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Zhang Y, Kissin DM, Liao KJ, DeSantis CE, Yartel AK, Gutman R. Multiple Imputation of Missing Race/Ethnicity Information in the National Assisted Reproductive Technology Surveillance System. J Womens Health (Larchmt) 2024; 33:328-338. [PMID: 38112534 PMCID: PMC10998289 DOI: 10.1089/jwh.2023.0267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
Background: Missing race/ethnicity data are common in many surveillance systems and registries, which may limit complete and accurate assessments of racial and ethnic disparities. Centers for Disease Control and Prevention's National Assisted Reproductive Technology (ART) Surveillance System (NASS) has a congressional mandate to collect data on all ART cycles performed by fertility clinics in the United States and provides valuable information on ART utilization and treatment outcomes. However, race/ethnicity data are missing for many ART cycles in NASS. Materials and Methods: We multiply imputed missing race/ethnicity data using variables from NASS and additional zip code-level race/ethnicity information in U.S. Census data. To evaluate imputed data quality, we generated training data by imposing missing values on known race/ethnicity under missing at random assumption, imputed, and examined the relationship between race/ethnicity and the rate of stillbirth per pregnancy. Results: The distribution of imputed race/ethnicity was comparable to the reported one with the largest difference of 0.53% for non-Hispanic Asian. Our imputation procedure was well calibrated and correctly identified that 89.91% (standard error = 0.18) of known race/ethnicity values on average in training data. Compared to complete-case analysis, using multiply imputed data reduced bias of parameter estimates (the range of bias for stillbirth per pregnancy across race/ethnicity groups is 0.02%-0.18% for imputed data analysis, versus 0.04%-0.66% for complete-case analysis) and yielded narrower confidence intervals. Conclusions: Our results underscore the importance of collecting complete race/ethnicity information for ART surveillance. However, when the missingness exists, multiply imputed race/ethnicity can improve the accuracy and precision of health outcomes estimated across racial/ethnic groups.
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Affiliation(s)
- Yujia Zhang
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dmitry M. Kissin
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kuo Jen Liao
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- CDC Foundation, Atlanta, Georgia, USA
| | - Carol E. DeSantis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- CDC Foundation, Atlanta, Georgia, USA
| | - Anthony K. Yartel
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- CDC Foundation, Atlanta, Georgia, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University, Providence, Rhode Island, USA
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Lee JC, DeSantis CE, Yartel AK, Kissin DM, Kawwass JF. Association of state insurance coverage mandates with assisted reproductive technology care discontinuation. Am J Obstet Gynecol 2023; 228:315.e1-315.e14. [PMID: 36368429 PMCID: PMC11000072 DOI: 10.1016/j.ajog.2022.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/21/2022] [Accepted: 10/29/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Insurance coverage for fertility services may reduce the financial burden of high-cost fertility care such as assisted reproductive technology and improve its utilization. Patients who exit care after failing to reach their reproductive goals report higher rates of mental health problems and a lower sense of well-being. It is important to understand the relationship between state-mandated insurance coverage for fertility services and assisted reproductive technology care discontinuation. OBJECTIVE This study aimed to assess whether state-mandated insurance coverage for fertility services is associated with lower rates of care discontinuation after an initial assisted reproductive technology cycle that did not result in a live birth. STUDY DESIGN This is a retrospective, population-based cohort study using data from United States fertility clinics reporting to the National Assisted Reproductive Technology Surveillance System during 2016 and 2018. Patients who began their first autologous assisted reproductive technology cycle during 2016 and 2017 and did not have a live birth were included. We describe the rate of assisted reproductive technology care discontinuation (no additional cycle within 12 months of the previous cycle's date of failure). Multivariable analyses were conducted to evaluate factors independently associated with care discontinuation, including the scope of fertility services included in state coverage mandate at assisted reproductive technology cycle initiation that were as follows: comprehensive (≥3 assisted reproductive technology cycles), limited (1, 2, or an unspecified number of assisted reproductive technology cycles), mandate not including assisted reproductive technology, and no mandate. RESULTS Among 91,324 patients who underwent their first autologous assisted reproductive technology cycle that did not result in live birth, 24,072 (26.4%) discontinued care. Compared with patients who lived in states with mandates for comprehensive assisted reproductive technology coverage, those in states with mandates for fertility services coverage that did not include assisted reproductive technology or states with no mandate were 46% (adjusted relative risk, 1.46; 95% confidence interval, 1.31-1.63) and 26% (adjusted relative risk, 1.26; 95% confidence interval, 1.15-1.39) more likely to discontinue care, respectively, after controlling for patient and cycle characteristics. Increasing patient age, distance from clinic ≥50 miles, previous live birth, fewer oocytes retrieved, and not having embryos cryopreserved were also associated with higher rates of discontinuation. Non-Hispanic Black, non-Hispanic Asian, and Hispanic patients had higher rates of care discontinuation than non-Hispanic White patients regardless of the existence or scope of state-mandated assisted reproductive technology coverage. CONCLUSION Comprehensive state-mandated insurance coverage for assisted reproductive technology is associated with lower rates of assisted reproductive technology care discontinuation.
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Affiliation(s)
- Jacqueline C Lee
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA.
| | - Carol E DeSantis
- CDC Foundation, Atlanta, GA; Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Anthony K Yartel
- CDC Foundation, Atlanta, GA; Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Dmitry M Kissin
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA; Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA
| | - Jennifer F Kawwass
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA; Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
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Korkidakis A, Desantis CE, Kissin D, Hacker MR, Koniares K, Yartel AK, Adashi EY, Penzias AS. INSURANCE MANDATES AND RACIAL AND ETHNIC INEQUITIES IN ASSISTED REPRODUCTIVE TECHNOLOGY UTILIZATION. Fertil Steril 2022. [DOI: 10.1016/j.fertnstert.2022.08.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brady JE, Vellozzi C, Hariri S, Kruger DL, Nerenz DR, Brown KA, Federman AD, Krauskopf K, Kil N, Massoud OI, Wise JM, Seay TA, Smith BD, Yartel AK, Rein DB. Hepatitis C care cascade among persons born 1945-1965: 3 medical centers. Am J Manag Care 2018; 24:421-427. [PMID: 30222920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Effective screening, diagnosis, and treatment are needed to reduce chronic hepatitis C virus (HCV) infection-associated morbidity and mortality. In order to successfully increase HCV treatment, it is necessary to identify and understand gaps in linkage of antibody-positive patients with newly identified HCV to subsequent HCV RNA testing, clinical evaluation, and treatment. STUDY DESIGN To estimate attainment of HCV care cascade steps among antibody-positive patients with newly identified HCV, we conducted chart reviews of patients with a new positive HCV antibody test at 3 academic medical centers participating in the Birth-Cohort Evaluation to Advance Screening and Testing of Hepatitis C (BEST-C) study. METHODS We tracked receipt of RNA testing, clinical evaluation, treatment initiation, and treatment completion among individuals born between 1945 and 1965 who were newly diagnosed as HCV antibody-positive between December 2012 and October 2015 at 3 BEST-C centers, predominantly from the participating medical centers' primary care practices and emergency departments. RESULTS Of the 130 HCV-seropositive individuals identified, 118 (91%) had an RNA or genotype test, 75 (58%) were RNA-positive, 73 (56%) were linked to care, 22 (17% overall; 29% among RNA-positive) started treatment, and 21 (16%; 28% among RNA-positive) completed treatment. CONCLUSIONS This analysis showed that although linkage to care was largely successful in the target birth cohort, the largest gap in the HCV care cascade was seen in initiating treatment. Greater emphasis on linking patients to clinical evaluation and treatment is necessary in order to achieve the public health benefits promised by birth-cohort testing.
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Affiliation(s)
- Joanne E Brady
- NORC at the University of Chicago, 4350 East-West Hwy, 8th Fl, Bethesda, MD 20814.
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Yartel AK, Rein DB, Brown KA, Krauskopf K, Massoud OI, Jordan C, Kil N, Federman AD, Nerenz DR, Brady JE, Kruger DL, Smith BD. Hepatitis C virus testing for case identification in persons born during 1945-1965: Results from three randomized controlled trials. Hepatology 2018; 67:524-533. [PMID: 28941361 PMCID: PMC7593980 DOI: 10.1002/hep.29548] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/15/2017] [Accepted: 09/19/2017] [Indexed: 12/25/2022]
Abstract
The Centers for Disease Control and Prevention and US Preventive Services Task Force recommend one-time hepatitis C virus (HCV) testing for persons born during 1945-1965 (birth cohort). However, few studies estimate the effect of birth cohort (BC) testing implementation on HCV diagnoses in primary care settings. We aimed to determine the probability of identifying HCV infections in primary care using targeted BC testing compared with usual care at three academic medical centers. From December 2012 to March 2014, each center compared one of three distinct interventions with usual care using an independently designed randomized controlled trial. Across centers, BC patients with no clinical documentation of previous HCV testing or diagnosis were randomly assigned to receive a one-time offering of HCV antibody (anti-HCV) testing via one of three independent implementation strategies (repeated-mailing outreach, electronic medical record-integrated provider best practice alert [BPA], and direct patient solicitation) or assigned to receive usual care. We estimated model-adjusted risk ratios (aRR) of anti-HCV-positive (anti-HCV+) identification using BC testing versus usual care. In the repeated mailing trial, 8992 patients (intervention, n = 2993; control, n = 5999) were included in the analysis. The intervention was eight times as likely to identify anti-HCV+ patients compared with controls (aRR, 8.0; 95% confidence interval [CI], 2.8-23.0; adjusted probabilities: intervention, 0.27%; control, 0.03%). In the BPA trial, data from 14,475 patients (BC, n = 8928; control, n = 5,547) were analyzed. The intervention was 2.6 times as likely to identify anti-HCV+ patients versus controls (aRR, 2.6; 95% CI, 1.1-6.4; adjusted probabilities: intervention, 0.29%; control, 0.11%). In the patient-solicitation trial, 8873 patients (BC, n = 4307; control, n = 4566) were analyzed. The intervention was five times as likely to identify anti-HCV+ patients compared with controls (aRR, 5.3; 95% CI, 2.3-12.3; adjusted probabilities: intervention, 0.68%; control, 0.11%). Conclusion: BC testing was effective in identifying previously undiagnosed HCV infections in primary care settings. (Hepatology 2018;67:524-533).
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Affiliation(s)
| | | | | | | | | | | | - Natalie Kil
- Icahn School of Medicine at Mount Sinai, New York, NY
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Yartel AK, Morgan RL, Rein DB, Ann Brown K, Kil NB, Massoud OI, Fallon MB, Smith BD. HIV Infection Status as a Predictor of Hepatitis C Virus RNA Testing in Primary Care. Am J Prev Med 2015; 49:423-7. [PMID: 25896194 PMCID: PMC4556132 DOI: 10.1016/j.amepre.2015.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/20/2015] [Accepted: 03/04/2015] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Receipt of hepatitis C virus (HCV) RNA testing following a positive HCV antibody (anti-HCV+) test result to establish current infection is a quality indicator for HCV-related care. This study examines HIV infection status as a predictor of HCV RNA test receipt after an anti-HCV+ result in the primary care setting. METHODS Electronic medical records of anti-HCV+ patients from a multisite retrospective study of patients aged ≥18 years who utilized one or more primary care outpatient services during 2005-2010 were analyzed in 2014. A multivariable logistic regression model examined the independent relationships between patient characteristics and receipt of HCV RNA testing. RESULTS Among 1,115 anti-HCV+ patients, 133 (11.9%) were also HIV-positive. Of these, 77.4% (n=103) underwent HCV RNA testing to determine current infection status. By contrast, 66.7% (n=654/980) of anti-HCV+ patients who were HIV-negative received HCV RNA testing. Following multivariable adjustment, the odds of receiving HCV RNA testing were higher among anti-HCV+ patients who were also HIV-positive (AOR=1.9, 95% CI=1.2, 3.0), compared with their HIV-negative counterparts. Elevated alanine aminotransferase level was also associated with receipt of HCV RNA testing (AOR=1.9, 95% CI=1.4, 2.4). Black race was associated with decreased odds of receiving HCV RNA testing (AOR=0.7, 95% CI=0.5, 1.0). CONCLUSIONS HIV infection status is independently associated with the likelihood of receiving HCV RNA testing following an anti-HCV+ result. One quarter of anti-HCV+ patients who were also HIV-positive and one third of their HIV-negative counterparts, respectively, did not receive testing to establish active HCV infection, which is imperative for appropriate care and treatment.
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Affiliation(s)
| | | | - David B Rein
- Public Health Department, NORC at the University of Chicago, Atlanta, Georgia
| | | | - Natalie B Kil
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Omar I Massoud
- Department of Medicine, University of Alabama at Birmingham (Massoud), Birmingham, Alabama
| | - Michael B Fallon
- Department of Internal Medicine, the University of Texas Medical School at Houston (Fallon), Houston, Texas
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Smith BD, Yartel AK, Krauskopf K, Massoud OI, Brown KA, Fallon MB, Rein DB. Hepatitis C virus antibody positivity and predictors among previously undiagnosed adult primary care outpatients: cross-sectional analysis of a multisite retrospective cohort study. Clin Infect Dis 2015; 60:1145-52. [PMID: 25595745 DOI: 10.1093/cid/civ002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) testing guidance issued by the Centers for Disease Control and Prevention in 1998 recommends HCV antibody (anti-HCV) testing for persons with specified risk factors. The purpose of this study was to determine the prevalence and predictors of anti-HCV positivity among primary care outpatients and estimate the proportion of unidentified anti-HCV-positive (anti-HCV+) persons using risk-based testing. METHODS We analyzed electronic medical record data from a 4-site retrospective study. Patients were aged ≥18 years, utilized ≥1 outpatient primary care service(s) between 2005 and 2010, and had no documented evidence of prior HCV diagnosis. Among persons tested for anti-HCV, we fit a multilevel logistic regression model to identify patient-level independent predictors of anti-HCV positivity. We estimated the proportion of unidentified anti-HCV+ persons by using multiple imputation to assign anti-HCV results to untested patients. RESULTS We observed 209 076 patients for a median of 5 months (interquartile range, 1-23 months). Among 17 464 (8.4%) patients who were tested for anti-HCV, 6.4% (n=1115) were positive. We identified history of injection drug use (adjusted odds ratio [95% confidence interval], 6.3 [5.2-7.6]), 1945-1965 birth cohort (4.4 [3.8-5.1]), and elevated alanine aminotransferase levels (4.8 [4.2-5.6]) as independently associated with anti-HCV positivity. We estimated that 81.5% (n=4890/6005) of anti-HCV+ patients were unidentified using risk-based testing. CONCLUSIONS In these outpatient primary care settings, risk-based testing may have missed 4 of 5 newly enrolled patients who are anti-HCV+. Without knowing their status, unidentified anti-HCV+ persons cannot receive further clinical evaluation or antiviral treatment, and are unlikely to benefit from secondary prevention recommendations to limit disease progression and mortality.
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Affiliation(s)
- Bryce D Smith
- Division of Viral Hepatitis, Centers for Disease Control and Prevention
| | - Anthony K Yartel
- Centers for Disease Control and Prevention Foundation, Atlanta, Georgia
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Smith BD, Yartel AK. Comparison of hepatitis C virus testing strategies: birth cohort versus elevated alanine aminotransferase levels. Am J Prev Med 2014; 47:233-41. [PMID: 25145616 PMCID: PMC5759754 DOI: 10.1016/j.amepre.2014.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 04/12/2014] [Accepted: 05/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is unidentified in an estimated 40%-85% of infected adults. Surveillance and modeling data have found significant increases in HCV-associated morbidity and mortality. PURPOSE To compare two HCV antibody (anti-HCV) testing strategies based on (1) elevated alanine aminotransferase levels (ALT) and (2) a birth cohort approach for people born during 1945-1965. METHODS Data from 19,055 adults aged 20-70 years who completed the National Health and Nutrition Examination Survey in 1999-2008 were analyzed in 2013. Two independent models were evaluated, based on membership in the 1945-1965 birth cohort or elevated ALT, to compare the number of identified anti-HCV-positive (anti-HCV+) individuals; proportion of total identified cases; and the number of people that would be tested using either strategy. RESULTS The prevalence of anti-HCV among adults aged 20-70 years was estimated at 2.0% (95% CI=1.8%, 2.3%), representing about 3.6 million people. The birth cohort strategy would result in testing about 85.4 million people and identifying nearly 2.8 million anti-HCV+ people with a sensitivity of 76.6%. The ALT strategy would test about 21.5 million adults and identify approximately 1.8 million anti-HCV+ people with a sensitivity of 50.0%. Implementing both strategies concurrently would identify 87.3% of anti-HCV+ adults. CONCLUSIONS The birth cohort strategy, which is recommended by both the CDC and the U.S. Preventive Services Task Force, would identify 1 million more anti-HCV+ people than the elevated ALT approach. Concurrent implementation would identify an even larger number of individuals ever infected.
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Smith BD, Jewett A, Burt RD, Zibbell JE, Yartel AK, DiNenno E. "To share or not to share?" Serosorting by hepatitis C status in the sharing of drug injection equipment among NHBS-IDU2 participants. J Infect Dis 2013; 208:1934-42. [PMID: 24136794 DOI: 10.1093/infdis/jit520] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Persons who inject drugs (PWID) are at high risk for acquiring hepatitis C virus (HCV) infection. The Centers for Disease Control and Prevention estimates there are 17 000 new infections per year, mainly among PWID. This study examines injection equipment serosorting-considering HCV serostatus when deciding whether and with whom to share injection equipment. OBJECTIVE To examine whether injection equipment serosorting is occurring among PWID in selected cities. METHODS Using data from the National HIV Behavioral Surveillance System-Injection Drug Users (NHBS-IDU2, 2009), we developed multivariate logistic regression models to examine the extent to which participants' self-reported HCV status is associated with their injection equipment serosorting behavior and knowledge of last injecting partner's HCV status. RESULTS Participants who knew their HCV status were more likely to know the HCV status of their last injecting partner, compared to those who did not know their status (HCV+: adjusted odds ratio [aOR] 4.1, 95% confidence interval [CI], 3.4-4.9; HCV-: aOR 2.5, 95% CI, 2.0-3.0). Participants who reported being HCV+, relative to those of unknown HCV status, were 5 times more likely to share injection equipment with a partner of HCV-positive status (aOR 4.8, 95% CI, 3.9-6.0). CONCLUSIONS Our analysis suggests PWID are more likely to share injection equipment with persons of concordant HCV status.
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Affiliation(s)
- Bryce D Smith
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
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