Massachusetts health reform and disparities in joint replacement use: difference in differences study

The Association Between Medicaid Expansion and Disparities in Vestibular Schwannoma Incidence

OBJECTIVES

The effect of Medicaid expansion as a part of the Affordable Care Act on vestibular schwannoma (VS) incidence overall and in marginalized populations has not yet been elucidated. The goal of this study was to determine if Medicaid expansion was associated with increases in VS incidence overall, as well as in patients of non-white race or in counties of low socioeconomic status (SES).

METHODS

We performed a difference-in-difference (DiD) analysis from January 1st 2010-December 31st 2017 utilizing the Surveillance, Epidemiology, and End Results (SEER) database. Our DiD method compared the change in VS rate between counties that did and did not expand Medicaid among patients of white and non-white race, in low and high SES counties, before and after expansion.

RESULTS

The study included 17,312 cases across 1020 counties. Medicaid expansion was associated with a 15% increase (incidence rate ratio 95% CI: [11%, 19]) in VS incidence. White populations saw a 10% increase (CI: [1.06, 1.19]), Black populations saw a 20% increase (CI: [1.10, 1.29]), and patients of other races saw a 44% increase in incidence associated with expansion (CI: [1.21, 1.70]). Low SES counties saw an increase in incidence 1.12 times higher than that of high SES counties (CI:[1.04, 1.20]).

CONCLUSION

Medicaid expansion was associated with increases in VS incidence across populations. Furthermore, this increase was more evident in disadvantaged populations, such as patients of non-white race and those from low SES counties. These findings emphasize the impact of Medicaid expansion on healthcare utilization for VS diagnosis.

LEVEL OF EVIDENCE

3-Retrospective Cohort Study Laryngoscope, 134:4383-4388, 2024.

British Columbia's Safer Opioid Supply Policy and Opioid Outcomes

Importance

In March 2020, British Columbia, Canada, became the first jurisdiction globally to launch a large-scale provincewide safer supply policy. The policy allowed individuals with opioid use disorder at high risk of overdose or poisoning to receive pharmaceutical-grade opioids prescribed by a physician or nurse practitioner, but to date, opioid-related outcomes after policy implementation have not been explored.

Objective

To investigate the association of British Columbia's Safer Opioid Supply policy with opioid prescribing and opioid-related health outcomes.

Design, Setting, and Participants

This cohort study used quarterly province-level data from quarter 1 of 2016 (January 1, 2016) to quarter 1 of 2022 (March 31, 2022), from British Columbia, where the Safer Opioid Supply policy was implemented, and Manitoba and Saskatchewan, where the policy was not implemented (comparison provinces).

Exposure

Safer Opioid Supply policy implemented in British Columbia in March 2020.

Main Outcomes and Measures

The main outcomes were rates of prescriptions, claimants, and prescribers of opioids targeted by the Safer Opioid Supply policy (hydromorphone, morphine, oxycodone, and fentanyl); opioid-related poisoning hospitalizations; and deaths from apparent opioid toxicity. Difference-in-differences analysis was used to compare changes in outcomes before and after policy implementation in British Columbia with those in the comparison provinces.

Results

The Safer Opioid Supply policy was associated with statistically significant increases in rates of opioid prescriptions (2619.6 per 100 000 population; 95% CI, 1322.1-3917.0 per 100 000 population; P < .001) and claimants (176.4 per 100 000 population; 95% CI, 33.5-319.4 per 100 000 population; P = .02). There was no significant change in prescribers (15.7 per 100 000 population; 95% CI, -0.2 to 31.6 per 100 000 population; P = .053). However, the opioid-related poisoning hospitalization rate increased by 3.2 per 100 000 population (95% CI, 0.9-5.6 per 100 000 population; P = .01) after policy implementation. There were no statistically significant changes in deaths from apparent opioid toxicity (1.6 per 100 000 population; 95% CI, -1.3 to 4.5 per 100 000 population; P = .26).

Conclusions and Relevance

Two years after its launch, the Safer Opioid Supply policy in British Columbia was associated with higher rates of safer supply opioid prescribing but also with a significant increase in opioid-related poisoning hospitalizations. These findings will help inform ongoing debates about this policy not only in British Columbia but also in other jurisdictions that are contemplating it.

Quasi-Experimental Design for Health Policy Research: A Methodology Overview

SUMMARY

Health policy impacts all aspects of the authors' field. Research on this topic informs future policy direction and serves as an impactful means to advocate for their patients. The present work aims to promote policy research in plastic surgery. To accomplish this goal, the authors discuss quasi-experimental research design. The authors include in-depth discussion regarding study techniques that are well suited to health policy, including interrupted time series, difference-in-differences analysis, regression discontinuity design, and instrumental variable design. For each study design, the authors discuss examples and potential limitations.

Uncemented Tibial Fixation Has Comparable Prognostic Outcomes and Safety Versus Cemented Fixation in Cruciate-Retaining Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Cemented and uncemented fixation are the primary methods of tibial prosthesis fixation in total knee arthroplasty. However, the optimal fixation method remains controversial. This article explored whether uncemented tibial fixation has better clinical and radiological outcomes, fewer complications, and revision rates compared to cemented tibial fixation.

METHODS

We searched the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2022 to identify randomized controlled trials (RCTs) that compared uncemented total knee arthroplasty (TKA) and cemented TKA. The outcome assessment consisted of clinical and radiological outcomes, complications (aseptic loosening, infection, and thrombosis), and revision rate. Subgroup analysis was used to explore the effects of different fixation methods on knee scores in younger patients.

RESULTS

Nine RCTs were finally analyzed with 686 uncemented knees and 678 cemented knees. The mean follow-up time was 12.6 years. The pooled data revealed significant advantages of uncemented fixations over cemented fixations in terms of the Knee Society Knee Score (KSKS) (p = 0.01) and the Knee Society Score-Pain (KSS-Pain) (p = 0.02). Cemented fixations showed significant advantages in maximum total point motion (MTPM) (p < 0.0001). There was no significant difference between uncemented fixation and cemented fixation regarding functional outcomes, range of motion, complications, and revision rates. When comparing among young people (<65 years), the differences in KSKS became statistically insignificant. No significant difference was shown in aseptic loosening and the revision rate among young patients.

CONCLUSIONS

The current evidence shows better knee score, less pain, comparable complications and revision rates for uncemented tibial prosthesis fixation, compared to cemented, in cruciate-retaining total knee arthroplasty.

Effect of Information Intervention on Prescribing Practice for Neuropathic Pain in Older Patients: A Nationwide Register-Based Study

INTRODUCTION

Management of prescription medicines is challenging for older patients due to frail health and the prevalence of multiple chronic conditions. A salient policy challenge of prescribing practices is that all physicians are not well informed about the national clinical guidelines. A feasible policy intervention to mitigate the harms caused by Potentially Inappropriate Medications is to influence the frequency of prescribing and other prescribing attributes of the drugs by providing accurate and up-to-date information about the national clinical guidelines.

OBJECTIVES

The objective of this study was to examine the effect of a nationwide information intervention on physicians' prescribing practices and patients' healthcare utilization.

METHODS

We used a quasi-experimental research design based on difference-in-differences variation and nationwide register data on prescribers and purchasers of pregabalin, nortriptyline, and amitriptyline combinations in Finland between January 2018 and May 2019. The study included 68,914 patients and 11,432 physicians.

RESULTS

We found that the information letter sent to all prescribers of pregabalin, nortriptyline, or amitriptyline combinations to patients aged 75 years or older decreased the probability of prescribing of these medications. The estimated effect of - 3.3 percentage points (95% confidence interval [- 0.041, - 0.024]) corresponds to a 29% reduction compared to the baseline mean of the outcome. The filled quantity, measured in Defined Daily Doses, of pregabalin, nortriptyline, and amitriptyline combinations per month was reduced by 11.7% [- 14.5% to - 8.9%] among patients aged 75 years or older. No effect on patients' healthcare utilization was observed.

CONCLUSIONS

Findings of the study suggest that personal information intervention was an effective policy tool for nudging physicians to reduce prescribing of potentially inappropriate medicines, whereas the reduction in prescribing was not accompanied by improvements or adverse effects in patients' health.

Socioeconomic Disparities in the Utilization of Total Knee Arthroplasty

BACKGROUND

Despite strong evidence supporting the efficacy of total knee arthroplasty (TKA), studies have shown significant socioeconomic disparities regarding who ultimately undergoes TKA. The purpose of the current study is to evaluate socioeconomic factors affecting whether a patient undergoes TKA after a diagnosis of osteoarthritis.

METHODS

From 2011 to 2018, claims for adult patients diagnosed with knee osteoarthritis in the New York Statewide Planning and Research Cooperative System (SPARCS) database were analyzed. International Classification of Diseases (ICD), 9/10 CM codes were used to identify the initial diagnosis for each patient. ICD 9/10 PCS codes were used to identify subsequent TKA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having TKA.

RESULTS

Of 313,794 osteoarthritis diagnoses, 33.3% proceeded to undergo TKA. Increased age (OR 1.007, P < .0001) and workers' compensation relative to commercial insurance (OR 1.865, P < .0001) had increased odds of TKA. Compared to White race, Asian (OR 0.705, P < .0001), Black (OR 0.497, P < .0001), and "other" race (OR 0.563, P < .0001) had lower odds of TKA. Hispanic ethnicity (OR 0.597, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.876, P < .0001), Medicaid (OR 0.452, P < .0001), self-pay (OR 0.523, P < .0001), and "other" insurance (OR 0.819, P < .0001) had lower odds of TKA. Increased social deprivation (OR 0.987, P < .0001) had lower odds of TKA.

CONCLUSION

TKA is associated with disparities among race, ethnicity, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in orthopedic care.

Effects of e-cigarette use on mental health among youths: quasi-experimental evidence from Canada

BACKGROUND AND AIMS

Existing research on mental health comorbidities of youth e-cigarette use is subject to confounding bias and reverse causality. This study aimed to measure the effects of e-cigarette use on youth mental health, using e-cigarette minimum legal age (MLA) law in Canada as a natural experiment.

DESIGN

We used difference-in-differences (DD), difference-in-differences-in-differences (DDD) and two-sample instrumental variables (TSIV) methods.

SETTING

Data were from nationally representative Canadian Community Health Surveys 2008-2019 and Canadian Student Tobacco Alcohol and Drugs Surveys 2008-2019.

PARTICIPANTS

The study sample comprised of respondents aged 15 to 18 (in DD analysis; n = 33 858) and aged 15 to 24 (in DDD analysis; n = 78 689).

MEASUREMENTS

Primary outcomes were self-reported mood disorders and anxiety disorders. Secondary outcomes were cannabis use, illicit drug use, cigarette use and strength of peer relationships at schools.

FINDINGS

After the e-cigarette MLA laws, risks of mood disorders declined by 1.9 percentage points (95% CI, 0.0-3.8; P = 0.05) in the DD analysis and by 2.6 percentage points (95% CI, 0.2-5.0; P = 0.03) in the DDD analysis. For anxiety disorders, while the DD estimate was negative but imprecisely estimated, the MLA law reduced risks of anxiety disorder by 3.6 percentage points (95% CI, 0.9-6.2; P = 0.01) in the DDD analysis. Youths in provinces with MLA laws were also less likely to report cannabis use and illicit drug use and more likely to feel being part of schools. TSIV analysis indicates that youth e-cigarette use increased the likelihood of mood and anxiety disorders by 44% and 37%, respectively.

CONCLUSION AND RELEVANCE

In Canada, the e-cigarette minimum legal age law appears to have reduced risks of mood and anxiety disorders, lowered substance use and improved peer relationships at schools. Combined with previous evidence of lower e-cigarette use following the minimum legal age law, our findings indicate that youth e-cigarette use increases risks of mood and anxiety disorders.

Changes in Youth Cannabis Use After an Increase in Cannabis Minimum Legal Age in Quebec, Canada

IMPORTANCE

In January 2020, Quebec raised the minimum legal age (MLA) for cannabis from 18 to 21 years. Evidence is needed to inform the ongoing debate on this policy. Although proponents believe that a higher MLA will protect youths from the harms of cannabis use, critics argue that it will push them back to the illegal market.

OBJECTIVE

To investigate changes in youth cannabis use after an increase in MLA for cannabis in Quebec.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study with difference-in-differences analysis compared changes in cannabis use among youths aged 15 to 20 years in Quebec vs all other Canadian provinces before and after Quebec's increase in MLA. All estimates in descriptive and regression analyses were weighted. Nationally representative data from the National Cannabis Surveys 2018-2020 were used.

INTERVENTION

Increase in MLA for cannabis in Quebec implemented in January 2020.

MAIN OUTCOMES AND MEASURES

Past-3-month cannabis use.

RESULTS

The study sample included 1005 respondents (mean [SD] age, 17.5 [1.7] years; 50.2% [SD, 50.0%] male). After policy implementation, the increase in past-3-month cannabis use among youths aged 18 to 20 was 16.4 percentage points (95% CI, -27.3 to -5.5 percentage points; P = .01), or 51%, lower in Quebec than in other provinces. Meanwhile, no significant change in cannabis use among youths aged 15 to 17 years was found. The results were robust to several checks, including accounting for possible confounding effects of the COVID-19 pandemic on cannabis use.

CONCLUSIONS AND RELEVANCE

In this study, an increase in the MLA from 18 to 21 years in Quebec was associated with a significantly lower increase in cannabis use among youths aged 18 to 20 years but no change in cannabis use among those aged 15 to 17 years. These findings can help to alleviate concerns that youths would switch to illegal markets in response to a higher MLA.

Socioeconomic Status Impacts Access to Orthopaedic Specialty Care

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Financial, personal, and structural barriers affect access to all aspects of orthopaedic specialty care.

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Disparities in access to care are present across all subspecialties of orthopaedic surgery in the United States.

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Improving timely access to care in orthopaedic surgery is crucial for both health equity and optimizing patient outcomes.

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Options for improving orthopaedic access include increasing Medicaid/Medicare payments to physicians, providing secondary resources to assist patients with limited finances, and reducing language barriers in both clinical care and patient education.

Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty

BACKGROUND

There is increasing focus on highlighting disparities in both access to and equity of care in orthopedics and understanding the impact disparities have on patient health. The purpose of the present study is to evaluate socioeconomic-related factors affecting whether a patient undergoes total hip arthroplasty (THA) after a diagnosis of osteoarthritis.

METHODS

From 2011 to 2018, patients ≥40 years of age diagnosed with hip osteoarthritis were identified in the New York Statewide Planning and Research Cooperative System, a comprehensive all-payer database collecting preadjudicated claims in New York State. International Classification of Diseases, Ninth Revision/Tenth Revision codes were used to identify the initial diagnosis and subsequent THA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of undergoing THA.

RESULTS

Of 142,681 hip osteoarthritis diagnoses, 48.6% proceeded to THA. Compared to non-Hispanic white patients, Asian (odds ratio [OR] 0.65, P < .0001), Black (OR 0.51, P < .0001), and "Other" race (OR 0.54, P < .0001) had lower odds of THA. Hispanic patients (OR 0.55, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.83, P < .0001), Medicaid (OR 0.49, P < .0001), Self-pay (OR 0.78, P < .0001), and workers' compensation (OR 0.71, P < .0001) had lower odds of THA. Having one or more Charlson Comorbidity Index (OR 0.45, P < .0001) was associated with lower odds of THA, as was increased social deprivation (OR 0.99, P < .0001).

CONCLUSION

THA is associated with disparities among race, gender, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.

A Pragmatic Randomized Controlled Trial of an Endoscopist Audit and Feedback Report for Colonoscopy

INTRODUCTION

Variation in endoscopist performance contributes to poor-quality colonoscopy. Audit and feedback (A/F) can be used to improve physician performance, particularly among lower performing physicians. In this large pragmatic randomized controlled trial, we compared A/F to improve endoscopists' colonoscopy performance to usual practice.

METHODS

Endoscopists practicing in Ontario, Canada, in 2014 were randomly assigned in October 2015 (index date) to receive (intervention group, n = 417) or not receive (control group, n = 416) an A/F report generated centrally using health administrative data. Colonoscopy performance was measured in both groups over two 12-month periods: prereport and postreport (relative to the index date). The primary outcome was polypectomy rate (PR). Secondary outcomes were cecal intubation rate, bowel preparation, and premature repeat after normal colonoscopy. A post hoc analysis used adenoma detection rate as the outcome. Outcomes were compared between groups for all endoscopists and for lower performing endoscopists using Poisson regression analyses under a difference-in-difference framework.

RESULTS

Among all endoscopists, PR did not significantly improve from prereport to postreport periods for those receiving the intervention (relative rate [RR], intervention vs control: 1.07 vs 1.05, P = 0.09). Among lower performing endoscopists, PR improved significantly (RR, intervention vs control 1.34 vs 1.11, P = 0.02) in the intervention group compared with controls. In this subgroup, adenoma detection rate also improved but not significantly (RR, intervention vs control 1.12 vs 1.04, P = 0.12). There was no significant improvement in secondary outcomes between the intervention and control groups.

DISCUSSION

A/F reports for colonoscopy improve performance in lower performing endoscopists (ClinicalTrials.gov: NCT02595775).

Factors Associated With State-Specific Medicaid Expansion and Receipt of Autologous Breast Reconstruction Among Patients Undergoing Mastectomy

IMPORTANCE

Despite demonstrated psychosocial benefits, autologous breast reconstruction remains underutilized. An analysis of the association between Medicaid expansion and autologous breast reconstruction has yet to be performed.

OBJECTIVE

To compare autologous breast reconstruction rates and determine the association between Medicaid expansion and breast reconstruction.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was performed using the State Inpatient Database from January 1, 2012, through September 30, 2015, and included 51 340 patients. Patients were identified using the International Classification of Diseases, Ninth Revision, codes for breast cancer, mastectomy, and autologous breast reconstruction. Data from states that expanded Medicaid (New Jersey, New York, and Washington) were compared with states that did not expand Medicaid (Florida, North Carolina, and Wisconsin). Data were analyzed from June 1, 2020, through February 28, 2021.

EXPOSURES

The Patient Protection and Affordable Care Act's Medicaid expansion was implemented in 2014; the preexpansion period ranged from 2012 to 2013 (2 years), whereas the postexpansion period ranged from 2014 to 2015 quarter 3 (1.75 years).

MAIN OUTCOMES AND MEASURES

Primary outcomes included use of autologous breast reconstruction before and after expansion. Independent covariates included patient demographics, comorbidities, and state of residence.

RESULTS

Among 45 850 patients who underwent mastectomy and 9215 patients who received autologous breast reconstruction, 36 777 (67%) were White and 32 205 (59%) had private insurance. The use of immediate or delayed autologous reconstruction increased from 18.1% (4951 of 27 290) to 23.0% (4264 of 18 560) throughout the study period. Compared with 2012, the odds of reconstruction were 64% higher in 2015 (odds ratio [OR], 1.64; 95% CI, 1.48-1.80; P < .001). African American (OR, 1.43; 95% CI, 1.33-1.55; P < .001) and Hispanic (OR, 1.44; 95% CI, 1.31-1.60; P < .001) patients had higher odds of reconstruction compared with White patients regardless of state of residence. However, Medicaid expansion was associated with a 28% decrease in the odds of reconstruction (OR, 0.72; 95% CI, 0.61-0.87; P < .001) for African American patients, a 40% decrease (OR, 0.60; 95% CI, 0.50-0.74; P < .001) for Hispanic patients, and 20% decrease (OR, 0.80; 95% CI, 0.67-0.96; P = .01) for patients with Asian, Native American, or other minority race/ethnicity. Medicaid expansion was not associated with changes in the odds of reconstruction for White patients.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, although the odds of receiving autologous breast reconstruction increased annually, Medicaid expansion was associated with decreased odds of reconstruction for African American patients, Hispanic patients, and other patients of color.

Closing the Socioeconomic Gap in Massachusetts: Trends in Total Hip Arthroplasty From 2013 to 2015

To extend insurance coverage to all residents, Massachusetts legislation expanded Medicaid eligibility and added new private insurance categories. To date, no one has analyzed the effect of these changes and compared recent trends in total hip arthroplasty (THA) utilization. Therefore, this study sought to update the current trends of THA utilization in Massachusetts from 2013 to 2015. The Massachusetts State Inpatient Database was queried for all patients who underwent primary THA between 2013 and 2015, and 30,308 patients were identified. Analyzed variables included age, sex, race, Charlson Comorbidity Index, median household income, primary payer, discharge disposition, length of stay, hospital charges, hospital costs, and complications. Categorical and continuous variables were assessed using chi-square analyses and analyses of variance, respectively. Between 2013 and 2015, annual THAs increased from 9361 to 10,562. Race did not vary significantly (P=.447), although an increase in patients using Medicaid and a decrease in patients using other insurance was observed (P<.001). Patients with an income quartile of 1 increased, whereas the number of THA patients in quartile 3 decreased (P<.001). There was a decrease in both hospital charges (P<.001) and costs (P<.001). Mean length of stay decreased (P<.001), and the number of patients with complications decreased (P<.001). Massachusetts has been successful in increasing access to THA procedures for low-income patients and increasing the number of patients who use Medicaid for THAs. The current delivery of health care in Massachusetts has shown improvement for its residents, serving as an example that other states can learn from. [Orthopedics. 2021;44(2):e167-e172.].

SUPPORT-AF III: supporting use of AC through provider prompting about oral anticoagulation therapy for AF

Only half of atrial fibrillation (AF) patients with elevated stroke risk receive anticoagulation (AC). Electronic health record (EHR) alerts have the potential to close the gap. We designed an outpatient EHR alert (linked to an order set for ordering AC, labs, and specialty referrals) that fired when cardiology and primary care providers (PCPs) saw AF patients not on AC. We assigned all untreated patients seen by cardiology providers and PCPs in the 8 months before and after the alert launch to pre- and post-launch intervention cohorts, respectively. Untreated AF patients seeing other types of providers became controls. We then compared the difference in AC starts between intervention and control patients post-launch to the same difference prelaunch (adjusting for covariates). We measured alert responsiveness as how often patients had at least one encounter with a provider, who interacted with the alert. The adjusted percentage of AC starts for the prelaunch cohort was 20% for intervention patients and 17% for controls (difference = 3%); post-launch, the percentage was 13% for both post-launch intervention and controls (difference = 0%). The difference in difference was - 3% (p value 0.63). For half of patients, at least one provider was responsive to our alert. Reasons for no AC commonly included relative contraindications (e.g. fall, gastrointestinal bleed). Our alert did not increase AC starts but responsiveness to it was high. Increasing AC starts will likely require education surrounding relative contraindications.

The association between socioeconomic status and joint replacement of the hip and knee: A population-based cohort study of older adults in Tasmania

BACKGROUND

A socioeconomic gradient exists in the utilisation of total hip replacements (THR) and total knee replacements (TKR) for osteoarthritis. However, the relations between socioeconomic status (SES) and time to THR or TKR is unknown.

AIM

To describe the association between SES and time to THR and TKR.

METHODS

1072 older-adults residing in Tasmania, Australia were studied. Incident primary THR and TKR were determined by data linkage to the Australian Orthopaedic Association National Joint Replacement Registry. At baseline, each participant's area-level SES was determined by the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD), from the Australian Bureau of Statistics' 2001 census data. IRSAD was analysed in two ways; 1) categorised into quartiles, whereby quartile 1 represented the most socioeconomically disadvantaged group, 2) the cohort dichotomised at the quartile 1 cut-point.

RESULTS

The mean age was 63.0 (±7.5) years, and 51% were women. Over the median follow-up of 12.9 (Interquartile range: 12.2-13.9) years, 56 (5%) participants had a THR, and 79 (7%) had a TKR. Compared to the most disadvantaged quartile, less disadvantaged participants were less likely to have a THR (i.e. less disadvantaged participants had a longer time to THR) (HR: 0.56, 95% CI 0.32, 1.00) but not TKR (HR: 0.90, 95% CI 0.53, 1.54). However, the former became non-significant after adjustment for pain and radiographic osteoarthritis, suggesting that the associations may be mediated by these factors.

CONCLUSIONS

This study suggests that time to joint replacement was determined according to the symptoms/need of the participants rather than their SES. This article is protected by copyright. All rights reserved.

Postacute Care Disposition for Total Hip and Total Knee Replacement Surgery for Asian Americans

This study explored differences in postacute disposition for total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a focus on whether Asian Americans (AS) experience joint replacement disparities observed in other racial/ethnic minorities compared with majority white patients. We used data from the Nationwide Inpatient Sample for 2009 through 2012. We looked at disposition to home health care (HHC) and transfer to another facility for postacute care (e.g., skilled nursing facility, rehabilitation facility) for each of the 4 years under study. Findings for AS were mixed. There were differences in discharge to postacute facilities other than HHC for AS compared with whites for THA for 2011 and 2012. For TKA, there were differences in disposition to HHC for Asians compared with whites for 2009 and 2012; for disposition to postacute facilities other than HHC for TKA, there were differences for 2011 and 2012 only. Differences for AS in postacute disposition to facilities other than HHC appear to increase over the 4 years of the study. Further research with additional data is warranted.

The impact of ductal carcinoma in situ on health services utilization

PURPOSE

To determine the intermediate-term impact of diagnosis and treatment of ductal carcinoma in situ of the breast (DCIS) on health services utilization, we compared utilization by cases of DCIS to unaffected controls.

METHODS

We identified a population-based cohort of Ontario females diagnosed with DCIS between 2010 and 2015. We matched 5 controls without any history of cancer to each case, on the date of diagnosis of the case (the index date), by age, annual mammography history, socioeconomic status, and comorbidity. We identified billing claims and hospital records, during the interval 13 to 60 months prior to, and subsequent to the index date, and computed rates per 100 person-years during both intervals, to conduct a difference-in-differences analysis. We used negative binomial regression to test if the change in rates in health services differed between cases and controls.

RESULTS

Visits with a breast diagnosis code, and claims for breast surgery and imaging, were significantly increased among cases compared to controls (all p values < 0.0001) after DCIS;however, there was no increase in visits for anxiety or depression (RR 1.13 (95% CI 0.97, 1.32, p = 0.11), visits to psychiatrists (RR 1.07 (95% CI 0.82, 1.40) p = 0.6), or hospital procedures other than breast surgery (RR 1.10 (95% CI 0.88, 1.37) p = 0.4).

CONCLUSIONS

DCIS is associated with more visits and procedures related to the breast compared to controls following diagnosis and treatment, but other health services utilization and visits related to anxiety and depression were not increased.

Examining Timeliness of Total Knee Replacement Among Patients with Knee Osteoarthritis in the U.S.: Results from the OAI and MOST Longitudinal Cohorts

BACKGROUND

Patients with knee osteoarthritis may undergo total knee replacement too early or may delay or underuse this procedure. We quantified these categories of total knee replacement utilization in 2 cohorts of participants with knee osteoarthritis and investigated factors associated with each category.

METHODS

Data were pooled from 2 multicenter cohort studies that collected demographic, patient-reported, radiographic, clinical examination, and total knee replacement utilization information longitudinally on 8,002 participants who had or were at risk for knee osteoarthritis and were followed for up to 8 years. Validated total knee replacement appropriateness criteria were longitudinally applied to classify participants as either potentially appropriate or likely inappropriate for total knee replacement. Participants were further classified on the basis of total knee replacement utilization into 3 categories: timely (indicating that the patient had total knee replacement within 2 years after the procedure had become potentially appropriate), potentially appropriate but knee not replaced (indicating that the knee had remained unreplaced for >2 years after the procedure had become potentially appropriate), and premature (indicating that the procedure was likely inappropriate but had been performed). Utilization rates were calculated, and factors associated with each category were identified.

RESULTS

Among 8,002 participants, 3,417 knees fulfilled our inclusion and exclusion criteria and were classified into 1 of 3 utilization categories as follows: 290 knees (8% of the total and 9% of the knees for which replacement was potentially appropriate) were classified as "timely", 2,833 knees (83% of the total and 91% of those for which replacement was potentially appropriate) were classified as "potentially appropriate but not replaced", and 294 knees (comprising 9% of the total and 26% of the 1,114 total knee replacements performed) were considered to be "likely inappropriate" yet underwent total knee replacement and were classified as "premature". Of the knees that were potentially appropriate but were not replaced, 1,204 (42.5%) had severe symptoms. Compared with the patients who underwent timely total knee replacement, the likelihood of being classified as potentially appropriate but not undergoing total knee replacement was greater for black participants and the likelihood of having premature total knee replacement was lower among participants with a body mass index of >25 kg/m and those with depression.

CONCLUSIONS

In 2 multicenter cohorts of patients with knee osteoarthritis, we observed substantial numbers of patients who had premature total knee replacement as well as of patients for whom total knee replacement was potentially appropriate but had not been performed >2 years after it had become potentially appropriate. Further understanding of these observations is needed, especially among the latter group.

CLINICAL RELEVANCE

Undergoing total knee replacement too early may result in little or no benefit while exposing the patient to the risks of a major operation, whereas waiting too long may cause limitations in physical activity that in turn increase the risk of additional disability and chronic disease; however, little is known about timing of this surgery. We quantified the extent of premature, timely, and delayed use, and found a high prevalence of both premature and delayed use.

Association of Canada's Provincial Bans on Electronic Cigarette Sales to Minors With Electronic Cigarette Use Among Youths

IMPORTANCE

Banning electronic cigarette (e-cigarette) sales to minors has been a key policy to protect children from e-cigarettes in the United States and Canada, but to date little is known about the outcome of such a ban.

OBJECTIVES

To investigate the association of banning e-cigarette sales to minors in Canada with e-cigarette use among youths and the mechanisms through which a ban might be associated with their e-cigarette use.

DESIGN, SETTING, AND PARTICIPANTS

This quasi-experimental difference-in-differences and triple-differences study used data from the nationally representative Canadian Tobacco, Alcohol and Drugs Survey (2013-2017) and Canadian Student Tobacco, Alcohol and Drugs Survey (2014-2017). Study samples consisted of respondents aged 15 to 18 years (in difference-in-differences analysis; n = 8212) and aged 15 to 25 years (in triple-differences analysis; n = 20 934) in the Canadian Tobacco, Alcohol and Drugs Survey, and students in grades 6 to 12 (in difference-in-differences analysis; n = 78 650) in the Canadian Student Tobacco, Alcohol and Drugs Survey.

INTERVENTIONS

Canada's provincial bans on e-cigarette sales to youths younger than 18 or 19 years (depending on province) implemented between 2015 and 2017.

MAIN OUTCOMES AND MEASURES

The primary outcome was past 30-day e-cigarette use among youths. Secondary outcomes were difficulty of access to e-cigarettes, perception of e-cigarette harm, and use of social sources of e-cigarettes.

RESULTS

After the bans, e-cigarette use among youths increased in all provinces, but the increase was 3.1 percentage points (95% CI, 0.2-6.0; P = .04), or 79%, lower in provinces with a ban than in provinces without a ban. Youths in provinces with a ban were 2.6 percentage points (95% CI, 1.5-3.7; P = .001), or 18%, less likely to believe that regular e-cigarette use poses no harm and 6.2 percentage points (95% CI, 1.1-11.4; P = .02), or 16%, more likely to self-report greater difficulty in obtaining e-cigarettes. Among youths who reported using e-cigarettes, the likelihood of obtaining e-cigarettes from social sources was 17.3 percentage points (95% CI, 5.2 -29.4; P = .01), or 29%, higher in provinces with a ban. These findings were robust to several sensitivity analyses.

CONCLUSIONS AND RELEVANCE

Banning e-cigarette sales to minors was associated with a significant reduction in the rate of increase in e-cigarette use by youths, but this policy alone could not reverse the overall increase in e-cigarette use. The findings from this study suggest that this policy should be supplemented with other measures that can reduce young people's desire to obtain e-cigarettes through social sources, such as a ban on e-cigarettes with flavors that appeal to youths and children.

Effect of psycho-social support by teachers on improving mental health and hope of adolescents in an earthquake-affected district in Nepal: A cluster randomized controlled trial

INTRODUCTION

Adolescents can be prone to mental health problems such as post-traumatic stress disorder (PTSD) and depression following disasters. School teachers can provide timely psycho-social support that could instill hope and improve mental health among adolescents in a post-earthquake situation in a low-resource setting. This study examined the effect of training for school teachers on psycho-social support on adolescents' mental health and hope in an earthquake affected district in Nepal.

METHODS

This cluster randomized controlled trial was conducted in 15 schools in Dhading, a severely affected district by the 2015 earthquake in Nepal. The schools were randomized, as a result, 8 were in the intervention group and 7 in the control group. A total of 1,220 adolescents were recruited at baseline of which 605 adolescents belonged to intervention group and 615 to control group. The follow-up rate at 6 months was 83%. This trial was registered with Clinicaltrials.gov with registration number NCT03387007.

RESULTS

The intervention did not show significant effects for PTSD symptoms (Intervention*time, β = 0.33, p = 0.536), depression symptoms (Intervention*time, β = 0.30, p = 0.249), and hope (Intervention*time, β = -0.23, p = 0.588), among the adolescents at 6 months follow-up.

CONCLUSION

The intervention did not improve mental health symptoms and hope among adolescents at 6 months follow-up. More focused and longer training could be necessary to address mental health among adolescents affected by earthquake. Additionally, longer follow-up could be necessary to assess the changes taking place over time.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03387007.

Knee replacement

Knee replacement surgery is one of the most commonly done and cost-effective musculoskeletal surgical procedures. The numbers of cases done continue to grow worldwide, with substantial variation in utilisation rates across regions and countries. The main indication for surgery remains painful knee osteoarthritis with reduced function and quality of life. The threshold for intervention is not well defined, and is influenced by many factors including patient and surgeon preference. Most patients have a very good clinical outcome after knee replacement, but multiple studies have reported that 20% or more of patients do not. So despite excellent long-term survivorship, more work is required to enhance this procedure and development is rightly focused on increasing the proportion of patients who have successful pain relief after surgery. Changing implant design has historically been a target for improving outcome, but there is greater recognition that improvements can be achieved by better implantation methods, avoiding complications, and improving perioperative care for patients, such as enhanced recovery programmes. New technologies are likely to advance future knee replacement care further, but their introduction must be regulated and monitored with greater rigour to ensure patient safety.

Disparities in Total Hip Arthroplasty Outcomes: Census Tract Data Show Interactions Between Race and Community Deprivation

INTRODUCTION

Socioeconomic factors such as poverty may mediate racial disparities in health outcomes after total hip arthroplasty (THA) and confound analyses of differences between blacks and whites.

METHODS

Using a large institutional THA registry, we built models incorporating individual and census tract data and analyzed interactions between race and percent of population with Medicaid coverage and its association with 2-year patient-reported outcomes.

RESULTS

Black patients undergoing THA had worse baseline and 2-year pain and function scores compared with whites. We observed strong positive correlations between census tract Medicaid coverage and percent living below poverty (rho = 0.69; P < 0.001). Disparities in 2-year Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function were magnified in communities with high census tract Medicaid coverage. For blacks in these communities, 2-year WOMAC function scores were predicted to be -5.54 points lower (80.42 versus 85.96) compared with blacks in less deprived communities, a difference not observed among whites.

CONCLUSION

WOMAC pain and function 2 years after THA are similar among blacks and whites in communities with little deprivation (low percent census tract Medicaid coverage). WOMAC function at 2 years is worse among blacks in areas of higher deprivation but is not seen among whites.

LEVEL OF EVIDENCE

Level II - Cohort Study.

Massachusetts Health Reform's Effect on Hospitalizations with Substance Use Disorder-Related Diagnoses

OBJECTIVE

To examine whether Massachusetts (MA) health reform affected substance (alcohol or drug) use disorder (SUD)-related hospitalizations in acute care hospitals.

DATA/STUDY SETTING

2004-2010 MA inpatient discharge data.

DESIGN

Difference-in-differences analysis to identify pre- to postreform changes in age- and sex-standardized population-based rates of SUD-related medical and surgical hospitalizations, adjusting for secular trends.

DATA EXTRACTION METHODS

We identified 373,751 discharges where a SUD-related diagnosis was a primary or secondary discharge diagnosis.

FINDINGS

Adjusted for age and sex, the rates of drug use-related and alcohol use-related hospitalizations prereform were 7.21 and 8.87 (per 1,000 population), respectively, in high-uninsurance counties, and 8.58 and 9.63, respectively, in low-uninsurance counties. Both SUD-related rates increased after health reform in high- and low-uninsurance counties. Adjusting for secular trends in the high- and low-uninsurance counties, health reform was associated with no change in drug- or alcohol-related hospitalizations.

CONCLUSIONS

Massachusetts health reform was not associated with any changes in substance use disorder-related hospitalizations. Further research is needed to determine how to reduce substance use disorder-related hospitalizations, beyond expanding insurance coverage.

Impact of Safety Net Hospitals in the Care of the Hand-Injured Patient: A National Perspective

A clear disparity in the pattern and provision of surgical care exists, particularly for patients with vulnerable socioeconomic backgrounds. For hand-injured patients in particular, this discrepancy has been frequently shown in their receiving appropriate care. With the advent of the Affordable Care Act and with Medicaid expansion on the horizon, more patients will be requiring access to care. Safety net programs have been shown to provide equivalent levels of care for patients compared with non-safety net providers, and the survival of these hospitals for the disadvantaged is essential to providing quality care for this growing patient population. In this article, the authors review the factors that affect the barriers to care, the importance of safety net hospitals, the epidemiology of the hand-injured patient, and how the Affordable Care Act will impact these safety net programs.

Did Pre-Affordable Care Act Medicaid Expansion Increase Access to Surgical Cancer Care?

BACKGROUND

Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities.

STUDY DESIGN

From the New York State Inpatient Database (1997 to 2006), we identified 67,685 nonelderly adults (18 to 64 years of age) who underwent cancer surgery. Estimated effects of 2001 Medicaid expansion on access were measured on payer mix, overall use of surgical cancer care, and percent use by racial/ethnic minorities. Measures were calculated quarterly, adjusted for covariates when appropriate, and then analyzed using interrupted time series.

RESULTS

The proportion of cancer operations paid by Medicaid increased from 8.9% to 15.1% in the 5 years after the expansion. The percentage of uninsured patients dropped by 21.3% immediately after the expansion (p = 0.01). Although the expansion was associated with a 24-case/year increase in the net Medicaid case volume (p < 0.0001), the overall all-payer net case volume remained unchanged. In addition, the adjusted percentage of ethnic minorities among Medicaid recipients of cancer surgery was unaffected by the expansion.

CONCLUSIONS

Pre-ACA Medicaid expansion did not increase the overall use or change the racial composition of beneficiaries of surgical cancer care. However, it successfully shifted the financial burden away from patient/hospital to Medicaid. These results might suggest similar effects in the post-ACA Medicaid expansion.

Reducing Hospital Readmission Disparities of Older Black and White Adults After Elective Joint Replacement: The Role of Nurse Staffing

OBJECTIVES

To examine racial differences in readmissions of older adults undergoing elective total hip and knee replacement, to determine the relationship between nurse staffing and readmission, and to study whether the relationship between staffing and readmission differs for older black and white adults.

DESIGN

Cross-sectional analysis of multiple linked secondary data sources.

SETTING

Nonfederal acute care hospitals in California, Florida, New Jersey, and Pennsylvania (n = 483).

PARTICIPANTS

Patients aged 65 and older undergoing elective total hip or total knee replacement (N = 106,848; n = 102,762 white, n = 4,086 black).

MEASUREMENTS

Unplanned readmission within 30 days of discharge.

RESULTS

Older black patients were more likely to have an unplanned readmission (7.5%) than their white counterparts (5.6%). Even after adjusting for patient- and hospital-level factors, older black patients had 40% greater likelihood of readmission (odds ratio (OR) = 1.40, 95% confidence interval (CI) = 1.21-1.61). Each additional patient per nurse was associated with 8% greater odds of readmission for older white patients (OR = 1.08, 95% CI = 1.01-1.15) and 15% greater odds for older black patients (OR = 1.15, 95% CI = 1.08-1.22) after adjusting for patient- and hospital-level factors.

CONCLUSION

Older minorities are more likely than their white counterparts to experience an unplanned readmission after elective orthopedic surgery. More-favorable nurse staffing was associated with lower odds of readmission of older black and white patients, but better-staffed hospitals had a greater protective effect for older black patients.

Impact of Massachusetts Health Reform on Inpatient Care Use: Was the Safety-Net Experience Different Than in the Non-Safety-Net?

OBJECTIVE

Most inpatient care for the uninsured and other vulnerable subpopulations occurs in safety-net hospitals. As insurance expansion increases the choice of hospitals for the previously uninsured, we examined if Massachusetts health reform was associated with shifts in the volume of inpatient care from safety-net to non-safety-net hospitals overall, or among other vulnerable sociodemographic (racial/ethnic minority, low socioeconomic status, high uninsured rate area) and clinical subpopulations (emergent status, diagnosis).

DATA SOURCES/STUDY SETTING

Discharge records for adults discharged from all nonfederal acute care hospitals in Massachusetts, New Jersey, New York, and Pennsylvania 2004-2010.

STUDY DESIGN

Using a difference-in-differences design, we compared pre-/post-reform changes in safety-net and non-safety-net hospital discharge outcomes in Massachusetts among adults 18-64 with corresponding changes in comparisons states with no reform, overall, and by subpopulations.

PRINCIPAL FINDINGS

Reform was not associated with changes in inpatient care use at safety-net and non-safety-net hospitals across all discharges or in most subpopulations examined.

CONCLUSIONS

Demand for inpatient care at safety-net hospitals may not decrease following insurance expansion. Whether this is due to other access barriers or patient preference needs to be explored.

Medicaid enrollment after liver transplantation: Effects of medicaid expansion

Liver transplantation (LT) recipients in the United States have low rates of paid employment, making some eligible for Medicaid public health insurance after transplant. We test whether recent expansions of Medicaid eligibility increased Medicaid enrollment and insurance coverage in this population. Patients of ages 18-59 years receiving first-time LTs in 2009-2013 were identified in the United Network for Organ Sharing registry and stratified according to insurance at transplantation (private versus Medicaid/Medicare). Posttransplant insurance status was assessed through June 2015. Difference-in-difference multivariate competing-risks models stratified on state of residence estimated effects of Medicaid expansion on Medicaid enrollment or use of uninsured care after LT. Of 12,837 patients meeting inclusion criteria, 6554 (51%) lived in a state that expanded Medicaid eligibility. Medicaid participation after LT was more common in Medicaid-expansion states (25%) compared to nonexpansion states (19%; P < 0.001). Multivariate analysis of 7279 patients with private insurance at transplantation demonstrated that after the effective date of Medicaid expansion (January 1, 2014), the hazard of posttransplant Medicaid enrollment increased in states participating in Medicaid expansion (hazard ratio [HR] = 1.5; 95% confidence interval [CI] = 1.1-2.0; P = 0.01), but not in states opting out of Medicaid expansion (HR = 0.8; 95% CI = 0.5-1.3; P = 0.37), controlling for individual characteristics and time-invariant state-level factors. No effects of Medicaid expansion on the use of posttransplant uninsured care were found, regardless of private or government insurance status at transplantation. Medicaid expansion increased posttransplant Medicaid enrollment among patients who had private insurance at transplantation, but it did not improve overall access to health insurance among LT recipients. Liver Transplantation 22 1075-1084 2016 AASLD.

Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights From Massachusetts

OBJECTIVE

To evaluate the impact of health insurance expansion on racial disparities in severity of peripheral arterial disease.

BACKGROUND

Lack of insurance and non-white race are associated with increased severity, increased amputation rates, and decreased revascularization rates in patients with peripheral artery disease (PAD). Little is known about how expanded insurance coverage affects disparities in presentation with and management of PAD. The 2006 Massachusetts health reform expanded coverage to 98% of residents and provided the framework for the Affordable Care Act.

METHODS

We conducted a retrospective cohort study of nonelderly, white and non-white patients admitted with PAD in Massachusetts (MA) and 4 control states. Risk-adjusted difference-in-differences models were used to evaluate changes in probability of presenting with severe disease. Multivariable linear regression models were used to evaluate disparities in disease severity before and after the 2006 health insurance expansion.

RESULTS

Before the 2006 MA insurance expansion, non-white patients in both MA and control states had a 12 to 13 percentage-point higher probability of presenting with severe disease (P < 0.001) than white patients. After the expansion, measured disparities in disease severity by patient race were no longer statistically significant in Massachusetts (+3.0 percentage-point difference, P = 0.385) whereas disparities persisted in control states (+10.0 percentage-point difference, P < 0.001). Overall, non-white patients in MA had an 11.2 percentage-point decreased probability of severe PAD (P = 0.042) relative to concurrent trends in control states.

CONCLUSIONS

The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe PAD and resolution of measured racial disparities in severe PAD in MA.

Utilization rates of knee-arthroplasty in OECD countries

BACKGROUND

The number of knee arthroplasties and the prevalence of obesity are increasing exponentially. To date there have been no published reviews on utilization rates of knee arthroplasty in OECD countries.

METHODS

We analysed economic, medical and population data relating to knee arthroplasty surgeries performed in OECD countries. Gross domestic product (GDP), health expenditures, obesity prevalence, knee arthroplasty utilization rates and growth in knee arthroplasty rates per 100,000 population were assessed for total population, for patients aged 65 years and over, and patients aged 64 years and younger.

RESULTS

Obesity prevalence and utilization of knee arthroplasty have increased significantly in the past. The mean utilization rate of knee arthroplasty was 150 (22-235) cases per 100,000 total population in 2011. The strongest annual increase (7%) occurred in patients 64 years and under. Differences between individual countries can be explained by economic and medical patterns, with countries with higher medical expenditures and obesity prevalence having significantly higher utilization rates. Countries with lower utilization rates have significantly higher growth in utilization rates. The future demand for knee prostheses will increase x-fold by 2030, with exact rates dependant upon economic, social and medical factors.

CONCLUSION

We observed a 10-fold variation in the utilization of knee arthroplasty among OECD countries. A significant and strong correlation of GDP, health expenditures and obesity prevalence with utilization of knee arthroplasty was found. Patients aged 64 years and younger show a two-fold higher growth rate in knee arthroplasty compared to the older population. This trend could result in a four-fold demand for knee arthroplasty in OECD countries by 2030.

Effect of Massachusetts healthcare reform on racial and ethnic disparities in admissions to hospital for ambulatory care sensitive conditions: retrospective analysis of hospital episode statistics

OBJECTIVES

To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states.

DESIGN

Difference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform.

SETTING

Hospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States.

PARTICIPANTS

Adults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007).

MAIN OUTCOME MEASURES

Admission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs.

RESULTS

After adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval -1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (-1.9%, -8.5% to 5.1%) or white and Hispanic people (2.0%, -7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, -2.3% to 5.3%).

CONCLUSIONS

Massachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions.