Uninsured immigrants in the United States significantly delayed the initiation of prenatal care after the changes to the Public Charge Rule

OBJECTIVE

We estimated the impact of the changes made to the Public Charge Rule on the initiation of prenatal care among uninsured immigrants in the United States.

STUDY DESIGN

We used a difference-in-differences approach to analyse the impact of the changes made to the Public Charge Rule (first difference) on initiation of prenatal care between uninsured and privately insured immigrants (second difference).

METHODS

We used the natality data by the National Center for Health Statistics as the main data source, which includes all singleton births in a hospital to an immigrant birthing person aged from 15 to 44. The study covers three phases: (1) the period prior to the leaked draft Executive Orders concerning changes made to the public charge policy-from January 2014 to December 2016; (2) the period after the draft Executive Orders were leaked until the proposal of the Public Charge Rule-from January 2017 to September 2018; and (3) post proposal of the Public Charge Rule -from October 2018 to December 2019.

RESULTS

After the proposal of the Public Charge Rule in 2018, the odds of initiating prenatal care in the first trimester decreased among uninsured immigrants by 12% (odds ratio [OR]: 0.880; 95% confidence interval [CI]: 0.832, 0.931) compared to privately insured immigrants. The odds of second trimester initiation of prenatal care was also negatively associated with the leak of the draft Executive Orders (OR: 0.942; 95% CI: 0.905, 0.981).

CONCLUSION

The results of this study suggest that uninsured immigrants in the United States significantly delayed prenatal care after the changes were made to the Public Charge Rule.

Rethinking antipsychotic formulary policy

In this commentary, we review recent research suggesting that (a) second-generation antipsychotics (SGAs) may be no more effective than first-generation antipsychotics (FGAs), (b) the reduced risk of EPS and tardive dyskinesia with SGAs is more weakly supported by the research literature than has been appreciated, and (c) benefits may be offset by greater metabolic risks of some SGAs and their substantially greater cost. Bearing in mind, as well, that risperidone, currently the least expensive SGA, will soon be available as an even less expensive generic drug, we propose a new algorithm for maintenance antipsychotic therapy. We further outline a cautious implementation procedure that relies on standardized documentation and feedback, without a restrictive formulary that would limit physician choice. The algorithm outlined here and the process for its implementation are intended as a stimulus for discussion of potential policy responses, not as a finalized proposition.

Use of pharmacy data to assess quality of pharmacotherapy for schizophrenia in a national health care system: individual and facility predictors

OBJECTIVES

This paper presents a profile of the use of antipsychotic medications in the treatment of schizophrenia in a national health system.

METHODS

Prescription drug records written for antipsychotic medications between June 1999 and September 1999 were collected for patients diagnosed with schizophrenia in the Department of Veteran Affairs (VA). Indicators were constructed describing whether patients received multiple antipsychotic medications and whether the total weekly dose was outside of the range specified in the treatment recommendations developed by the schizophrenia Patient Outcomes Research Team (PORT). Generalized estimation equations were used to identify patient and facility characteristics that are associated with adherence to PORT recommendations.

RESULTS

Of the 34,925 patients in the final sample, 2,383 (6.8%) received prescriptions for more than one antipsychotic (polypharmacy). A higher number of patients (4,554 or 13.0%) were dosed above the PORT recommendations on an antipsychotic medication and even more (8,148 or 23.3%) were dosed below the recommended PORT dosage. Older patients, minorities, and those with comorbid depression or substance abuse were generally less likely to receive multiple antipsychotics or be dosed above PORT recommendations. Neither academic emphasis (the percentage of the mental health budget spent on research and education) nor fiscal stress was significantly associated with adherence to recommendations.

CONCLUSIONS

In the nation's largest mental health system, a relatively small number of patients were prescribed multiple antipsychotic medications, but more than a third were dosed outside of the PORT recommended range.

The effect of institutional fiscal stress on the use of atypical antipsychotic medications in the treatment of schizophrenia

This paper examines the effects of medical center budget stress on the use of expensive atypical antipsychotic medications for the treatment of schizophrenia in the Department of Veterans Affairs (VA). VA prescription drug records were collected for patients diagnosed with schizophrenia. Generalized estimation equations were used to identify patient and facility characteristics (especially fiscal stress) that are associated with the use of atypical antipsychotics. Of the 34,925 patients in the final sample, over half received an atypical antipsychotic, usually either olanzapine or risperidone. Unexpectedly, increased fiscal stress was associated with increased likelihood of receiving atypical antipsychotics. Among patients who receive atypicals, however, fiscal stress was associated with reduced likelihood of receiving the more expensive atypicals (clozapine and olanzapine) but positively associated with receiving the least expensive atypical (risperidone). Institutional fiscal pressure does not seem to reduce the broad availability of these medications overall but does affect which drug is prescribed.

Patterns of mental health utilization and costs among children in a privately insured population

OBJECTIVE

To examine trends in mental health service use and cost among privately insured children.

DATA SOURCES

Inpatient and outpatient claims from the MarketScan database, a collection of health care claims for a national sample of over seven million privately insured individuals. Claims were analyzed for all users of mental health services 17 years of age and under from 1993 to 1996.

STUDY DESIGN

The proportion of children receiving mental health services and annual costs and treatment days per treated child were compared across diagnostic groups over time.

PRINCIPLE FINDINGS

The proportion of covered children receiving any mental health services fell substantially (-30.0 percent). Inpatient mental health costs per treated child fell $4,587 (-46.9 percent) during the period, driven by decreases in the number of hospital days per treated child per year (-22.9 percent) and per diem costs (-14.5 percent). Outpatient mental health costs also fell during the period due to a 5.1 percent decline in the number of treatment days and a 25.9 percent fall in costs per day. Children whose primary diagnosis was hyperactivity experienced the largest decrease in inpatient costs per treated patient, those diagnosed with schizophrenia experienced the smallest decrease, and those diagnosed with substance abuse disorders experienced large increases.

CONCLUSIONS

Changes in mental health service delivery have resulted in substantially reduced access to mental health care among children and significant declines in service use and costs among those who do receive services.

Comparing quality of mental health care for public-sector and privately insured populations

OBJECTIVE

This study examined the methodological difficulties of comparing quality of care in large health care systems. It demonstrated methods for measuring quality of mental health care and, using these measures, compared patients from Department of Veterans Affairs (VA) hospitals with privately insured patients.

METHODS

Individuals receiving VA inpatient mental health care during the first six months of each fiscal year from 1993 to 1997 were identified from discharge abstracts. A similar cohort of privately insured individuals was identified using MEDSTAT's MarketScan database from 1993 to 1995. Individuals in both cohorts were tracked for six months after discharge. Length of stay, readmission rates, and access to outpatient services were calculated.

RESULTS

The private sector outperformed VA on most quality measures, although differences were modest and can likely be explained by the greater severity of illness and social disadvantages of VA patients. Readmission rates increased considerably over time in the private sector, whereas they declined for VA patients. Quality measures varied by diagnosis, with VA performing better than the private sector in treating patients diagnosed with substance abuse and mental disorders not elsewhere classified but worse in treating patients diagnosed with depression.

CONCLUSIONS

Although the private sector modestly outperformed VA on most quality measures, VA treats a more troubled population, and it improved markedly over time compared with the private sector. As health systems strive to reduce costs of care, methods for comparing and evaluating the quality of care become increasingly important. However, methodological challenges remain substantial.

Shifting to outpatient care? Mental health care use and cost under private insurance

OBJECTIVE

Concern over rising health care costs has put pressure on providers to reduce costs, purportedly by reducing inpatient care and increasing outpatient care.

METHOD

Inpatient and outpatient claims were analyzed for adult users of mental health services (180,000/year on average) from a national study group of 3.9 million privately insured individuals per year from 1993 to 1995. Costs and treatment days per patient were compared across diagnostic groups and stratified by whether patients were hospitalized.

RESULTS

Inpatient mental health costs fell $2,507 (30.4%) over the period, driven primarily by decreases in hospital days per patient per year (19.9%), with smaller changes in the proportion of enrollees who received inpatient care (increase of 0.8%) and a decrease in per diem costs (9.1%). Outpatient mental health costs also declined over the period, falling 13.6% for patients also using inpatient services and 14.6% for patients receiving only outpatient care. Patients whose primary diagnosis was mild to moderate depression saw the largest decreases in inpatient cost per patient (42.8%); those diagnosed with schizophrenia experienced the smallest decrease (23.5%). For patients using outpatient services only, those diagnosed with substance abuse experienced the largest decrease in costs (23.5%); those diagnosed with schizophrenia experienced the smallest decrease (8.6%).

CONCLUSIONS

Substantial cost reductions for mental health services are primarily a result of reductions in inpatient and outpatient treatment days. Declines in inpatient service use were not accompanied by increases in outpatient service use, even for severely ill patients requiring hospitalization. Managed care has not caused a shift in the pattern of care but an overall reduction of care.

Changes in inpatient mental health utilization and costs in a privately insured population, 1993 to 1995

BACKGROUND

Concerns over rising health care costs have led to pressure on health care providers to reduce inpatient costs.

METHODS

Inpatient claims data were analyzed for adult users of mental health services (n = 45,579) from a national sample of over 3.8 million privately insured individuals between 1993 and 1995 from the MarketScan database. Costs and annual hospital days per treated patient were compared across diagnostic groups and plan types.

RESULTS

Inpatient mental health costs fell 30.5% over the period, driven primarily by decreases in the number of hospital days per treated patient per year (-20.0%), with smaller changes in the proportion of enrollees who received care (-0.2%), and per diem costs (-13.1%). Patients whose primary diagnosis was mild/moderate depression saw the largest decrease in costs per treated patient (44.5%), and those diagnosed with schizophrenia experienced the smallest decrease (23.5%). There was no evidence of substitution of medical for psychiatric care.

CONCLUSIONS

Inpatient cost reductions have been substantial and are primarily caused by reductions in the number of inpatient mental health treatment days per treated patient. Further research is needed to evaluate the impact of these changes on outcome, quality of care, and patient satisfaction.

Inpatient treatment of comorbid psychiatric and substance abuse disorders: comparison of public sector and privately insured populations

Public health delivery systems are increasingly compared to private systems as policymakers continue to focus on reducing the costs of care. However, there are very few studies comparing trends in utilization and cost between public and private providers. This study examines discharge abstract records for VA patients and insurance claims data for a national sample of privately insured individuals to investigate trends in inpatient utilization and costs for dually diagnosed individuals in these two systems. Although the substantial differences in the populations treated could account for the differences in these measures across systems, this study is useful in illustrating the possibilities and limitations of system comparisons.

Simultaneous detection of microorganisms in soil suspension based on PCR amplification of bacterial 16S rRNA fragments

The effect of buffer composition on simultaneous PCR amplification of 16S rRNA gene fragments of five bacterial species was examined using a number of different buffer systems. Tris-based PCR buffers at final concentrations of 10 mM proved unreliable. However, when the final concentration of Tris was increased to 75 mM, all five samples were routinely detected. The use of other buffers, 3-[(1,1-dimethyl-2-hydroxyethyl)amino]-2-hydroxypropanesulfonic acid (AMPSO) and 3-[cyclohexylamino]-2-hydroxy-1-propanesulfonic acid (CAPSO), resulted in PCR amplification of five products even at low final concentrations (10 mM). The presence of certain proteins in the amplification reaction could overcome an inhibitory effect seen when soil suspension was present in the reaction, as might occur when testing field samples for the presence of bacteria. Bovine serum albumin was found to be the most effective additive tested in overcoming inhibition.

Analysis of a cloned Francisella tularensis outer membrane protein gene and expression in attenuated Salmonella typhimurium

We have determined the nucleotide sequence of fopA from Francisella tularensis. Using the polymerase chain reaction fopA was detected in high and low virulence biotypes of F. tularensis. fopA was stably maintained in pBluescript in attenuated Salmonella typhimurium where FopA was expressed and located in the outer membrane. This recombinant will be suitable for studies on the role of FopA in immunity against tularaemia.

Hemolytic and sphingomyelinase activities of Clostridium perfringens alpha-toxin are dependent on a domain homologous to that of an enzyme from the human arachidonic acid pathway

The N-terminal domain of Clostridium perfringens alpha-toxin, homologous with the nontoxic phospholipase C of Bacillus cereus, was expressed in Escherichia coli and shown to retain all of the phosphatidylcholine hydrolyzing activity of the alpha-toxin, but not the sphingomyelinase, hemolytic, or lethal activities. The C-terminal domain of alpha-toxin showed sequence and predicted structural homologies with the N-terminal region of arachidonate 5-lipoxygenase, an enzyme from the human arachidonic acid pathway which plays a role in inflammatory and cardiovascular diseases in humans.

Rare occurrence of Proteus vulgaris in faeces: a reason for its rare association with urinary tract infections

The faecal carriage rates of different species of Proteeae were assessed in studies with 220 faecal isolates from 219 individuals of whom approximately one-third were well and the remainder had gastro-enteritis. As a result of the development of new media that allowed replacement of the phenylalanine deaminase test with the tryptophan deaminase test and made it possible to combine tests for indole and urease production and for hydrogen sulphide and ornithine decarboxylase formation in two single-tube tests, all strains were speciated with speed, economy and accuracy. Most (96%) isolates were either Proteus mirabilis (62%) or Morganella morgani (34%). The significance of these findings in relation to urinary tract infection is discussed. P. vulgaris was found in only one (0.45%) faecal specimen and this rarity of carriage in faeces is believed to be the main reason for its rare association with urinary tract infections. The frequent association of M. morgani, in the absence of other enteropathogenic bacteria, with severe gastroenteritis was noted with interest.