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Zhang D, Lee JS, Pollack LM, Dong X, Taliano JM, Rajan A, Therrien NL, Jackson SL, Popoola A, Luo F. Association of Economic Policies With Hypertension Management and Control: A Systematic Review. JAMA HEALTH FORUM 2024; 5:e235231. [PMID: 38334993 PMCID: PMC10858400 DOI: 10.1001/jamahealthforum.2023.5231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/30/2023] [Indexed: 02/10/2024] Open
Abstract
Importance Economic policies have the potential to impact management and control of hypertension. Objectives To review the evidence on the association between economic policies and hypertension management and control among adults with hypertension in the US. Evidence Review A search was carried out of PubMed/MEDLINE, Cochrane Library, Embase, PsycINFO, CINAHL, EconLit, Sociological Abstracts, and Scopus from January 1, 2000, through November 1, 2023. Included were randomized clinical trials, difference-in-differences, and interrupted time series studies that evaluated the association of economic policies with hypertension management. Economic policies were grouped into 3 categories: insurance coverage expansion such as Medicaid expansion, cost sharing in health care such as increased drug copayments, and financial incentives for quality such as pay-for-performance. Antihypertensive treatment was measured as taking antihypertensive medications or medication adherence among those who have a hypertension diagnosis; and hypertension control, measured as blood pressure (BP) lower than 140/90 mm Hg or a reduction in BP. Evidence was extracted and synthesized through dual review of titles, abstracts, full-text articles, study quality, and policy effects. Findings In total, 31 articles were included. None of the studies examined economic policies outside of the health care system. Of these, 16 (52%) assessed policies for insurance coverage expansion, 8 (26%) evaluated policies related to patient cost sharing for prescription drugs, and 7 (22%) evaluated financial incentive programs for improving health care quality. Of the 16 studies that evaluated coverage expansion policies, all but 1 found that policies such as Medicare Part D and Medicaid expansion were associated with significant improvement in antihypertensive treatment and BP control. Among the 8 studies that examined patient cost sharing, 4 found that measures such as prior authorization and increased copayments were associated with decreased adherence to antihypertensive medication. Finally, all 7 studies evaluating financial incentives aimed at improving quality found that they were associated with improved antihypertensive treatment and BP control. Overall, most studies had a moderate or low risk of bias in their policy evaluation. Conclusions and Relevance The findings of this systematic review suggest that economic policies aimed at expanding insurance coverage or improving health care quality successfully improved medication use and BP control among US adults with hypertension. Future research is needed to investigate the potential effects of non-health care economic policies on hypertension control.
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Affiliation(s)
- Donglan Zhang
- Center for Population Health and Health Services Research, Department of Foundations of Medicine, New York University Grossman Long Island School of Medicine, Mineola
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Jun Soo Lee
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa M. Pollack
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Xiaobei Dong
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee
| | - Joanna M. Taliano
- Office of Science Quality and Library Services, Office of Science, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anand Rajan
- Center for Population Health and Health Services Research, Department of Foundations of Medicine, New York University Grossman Long Island School of Medicine, Mineola
| | - Nicole L. Therrien
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sandra L. Jackson
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adebola Popoola
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Feijun Luo
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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Qiu S, Liu Y, Adetunji DO, Hartzell S, Larson M, Friedman S. Dose Changes for Long-term Opioid Patients Following a State Opioid Prescribing Policy. Med Care 2023; 61:657-664. [PMID: 37582299 PMCID: PMC10566257 DOI: 10.1097/mlr.0000000000001907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND In 2018, Nevada implemented opioid prescribing legislation (AB474) to support the uptake of CDC pain care guidelines. We studied the law's association with doses over threshold levels of morphine milligram equivalents (MMEs) and with time to dose increases and decreases, among long-term opioid patients. METHODS A difference-in-difference study examined dosing changes across opioid prescription episodes (ie, prescriptions within 30 day and within the same dosing threshold). Patients with at least 120 days supply over 6 months in Nevada and Colorado Medicaid pharmacy claims were included. Using a logistic regression model, we compare the predicted probabilities that opioid episodes exceeded 50 MME before and after implementation of the law, in both states. Adjusted hazard ratios (aHR) from a gap time survival model estimated time to escalate above 50 MME among low-dose episodes (<50 MME), and time to de-escalate below 50 MME among high-dose episodes (≥50 MME). RESULTS Among 453,577 episodes (74,292 patients), the Nevada law was associated with a 2.9% reduction in prescriptions over 50 MME (95% CI: -3.5, -2.3) compared with Colorado. While the law was also associated with slower escalation (Nevada: aHR = 0.75; 95% CI: 0.72, 0.77, Colorado: aHR = 1.04; 95% CI: 1.01, 1.06), it was also associated with slower de-escalation (Nevada: aHR = 0.87; 95% CI: 0.84, 0.89, Colorado: aHR = 0.97; 95% CI: 0.96, 0.99). CONCLUSIONS Slower dose escalations, rather than faster dose de-escalation, likely explain post-law reductions in doses over 50 MME. Slower dose de-escalations may be due to longer days supply post-policy.
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Affiliation(s)
- Sijia Qiu
- Department of Health Behavior, Policy, and Administration Sciences, School of Public Health, University of Nevada, Reno, Reno, NV
- Kaiser Permanente Southern California, Pasadena, CA
| | - Yan Liu
- Department of Health Behavior, Policy, and Administration Sciences, School of Public Health, University of Nevada, Reno, Reno, NV
| | - Doyinsola O Adetunji
- Department of Health Behavior, Policy, and Administration Sciences, School of Public Health, University of Nevada, Reno, Reno, NV
| | - Sarah Hartzell
- Department of Health Behavior, Policy, and Administration Sciences, School of Public Health, University of Nevada, Reno, Reno, NV
| | - Madalyn Larson
- Department of Health Behavior, Policy, and Administration Sciences, School of Public Health, University of Nevada, Reno, Reno, NV
| | - Sarah Friedman
- Department of Health Behavior, Policy, and Administration Sciences, School of Public Health, University of Nevada, Reno, Reno, NV
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Lu CH, Jette G, Falls Z, Jacobs DM, Gibson W, Bednarczyk EM, Kuo TY, Lape-Newman B, Leonard KE, Elkin PL. A cohort of patients in New York State with an alcohol use disorder and subsequent treatment information - A merging of two administrative data sources. J Biomed Inform 2023; 144:104443. [PMID: 37455008 PMCID: PMC11178131 DOI: 10.1016/j.jbi.2023.104443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Despite the high prevalence of alcohol use disorder (AUD) in the United States, limited research is focused on the associations among AUD, pain, and opioids/benzodiazepine use. In addition, little is known regarding individuals with a history of AUD and their potential risk for pain diagnoses, pain prescriptions, and subsequent misuse. Moreover, the potential risk of pain diagnoses, prescriptions, and subsequent misuse among individuals with a history of AUD is not well known. The objective was to develop a tailored dataset by linking data from 2 New York State (NYS) administrative databases to investigate a series of hypotheses related to AUD and painful medical disorders. METHODS Data from the NYS Office of Addiction Services and Supports (OASAS) Client Data System (CDS) and Medicaid claims data from the NYS Department of Health Medicaid Data Warehouse (MDW) were merged using a stepwise deterministic method. Multiple patient-level identifier combinations were applied to create linkage rules. We included patients aged 18 and older from the OASAS CDS who initially entered treatment with a primary substance use of alcohol and no use of opioids between January 1, 2003, and September 23, 2019. This cohort was then linked to corresponding Medicaid claims. RESULTS A total of 177,685 individuals with a primary AUD problem and no opioid use history were included in the dataset. Of these, 37,346 (21.0%) patients had an OUD diagnosis, and 3,365 (1.9%) patients experienced an opioid overdose. There were 121,865 (68.6%) patients found to have a pain condition. CONCLUSION The integrated database allows researchers to examine the associations among AUD, pain, and opioids/benzodiazepine use, and propose hypotheses to improve outcomes for at-risk patients. The findings of this study can contribute to the development of a prognostic prediction model and the analysis of longitudinal outcomes to improve the care of patients with AUD.
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Affiliation(s)
- Chi-Hua Lu
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Gail Jette
- Division of Outcomes, Management, and Systems Information, Office of Addiction Services and Supports, Albany, NY, USA
| | - Zackary Falls
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - David M Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Walter Gibson
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Edward M Bednarczyk
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Tzu-Yin Kuo
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | | | - Kenneth E Leonard
- Clinical and Research Institute on Addictions, University at Buffalo, Buffalo, NY, USA
| | - Peter L Elkin
- Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA; Faculty of Engineering, University of Southern Denmark, Denmark; U.S. Department of Veterans Affairs, WNY VA, Buffalo, NY, USA
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Huguet N, Green BB, Larson AE, Moreno L, DeVoe JE. Diabetes and Hypertension Prevention and Control in Community Health Centers: Impact of the Affordable Care Act. J Prim Care Community Health 2023; 14:21501319231195697. [PMID: 37646147 PMCID: PMC10467290 DOI: 10.1177/21501319231195697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 07/27/2023] [Accepted: 08/02/2023] [Indexed: 09/01/2023] Open
Abstract
Access to care significantly improved following the implementation of the Patient Protection and Affordable Care Act. Since its implementation, the number of uninsured Americans has significantly decreased. Medicaid expansion played an important role in community health centers, who serve historically marginalized populations, leading to increased clinic revenue, and improved access to care. As the continuous Medicaid enrollment provision established during the pandemic ended, and states have to make decisions about their program eligibility, exploring the impact of Medicaid expansion on the detection, and management of hypertension and diabetes could inform these decisions. We summarized the effect of Medicaid expansion on community health centers and their patients specific to hypertension and diabetes from existing literature. These studies suggest the beneficial impact of the Affordable Care Act and acquiring insurance on diabetes and hypertension disease detection, treatment, and control for patients receiving care in community health centers. Overall, these studies suggest the clear importance of health insurance coverage, and notably insurance stability, on diabetes and hypertension control.
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Affiliation(s)
| | - Beverly B. Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Laura Moreno
- Oregon Health & Science University, Portland, OR, USA
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Sood RK, Bae JY, Sabety A, Chan PY, Heindrichs C. ActionHealthNYC: Effectiveness of a Health Care Access Program for the Uninsured, 2016-2017. Am J Public Health 2021; 111:1318-1327. [PMID: 34111367 DOI: 10.2105/ajph.2021.306271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To evaluate the effectiveness of a novel health care access program (ActionHealthNYC) for uninsured immigrants. Methods. The evaluation was conducted as a randomized controlled trial in New York City from May 2016 through June 2017. Using baseline and follow-up survey data, we assessed health care access, patient experience, and health status. Results. At baseline, 25% of participants had a regular source of care; two thirds had visited a doctor in the past year and reported 2.5 visits in the past 12 months, on average. Nine to 12 months later, intervention participants were 1.2 times more likely to report having a primary care provider (58% vs 46%), were 1.2 times more likely to have seen a doctor in the past 9 months (91% vs 77%), and had 1.5 times more health care visits (4.1 vs 2.9) compared with control participants. Conclusions. ActionHealthNYC increased health care access among program participants. Public Health Implications. State and local policymakers should build on the progress that has been made over the last decade to expand and improve access to health care for uninsured immigrants.
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Affiliation(s)
- Rishi K Sood
- Rishi K. Sood is with the Bureau of Equitable Health Systems, New York City Department of Health and Mental Hygiene, Queens, NY. Jin Yung Bae and Caroline Heindrichs were with the Bureau of Primary Care Access and Planning, New York City Department of Health and Mental Hygiene. Adrienne Sabety was with the Interfaculty Initiative in Health Policy at Harvard University, Cambridge, MA. Pui Ying Chan is with the Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene
| | - Jin Yung Bae
- Rishi K. Sood is with the Bureau of Equitable Health Systems, New York City Department of Health and Mental Hygiene, Queens, NY. Jin Yung Bae and Caroline Heindrichs were with the Bureau of Primary Care Access and Planning, New York City Department of Health and Mental Hygiene. Adrienne Sabety was with the Interfaculty Initiative in Health Policy at Harvard University, Cambridge, MA. Pui Ying Chan is with the Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene
| | - Adrienne Sabety
- Rishi K. Sood is with the Bureau of Equitable Health Systems, New York City Department of Health and Mental Hygiene, Queens, NY. Jin Yung Bae and Caroline Heindrichs were with the Bureau of Primary Care Access and Planning, New York City Department of Health and Mental Hygiene. Adrienne Sabety was with the Interfaculty Initiative in Health Policy at Harvard University, Cambridge, MA. Pui Ying Chan is with the Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene
| | - Pui Ying Chan
- Rishi K. Sood is with the Bureau of Equitable Health Systems, New York City Department of Health and Mental Hygiene, Queens, NY. Jin Yung Bae and Caroline Heindrichs were with the Bureau of Primary Care Access and Planning, New York City Department of Health and Mental Hygiene. Adrienne Sabety was with the Interfaculty Initiative in Health Policy at Harvard University, Cambridge, MA. Pui Ying Chan is with the Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene
| | - Caroline Heindrichs
- Rishi K. Sood is with the Bureau of Equitable Health Systems, New York City Department of Health and Mental Hygiene, Queens, NY. Jin Yung Bae and Caroline Heindrichs were with the Bureau of Primary Care Access and Planning, New York City Department of Health and Mental Hygiene. Adrienne Sabety was with the Interfaculty Initiative in Health Policy at Harvard University, Cambridge, MA. Pui Ying Chan is with the Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene
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Tillman P. Applying the Chronic Care Model in a Free Clinic. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Marino M, Angier H, Springer R, Valenzuela S, Hoopes M, O'Malley J, Suchocki A, Heintzman J, DeVoe J, Huguet N. The Affordable Care Act: Effects of Insurance on Diabetes Biomarkers. Diabetes Care 2020; 43:2074-2081. [PMID: 32611609 PMCID: PMC7440906 DOI: 10.2337/dc19-1571] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 05/14/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers. RESEARCH DESIGN AND METHODS This was a retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE (Accelerating Data Value Across a National Community Health Center Network) network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (n = 25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre- to post-ACA expansion. Primary outcomes included changes from 24 months pre- to 24 months post-ACA in glycosylated hemoglobin (HbA1c), systolic (SBP) and diastolic (DBP) blood pressure, and LDL cholesterol levels. RESULTS Newly insured patients exhibited a reduction in adjusted mean HbA1c levels (8.24% [67 mmol/mol] to 8.17% [66 mmol/mol]), which was significantly different from continuously uninsured patients, whose HbA1c levels increased (8.12% [65 mmol/mol] to 8.29% [67 mmol/mol]; difference-in-differences [DID] -0.24%; P < 0.001). Newly insured patients showed greater reductions than continuously uninsured patients in adjusted mean SBP (DID -1.8 mmHg; P < 0.001), DBP (DID -1.0 mmHg; P < 0.001), and LDL (DID -3.3 mg/dL; P < 0.001). Among patients with elevated HbA1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured patients to have a controlled HbA1c measurement by 24 months post-ACA (hazard ratio 1.25; 95% CI 1.02-1.54]. CONCLUSIONS Post-ACA, newly insured patients had greater improvements in diabetes-related biomarkers than continuously uninsured, discontinuously insured, or continuously insured patients. Findings suggest that health insurance gain via ACA facilitates access to appropriate diabetes care, leading to improvements in diabetes-related biomarkers.
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Affiliation(s)
- Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR .,Biostatistics Group, Oregon Health & Science University-Portland State University School of Public Health, Portland, OR
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Jean O'Malley
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR.,OCHIN, Portland, OR
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
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Lobo JM, Kim S, Kang H, Ocker G, McMurry TL, Balkrishnan R, Anderson R, McCall A, Benitez J, Sohn MW. Trends in Uninsured Rates Before and After Medicaid Expansion in Counties Within and Outside of the Diabetes Belt. Diabetes Care 2020; 43:1449-1455. [PMID: 31988065 PMCID: PMC7305008 DOI: 10.2337/dc19-0874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 11/08/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine trends in uninsured rates between 2012 and 2016 among low-income adults aged <65 years and to determine whether the Patient Protection and Affordable Care Act (ACA), which expanded Medicaid, impacted insurance coverage in the Diabetes Belt, a region across 15 southern and eastern U.S. states in which residents have high rates of diabetes. RESEARCH DESIGN AND METHODS Data for 3,129 U.S. counties, obtained from the Small Area Health Insurance Estimates and Area Health Resources Files, were used to analyze trends in uninsured rates among populations with a household income ≤138% of the federal poverty level. Multivariable analysis adjusted for the percentage of county populations aged 50-64 years, the percentage of women, Distressed Communities Index value, and rurality. RESULTS In 2012, 39% of the population in the Diabetes Belt and 34% in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates declined rapidly to 13% in Diabetes Belt counties and to 15% in non-Belt counties. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3% in Diabetes Belt counties and by 4.9% in non-Belt counties. In 2016, uninsured rates were 15% higher for both Diabetes Belt and non-Belt counties in the nonexpansion states than in the expansion states. CONCLUSIONS ACA-driven Medicaid expansion was more significantly associated with reduced uninsured rates in Diabetes Belt than in non-Belt counties. Initial disparities in uninsured rates between Diabetes Belt and non-Belt counties have not existed since 2014 among expansion states. Future studies should examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the Diabetes Belt.
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Affiliation(s)
- Jennifer M Lobo
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - Soyoun Kim
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - Hyojung Kang
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL
| | - Gabrielle Ocker
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - Timothy L McMurry
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - Rajesh Balkrishnan
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - Roger Anderson
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - Anthony McCall
- Division of Endocrinology and Metabolism, Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA
| | - Joseph Benitez
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, KY
| | - Min-Woong Sohn
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, KY
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Turner BJ, Liang Y, Ramachandran A, Poursani R. Telephone or Visit-Based Community Health Worker Care Management for Uncontrolled Diabetes Mellitus: A Longitudinal Study. J Community Health 2020; 45:1123-1131. [PMID: 32472457 PMCID: PMC7256181 DOI: 10.1007/s10900-020-00849-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Community health workers (CHWs) can reduce health disparities for low income patients but type of contact and outcomes has had limited study. Low-income Hispanic primary care patients with hemoglobin A1c [HbA1c] ≥ 9% received care managment (CM) over 6 months classified as: (CM1) telephone only; (CM2) clinic visit but no calls; (CM3) clinic visit with calls; and (CM4) ≥ 2 visits ± calls. Type of CM delivery and time to DM control (HbA1c < 9%) examined in Cox proportional hazards model and more rapid control within 6 months using logistic regression. Models adjusted for demographics, clinical, and health care variables. At baseline, 523 patients had mean HbA1c 10.9% (SD = 1.7%), mean age 57.9 years (SD = 10), 58.5% women, 87.6% Hispanic, and 55.5% uninsured. CM types for patients: 51 (9.8%) CM1; 192 (36.7%) CM2; 44 (8.4%) CM3; and 236 (45.4%) CM4. Median time to HbA1c control was 197 days (95% CI [71, 548]) and 41.5% achieved control within 6 months. Compared with CM1, control was more rapid for CM2 (Hazard ratio [HR] 1.45, 95% CI [1.01, 2.09], p = 0.043) and CM4 but not significant (HR [95% CI] 1.29 [0.91, 1.83], p = 0.15). Adjusted odds of more rapid control within 6 months were twofold higher for CM2 (p = 0.04) and CM4 (p = 0.055), respectively, versus CM1. CM2 did not differ from CM1. DM control was less likely for CM by telephone only than face-to-face in clinic. To benefit vulnerable patients with uncontrolled DM, in-person engagement may be required.
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Affiliation(s)
- Barbara J Turner
- Department of Medicine, Keck Medical Center of University of Southern California, 2020 Zonal Avenue, Los Angeles, CA, 90033, USA.
- Gehr Center for Health Systems Science and Innovation, Keck School of Medicine of USC, 2020 Zonal Avenue, IRD 322, Los Angeles, CA, 90033, USA.
| | - Yuanyuan Liang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 660 W. Redwood Street, Baltimore, MD, 21201, USA
| | - Ambili Ramachandran
- Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio (UT Health San Antonio), 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Ramin Poursani
- Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio (UT Health San Antonio), 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
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Disparities in Biomarkers for Patients With Diabetes After the Affordable Care Act. Med Care 2020; 58 Suppl 6 Suppl 1:S31-S39. [PMID: 32412951 DOI: 10.1097/mlr.0000000000001257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Racial and ethnic minorities are disproportionately affected by diabetes and at greater risk of experiencing poor diabetes-related outcomes compared with non-Hispanic whites. The Affordable Care Act (ACA) was implemented to increase health insurance coverage and reduce health disparities. OBJECTIVE Assess changes in diabetes-associated biomarkers [hemoglobin A1c (HbA1c) and low-density lipoprotein] 24 months pre-ACA to 24 months post-ACA Medicaid expansion by race/ethnicity and insurance group. RESEARCH DESIGN Retrospective cohort study of community health center (CHC) patients. SUBJECTS Patients aged 19-64 with diabetes living in 1 of 10 Medicaid expansion states with ≥1 CHC visit and ≥1 HbA1c measurement in both the pre-ACA and the post-ACA time periods (N=13,342). METHODS Linear mixed effects and Cox regression modeled outcome measures. RESULTS Overall, 33.5% of patients were non-Hispanic white, 51.2% Hispanic, and 15.3% non-Hispanic black. Newly insured Hispanics and non-Hispanic whites post-ACA exhibited modest reductions in HbA1c levels, similar benefit was not observed among non-Hispanic black patients. The largest reduction was among newly insured Hispanics versus newly insured non-Hispanic whites (P<0.05). For the subset of patients who had uncontrolled HbA1c (HbA1c≥9%) within 3 months of the ACA Medicaid expansion, non-Hispanic black patients who were newly insured gained the highest rate of controlled HbA1c (hazard ratio=2.27; 95% confidence interval, 1.10-4.66) relative to the continuously insured group. CONCLUSIONS The impact of the ACA Medicaid expansion on health disparities is multifaceted and may differ across racial/ethnic groups. This study highlights the importance of CHCs for the health of minority populations.
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Saloner B, Wilk AS, Levin J. Community Health Centers and Access to Care Among Underserved Populations: A Synthesis Review. Med Care Res Rev 2019; 77:3-18. [DOI: 10.1177/1077558719848283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Community health centers (CHCs) deliver affordable health services to underserved populations, especially uninsured and Medicaid enrollees. Since the early 2000s, CHCs have grown because of federal investments in CHC capacity and expansions of Medicaid eligibility. We review 24 relevant studies from 2000 to 2017 to evaluate the relationship between CHCs, policies that invest in services for low-income individuals, and access to care. Most included studies use quasi-experimental designs. Greater spending on CHCs improves access to care, especially for low-income and minority individuals. Medicaid expansions also increase CHC use. Some studies indicate that CHC investments complement Medicaid expansions to increase access cost-effectively. Further research should explore patient preferences and patterns of CHC utilization versus other sites of care and population subgroups for which expanding CHC capacity improves access to care most. Researchers should endeavor to use measures and sample definitions that facilitate comparisons with other estimates in the literature.
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Affiliation(s)
- Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Adam S. Wilk
- Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Jonathan Levin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Marino M, Angier H, Valenzuela S, Hoopes M, Killerby M, Blackburn B, Huguet N, Heintzman J, Hatch B, O'Malley JP, DeVoe JE. Medicaid coverage accuracy in electronic health records. Prev Med Rep 2018; 11:297-304. [PMID: 30116701 PMCID: PMC6082971 DOI: 10.1016/j.pmedr.2018.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 07/19/2018] [Accepted: 07/21/2018] [Indexed: 01/21/2023] Open
Abstract
Health insurance coverage facilitates access to preventive screenings and other essential health care services, and is linked to improved health outcomes; therefore, it is critical to understand how well coverage information is documented in the electronic health record (EHR) and which characteristics are associated with accurate documentation. Our objective was to evaluate the validity of EHR data for monitoring longitudinal Medicaid coverage and assess variation by patient demographics, visit types, and clinic characteristics. We conducted a retrospective, observational study comparing Medicaid status agreement between Oregon community health center EHR data linked at the patient-level to Medicaid enrollment data (gold standard). We included adult patients with a Medicaid identification number and ≥1 clinic visit between 1/1/2013-12/31/2014 [>1 million visits (n = 135,514 patients)]. We estimated statistical correspondence between EHR and Medicaid data at each visit (visit-level) and for different insurance cohorts over time (patient-level). Data were collected in 2016 and analyzed 2017-2018. We observed excellent agreement between EHR and Medicaid data for health insurance information: kappa (>0.80), sensitivity (>0.80), and specificity (>0.85). Several characteristics were associated with agreement; at the visit-level, agreement was lower for patients who preferred a non-English language and for visits missing income information. At the patient-level, agreement was lower for black patients and higher for older patients seen in primary care community health centers. Community health center EHR data are a valid source of Medicaid coverage information. Agreement varied with several characteristics, something researchers and clinic staff should consider when using health insurance information from EHR data.
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Affiliation(s)
- Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - Marie Killerby
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brenna Blackburn
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brigit Hatch
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,OCHIN, Portland, OR, USA
| | - Jean P O'Malley
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,OCHIN, Portland, OR, USA
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,OCHIN, Portland, OR, USA
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Abstract
BACKGROUND The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics. QUESTIONS/PURPOSES (1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state? METHODS We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race, gender, language spoken, and income level) also was compared using an interrupted time-series design. RESULTS There was a 36% absolute reduction (95% CI, 35%-38%; p < 0.001) in uninsured visits (73% relative reduction; 95% CI, 71%-75%; p < 0.001). There was an immediate 28% absolute reduction (95% CI, 21%-34%; p < 0.001) at the time of ACA implementation, which continued to decline thereafter. After controlling for potential confounding variables such as gender, race, age, and income level, we found that patients who were white, men, younger than 65 years, and seen after January 2014 were more likely to have insurance than patients of other races, women, older patients, and patients treated before January 2014. CONCLUSIONS After the ACA was implemented, the proportion of patients with health insurance at our safety net adult orthopaedic surgery clinic increased substantially. The reduction in uninsured patients was not equal across genders, races, ages, and incomes. Future studies may benefit from identifying barriers to insurance acquisition in these subpopulations. The results of this study could affect orthopaedic practices in the United States by guiding policy decisions regarding health care. LEVEL OF EVIDENCE Level III, therapeutic study.
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Angier H, Hoopes M, Marino M, Huguet N, Jacobs EA, Heintzman J, Holderness H, Hood CM, DeVoe JE. Uninsured Primary Care Visit Disparities Under the Affordable Care Act. Ann Fam Med 2017; 15:434-442. [PMID: 28893813 PMCID: PMC5593726 DOI: 10.1370/afm.2125] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 05/24/2017] [Accepted: 07/03/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Health insurance coverage affects a patient's ability to access optimal care, the percentage of insured patients on a clinic's panel has an impact on the clinic's ability to provide needed health care services, and there are racial and ethnic disparities in coverage in the United States. Thus, we aimed to assess changes in insurance coverage at community health center (CHC) visits after the Patient Protection and Affordable Care Act (ACA) Medicaid expansion by race and ethnicity. METHODS We undertook a retrospective, observational study of visit payment type for CHC patients aged 19 to 64 years. We used electronic health record data from 10 states that expanded Medicaid and 6 states that did not, 359 CHCs, and 870,319 patients with more than 4 million visits. Our analyses included difference-in-difference (DD) and difference-in-difference-in-difference (DDD) estimates via generalized estimating equation models. The primary outcome was health insurance type at each visit (Medicaid-insured, uninsured, or privately insured). RESULTS After the ACA was implemented, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the greatest increases in Medicaid-insured visit rates after ACA implementation in expansion states (rate ratio [RR] = 1.77; 95% CI, 1.56-2.02) and the largest gains in privately insured visit rates in nonexpansion states (RR = 3.63; 95% CI, 2.73-4.83). In expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (DD = 2.03; 95% CI, 1.53-2.70), and this relative change was more than 2 times greater in expansion states compared with nonexpansion states (DDD = 2.06; 95% CI, 1.52-2.78). CONCLUSION The lower rates of uninsured visits for all racial and ethnic groups after ACA implementation suggest progress in expanding coverage to CHC patients; this progress, however, was not uniform when comparing expansion with nonexpansion states and among all racial and ethnic minority subgroups. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.
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Affiliation(s)
| | | | - Miguel Marino
- Oregon Health & Science University, Portland, Oregon
| | | | - Elizabeth A Jacobs
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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