

MATERIALS AND METHODS

Patient portal-based recruitment was implemented at Columbia University Irving Medical Center. Patient engagement was assessed using patient's electronic health record (EHR) at four recruitment stages: Consenting to be contacted, opening messages, responding to messages, and showing interest in participating. Demographic and socioeconomic data were also collected from patient's EHR and univariate logistic regression analyses were conducted to assess patient engagement.

RESULTS

Between October 2022 and November 2023, a total of 59 592 patients received patient portal messages inviting them to join the AoURP. Among them, 24 445 (41.0%) opened the message, 8983 (15.1%) responded, and 3765 (6.3%) showed interest in joining the program. Though we were unable to link enrollment data with EHR data, we estimate about 2% of patients contacted ultimately enrolled in the AoURP. Patients from underrepresented race and ethnicity communities had lower odds of consenting to be contacted and opening messages, but higher odds of showing interest after responding.

DISCUSSION

Patient portal messaging provided both patients and recruitment staff with a more efficient approach to outreach, but patterns of engagement varied across UBR groups.

CONCLUSION

Patient portal-based recruitment enables researchers to contact a substantial number of participants from diverse communities. However, more effort is needed to improve engagement from underrepresented racial and ethnic groups at the early stages of the recruitment process.

Insurance-Related Disparities in Withdrawal of Life Support and Mortality After Spinal Cord Injury

Importance

Identifying disparities in health outcomes related to modifiable patient factors can improve patient care.

Objective

To compare likelihood of withdrawal of life-supporting treatment (WLST) and mortality in patients with complete cervical spinal cord injury (SCI) with different types of insurance.

Design, Setting, and Participants

This retrospective cohort study collected data between 2013 and 2020 from 498 trauma centers participating in the Trauma Quality Improvement Program. Participants included adult patients (older than 16 years) with complete cervical SCI. Data were analyzed from November 1, 2023, through May 18, 2024.

Exposure

Uninsured or public insurance compared with private insurance.

Main Outcomes and Measures

Coprimary outcomes were WLST and mortality. The adjusted odds ratio (aOR) of each outcome was estimated using hierarchical logistic regression. Propensity score matching was used as an alternative analysis to compare public and privately insured patients. Process of care outcomes, including the occurrence of a hospital complication and length of stay, were compared between matched patients.

Results

The study included 8421 patients with complete cervical SCI treated across 498 trauma centers (mean [SD] age, 49.1 [20.2] years; 6742 male [80.1%]). Among the 3524 patients with private insurance, 503 had WLST (14.3%) and 756 died (21.5%). Among the 3957 patients with public insurance, 906 had WLST (22.2%) and 1209 died (30.6%). Among the 940 uninsured patients, 156 had WLST (16.6%) and 318 died (33.8%). A significant difference was found between uninsured and privately insured patients in the adjusted odds of WLST (aOR, 1.49; 95% CI, 1.11-2.01) and mortality (aOR, 1.98; 95% CI, 1.50-2.60). Similar results were found in subgroup analyses. Matched public compared with private insurance patients were found to have significantly greater odds of hospital complications (odds ratio, 1.27; 95% CI, 1.14-1.42) and longer hospital stay (mean difference 5.90 days; 95% CI, 4.64-7.20), which was redemonstrated on subgroup analyses.

Conclusions and Relevance

Health insurance type was associated with significant differences in the odds of WLST, mortality, hospital complications, and days in hospital among patients with complete cervical SCI in this study. Future work is needed to incorporate patient perspectives and identify strategies to close the quality gap for the large number of patients without private insurance.

Qualitative perspectives of Medicaid-insured patients on ambulatory care at an academic medical center: challenges and opportunities

BACKGROUND

Ambulatory access to academic medical centers (AMCs) for patients insured with Medi-Cal (i.e., Medicaid in California) is understudied, particularly among the 85% of beneficiaries enrolled in managed care plans. As more AMCs develop partnerships with these plans, data on patient experiences of access to care and quality are needed to guide patient-centered improvements in care delivery.

METHODS

The authors conducted semi-structured, qualitative interviews with Medi-Cal-insured patients with initial visits at a large, urban AMC during 2022. Participant recruitment was informed by a database of ambulatory Medi-Cal encounters. The interview guide covered Medi-Cal enrollment, scheduling, and visit experience. Interviews were transcribed and inductively coded, then organized into themes across four domains: access, affordability, patient-provider interactions, and continuity.

RESULTS

Twenty participant interviews were completed (55% female, 85% English speaking, 80% self-identified minority or "other" race, and 30% Hispanic or Latino) with primary and/or specialty care visits. Within the access domain, participants reported delays with Medi-Cal enrollment and access to specialist care or testing, though appointment scheduling was reported to be easy. Affordability concerns included out-of-pocket medical and parking costs, and missed income when patients or families skipped work to facilitate care coordination. Participants considered clear, bilateral communication with providers fundamental to positive patient-provider interactions. Some participants perceived discrimination by providers based on their insurance status. Participants valued continuity, but experienced frustration arising from frequent and unexpected health plan changes that disrupted care with their established AMC providers.

CONCLUSIONS

The missions of AMCs typically focus on clinical care, education, research, and equity. However, reports from Medi-Cal insured patients receiving care at AMCs highlight their stress and confusion related to inconsistent provider access, uncompensated costs, variability in perceptions of quality, and fragmented care. Recommendations based upon patient-reported concerns suggest opportunities for AMC health system-level improvements that are compatible with AMC missions.

Segregation by Payer in Obstetrics and Gynecology Residency Ambulatory Care Sites

Importance

Many teaching hospitals in the US segregate patients by insurance status, with resident clinics primarily composed of publicly insured or uninsured patients and faculty practices seeing privately insured patients. The prevalence of this model in obstetrics and gynecology residencies is unknown.

Objectives

To examine the prevalence of payer-based segregation in obstetrics and gynecology residency ambulatory care sites nationally and to compare residents' and program directors' perceptions of differences in quality of care between payer-segregated and integrated sites.

Design, Setting, and Participants

This national survey study included all 6060 obstetrics and gynecology residents and 293 obstetrics and gynecology residency program directors in the US as of January 2023. The proportion of program directors reporting payer segregation was calculated to characterize the national prevalence of this model in obstetrics and gynecology. Perceived differences in care quality were compared between residents and program directors at payer-segregated sites.

Main Outcome and Measures

The primary measure was prevalence of payer-based segregation in obstetrics and gynecology residency programs in the US as reported by residency program directors. The secondary measure was resident and program director perceptions of care quality in these ambulatory care settings. Before study initiation, the study hypothesis was that residents and program directors at ambulatory sites with payer-based segregation would report more disparity in perceived health care quality between resident and faculty practices compared with those from integrated sites.

Results

A total of 251 residency program directors (response rate, 85.7%) and 3471 residents (response rate, 57.3%) were included in the study. Resident respondent demographics reflected demographics of obstetrics and gynecology residents nationally in terms of racial and ethnic distribution (6 [0.2%] American Indian or Alaska Native; 425 [13.0%] Asian; 239 [7.3%] Black or African American; 290 [8.9%] Hispanic, Latinx, or Spanish; 7 [0.2%] Native Hawaiian or Other Pacific Islander; 2052 [62.7%] non-Hispanic White; 49 [1.5%] multiracial; 56 [1.7%] other [any race not listed]; and 137 [4.2%] preferred not to say) and geographic distribution (regional prevalence of payer-based segregation: 36 of 53 [67.9%] in the Northeast, 35 of 44 [79.5%] in the Midwest, 43 of 67 [64.2%] in the South, and 13 of 22 [59.1%] in the West), with 2837 respondents (86.9%) identifying as female. Among program directors, 127 (68.3%) reported payer-based segregation in ambulatory care. University programs were more likely to report payer-based segregation compared with community, hybrid, and military programs (63 of 85 [74.1%] vs 31 of 46 [67.4%], 32 of 51 [62.7%], and 0, respectively; P = .04). Residents at payer-segregated programs were less likely than their counterparts at integrated programs to report equal or higher care quality from residents compared with faculty (1662 [68.7%] vs 692 [81.6%] at segregated and integrated programs, respectively; P < .001).

Conclusions and Relevance

In this survey study of residents and residency program directors, payer-based segregation was prevalent in obstetrics and gynecology residency programs, particularly at university programs. These findings reveal an opportunity for structural reform to promote more equitable care in residency training programs.

Healthcare disparities in pancreatitis: knowledge gaps and next steps

PURPOSE OF REVIEW

This review examines current research on healthcare disparities in pancreatitis, identifies knowledge gaps, and proposes strategies to develop targeted multilevel interventions to address inequities in pancreatitis care.

RECENT FINDINGS

Current literature has identified patient, disease, and healthcare-level factors contributing to disparities in risk factors and health outcomes of pancreatitis. Moreover, social structures, economic systems, social vulnerability, and policy significantly influence the pancreatitis care continuum.

SUMMARY

Understanding the root causes of health inequities is critical to developing effective approaches for the prevention, early detection, and management of pancreatitis.

Hospital Presumptive Eligibility Emergency Medicaid Programs: An Opportunity for Continuous Insurance Coverage?

BACKGROUND

Lack of health insurance is a public health crisis, leading to foregone care and financial strain. Hospital Presumptive Eligibility (HPE) is a hospital-based emergency Medicaid program that provides temporary (up to 60 d) coverage, with the goal that hospitals will assist patients in applying for ongoing Medicaid coverage. It is unclear whether HPE is associated with successful longer-term Medicaid enrollment.

OBJECTIVE

To characterize Medicaid enrollment 6 months after initiation of HPE and determine sociodemographic, clinical, and geographic factors associated with Medicaid enrollment.

DESIGN

This was a cohort study of all HPE approved inpatients in California, using claims data from the California Department of Healthcare Services.

SETTING

The study was conducted across all HPE-participating hospitals within California between January 1, 2016 and December 31, 2017.

PARTICIPANTS

We studied California adult hospitalized inpatients, who were uninsured at the time of hospitalization and approved for HPE emergency Medicaid. Using multivariable logistic regression models, we compared HPE-approved patients who enrolled in Medicaid by 6 months versus those who did not.

EXPOSURES

HPE emergency Medicaid approval at the time of hospitalization.

MAIN OUTCOMES AND MEASURES

The primary outcome was full-scope Medicaid enrollment by 6 months after the hospital's presumptive eligibility approval.

RESULTS

Among 71,335 inpatient HPE recipients, a total of 45,817 (64.2%) enrolled in Medicaid by 6 months. There was variability in Medicaid enrollment across counties in California (33%-100%). In adjusted analyses, Spanish-preferred-language patients were less likely to enroll in Medicaid (aOR 0.77, P <0.001). Surgical intervention (aOR 1.10, P <0.001) and discharge to another inpatient facility or a long-term care facility increased the odds of Medicaid enrollment (vs. routine discharge home: aOR 2.24 and aOR 1.96, P <0.001).

CONCLUSION

California patients who enroll in HPE often enroll in Medicaid coverage by 6 months, particularly among patients requiring surgical intervention, repeated health care visits, and ongoing access to care. Future opportunities include prospective evaluation of HPE recipients to understand the impact that Medicaid enrollment has on health care utilization and financial solvency.

A Hexagonal Aim as a Driver of Change for Health Care and Health Insurance Systems

Policy Points Improving health systems requires the pursuit of both patient-centered care and a supportive environment for health professionals. This Quadruple Aim includes improving the experience of care, improving the health of populations, reducing per capita costs of care, and improving the work life of the care providers. We propose expanding a recently defined Fifth Aim of health equity to include health democracy, ensuring that that the health and health care wants, needs, and responsibilities of populations are being met, and also propose adding a Sixth Aim of preserving and improving the health of the environment to create the best health possible. As social tension and environmental changes continue to impact the structure of our society, this "Hexagonal Aim" might provide additional ethical guiderails as we set our health care goals to foster sustainable and improved population health.

Race, Ethnicity, and Intensive Care Utilization for Common Pediatric Diagnoses: U.S. Pediatric Health Information System 2019 Database Study

OBJECTIVES

Racial and ethnic disparities in healthcare delivery for acutely ill children are pervasive in the United States; it is unknown whether differential critical care utilization exists.

DESIGN

Retrospective study of the Pediatric Health Information System (PHIS) database.

SETTING

Multicenter database of academic children's hospitals in the United States.

PATIENTS

Children discharged from a PHIS hospital in 2019 with one of the top ten medical conditions where PICU utilization was present in greater than or equal to 5% of hospitalizations.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Race and ethnicity categories included Asian, Black, Hispanic, White, and other. Primary outcomes of interest were differences in rate of PICU admission, and for children requiring PICU care, total hospital length of stay (LOS). One-quarter ( n = 44,200) of the 178,134 hospital discharges included a PICU admission. In adjusted models, Black children had greater adjusted odds ratio (aOR [95% CI]) of PICU admission in bronchiolitis (aOR, 1.08 [95% CI, 1.02-1.14]; p = 0.01), respiratory failure (aOR, 1.18 [95% CI, 1.10-1.28]; p < 0.001), seizure (aOR, 1.28 [95% CI, 1.08-1.51]; p = 0.004), and diabetic ketoacidosis (DKA) (aOR, 1.18 [95% CI, 1.05-1.32]; p = 0.006). Together, Hispanic, Asian, and other race children had greater aOR of PICU admission in five of the diagnostic categories, compared with White children. The geometric mean (± sd ) hospital LOS ranged from 47.7 hours (± 2.1 hr) in croup to 206.6 hours (± 2.8 hr) in sepsis. After adjusting for demographics and illness severity, children from families of color had longer LOS in respiratory failure, pneumonia, DKA, and sepsis.

CONCLUSIONS

The need for critical care to treat acute illness in children may be inequitable. Additional studies are needed to understand and eradicate differences in PICU utilization based on race and ethnicity.

Life-Stage and Contextual Factors of Advance Care Planning Among Older Adults With Limited Income

Patient perspectives are essential to understand healthcare disparities such as low rates of advance care planning (ACP) among adults with limited income. We completed twenty semi-structured interviews using purposive and snowball sampling. Initial and final themes emerged from inductive inclusion of recurring codes and deductive application of the cumulative disadvantage theory. Four themes emerged: (1) structural, (2) life-stage, (3) social stressors and resources, and (4) individual stress responses and ACP readiness. ACP resources among participants included positive structural and social support and previous familial death experiences that were mitigated by stress avoidance and competing priorities. Structural resources and healthcare stressors should be addressed with policy and research to improve continuous healthcare participation and support early, comprehensive ACP.

Associations of social determinants of health with life expectancy and future health risks among individuals with type 2 diabetes: two nationwide cohort studies in the UK and USA

BACKGROUND

Social determinants of health (SDHs) are the primary drivers of preventable health inequities, and the associations between SDHs and health outcomes among individuals with type 2 diabetes remain unclear. This study aimed to estimate the associations of combined SDHs with life expectancy and future health risks among adults with type 2 diabetes from the UK and USA.

METHODS

In an analysis of two nationwide cohort studies, adults with type 2 diabetes were identified from the UK Biobank from March 13, 2006, to Oct 1, 2010 (adults aged 37-73 years) and the US National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018 (adults aged ≥20 years). Participants with type 2 diabetes at baseline were included in our analysis. Participants without information on SDHs or follow-up were excluded. The UK Biobank assessed 17 SDHs and the US NHANES assessed ten SDHs, with each SDH dichotomised into advantaged and disadvantaged levels. The combined score of SDHs were calculated as the sum of the weighted scores for each SDH. Participants were then categorised into tertiles (favourable, medium, and unfavourable SDH groups). Primary outcomes were life expectancy and mortality in both cohorts, and incidences of cardiovascular disease, diabetes-related microvascular disease, dementia, and cancer in the UK Biobank. Outcomes were obtained from disease registries up until Dec 31, 2021, in the UK Biobank and Dec 31, 2019, in the US NHANES cohorts.

FINDINGS

We included 17 321 participants from the UK Biobank cohort (median age 61·0 years [IQR 56·0-65·0]; 6028 [34·8%] women and 11 293 [65·2%] men) and 7885 participants from the NHANES cohort (mean age 59·2 years [95% CI 58·7-59·6]; 3835 [49·1%, weighted] women and 4050 [50·9%, weighted] men) in our analysis. In the UK Biobank, 3235 deaths (median follow-up 12·3 years [IQR 11·5-13·2]), 3010 incident cardiovascular disease (12·1 years [10·8-13·0]), 1997 diabetes-related microvascular disease (8·0 years [7·1-8·9]), 773 dementia (12·6 years [11·8-13·5]), and 2259 cancer cases (11·3 years [10·4-12·2]) were documented; and the US NHANES documented 2278 deaths during a median follow-up of 7·0 years (3·7-11·2). After multivariable adjustment, compared with the favourable SDH group, the hazard ratio was 1·33 (95% CI 1·21-1·46) in the medium SDH group and 1·89 (1·72-2·07) in the unfavourable SDH group in the UK Biobank cohort; 1·51 (1·34-1·70) in the medium SDH group and 2·02 (1·75-2·33) in the unfavourable SDH group in the US NHANES cohort for all-cause mortality; 1·13 (1·04-1·24) in the medium SDH group and 1·40 (1·27-1·53) in the unfavourable SDH group for incident cardiovascular disease; 1·13 (1·01-1·27) in the medium SDH group and 1·41 (1·26-1·59) in the unfavourable SDH group for incident diabetes-related microvascular disease; 1·35 (1·11-1·64) in the medium SDH group and 1·76 (1·46-2·13) in the unfavourable SDH group for incident dementia; and 1·02 (0·92-1·13) in the medium SDH group and 1·17 (1·05-1·30) in the unfavourable SDH group for incident cancer in the UK Biobank cohort (ptrend<0·010 for each category). At the age of 45 years, the mean life expectancy of participants was 1·6 years (0·6-2·3) shorter in the medium SDH group and 4·4 years (3·3-5·4) shorter in the unfavourable SDH group than in the favourable SDH group in the UK Biobank. In the US NHAHES cohort, the life expectancy was 1·7 years (0·6-2·7) shorter in the medium SDH group and 3·0 years (1·8-4·3) shorter in the unfavourable SDH group, compared with the favourable group.

INTERPRETATION

Combined unfavourable SDHs were associated with a greater loss of life expectancy and higher risks of developing future adverse health outcomes among adults with type 2 diabetes. These associations were similar across two nationwide cohorts from varied social contexts, and were largely consistent across populations with different demographic, lifestyle, and clinical features. Thus, assessing the combined SDHs of individuals with type 2 diabetes might be a promising approach to incorporate into diabetes care to identify socially vulnerable groups and reduce disease burden.

FUNDING

The National Natural Science Foundation of China, the National Key R&D Program of China, and the Fundamental Research Funds for the Central Universities.

Disparities in Care for Psoriasis

Race, ethnicity, language, sex, age, income, insurance status, location, and other socioeconomic and demographic factors influence access to and quality of care for patients with psoriasis, which can potentially lead to inequitable outcomes.

Association of Medicaid coverage with emergency department utilization after self-harm in Korea: A nationwide registry-based study

BACKGROUND

Self-harm presents an important public health challenge. It imposes a notable burden on the utilization of emergency department (ED) services and medical expenses from patients and family. The Medicaid system is vital in providing financial support for individuals who struggle with medical expenses. This study explored the association of Medicaid coverage with ED visits following incidents of self-harm, utilizing nationwide ED surveillance data in Korea.

METHODS

Data of all patients older than 14 years who presented to EDs following incidents of self-harm irrespective of intention to end their life, including cases of self-poisoning, were gathered from the National ED Information System (NEDIS). The annual self-harm visit rate (SHVR) per 100,000 people was calculated for each province and a generalized linear model analysis was conducted, with SHVR as a dependent variable and factors related to Medicaid coverage as independent variables.

RESULTS

A 1% increase in Medicaid enrollment rate was linked to a significant decrease of 14% in SHVR. Each additional 1,000 Korean Won of Medicaid spending per enrollee was correlated with a 1% reduction in SHVR. However, an increase in Medicaid visits per enrollee and an extension of Medicaid coverage days were associated with an increase in SHVR. SHVR exhibited a stronger associated with parameters of Medicaid coverage in adolescents and young adults than in older adult population.

CONCLUSION

Expansion of Medicaid coverage coupled with careful monitoring of shifts in Medicaid utilization patterns can mitigate ED overloading by reducing visits related to self-harm.

Cross-Sectional Study to Evaluate Disparity in Healthcare Access for Patients With a Headache Having Cigna or Medicaid Insurance

INTRODUCTION

This study aims to study the disparity in Cigna and Medicaid insurance holders, to secure an appointment for a patient with a headache for two days unrelieved by over-the-counter medication.

METHODOLOGY

This is a cross-sectional "secret shopper" type study, assessing the three most populated cities in seven states with the lowest Medicaid coverage and Internal Medicine specialists within a 10-mile radius, with a minimum rating of 3 stars and a willingness to accept new patients.

RESULTS

There was a statistically significant difference in the average waiting period for those with Medicaid and Cigna in the states of Missouri, Nebraska, and Utah, as well as the total average for all seven states. Moreover, there were more healthcare providers who accepted Medicaid rather than Cigna in New Hampshire; whereas in Wyoming, the numbers for Medicaid and Cigna were almost equal.

CONCLUSIONS

The significant Medicaid-Cigna acceptance rate disparities should be corrected to ensure higher healthcare access.

The Impact of Social Determinants of Health on Transition From Pediatric to Adult Cardiology Care

Social determinants of health (SDoH) are the economic, social, environmental, and psychosocial factors that influence health. Adolescents and young adults with congenital heart disease (CHD) require lifelong cardiology follow-up and therefore coordinated transition from pediatric to adult healthcare systems. However, gaps in care are common during transition, and they are driven in part by pervasive disparities in SDoH, including race, ethnicity, socioeconomic status, access to insurance, and remote location of residence. These disparities often coexist and compound the challenges faced by patients and families. For example, Black and Indigenous individuals are more likely to be subject to systemic racism and implicit bias within healthcare and other settings, to be unemployed and poor, to have limited access to insurance, and to have a lower likelihood of transfer of care to adult CHD specialists. SDoH also are associated with acquired cardiovascular disease, a comorbidity that adults with CHD face. This review summarizes existing evidence regarding the impact of SDoH on the transition to adult care and proposes strategies at the individual, institutional, and population and/or system levels. to reduce inequities faced by transition-age youth. These strategies include routinely screening for SDoH in clinical settings with referral to appropriate services, providing formal transition education for all transition-age youth, including training on navigating complex medical systems, creating satellite cardiology clinics to facilitate access to care for those who live remote from tertiary centres, advocating for lifelong insurance coverage where applicable, mandating cultural-sensitivity training for providers, and increasing the diversity of healthcare providers in pediatric and adult CHD care.

Frontline perspectives on barriers to care for patients with California Medicaid: a qualitative study

BACKGROUND

While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions.

METHODS

To understand barriers to ambulatory care access for patients with Medi-Cal (California's Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal.

RESULTS

Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation.

CONCLUSIONS

Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.

Prevalence of Positive Childhood Experiences and Associations with Current Anxiety, Depression, and Behavioral or Conduct Problems among U.S. Children Aged 6-17 Years

Positive childhood experiences (PCEs) have substantial potential to improve children's mental health. We examined the prevalence of 26 specific PCEs, overall and by demographics, and the individual and cumulative effects of PCEs with current diagnosis of three mental health conditions using nationally representative, parent-reported data on U.S. children aged 6-17 years from the 2018-2019 National Survey of Children's Health (n=35,583). The prevalence of each PCE varied, with a range between 22.6% (gets recommended amount of physical activity) to 92.1% (parent(s) have positive mental health). Accounting for demographics, there were associations between most specific PCEs and lower prevalence of current childhood anxiety (22 of 26 PCEs), depression (22 of 26 PCEs), and behavioral or conduct problems (21 of 26 PCEs). There was a dose-response relationship between children in higher cumulative PCE quartiles and lower proportions of anxiety, depression, and behavioral or conduct problems. Findings generally did not attenuate after further adjusting for adverse childhood experiences. PCEs are common among U.S. children, but vary substantially by type of PCE and subpopulation. This has critical implications for focusing prevention and intervention strategies to bolster PCEs in ways that could improve health equity and children's mental health.

Polypharmacy Is Associated with Sociodemographic Factors and Socioeconomic Status in United States Adults

A thorough understanding of polypharmacy is required to create public health initiatives that minimize the potential for adverse outcomes. This study aimed to investigate the relationship between sociodemographic factors, socioeconomic status (SES), and polypharmacy risk in United States (US) individuals between 1999-2000 and 2017-2018. The cross-sectional National Health and Nutrition Examination Survey dataset covered ten cycles between 1999-2000 and 2017-2018. All individuals aged ≥18 years were included. The simultaneous use of at least five medications by one person is known as polypharmacy. Multivariable logistic regression showed that there was a statistically significant association between polypharmacy sociodemographic factors (such as age between 45 and 64 (odds ratio [OR] = 3.76; 95% confidence interval [CI] = 3.60-3.92; p < 0.0001) and age of 65 years or above (OR = 3.96; 95% CI = 3.79-4.13; p < 0.0001), especially women (OR = 1.09; 95% CI = 1.06-1.13; p < 0.0001), non-Hispanic blacks (OR = 1.66; 95% CI = 1.51-1.83; p < 0.0001), and veterans (OR = 1.27; 95% CI = 1.22-1.31; p < 0.0001)) and SES (such as being married (OR = 1.14; 95% CI = 1.08-1.19; p = 0.031), widowed, divorced, or separated (OR = 1.21; 95% CI = 1.15-1.26; p < 0.0001), a college graduate or above (OR = 1.21, 95% CI = 1.15-1.27, p < 0.0001), and earning > USD 55,000 per year (OR = 1.86; 95% CI = 1.79-1.93; p < 0.0001)). Individuals aged 45 years and above, women, and non-Hispanic blacks with higher educational levels and yearly incomes were more likely to experience polypharmacy in the US between 1999-2000 and 2017-2018.

Racial and Ethnic Differences in Heroin, Methamphetamine, and Cocaine Use, Treatment, and Mortality Trends in 3 National Data Sources-United States, 2010-2019

BACKGROUND

As overdose deaths continue to rise, public health officials need comprehensive surveillance data to design effective prevention, harm reduction, and treatment strategies. Disparities across race and ethnicity groups, as well as trends in substance use, treatment, or overdose deaths, have been examined individually, but reports rarely compare findings across multiple substances or data sources.

OBJECTIVE

To provide a broad assessment of the overdose crisis, we describe trends in substance use, treatment, and overdose mortality across racial and ethnic groups for multiple substances.

RESEARCH DESIGN

We conducted a longitudinal, cross-sectional analysis comparing trends.

SUBJECTS

We identified self-reported use from the National Survey on Drug Use and Health, substance use treatment admissions from the Treatment Episode Data Set-Admissions, and overdose deaths from the CDC's Multiple Cause of Death files.

MEASURES

We measured rates of substance use, treatment, and deaths involving heroin, methamphetamine, and cocaine among United States adults from 2010 to 2019.

RESULTS

Heroin, methamphetamine, and cocaine use increased, though not all changes were statistically significant. Treatment admissions indicating heroin and methamphetamine increased while admissions indicating cocaine decreased. Overdose deaths increased among all groups: methamphetamine (257%-1,115%), heroin (211%-577%), and cocaine (88%-259%). Changes in rates of use, treatment, and death for specific substances varied by racial and ethnic group.

CONCLUSIONS

Substance use, treatment, and overdose mortality changed considerably, though not always equivalently. Identifying diverging trends in substance-related measures for specific substances and racial and ethnic groups can inform targeted investment in treatment to reduce disparities and respond to emerging changes in the overdose crisis.

National trends in patterns of under-vaccination in early childhood: National Immunization Survey-Child, United States, 2011-2021

BACKGROUND

The study's objective was to examine national trends in patterns of under-vaccination in the United States.

RESEARCH DESIGN AND METHODS

The National Immunization Survey-Child (NIS-Child) is an annual cross-sectional survey that collects provider-verified vaccination records from a large national probability sample of children. Records from the 2011-2021 NIS-Child were used to assess receipt of the combined 7-vaccine series by age 24 months. Based on prior work, patterns indicative of hesitancy included zero vaccines, not starting ≥1 series, and consistent vaccine-limiting. Patterns indicative of practical issues included starting all series but missing doses. Up-to-date (UTD) was defined as receiving all doses in the combined 7-vaccine series.

RESULTS

The study population comprised 127,257 children. Over the observation period, patterns indicative of hesitancy significantly decreased (p-trend < 0.0001), patterns indicative of practical issues significantly decreased (p-trend < 0.0001), and UTD significantly increased (p-trend < 0.0001). In 2021, the weighted percentage in each category was as follows: probable hesitancy 6.3% (95% confidence interval [CI] 5.4%, 7.2%), probable practical issues 26.0% (95% CI 24.4%, 27.6%), and UTD 67.7% (95% CI 66.0%, 69.4%).

CONCLUSION

Over an 11-year period, vaccination coverage in the United States for the combined 7-vaccine series has improved, with patterns suggestive of practical issues or hesitancy declining.

Regional variations in heart failure: a global perspective

Heart failure (HF) is a global public health concern that affects millions of people worldwide. While there have been significant therapeutic advancements in HF over the last few decades, there remain major disparities in risk factors, treatment patterns and outcomes across race, ethnicity, socioeconomic status, country and region. Recent research has provided insight into many of these disparities, but there remain large gaps in our understanding of worldwide variations in HF care. Although the majority of the global population resides across Asia, Africa and South America, these regions remain poorly represented in epidemiological studies and HF trials. Recent efforts and registries have provided insight into the clinical profiles and outcomes across HF patterns globally. The prevalence of HF and associated risk factors has been reported and varies by country and region ranges, with minimal data on regional variations in treatment patterns and long-term outcomes. It is critical to improve our understanding of the different factors that contribute to global disparities in HF care so we can build interventions that improve our general cardiovascular health and mitigate the social and economic cost of HF. In this narrative review, we hope to provide an overview of the global and regional variations in HF care and outcomes.

Neurodevelopmental Outcomes in Infants Screened for Retinopathy of Prematurity

Importance

Preterm infants screened for retinopathy of prematurity (ROP) are at risk for heterogenous neurodevelopment outcomes that are difficult to predict.

Objective

To characterize the potential association between socioeconomic and clinical risk factors and neurodevelopmental outcomes in a diverse, multicenter cohort of premature neonates screened for ROP.

Design, Setting, and Participants

This was a retrospective cohort study using electronic medical records and US Census Bureau income data. This study was performed at academic (University of California, Los Angeles [UCLA] Mattel Children's Hospital and UCLA Santa Monica Hospital), community (Cedars-Sinai Medical Center), and LA county (Harbor-UCLA Medical Center) neonatal intensive care units. Participants included infants who met American Academy of Pediatrics guidelines for ROP screening and had records from at least 1 Bayley Scales of Infant and Toddler Development (BSID) neurodevelopment assessment between 0 and 36 months of adjusted age. Data analyses were conducted from January 1, 2011, to September 1, 2022.

Exposures

Demographic and clinical information, proxy household income, and health insurance type were collected as risk factors.

Main Outcomes and Measures

Neurodevelopmental outcomes in the cognitive, language, and motor domains measured via BSID were the primary outcomes.

Results

A total of 706 infants (mean [SD] age, 28.6 [2.4] weeks; 375 male [53.1%]) met inclusion criteria. In a multivariable model, which included adjustments for birth weight, sex, insurance type, intraventricular hemorrhage (IVH), and age at assessment, public health insurance was associated with a 4-fold increased risk of moderate to severe neurodevelopmental impairment (NDI) in cognitive and language domains (cognitive, odds ratio [OR], 3.65; 95% CI, 2.28-5.86; P = 8.1 × 10-8; language, OR, 3.96; 95% CI, 2.61-6.02; P = 1.0 × 10-10) and a 3-fold increased risk in the motor domain (motor, OR, 2.60; 95% CI, 1.59-4.24; P = 1.4 × 10-4). In this adjusted model, clinical factors that were associated with an increased risk of moderate to severe NDI included lower birth weight, diagnosis of IVH, male sex, and older age at time of Bayley assessment. In unadjusted analyses, infants who received either laser or anti-VEGF treatment, compared with infants without treatment-requiring ROP, had lower BSID scores in multiple domains at 0 to 12 months, 12 to 24 months, and 24 to 36 months (DATA). In the multivariable model, treatment type was no longer associated with worse neurodevelopmental outcomes in any domain.

Conclusions and Relevance

Study results suggest an association between public insurance type and NDI in a diverse population screened for ROP, indicating the complexities of neurodevelopment. This study also supports the early neurodevelopmental safety of anti-VEGF treatment, as anti-VEGF therapy was not found to be independently associated with worse NDI in any domain.

Health Care Policy and Disparities in Health

ABSTRACT

The United States has seen a 33% decline in age-adjusted cancer mortality since 1991. Despite this achievement, the United States has some of the greatest health disparities of any developed nation. US government policies are increasingly directed toward reducing health disparities and promoting health equity. These policies govern the conduct of research, cancer prevention, access, and payment for care. Although implementation of policies has played a significant role in the successes of cancer control, inconsistent implementation of policy has resulted in divergent outcomes; poorly designed or inadequately implemented policies have hindered progress in reducing cancer death rates and, in certain cases, exacerbated existing disparities. Examining policies affecting cancer control in the United States and realizing their unintended consequences are crucial in addressing cancer inequities.

Limited English Proficiency Is Associated With Diabetic Retinopathy in Patients Presenting for Cataract Surgery

Purpose

To investigate the relationship between limited English proficiency (LEP) and diabetic retinopathy (DR) in patients presenting for cataract surgery.

Methods

This is a retrospective observational study of patients who underwent cataract surgery between January 2014 and February 2020. Patients who self-identified as needing or preferring an interpreter were defined as having LEP. Differences in demographics, characteristics, and outcomes including history of type 2 diabetes (T2DM), DR, preoperative best corrected visual acuity (BCVA), macular edema, and anti-vascular endothelial growth factor injections were analyzed. Statistical comparisons were assessed using logistic regression with generalized estimating equations.

Results

We included 13,590 eyes. Of these, 868 (6.4%) were from LEP patients. Patients with LEP were more likely to be Hispanic (P < 0.001), female sex (P = 0.008), or older age (P = 0.003) and have worse mean BCVA at presentation (P < 0.001). Patients with LEP had a significantly higher rate of T2DM (P < 0.001), macular edema (P = 0.033), and DR (18.1% vs. 5.8%, P < 0.001). Findings remained significant when controlling for age, sex, race/ethnicity, and type of health insurance. Patients with LEP and DR were more likely to have had later stages of DR (P = 0.023).

Conclusions

Patients with LEP presenting for cataract surgery had a higher rate of DR and associated complications compared to patients with English proficiency. Further studies are needed to understand how language disparities influence health and what measures could be taken to improve healthcare in this vulnerable population.

Translational Relevance

Our study highlights healthcare disparities within ophthalmology and emphasizes the importance of advocating for improved healthcare delivery for patients with LEP.

Equity Promoting Integrated Care: Definition and Future Development

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems.

Correlating state-specific and national trends in breast reconstruction after Medicaid expansion: A decade-long update on the Affordable Care Act's impact

While disparities in access to reconstruction persist, a comprehensive analysis comparing state-based outcomes and national patterns in breast reconstruction as a result of Medicaid expansion has never been examined. In this study, we investigated how breast reconstruction rates changed as a result of Medicaid expansion and compared these state-based findings to national counterparts. Patient data from the Healthcare Cost and Utilization Project among states that chose to expand Medicaid were compared with those from states that did not expand. The difference-in-differences estimate of expansion to nonexpansion states was 7.05 (p = 0.10) for implant-based reconstruction, -11.56 (p = 0.01) for autologous reconstruction, and -7.08 (p = 0.18) for overall reconstruction. Comparing rates of nonexpansion states to national trends yielded estimates of -0.06 (p = 0.04), 0.06 (p = 0.01), and 0.004 (p = 0.90) for implant-based, autologous, and overall breast reconstruction, respectively. Similarly, comparing rates of expansion states to national trends yielded estimates of 0.02 (p = 0.38), -0.05 (p = 0.03), and -0.02 (p = 0.44) for implant-based, autologous, and overall breast reconstruction, respectively. In this study on national health policy, Medicaid expansion was associated with a significant increase in autologous rates while state-specific trends alone did not appear to predict the national outcomes of sweeping legislative changes that were differentially applied among states.