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Weisz D, Gusmano MK, Amba V, Rodwin VG. Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City? J Racial Ethn Health Disparities 2024; 11:1783-1790. [PMID: 37338791 DOI: 10.1007/s40615-023-01650-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/14/2023] [Accepted: 05/15/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND/PURPOSE In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA. METHODS We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period. RESULTS Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period. CONCLUSIONS Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.
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Affiliation(s)
- Daniel Weisz
- Columbia University Robert N. Butler Columbia Aging Center, 722 West 168Th Street, New York, NY, 10032, USA.
| | - Michael K Gusmano
- Lehigh University College of Health, 124 East Morton Street, Bethlehem, PA, 18015, USA
- The Hastings Center, 21 Malcom Gordon Road, Garrison, NY, 10524, USA
| | - Vineeth Amba
- Rutgers University Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ, 08854, USA
| | - Victor G Rodwin
- New York University Robert. F Wagner Graduate School of Public Service, 295 Lafayette St, New York, NY, 10012, USA
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2
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Henkin S, Kearing SA, Martinez-Camblor P, Zacharias N, Creager MA, Young MN, Goodney PP, Columbo JA. The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease. Vasc Med 2024:1358863X241237776. [PMID: 38607558 DOI: 10.1177/1358863x241237776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Background: In 2014, the Affordable Care Act Medicaid Expansion (ME) increased Medicaid eligibility for adults with an income level up to 138% of the federal poverty level. In this study, we examined the impact of ME on mortality and amputation in patients with peripheral artery disease (PAD). Methods: The 100% MedPAR and Part-B Carrier files from 2011 to 2018 were queried to identify all fee-for-service Medicare beneficiaries with PAD using International Classification of Diseases codes. Our primary exposure was whether a state had adopted the ME on January 1, 2014. Our primary outcomes were the change in all-cause 1-year mortality and leg amputation. We used a state-level difference-in-differences (DID) analysis to compare the rates of the primary outcomes among patients who were in states (including the District of Columbia) who adopted ME (n = 25) versus those who were in states that did not (n = 26). We performed a subanalysis stratifying by sex, race, region, and dual-eligibility status. Results: Over the 8-year period, we studied 37,743,929 patients. The average unadjusted 1-year mortality decreased from 2011 to 2018 in both non-ME (9.5% to 8.7%, p < 0.001) and ME (9.1% to 8.3%, p < 0.001) states. The average unadjusted 1-year amputation rate did not improve in either the non-ME (0.86% to 0.87%, p = 0.17) or ME (0.69% to 0.69%, p = 0.65) states. Across the entire cohort, the DID model revealed that ME did not lead to a significant change in mortality (p = 0.15) or amputation (p = 0.34). Conclusion: Medicaid Expansion was not associated with reduced mortality or leg amputation in Medicare beneficiaries with PAD.
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Affiliation(s)
- Stanislav Henkin
- Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Stephen A Kearing
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | | | - Nikolaos Zacharias
- Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Mark A Creager
- Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael N Young
- Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philip P Goodney
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jesse A Columbo
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Schmidt S, Jacobs MA, Kim J, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Presentation Acuity and Surgical Outcomes for Patients With Health Insurance Living in Highly Deprived Neighborhoods. JAMA Surg 2024; 159:411-419. [PMID: 38324306 PMCID: PMC10851138 DOI: 10.1001/jamasurg.2023.7468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/14/2023] [Indexed: 02/08/2024]
Abstract
Importance Insurance coverage expansion has been proposed as a solution to improving health disparities, but insurance expansion alone may be insufficient to alleviate care access barriers. Objective To assess the association of Area Deprivation Index (ADI) with postsurgical textbook outcomes (TO) and presentation acuity for individuals with private insurance or Medicare. Design, Setting, and Participants This cohort study used data from the National Surgical Quality Improvement Program (2013-2019) merged with electronic health record data from 3 academic health care systems. Data were analyzed from June 2022 to August 2023. Exposure Living in a neighborhood with an ADI greater than 85. Main Outcomes and Measures TO, defined as absence of unplanned reoperations, Clavien-Dindo grade 4 complications, mortality, emergency department visits/observation stays, and readmissions, and presentation acuity, defined as having preoperative acute serious conditions (PASC) and urgent or emergent cases. Results Among a cohort of 29 924 patients, the mean (SD) age was 60.6 (15.6) years; 16 424 (54.9%) were female, and 13 500 (45.1) were male. A total of 14 306 patients had private insurance and 15 618 had Medicare. Patients in highly deprived neighborhoods (5536 patients [18.5%]), with an ADI greater than 85, had lower/worse odds of TO in both the private insurance group (adjusted odds ratio [aOR], 0.87; 95% CI, 0.76-0.99; P = .04) and Medicare group (aOR, 0.90; 95% CI, 0.82-1.00; P = .04) and higher odds of PASC and urgent or emergent cases. The association of ADIs greater than 85 with TO lost significance after adjusting for PASC and urgent/emergent cases. Differences in the probability of TO between the lowest-risk (ADI ≤85, no PASC, and elective surgery) and highest-risk (ADI >85, PASC, and urgent/emergent surgery) scenarios stratified by frailty were highest for very frail patients (Risk Analysis Index ≥40) with differences of 40.2% and 43.1% for those with private insurance and Medicare, respectively. Conclusions and Relevance This study found that patients living in highly deprived neighborhoods had lower/worse odds of TO and higher presentation acuity despite having private insurance or Medicare. These findings suggest that insurance coverage expansion alone is insufficient to overcome health care disparities, possibly due to persistent barriers to preventive care and other complex causes of health inequities.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
- Department of Primary Care and Rural Medicine, School of Medicine, Texas A&M University, Bryan
- Department of Medical Physiology, School of Medicine, Texas A&M University, Bryan
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Xiang R, Hou X, Li R. Health risks from extreme heat in China: Evidence from health insurance. JOURNAL OF ENVIRONMENTAL MANAGEMENT 2024; 354:120300. [PMID: 38359625 DOI: 10.1016/j.jenvman.2024.120300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/19/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
Global warming has accentuated the effects of extreme heat on health. Health insurance, functioning as a risk management tool, has the potential to alleviate these impacts. Consequently, this paper investigates the correlation between extreme heat events and the demand for health insurance in China. Using data from the China Health and Nutrition Survey, we have observed a substantial increase in the likelihood of residents purchasing health insurance during extreme heat events. To be specific, for every extra day of extreme heat events annually, there is a 0.3% increase in the probability of purchasing health insurance. This effect is not uniform across different demographic groups. It is particularly pronounced among middle-aged and elderly individuals, rural residents, those with lower educational levels, higher income brackets, and individuals residing in underprivileged areas with limited access to green spaces and healthcare facilities. Furthermore, our study indicates that the increased frequency of extreme heat events not only impacts individuals' physical health but also triggers negative emotions, which in turn drive risk-averse behavior related to health insurance purchases. These findings carry substantial policy implications for mitigating the economic consequences of climate change.
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Affiliation(s)
- Ruojun Xiang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China.
| | - Xiaojuan Hou
- Financial Technology Laboratory, Jinan University, Guangzhou 510632, China.
| | - Ruifeng Li
- School of Management, Beijing University of Chinese Medicine, Beijing, 100029, China.
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Garber MD. Precision and Weighting of Effects Estimated by the Generalized Synthetic Control and Related Methods: The Case of Medicaid Expansion. Epidemiology 2024; 35:273-277. [PMID: 38290146 DOI: 10.1097/ede.0000000000001702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Michael D Garber
- From the Herbert Wertheim School of Public Health and Human Longevity Science, Scripps Institution of Oceanography, UC San Diego, San Diego, CA
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO
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6
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Nianogo RA, Zhao F, Li S, Nishi A, Basu S. Medicaid Expansion and Racial-Ethnic and Sex Disparities in Cardiovascular Diseases Over 6 Years: A Generalized Synthetic Control Approach. Epidemiology 2024; 35:263-272. [PMID: 38290145 DOI: 10.1097/ede.0000000000001691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Studies have suggested Medicaid expansion enacted in 2014 has resulted in a reduction in overall cardiovascular disease (CVD) mortality in the United States. However, it is unknown whether Medicaid expansion has a similar effect across race-ethnicity and sex. We investigated the effect of Medicaid expansion on CVD mortality across race-ethnicity and sex. METHODS Data come from the behavioral risk factor surveillance system and the US Centers for Disease Control's Wide-ranging Online Data for Epidemiologic Research, spanning the period 2000-2019. We used the generalized synthetic control method, a quasi-experimental approach, to estimate effects. RESULTS Medicaid expansion was associated with -5.36 (mean difference [MD], 95% confidence interval [CI] = -22.63, 11.91) CVD deaths per 100,000 persons per year among Blacks; -4.28 (MD, 95% CI = -30.08, 21.52) among Hispanics; -3.18 (MD, 95% CI = -8.30, 1.94) among Whites; -5.96 (MD, 95% CI = -15.42, 3.50) among men; and -3.34 (MD, 95% CI = -8.05, 1.37) among women. The difference in mean difference (DMD) between the effect of Medicaid expansion in Blacks compared with Whites was -2.18; (DMD, 95% CI = -20.20, 15.83); between that in Hispanics compared with Whites: -1.10; (DMD, 95% CI = -27.40, 25.20) and between that in women compared with men: 2.62; (DMD, 95% CI = -7.95, 13.19). CONCLUSIONS Medicaid expansion was associated with a reduction in CVD mortality overall and in White, Black, Hispanic, male, and female subpopulations. Also, our study did not find any difference or disparity in the effect of Medicaid on CVD across race-ethnicity and sex-gender subpopulations, likely owing to imprecise estimates.
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Affiliation(s)
- Roch A Nianogo
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA
- California Center for Population Research, UCLA, Los Angeles, CA
| | - Fan Zhao
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA
- California Center for Population Research, UCLA, Los Angeles, CA
| | - Stephen Li
- Los Angeles County Department of Public Health (LACDPH), Los Angeles, CA
| | - Akihiro Nishi
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA
- California Center for Population Research, UCLA, Los Angeles, CA
- Bedari Kindness Institute, University of California, Los Angeles, Los Angeles, CA
| | - Sanjay Basu
- Center for Primary Care, Harvard Medical School, Boston, MA
- Research and Development, Waymark, San Francisco, CA
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7
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Lin L, Zai X. Assessing the impact of public insurance on healthcare utilization and mortality: A nationwide study in China. SSM Popul Health 2024; 25:101615. [PMID: 38322784 PMCID: PMC10844660 DOI: 10.1016/j.ssmph.2024.101615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/29/2023] [Accepted: 01/24/2024] [Indexed: 02/08/2024] Open
Abstract
We investigate the effects of a significant health insurance expansion in rural China known as the New Cooperative Medical Scheme (NCMS). Our analysis is based on a nationwide dataset spanning from 2004 to 2011. We find that the NCMS effectively increases healthcare utilization, particularly inpatient admissions, and reduces the incidence for infectious diseases. In addition to the increased healthcare utilization, the reduction in the incidence for infectious diseases can be attributed to improved health knowledge and health behavior, both of which are associated with the expansion of insurance coverage. Our findings affirm the importance of insurance coverage in safeguarding low-income individuals from the adverse health consequences linked to infectious diseases.
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Affiliation(s)
- Lin Lin
- School of Public Management, East China Normal University, Shanghai, China
| | - Xianhua Zai
- Department of Labor Demography, Max Planck Institute for Demographic Research, Rostock, Germany
- Max Planck – University of Helsinki Center for Social Inequalities in Population Health, Rostock, Germany and Helsinki, Finland
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8
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Albert MA, Churchwell K, Desai N, Johnson JC, Johnson MN, Khera A, Mieres JH, Rodriguez F, Velarde G, Williams DR, Wu JC. Addressing Structural Racism Through Public Policy Advocacy: A Policy Statement From the American Heart Association. Circulation 2024; 149:e312-e329. [PMID: 38226471 DOI: 10.1161/cir.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
During the COVID-19 pandemic, the American Heart Association created a new 2024 Impact Goal with health equity at its core, in recognition of the increasing health disparities in our country and the overwhelming evidence of the damaging effect of structural racism on cardiovascular and stroke health. Concurrent with the announcement of the new Impact Goal was the release of an American Heart Association presidential advisory on structural racism, recognizing racism as a fundamental driver of health disparities and directing the American Heart Association to advance antiracist strategies regarding science, business operations, leadership, quality improvement, and advocacy. This policy statement builds on the call to action put forth in our presidential advisory, discussing specific opportunities to leverage public policy in promoting overall well-being and rectifying those long-standing structural barriers that impede the progress that we need and seek for the health of all communities. Although this policy statement discusses difficult aspects of our past, it is meant to provide a forward-looking blueprint that can be embraced by a broad spectrum of stakeholders who share the association's commitment to addressing structural racism and realizing true health equity.
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Ali MR, Nacer H, Lawson CA, Khunti K. Racial and Ethnic Disparities in Primary Prevention of Cardiovascular Disease. Can J Cardiol 2024:S0828-282X(24)00076-X. [PMID: 38309463 DOI: 10.1016/j.cjca.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/19/2023] [Accepted: 01/02/2024] [Indexed: 02/05/2024] Open
Abstract
Cardiovascular disease (CVD) disproportionately affects ethnic-minority groups globally. Ethnic-minority groups face particularly high CVD burden and mortality, exacerbated by disparities across modifiable risk factors, wider determinants of health, and limited access to preventative interventions. This narrative review summarizes evidence on modifiable risk factors, such as physical activity, hypertension, diet, smoking, alcohol consumption, diabetes, and the polypill for the primary prevention of CVD in ethnic minorities. Across these factors, we find inequities in risk factor prevalence. The evidence underscores that inequalities in accessibility to interventions and treatments impede progress in reducing CVD risk using primary prevention interventions for ethnic-minority people. Although culturally tailored interventions show promise, further research is required across the different risk factors. Social determinants of health and structural inequities also exacerbate CVD risk for ethnic-minority people and warrant greater attention. Additionally, we find that only limited ethnicity-specific data and guidelines are available on CVD primary prevention interventions for most risk factors. To address these gaps in research, we provide recommendations that include the following: investigating the sustainability and real-world effectiveness of culturally sensitive interventions; ensuring that ethnic-minority peoples' perspectives are considered in research; longitudinal tracking of risk factors; interventions and outcomes in ethnic-minority people; and ensuring that data collection and reporting of ethnicity data are standardized.
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Affiliation(s)
- Mohammad R Ali
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom; Diabetes Research Centre, University of Leicester, Leicester, United Kingdom.
| | | | - Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom; National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands, University of Leicester, Leicester, UK
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10
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Gaba AG, Cao L, Renfrew RJ, Witte D, Wernisch JM, Sahmoun AE, Goel S, Egland KA, Crosby RD. The Impact of Medicaid Expansion Under the Affordable Care Act on the Gap Between American Indians and Whites in Breast Cancer Management and Prognosis. Clin Breast Cancer 2024; 24:142-155. [PMID: 38171945 PMCID: PMC10984638 DOI: 10.1016/j.clbc.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/26/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Breast cancer (BC) death rates in the USA have not significantly declined for American Indians (AIs) in comparison to Whites. Our objective was to determine whether Medicaid Expansion as part of the Affordable Care Act led to improved BC outcomes for AIs relative to Whites. PATIENTS AND METHODS Using the National Cancer Database, we conducted a retrospective cohort study. Included were BC patients who were AI and White; 40 to 64 years of age; diagnosed in 2009 to 2016; lived in states that expanded Medicaid in January 2014, and states that did not expand Medicaid. Our outcomes were stage at diagnosis, insurance status, timely treatment, and 3-year mortality. RESULTS There were 359,484 newly diagnosed BC patients, 99.49% White, 0.51% AI. Uninsured rates declined more in the expansion states than in the nonexpansion states (OR = 0.44, 95% CI: 0.15-0.97, P < 0.001). Lower rates of Stage I BC diagnosis was found in AIs compared to Whites (46.58% vs. 55.33%, P < .001); these differential rates did not change after Medicaid expansion. Rates of definitive treatment initiation within 30 days of diagnosis declined after Medicaid expansion (P < .001); there was a smaller decline in the expansion states (OR 1.118, 95% CI: 1.09, 1.15, P < .001). Three year mortality was not different between expansion and nonexpansion states post Medicaid expansion. CONCLUSIONS In newly diagnosed BCs, uninsured rates declined more in the states that expanded Medicaid in January 2014. Timely treatment post Medicaid expansion declined less in states that expanded Medicaid. There was no differential benefit of Medicaid expansion in the 2 races.
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Affiliation(s)
- Anu G Gaba
- Department of Medicine, Sanford Roger Maris Cancer Center, University of North Dakota, Fargo, ND.
| | - Li Cao
- Sanford Center for Biobehavioral Research, Fargo, ND
| | | | | | | | - Abe E Sahmoun
- Department of Internal Medicine, University of North Dakota School of Medicine, Fargo, ND
| | - Sanjay Goel
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | - Ross D Crosby
- Sanford Center for Biobehavioral Research, Fargo, ND
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Milam AJ, Ogunniyi MO, Faloye AO, Castellanos LR, Verdiner RE, Stewart JW, Chukumerije M, Okoh AK, Bradley S, Roswell RO, Douglass PL, Oyetunji SO, Iribarne A, Furr-Holden D, Ramakrishna H, Hayes SN. Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:530-545. [PMID: 38267114 DOI: 10.1016/j.jacc.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/08/2023] [Indexed: 01/26/2024]
Abstract
There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.
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Affiliation(s)
- Adam J Milam
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA.
| | - Modele O Ogunniyi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA; Grady Health System, Atlanta, Georgia, USA
| | - Abimbola O Faloye
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA. https://twitter.com/bfaloyeMD
| | - Luis R Castellanos
- Division of Cardiovascular Medicine, Department of Medicine, University of California-San Diego, La Jolla, California, USA. https://twitter.com/lrcastel
| | - Ricardo E Verdiner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA. https://twitter.com/VerdinerMD
| | - James W Stewart
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA. https://twitter.com/stewartwjames
| | - Merije Chukumerije
- Department of Cardiovascular Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA. https://twitter.com/DrMerije
| | - Alexis K Okoh
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. https://twitter.com/OkohMD
| | - Steven Bradley
- Department of Anesthesia and Critical Care, Moffitt Cancer Center, Tampa, Florida, USA. https://twitter.com/stevenbradleyMD
| | - Robert O Roswell
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York, USA. https://twitter.com/DrRobRoswell
| | - Paul L Douglass
- Center for Cardiovascular Care, Wellstar Atlanta Medical Center, Atlanta, Georgia, USA
| | - Shakirat O Oyetunji
- Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington, USA. https://twitter.com/LaraOyetunji
| | - Alexander Iribarne
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Debra Furr-Holden
- Department of Epidemiology, School of Global Public Health, New York University, New York, New York, USA. https://twitter.com/DrDebFurrHolden
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/SharonneHayes
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12
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Thomas CL, Lange EMS, Banayan JM, Zhu Y, Liao C, Peralta FM, Grobman WA, Scavone BM, Toledo P. Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery. JAMA Netw Open 2024; 7:e2350825. [PMID: 38194235 PMCID: PMC10777252 DOI: 10.1001/jamanetworkopen.2023.50825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/19/2023] [Indexed: 01/10/2024] Open
Abstract
Importance General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity. Objective To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity. Design, Setting, and Participants In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023. Exposure Cesarean delivery. Main Outcomes and Measures The rate of general anesthesia for cesarean delivery by race and ethnicity. Results Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity. Conclusions and Relevance Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.
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Affiliation(s)
- Caroline Leigh Thomas
- Department of Anesthesiology and Critical Care, University of Chicago Medical Center, Chicago, Illinois
| | | | | | - Yinhua Zhu
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Chuanhong Liao
- Department of Public Health Services, University of Chicago, Chicago, Illinois
| | - Feyce M. Peralta
- Department of Anesthesiology, Northwestern University, Chicago, Illinois
| | - William A. Grobman
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus
| | - Barbara M. Scavone
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Illinois
- Department Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, Illinois
| | - Paloma Toledo
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
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Wahid N, Lee J, Rosenblatt R, Kaplan A, Tipirneni R, Fortune BE, Safford M, Brown RS. Affordable Care Act Medicaid expansion associated with increased liver transplant waitlist access without worsening mortality. Liver Transpl 2024; 30:20-29. [PMID: 37486623 DOI: 10.1097/lvt.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Abstract
It is unclear what impact Affordable Care Act (ACA) Medicaid expansion has had on the liver transplantation (LT) waitlist. We aimed to assess associations between ACA Medicaid expansion and LT waitlist outcomes. The United Network for Organ Sharing Standard Transplant Analysis and Research (UNOS STAR) database was queried for patients listed for LT between January 1, 2009, and December 31, 2018. Our primary outcome was waitlist mortality and our secondary outcomes included Medicaid use on the LT waitlist and transplant rate. States were divided into groups based on their expansion status and the study period was divided into 2 time intervals-pre-expansion and post-expansion. Difference-in-difference (DiD) models were created to assess the impacts of expansion on each of the outcomes and for racial/ethnic and sex groups. In total, 56,414 patients from expansion states and 32,447 patients from nonexpansion states were included. Three-year waitlist mortality decreased at a similar rate in both cohorts [DiD estimate: 0.1, (95% CI, -1.1, -1.4), p = 0.838], but Medicaid use increased [DiD estimate: +7.7, (95% CI, 6.7, 8.7), p < 0.001] to a greater degree in expansion states after expansion than nonexpansion states. Between the 2 time intervals, Medicaid use on the LT waitlist increased from 19.4% to 26.1% in expansion states but decreased from 13.4% to 12.1% in nonexpansion states. In patients on Medicaid, there was a slight increase in the 3-year transplant rate associated with Medicaid expansion [DiD estimate +5.0, (95% CI, 1.8, 8.3), p = 0.002], which may in part be explained by differences in patient characteristics. Medicaid expansion was associated with increased Medicaid use on the LT waitlist without worsening overall waitlist mortality or transplant rate, suggesting that lenient and widespread public health insurance may increase access to the LT waitlist without adversely affecting outcomes.
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Affiliation(s)
- Nabeel Wahid
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - Jihui Lee
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Alyson Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Renuka Tipirneni
- Department of Internal Medicine, Division of General Medicine, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Brett E Fortune
- Department of Medicine, Division of Hepatology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Monika Safford
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Robert S Brown
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
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14
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Murdock ME, Cruz GJ, Derby L, Ellis J, Kronish IM, Edmondson D, Birk JL. Health insurance, perceived threat, and posttraumatic stress after suspected acute coronary syndrome. Health Psychol 2024; 43:34-40. [PMID: 37917470 PMCID: PMC10841455 DOI: 10.1037/hea0001321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Threat perceptions during evaluation for acute coronary syndrome (ACS) in the emergency department (ED) predict posttraumatic stress symptoms (PSS). It is unknown how health insurance status affects threat perceptions. We tested whether lacking health insurance is associated with higher threat perceptions and PSS in patients with suspected ACS in the ED and whether threat perceptions mediate associations between lack of health insurance and subsequent PSS. METHOD Patients in the Columbia University Irving Medical Center ED with suspected ACS enrolled in an observational cohort study of psychological and cardiovascular outcomes. A multivariable linear regression model tested health insurance status as the predictor of ED threat perceptions and PSS 1-month posthospitalization, adjusting for age, gender, education, Charlson Comorbidity Index, and Global Registry of Acute Coronary Events risk score. A bootstrapped mediation model tested health insurance status as the predictor, PSS 1-month posthospitalization as the outcome, and ED threat perceptions as the mediator, with the same covariates. RESULTS Of 1,741 patients with suspected ACS in the ED (Mage = 61.01 years, SD = 13.27; 47.1% women), a plurality identified as "Other" race (36.1%), Black (23.9%), and White (22.4%), and 10.3% of patients were uninsured. Lack of health insurance was associated with greater threat perceptions, b = -0.16, 95% CI [-0.26, -0.06], p = .002. Threat perceptions mediated the association between lack of health insurance and higher 1-month PSS, indirect effect = -1.04, 95% CI [-1.98, -0.17]. CONCLUSIONS Lacking health insurance may heighten threat perceptions during ACS evaluation, which may put patients at risk of developing PSS. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Margaret E. Murdock
- Center for Behavioral and Cardiovascular Health, Columbia University Irving Medical Center
| | - Gaspar J. Cruz
- Center for Behavioral and Cardiovascular Health, Columbia University Irving Medical Center
| | - Lilly Derby
- Department of Clinical Psychology, Rutgers University
| | - Julia Ellis
- Center for Behavioral and Cardiovascular Health, Columbia University Irving Medical Center
| | - Ian M. Kronish
- Center for Behavioral and Cardiovascular Health, Columbia University Irving Medical Center
| | - Donald Edmondson
- Center for Behavioral and Cardiovascular Health, Columbia University Irving Medical Center
| | - Jeffrey L. Birk
- Center for Behavioral and Cardiovascular Health, Columbia University Irving Medical Center
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15
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Ibrahim R, Shahid M, Srivathsan K, Sorajja D, Deshmukh A, Lee JZ. Mortality trends, disparities, and social vulnerability in cardiac arrest mortality in the young: A cross-sectional analysis. J Cardiovasc Electrophysiol 2024; 35:35-43. [PMID: 37921096 DOI: 10.1111/jce.16112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/26/2023] [Accepted: 10/10/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Cardiac arrest (CA) is a leading cause of death in the United States (US). Social determinants of health may impact CA outcomes. We aimed to assess mortality trends, disparities, and the influence of the social vulnerability index (SVI) on CA outcomes in the young. METHODS We conducted a cross-sectional analysis of age-adjusted mortality rates (AAMRs) related to CA in the United States from the Years 1999 to 2020 in individuals aged 35 years and younger. Data were obtained from death certificates and analyzed using log-linear regression models. We examined disparities in mortality rates based on demographic variables. We also explored the impact of the SVI on CA mortality. RESULTS A total of 4792 CA deaths in the young were identified. Overall AAMR decreased from 0.20 in 1999 to 0.14 in 2020 with an average annual percentage change of -1.3% (p = .001). Black (AAMR: 0.30) and male populations (AAMR: 0.14) had higher AAMR compared with White (AAMR: 0.11) and female (AAMR: 0.11) populations, respectively. Nonmetropolitan (AAMR: 0.29) and Southern (AAMR: 0.26) regions were also impacted by higher AAMR compared with metropolitan (AAMR: 0.11) and other US census regions, respectively. A higher SVI was associated with greater mortality risks related to CA (risk ratio: 1.82 [95% CI, 1.77-1.87]). CONCLUSIONS Our analysis of CA in the young revealed disparities based on demographics, with a decline in AAMR from 1999 to 2020. There is a correlation between a higher SVI and increased CA mortality risk, highlighting the importance of targeted interventions to address these disparities effectively.
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Affiliation(s)
- Ramzi Ibrahim
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Mahek Shahid
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | | | - Dan Sorajja
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Justin Z Lee
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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16
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Shearer E, Bundorf MK. Changes in emergency department use associated with Medicaid expansion under the Affordable Care Act: A comparison of waiver and traditional expansion states. J Am Coll Emerg Physicians Open 2023; 4:e13060. [PMID: 37915356 PMCID: PMC10616539 DOI: 10.1002/emp2.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/24/2023] [Accepted: 10/10/2023] [Indexed: 11/03/2023] Open
Abstract
Objective To determine whether changes in emergency department use associated with Medicaid expansions differed between states undergoing waiver and traditional expansions. Methods Design: This study was a cross-sectional difference-in-difference and event studies of Medicaid Expansion among states that expanded during or after 2014. Setting: We used a nationally representative cross-sectional survey from all 50 United States and the District of Columbia from 2010 to 2016. Participants: Adults aged 19-65 years with incomes <138% of the federal poverty level were included. Main Outcomes and Measures: Main outcomes were self-reported emergency department (ED) utilization in the last 12 months. Results Individuals in states across all expansion types were not more likely to report any ED use in the previous year (2.8 percentage point increase [0.0-5.5], P = 0.052) but were more likely to report visiting an ED 2 times or more in the previous year (2.0 [0.0-4.1], P = 0.049) than those in non-expansion states. Individuals in states undergoing traditional expansions likewise were not more likely to report any ED use (2.2 [-0.7 to 1.5], P = 0.136) but were more likely to report visiting an ED 2 times or more in the previous year (2.3 [0.1-4.4], P = 0.038). Conversely, individuals in waiver states were more likely to report increase in any ED use (5.6 [0.3-11.0], P = 0.038), but were not more likely to report use of EDs 2 times or more in the previous year (0.8 [-3.2-4.9], P = 0.688). The differences between traditional and waiver states in any ED use and ED use 2 times or more in the previous 12 months were not statistically significant (P = 0.215 and P = 0.501, respectively). Conclusions Three years after expanding Medicaid under the Affordable Care Act, there is little evidence of differences between traditional and waiver expansion states in changes in any ED use or intensive ED use. Future studies should investigate longer term changes in ED use.
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Affiliation(s)
- Emily Shearer
- Department of Emergency MedicineAlpert School of Medicine at Brown UniversityProvidenceRhode IslandUSA
| | - M. Kate Bundorf
- Sanford School of Public PolicyDuke UniversityDurhamNorth CarolinaUSA
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Khatana SAM, Yang L, Eberly LA, Nathan AS, Gupta R, Lorch SA, Groeneveld PW. Medicaid Expansion And Outpatient Cardiovascular Care Use Among Low-Income Nonelderly Adults, 2012-15. Health Aff (Millwood) 2023; 42:1586-1594. [PMID: 37931196 PMCID: PMC10923246 DOI: 10.1377/hlthaff.2023.00512] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Adults with lower socioeconomic status have a disproportionately higher burden of cardiovascular disease. Medicaid expansion under the Affordable Care Act, which went into effect January 1, 2014, in adopting states, led to an expansion of health insurance coverage for low-income adults. To understand whether Medicaid expansion was associated with increased access to outpatient cardiovascular care in expansion states, we examined Medicaid Analytic eXtract administrative claims data for nonelderly adult beneficiaries from the period 2012-15 for two states that expanded Medicaid eligibility (New Jersey and Minnesota) and two states that did not (Georgia and Tennessee) and calculated population-level rates of cardiovascular care use. There was a 38.1 percent greater increase in expansion states in the rate of beneficiaries with outpatient visits for cardiovascular disease management associated with Medicaid expansion relative to nonexpansion states. This was accompanied by a 42.9 percent greater increase in the prescription rate for cardiovascular disease management agents. These results suggest that expansion of Medicaid eligibility was associated with an increase in cardiovascular care use among low-income nonelderly adults in expansion states.
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Affiliation(s)
- Sameed Ahmed M Khatana
- Sameed Ahmed M. Khatana , University of Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
| | - Lin Yang
- Lin Yang, University of Pennsylvania
| | | | | | - Ravi Gupta
- Ravi Gupta, Johns Hopkins University, Baltimore, Maryland
| | - Scott A Lorch
- Scott A. Lorch, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Peter W Groeneveld
- Peter W. Groeneveld, University of Pennsylvania and Corporal Michael J. Crescenz VA Medical Center
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18
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Michelly Gonçalves Brandão S, Brunner-La Rocca HP, Pedroso de Lima AC, Alcides Bocchi E. A review of cost-effectiveness analysis: From theory to clinical practice. Medicine (Baltimore) 2023; 102:e35614. [PMID: 37861539 PMCID: PMC10589545 DOI: 10.1097/md.0000000000035614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/21/2023] [Indexed: 10/21/2023] Open
Abstract
Cost-effectiveness analysis has long been practiced; registries date back to the United States of America War Department in 1886. In addition, everyone does intuitive cost-effectiveness analyses in their daily lives. In routine medical care, health economic assessment becomes increasingly important due to progressively limited resources, rising demands, population increases, and continuous therapeutic innovations. The health economic assessment must analyze the outcomes and costs of actions and technologies as objectively as possible to guarantee efficient assessment of novel interventions for Public Health Policy. In other words, it is necessary to determine how much society or patients are willing to or able to pay for novel interventions compared with existing alternatives, given the available resources. In addition, increased cost may displace other health care services already provided in case of fixed budget health care systems. To conduct such analyses, researchers must use standard methodologies and interpretations in light of regional characteristics according to social and economic determinants as well as clinical practice. Such an approach may be essential for transforming the current healthcare system to a value-based model. In this narrative review, concepts of the importance of and some approaches to health economic evaluation in clinical practice will be discussed.
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Affiliation(s)
| | - Hans-Peter Brunner-La Rocca
- Heart Failure Clinic, Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Edimar Alcides Bocchi
- Instituto do Coracao do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
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Wang MC, Bangaru S, Zhou K. Care for Vulnerable Populations with Chronic Liver Disease: A Safety-Net Perspective. Healthcare (Basel) 2023; 11:2725. [PMID: 37893800 PMCID: PMC10606794 DOI: 10.3390/healthcare11202725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Safety-net hospitals (SNHs) and facilities are the cornerstone of healthcare services for the medically underserved. The burden of chronic liver disease-including end-stage manifestations of cirrhosis and liver cancer-is high and rising among populations living in poverty who primarily seek and receive care in safety-net settings. For many reasons related to social determinants of health, these individuals often present with delayed diagnoses and disease presentations, resulting in higher liver-related mortality. With recent state-based policy changes such as Medicaid expansion that impact access to insurance and critical health services, an overview of the body of literature on SNH care for chronic liver disease is timely and informative for the liver disease community. In this narrative review, we discuss controversies in the definition of a SNH and summarize the known disparities in the cascade of the care and management of common liver-related conditions: (1) steatotic liver disease, (2) liver cancer, (3) chronic viral hepatitis, and (4) cirrhosis and liver transplantation. In addition, we review the specific impact of Medicaid expansion on safety-net systems and liver disease outcomes and highlight effective provider- and system-level interventions. Lastly, we address remaining gaps and challenges to optimizing care for vulnerable populations with chronic liver disease in safety-net settings.
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Affiliation(s)
- Mark C Wang
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Saroja Bangaru
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
| | - Kali Zhou
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
- Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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20
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Glance LG, Smith DI, Joynt Maddox KE. Do Anesthesiologists Have a Role in Promoting Equitable Health Care? Anesthesiology 2023; 139:244-248. [PMID: 37552097 DOI: 10.1097/aln.0000000000004672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York; Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York; RAND Health, RAND, Boston, Massachusetts
| | - Daryl I Smith
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Karen E Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri; Center for Health Economics and Policy at the Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri
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21
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Shah NS, Khan SS. Investing in Communities to Modify Social Drivers of Cardiovascular Risk: Moving From Observation to Action. JACC. ADVANCES 2023; 2:100575. [PMID: 38125005 PMCID: PMC10732308 DOI: 10.1016/j.jacadv.2023.100575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Nilay S. Shah
- Department of Medicine (Cardiology), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sadiya S. Khan
- Department of Medicine (Cardiology), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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22
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Flores NM, Do V, Rowland ST, Casey JA, Kioumourtzoglou MA. The role of insurance status in the association between short-term temperature exposure and myocardial infarction hospitalizations in New York State. Environ Epidemiol 2023; 7:e258. [PMID: 37545806 PMCID: PMC10403039 DOI: 10.1097/ee9.0000000000000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/01/2023] [Indexed: 08/08/2023] Open
Abstract
Myocardial infarction (MI) is a leading cause of morbidity and mortality in the United States and its risk increases with extreme temperatures. Climate change causes variability in weather patterns, including extreme temperature events that disproportionately affect socioeconomically disadvantaged communities. Many studies on the health effects of extreme temperatures have considered community-level socioeconomic disadvantage. Objectives To evaluate effect modification of the relationship between short-term ambient temperature and MI, by individual-level insurance status (insured vs. uninsured). Methods We identified MI hospitalizations and insurance status across New York State (NYS) hospitals from 1995 to 2015 in the New York Department of Health Statewide Planning and Research Cooperative System database, using International Classification of Diseases codes. We linked short-term ambient temperature (averaging the 6 hours preceding the event [MI hospitalization]) or nonevent control period in patient residential zip codes. We employed a time-stratified case-crossover study design for both insured and uninsured strata, and then compared the group-specific rate ratios. Results Over the study period, there were 1,095,051 primary MI admissions, 966,475 (88%) among insured patients. During extremely cold temperatures (<5.8 °C) insured patients experienced reduced rates of MI; this was not observed among the uninsured counterparts. At warmer temperatures starting at the 65th percentile (15.7 °C), uninsured patients had higher rates than insured patients (e.g., for a 6-hour pre-event average temperature increase from the median to the 75th percentile, the rate of MI increased was 2.0% [0.0%-4.0%] higher in uninsured group). Conclusions Uninsured individuals may face disproportionate rates of MI hospitalization during extreme temperatures.
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Affiliation(s)
- Nina M. Flores
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Vivian Do
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Sebastian T. Rowland
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York
- Physicians, Scientists, and Engineers (PSE) for Healthy Energy, Oakland, California
| | - Joan A. Casey
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington
| | - Marianthi A. Kioumourtzoglou
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, New York
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23
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Jiang GY, Urwin JW, Wasfy JH. Medicaid Expansion Under the Affordable Care Act and Association With Cardiac Care: A Systematic Review. Circ Cardiovasc Qual Outcomes 2023; 16:e009753. [PMID: 37339189 DOI: 10.1161/circoutcomes.122.009753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/20/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The goal of the Affordable Care Act was to improve health outcomes through expanding insurance, including through Medicaid expansion. We systematically reviewed the available literature on the association of Affordable Care Act Medicaid expansion with cardiac outcomes. METHODS Consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we performed systematic searches in PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature using the keywords such as Medicaid expansion and cardiac, cardiovascular, or heart to identify titles published from 1/2014 to 7/2022 that evaluated the association between Medicaid expansion and cardiac outcomes. RESULTS A total of 30 studies met inclusion and exclusion criteria. Of these, 14 studies (47%) used a difference-in-difference study design and 10 (33%) used a multiple time series design. The median number of postexpansion years evaluated was 2 (range, 0.5-6) and the median number of expansion states included was 23 (range, 1-33). Commonly assessed outcomes included insurance coverage of and utilization of cardiac treatments (25.0%), morbidity/mortality (19.6%), disparities in care (14.3%), and preventive care (41.1%). Medicaid expansion was generally associated with increased insurance coverage, reduction in overall cardiac morbidity/mortality outside of acute care settings, and some increase in screening for and treatment of cardiac comorbidities. CONCLUSIONS Current literature demonstrates that Medicaid expansion was generally associated with increased insurance coverage of cardiac treatments, improvement in cardiac outcomes outside of acute care settings, and some improvements in cardiac-focused prevention and screening. Conclusions are limited because quasi-experimental comparisons of expansion and nonexpansion states cannot account for unmeasured state-level confounders.
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Affiliation(s)
- Ginger Y Jiang
- Division of Cardiovascular Medicine (GYJ) and Department of Medicine (JWU), Beth Israel Deaconess Medical Center, Boston, MA. Cardiology Division, Massachusetts General Hospital, Boston, MA (JHW). Harvard Medical School, Boston, MA (GYJ, JWU, JHW)
| | - John W Urwin
- Division of Cardiovascular Medicine (GYJ) and Department of Medicine (JWU), Beth Israel Deaconess Medical Center, Boston, MA. Cardiology Division, Massachusetts General Hospital, Boston, MA (JHW). Harvard Medical School, Boston, MA (GYJ, JWU, JHW)
| | - Jason H Wasfy
- Division of Cardiovascular Medicine (GYJ) and Department of Medicine (JWU), Beth Israel Deaconess Medical Center, Boston, MA. Cardiology Division, Massachusetts General Hospital, Boston, MA (JHW). Harvard Medical School, Boston, MA (GYJ, JWU, JHW)
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Simon RC, Kim J, Schmidt S, Brimhall BB, Salazar CI, Wang CP, Wang Z, Sarwar ZU, Manuel LS, Damien P, Shireman PK. Association of Insurance Type With Inpatient Surgery 30-Day Complications and Costs. J Surg Res 2023; 282:22-33. [PMID: 36244224 DOI: 10.1016/j.jss.2022.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/10/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Safety-net hospitals (SNHs) have higher postoperative complications and costs versus low-burden hospitals. Do low socioeconomic status/vulnerable patients receive care at lower-quality hospitals or are there factors beyond providers' control? We studied the association of private, Medicare, and vulnerable insurance type with complications/costs in a high-burden SNH. METHODS Retrospective inpatient cohort study using National Surgical Quality Improvement Program (NSQIP) data (2013-2019) with cost data risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status, and expanded operative stress score (OSS) to evaluate 30-day unplanned reoperations, any complication, Clavien-Dindo IV (CDIV) complications, and hospitalization variable costs. RESULTS Cases (Private 1517; Medicare 1224; Vulnerable 3648) with patient mean age 52.3 y [standard deviation = 14.7] and 47.3% male. Adjusting for frailty and OSS, vulnerable patients had higher odds of PASC (aOR = 1.71, CI = 1.39-2.10, P < 0.001) versus private. Adjusting for frailty, PASC and OSS, Medicare (aOR = 1.27, CI = 1.06-1.53, P = 0.009), and vulnerable (aOR = 2.44, CI = 2.13-2.79, P < 0.001) patients were more likely to undergo urgent/emergent surgeries. Vulnerable patients had increased odds of reoperation and any complications versus private. Variable cost percentage change was similar between private and vulnerable after adjusting for case status. Urgent/emergent case status increased percentage change costs by 32.31%. We simulated "switching" numbers of private (3648) versus vulnerable (1517) cases resulting in an estimated variable cost of $49.275 million, a 25.2% decrease from the original $65.859 million. CONCLUSIONS Increased presentation acuity (PASC and urgent/emergent surgeries) in vulnerable patients drive increased odds of complications and costs versus private, suggesting factors beyond providers' control. The greatest impact on outcomes may be from decreasing the incidence of urgent/emergent surgeries by improving access to care.
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Affiliation(s)
- Richard C Simon
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas
| | | | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Zhu Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Zaheer U Sarwar
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas
| | - Laura S Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, Texas
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas; University Health, San Antonio, Texas; Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas.
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Mandal B, Porto N, Kiss DE, Cho SH, Head LS. Health insurance coverage during the COVID-19 pandemic: The role of Medicaid expansion. THE JOURNAL OF CONSUMER AFFAIRS 2022; 57:JOCA12500. [PMID: 36718253 PMCID: PMC9877596 DOI: 10.1111/joca.12500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 10/11/2022] [Accepted: 11/13/2022] [Indexed: 06/18/2023]
Abstract
Using data from the US Census Bureau's Household Pulse Survey, we analyzed the likelihood of loss of health insurance and enrollment into new health coverage during the early months of the COVID-19 pandemic. Loss of employment was associated with a significant increase in the likelihood of loss of health insurance and, specifically, an increase in the likelihood of employer-sponsored health insurance. However, individuals in Medicaid expansion states experienced a lower likelihood of loss of health insurance compared with individuals in nonexpansion states. At the same time, there was a statistically significant increase in Medicaid enrollment in expansion states, by 3.2 percentage points. Reemployment or acquiring employment was associated with a gain in health insurance coverage. During an economic downturn, eligibility, and coverage gaps leave many without affordable coverage options, and the pandemic will likely bring renewed attention to gaps in Medicaid coverage in nonexpansion states.
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Affiliation(s)
- Bidisha Mandal
- School of Economic SciencesWashington State UniversityPullmanWashingtonUSA
| | - Nilton Porto
- Human Development & Family ScienceUniversity of Rhode IslandKingstonRhode IslandUSA
| | - D. Elizabeth Kiss
- Department of Personal Financial PlanningKansas State UniversityManhattanKansasUSA
| | - Soo Hyun Cho
- Family and Consumer SciencesCalifornia State UniversityLong BeachCaliforniaUSA
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Mwansa H, Barry I, Knapp SM, Mazimba S, Calhoun E, Sweitzer NK, Breathett K. Association Between the Affordable Care Act Medicaid Expansion and Receipt of Cardiac Resynchronization Therapy by Race and Ethnicity. J Am Heart Assoc 2022; 11:e026766. [PMID: 36129039 DOI: 10.1161/jaha.122.026766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Black and Hispanic patients are less likely to receive cardiac resynchronization therapy (CRT) than White patients. Medicaid expansion has been associated with increased access to cardiovascular care among racial and ethnic groups with higher prevalence of underinsurance. It is unknown whether the Medicaid expansion was associated with increased receipt of CRT by race and ethnicity. Methods and Results Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington, DC, we analyzed 1061 patients from early-adopter states (Medicaid expansion by January 2014) and 745 patients from nonadopter states (no implementation 2013-2014). Estimates of change in census-adjusted rates of CRT with or without defibrillator by race and ethnicity and Medicaid adopter status 1 year before and after January 2014 were conducted using a quasi-Poisson regression model. Following the Medicaid expansion, the rate of CRT did not significantly change among Black individuals from early-adopter states (1.07 [95% CI, 0.78-1.48]) or nonadopter states (0.79 [95% CI, 0.57-1.09]). There were no significant changes in rates of CRT among Hispanic individuals from early-adopter states (0.99 [95% CI, 0.70-1.38]) or nonadopter states (1.01 [95% CI, 0.65-1.57]). There was a 34% increase in CRT rates among White individuals from early-adopter states (1.34 [95% CI, 1.05-1.70]), and no significant change among White individuals from nonadopter states (0.77 [95% CI, 0.59-1.02]). The change in CRT rates among White individuals was associated with the timing of the Medicaid implementation (P=0.003). Conclusions Among states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, implementation of Medicaid expansion was associated with increase in CRT rates among White individuals residing in states that adopted the Medicaid expansion policy. Further work is needed to address disparities in CRT among Black and Hispanic patients.
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Affiliation(s)
- Hunter Mwansa
- Frankel Cardiovascular Center University of Michigan Ann Arbor MI
| | - Ibrahim Barry
- Division of Cardiovascular Medicine, Sarver Heart Center University of Arizona Tucson AZ
| | - Shannon M Knapp
- Statistics Consulting Lab Bio5 Institute, University of Arizona Tucson AZ.,Division of Cardiovascular Medicine Indiana University Indianapolis IN
| | - Sula Mazimba
- Division of Cardiovascular Medicine University of Virginia Health System Charlottesville VA
| | | | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center University of Arizona Tucson AZ.,Division of Cardiovascular Medicine Washington University St. Louis MO
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Palaniappan A, Blitzer D, Takayama H, Sellke FW. Estimating the causal effect of the Medicaid expansion on heart transplant volume with a differences-in-differences model. JTCVS OPEN 2022; 11:200-213. [PMID: 36172439 PMCID: PMC9510887 DOI: 10.1016/j.xjon.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/25/2022] [Accepted: 06/10/2022] [Indexed: 10/25/2022]
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Impact of Medicaid Expansion on Incidence and Mortality from Gastric and Esophageal Cancer. Dig Dis Sci 2022; 68:1178-1186. [PMID: 35972583 DOI: 10.1007/s10620-022-07659-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 08/02/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Individuals in Medicaid expanded states have increased access to treatment for medical conditions and other health care resources. Esophageal and gastric cancer are associated with several modifiable risk factors (e.g. smoking, drinking, Helicobacter pylori infection). The impact of Medicaid expansion on these cancers incidence and mortality remains uninvestigated. METHODS We evaluated the association between Medicaid expansion and gastric and esophageal cancer incidence and mortality in adults aged 25-64. We employed an observational design using a difference-in-differences method with state level data, from 2010 to 2017. Annual, age-adjusted gastric and esophageal cancer incidence and mortality rates, from the CDC Wonder Database, were analyzed. Rates were adjusted for by several socio-demographic factors. RESULTS Expansion and non-expansion states were similar in percent Hispanic ethnicity and female gender. The non-expansion states had significantly higher proportion of Black race, diabetics, obese persons, smokers, and those living below the federal poverty line. Adjusted analyses demonstrate that expansion states had significantly fewer new cases of gastric cancer: - 1.6 (95% CI 0.2-3.5; P = 0.08) per 1,000,000 persons per year. No significant association was seen between Medicaid expansion and gastric cancer mortality (0.46 [95% CI - 0.08 to 0.17; P = 0.46]) and esophageal cancer incidence (0.8 [95% CI - 0.08 to 0.24; P = 0.33]) and mortality (1.0 [95% CI - 0.06 to 0.26; P = 0.21]) in multivariable analyses. CONCLUSION States that adopted Medicaid expansion saw a decrease in gastric cancer incidence when compared to states that did not expand Medicaid. Though several factors may influence gastric cancer incidence, this association is important to consider during health policy negotiations.
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Apenyo T, Vera-Urbina AE, Ahmad K, Taveira TH, Wu WC. Association between median household income, state Medicaid expansion status, and COVID-19 outcomes across US counties. PLoS One 2022; 17:e0272497. [PMID: 35951587 PMCID: PMC9371257 DOI: 10.1371/journal.pone.0272497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 07/20/2022] [Indexed: 11/21/2022] Open
Abstract
Objective To study the relationship between county-level COVID-19 outcomes (incidence and mortality) and county-level median household income and status of Medicaid expansion of US counties. Methods Retrospective analysis of 3142 US counties was conducted to study the relationship between County-level median-household-income and COVID-19 incidence and mortality per 100,000 people in US counties, January-20th-2021 through December-6th-2021. County median-household-income was log-transformed and stratified by quartiles. Multilevel-mixed-effects-generalized-linear-modeling adjusted for county socio-demographic and comorbidities and tested for Medicaid-expansion-times-income-quartile interaction on COVID-19 outcomes. Results There was no significant difference in COVID-19 incidence-rate across counties by income quartiles or by Medicaid expansion status. Conversely, for non-Medicaid-expansion states, counties in the lowest income quartile had a 41% increase in COVID-19 mortality-rate compared to counties in the highest income quartile. Mortality-rate was not related to income in counties from Medicaid-expansion states. Conclusions Median-household-income was not related to COVID-19 incidence-rate but negatively related to COVID-19 mortality-rate in US counties of states without Medicaid-expansion.
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Affiliation(s)
- Tsikata Apenyo
- Division of Biology and Medicine, The Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island, United States of America
| | - Antonio Elias Vera-Urbina
- Department of Biology, The University of Puerto Rico, San Juan, Puerto Rico, United States of America
| | - Khansa Ahmad
- Division of Biology and Medicine, The Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island, United States of America
- Department of Internal Medicine, The Providence Veterans Affairs Medical Center, Providence, Rhode Island, United States of America
- Department of Internal Medicine, Lifespan Hospitals, Providence, Rhode Island, United States of America
| | - Tracey H. Taveira
- Division of Biology and Medicine, The Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island, United States of America
- Department of Internal Medicine, The Providence Veterans Affairs Medical Center, Providence, Rhode Island, United States of America
- College of Pharmacy, The University of Rhode Island, Kingston, Rhode Island, United States of America
| | - Wen-Chih Wu
- Division of Biology and Medicine, The Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island, United States of America
- Department of Internal Medicine, The Providence Veterans Affairs Medical Center, Providence, Rhode Island, United States of America
- Department of Internal Medicine, Lifespan Hospitals, Providence, Rhode Island, United States of America
- College of Pharmacy, The University of Rhode Island, Kingston, Rhode Island, United States of America
- Department of Epidemiology, The School of Public Health at Brown University, Providence, Rhode Island, United States of America
- * E-mail:
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Ma C, Congly SE, Chyou DE, Ross-Driscoll K, Forbes N, Tsang ES, Sussman DA, Goldberg DS. Factors Associated With Geographic Disparities in Gastrointestinal Cancer Mortality in the United States. Gastroenterology 2022; 163:437-448.e1. [PMID: 35483444 PMCID: PMC9703359 DOI: 10.1053/j.gastro.2022.04.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/21/2022] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND & AIMS Significant geographic variability in gastrointestinal (GI) cancer-related death has been reported in the United States. We aimed to evaluate both modifiable and nonmodifiable factors associated with intercounty differences in mortality due to GI cancer. METHODS Data from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research platform were used to calculate county-level mortality from esophageal, gastric, pancreatic, and colorectal cancers. Multivariable linear regression models were fit to adjust for county-level covariables, considering both patient (eg, sex, race, obesity, diabetes, alcohol, and smoking) and structural factors (eg, specialist density, poverty, insurance prevalence, and colon cancer screening prevalence). Intercounty variability in GI cancer-related mortality explained by these covariables was expressed as the multivariable model R2. RESULTS There were significant geographic disparities in GI cancer-related county-level mortality across the US from 2010-2019 with the ratio of mortality between 90th and 10th percentile counties ranging from 1.5 (pancreatic) to 2.1 (gastric cancer). Counties with the highest 5% mortality rates for gastric, pancreatic, and colorectal cancer were primarily in the Southeastern United States. Multivariable models explained 43%, 61%, 14%, and 39% of the intercounty variability in mortality rates for esophageal, gastric, pancreatic, and colorectal cancer, respectively. Cigarette smoking and rural residence (independent of specialist density) were most strongly associated with GI cancer-related mortality. CONCLUSIONS Both patient and structural factors contribute to significant geographic differences in mortality from GI cancers. Our findings support continued public health efforts to reduce smoking use and improve care for rural patients, which may contribute to a reduction in disparities in GI cancer-related death.
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Affiliation(s)
- Christopher Ma
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Stephen E. Congly
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darius E. Chyou
- Miller School of Medicine, University of Miami, Miami, Florida
| | | | - Nauzer Forbes
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erica S. Tsang
- Department of Medicine, Division of Hematology & Oncology, University of California, San Francisco, California,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | - Daniel A. Sussman
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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Wang XJ, Borah B, Rojas R, Kamath MJ, Moriarty J, Allen AM, Kamath PS. Patients Hospitalized for Complications of Cirrhosis may Have Benefited From Medicaid Expansion Under the Affordable Care Act. Mayo Clin Proc Innov Qual Outcomes 2022; 6:291-301. [PMID: 35722655 PMCID: PMC9198455 DOI: 10.1016/j.mayocpiqo.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective The benefit of the Affordable Care Act (ACA) for patients with cirrhosis is unclear. We determined the impact of ACA expansion on outcomes in patients hospitalized for complications of cirrhosis. Patients and Methods We compared hospitalizations; in-hospital outcomes; and readmissions among patients with cirrhosis identified using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, 10th Revision, codes in states that expanded Medicaid under ACA (expanded [E] states) and those that did not (nonexpanded [NE] states). Data from the State Inpatient Databases were obtained for 3 pairs of contiguous E and NE states with both pre-ACA expansion and post-ACA expansion data. The difference-in-difference analysis was performed to compare the pre- and post-ACA data between the E and NE states. The outcomes were admission rates, hospital complications, resource utilization, length of stay, in-hospital mortality, discharge destination, cost of initial hospitalization, and readmission characteristics. Results There were 228,349 admissions (E states, 149,705; NE states, 78,644). After ACA implementation, the E states had lower rates of admission increase per 100,000 population (22.9 in E states vs 25.5 in NE states, P=.005), sepsis (relative risk, 0.884; P=.0084), and hepatic coma (relative risk, 0.763; P<.001) than the NE states. The length of stay was lower by 0.21 days (P=.00028), with a $587.40 lower cost per hospitalization (P=.00091), in the E states than in the NE states. The readmission rates within 30, 60, and 90 days decreased in the E states after ACA implementation but increased in the NE states after ACA implementation. Conclusion Among patients hospitalized for cirrhosis, quality indicators, such as the rate of admission increase, complications, costs, and readmissions, were more favorable in the states that expanded Medicaid. Medicaid expansion under ACA may have benefited patients with cirrhosis.
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Affiliation(s)
- Xiao Jing Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Bijan Borah
- Division of Health Care Policy and Research, Section of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Ricardo Rojas
- Division of Health Care Policy and Research, Section of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - James Moriarty
- Division of Health Care Policy and Research, Section of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Pain D, Takvorian SU, Narayan V. Disparities in Clinical Care and Research in Renal Cell Carcinoma. KIDNEY CANCER 2022. [DOI: 10.3233/kca-220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Disparities in cancer screening, prevention, therapy, clinical outcomes, and research are increasingly recognized and pervade all malignancies. In response, several cancer research and clinical care organizations have issued policy statements to acknowledge and address barriers to achieving health equity in cancer care. The increasingly specialized nature of oncology warrants a disease-focused appraisal of existing disparities and potential solutions. Although clear improvements in clinical outcomes have been recently observed for patients with renal cell carcinoma (RCC), these improvements have not been equally shared across diverse populations. This review describes existing RCC cancer disparities and their potential contributing factors and discusses opportunities to improve health equity in clinical research for all patients with RCC.
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Affiliation(s)
- Debanjan Pain
- Division of Hematology/Medical Oncology, University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA, USA
| | - Samuel U. Takvorian
- Division of Hematology/Medical Oncology, University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA, USA
| | - Vivek Narayan
- Division of Hematology/Medical Oncology, University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA, USA
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Warraich HJ, Kumar P, Wadhera RK. Authors' reply to Reed. BMJ 2022; 378:o1871. [PMID: 35882399 DOI: 10.1136/bmj.o1871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Pankaj Kumar
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Khan SU, Hagan KK, Javed Z. Disproportionate Impact of COVID-19 Among Socially Vulnerable Patients. Circ Cardiovasc Qual Outcomes 2022; 15:e009294. [PMID: 35862022 PMCID: PMC9387662 DOI: 10.1161/circoutcomes.122.009294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Safi U Khan
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Institute, TX (S.U.K.)
| | - Kobina K Hagan
- Center for Health Data Science and Analytics, Houston Methodist Research Institute, TX (K.K.H., Z.J.)
| | - Zulqarnain Javed
- Center for Health Data Science and Analytics, Houston Methodist Research Institute, TX (K.K.H., Z.J.)
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Oseran AS, Sun T, Wadhera RK. Health Care Access and Management of Cardiovascular Risk Factors Among Working-Age Adults With Low Income by State Medicaid Expansion Status. JAMA Cardiol 2022; 7:708-714. [PMID: 35648424 DOI: 10.1001/jamacardio.2022.1282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Medicaid expansion led to gains in insurance coverage among working-age adults with low income. To date, the extent to which disparities in access and cardiovascular care persist for this population in Medicaid nonexpansion and expansion states is unknown. Objective To compare insurance coverage, health care access, and cardiovascular risk factor management between working-age adults (age 18-64 years) with low income in Medicaid nonexpansion and expansion states and between uninsured and insured adults in these states. Design, Setting, and Participants This cross-sectional study analyzed data on adults aged 18 to 64 years with low income from the Behavioral Risk Factor Surveillance System from January 1 to December 31, 2019. Exposures State Medicaid expansion and insurance status. Main Outcomes and Measures The main outcomes were health care access and monitoring and treatment of cardiovascular risk factors. The estimated adjusted risk difference (RD) in outcomes was estimated to compare adults in Medicaid nonexpansion and expansion states and uninsured and insured individuals in nonexpansion and expansion states. Results The weighted study population consisted of 28 028 451 working-age adults with low income, including 10 094 994 (36.0%) in Medicaid nonexpansion states (63.4% female) and 17 933 457 (64.0%) in expansion states (59.2% female). Adults in nonexpansion states had higher uninsurance rates (42.4% [95% CI, 40.2%-44.7%] vs 23.8% [95% CI, 22.8%-24.8%]), were less likely to have a usual source of care (55.4% [95% CI, 53.1%-57.6%] vs 65.4% [95% CI, 64.3%-66.5%]; adjusted RD, -11.4% [95% CI, -13.9% to -8.8%]) or a recent examination (78.9% [95% CI, 77.0%-80.9%] vs 84.4% [95% CI, 83.5%-85.2%]; RD, -6.2% [95% CI, -8.4% to -4.0%]), and were more likely to have deferred care owing to cost (36.1% [95% CI, 34.0%-38.2%] vs 21.8% [95% CI, 20.9%-22.8%]; RD, 14.2% [95% CI, 11.9%-16.6%]) than were those in expansion states. There were no significant differences in cardiovascular risk factor management between these groups. In nonexpansion states, uninsured adults had significantly worse access to care across these measures and were less likely to receive indicated monitoring of cholesterol (72.6% [95% CI, 67.7%-77.4%] vs 93.7%; [95% CI, 92.4%-95.0%]; RD, -17.2% [95% CI, -21.8% to -12.6%]) and hemoglobin A1c (55.2% [95% CI, 40.0%-72.5%] vs 88.5% [95% CI, 79.2%-97.9%]; RD, -25.8% [95% CI, -47.6% to -4.1%]) levels or to receive treatment for hypertension (49.4% [95% CI, 43.3%-55.6%] vs 74.7% [95% CI, 71.5%-78.0%]; RD, -16.3% [95% CI, -23.2% to -9.4%]) and hyperlipidemia (30.2% [95% CI, 23.5%-36.8%] vs 58.7% [95% CI, 53.9%-63.5%]; RD, -19.3% [95% CI, -27.9% to -10.7%]) compared with insured adults. These patterns were similar for uninsured and insured adults in expansion states. Conclusions and Relevance In this study, working-age adults with low income in Medicaid nonexpansion states experienced higher uninsurance rates and worse access to care than did those in expansion states; however, cardiovascular risk factor management was similar and treatment rates were low. In nonexpansion states, uninsured adults were less likely to receive appropriate cardiovascular risk factor management compared with insured adults.
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Affiliation(s)
- Andrew S Oseran
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Division of Cardiology, Massachusetts General Hospital, Boston
| | - Tianyu Sun
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Jiang Q, Yu T, Huang K, Huang X, Zhang Q, Hu S. The impact of medical insurance reimbursement on postoperative inflammation reaction in distinct cardiac surgery from a single center. BMC Health Serv Res 2022; 22:494. [PMID: 35418067 PMCID: PMC9008956 DOI: 10.1186/s12913-022-07920-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Evidences shows that socioeconomic status is reversely associated with the risk of morbidity and mortality for people with cardiovascular disease via pro-inflammation mechanism, but the population profile is not deeply defined on. We aimed to investigate the impact of medical insurance coverage on postoperative systemic inflammatory reaction in two kinds of disease populations undergoing distinct cardiac procedures. Methods A total of 515 patients receiving open mitral valve procedure with high-total expense from May 2013 through May 2021 in Sichuan Provincial People’s Hospital were retrospectively collected and stratified according to medical insurance reimbursement: low coverage with high out-pocket (< 30%), medium coverage (≤ 60%, but ≥ 30%), and high coverage (> 60%). Another 118 cases undergoing atrium septum defect (ASD) or patent foramen ovale (PFO) occlusion and taking on consistent low-total expense and low-coverage (< 30%) were also classified according to their insured conditions. The postoperative systemic inflammatory response indexes were high sensitivity C-reactive protein (hs-CRP) and the neutrophil–lymphocyte ratio (NLR). Results Low insurance reimbursement population undergoing open mitral valve procedure had a higher level of hs-CRP and NLR but not troponin I protein or lactate within 48 h postoperatively, and higher thoracic drainage, longer ventilation use and stay in intensive care unit. No significant difference in inflammatory indexes existed among diverse medical insurance coverage in population undergoing ASD/PFO occlusion. Conclusions Higher inflammatory reaction and weaker clinical recovery was associated with lower insurance coverage population undergoing open mitral valve procedure but not ASD/PFO interventional occlusion procedure. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07920-8.
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Affiliation(s)
- Qin Jiang
- Department of Cardiac Surgery, Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, No.32, West Second Section First Ring Road, Chengdu, 610072, China.
| | - Tao Yu
- Department of Cardiac Surgery, Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, No.32, West Second Section First Ring Road, Chengdu, 610072, China
| | - Keli Huang
- Department of Cardiac Surgery, Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, No.32, West Second Section First Ring Road, Chengdu, 610072, China
| | - Xiaobo Huang
- Department of Surgical Intensive Care Unit, Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, Chengdu, China
| | - Qingfeng Zhang
- Department of Cardiovascular Ultrasound and Non-invasive Cardiology, Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, Chengdu, China
| | - Shengshou Hu
- Department of Cardiac Surgery, Fuwai Hospital, National, Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Cram P, Selker H, Carnahan J, Romero-Brufau S, Fischer MA. Getting to 100%: Research Priorities and Unanswered Questions to Inform the US Debate on Universal Health Insurance Coverage. J Gen Intern Med 2022; 37:949-953. [PMID: 35060003 PMCID: PMC8904700 DOI: 10.1007/s11606-021-07234-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
A majority of Americans favor universal health insurance, but there is uncertainty over how best to achieve this goal. Whatever the insurance design that is implemented, additional details that must be considered include breadth of services covered, restrictions and limits on volumes of services, cost-sharing for individuals, and pricing. In the hopes that research can inform this ongoing debate, we review evidence supporting different models for achieving universal coverage in the US and identify areas where additional research and stakeholder input is needed. Key areas in need of further research include how care should be organized, how costs can be reduced, and what healthcare services universal insurance should cover.
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Affiliation(s)
- Peter Cram
- Department of Internal Medicine, Medical Branch, University of Texas, 301 University Blvd, Galveston, TX, 77555, USA. .,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Harry Selker
- Institute for Clinical Research and Health Policy Studies, Tufts University School of Medicine, Boston, MA, USA
| | - Jennifer Carnahan
- Indiana University School of Medicine, Indianapolis, IN, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA
| | - Santiago Romero-Brufau
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael A Fischer
- Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA, USA
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Gatto AP, Feeley BT, Lansdown DA. Low socioeconomic status worsens access to care and outcomes for rotator cuff repair: a scoping review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:26-34. [PMID: 37588282 PMCID: PMC10426503 DOI: 10.1016/j.xrrt.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Poor socioeconomic status (SES) is consistently associated with poor quality of health care, particularly in the field of orthopedics. Expanding insurance coverage has created a larger patient population by specifically making health care more accessible, translating to greater demand for care in the low-SES population. The purpose of this article is to provide a scoping review of literature observing access and outcomes of rotator cuff repair surgery among low-SES populations. Methods We performed a systematic review of articles using PubMed, Embase, and EBSCO (May 2021) from 2010 onward. Peer-reviewed articles that recorded at least one SES measure specific to patients who underwent rotator cuff repair from the United States were included. SES measures were methodically defined as income, occupation, employment, education, and race. All data that aligned with these SES measures were extracted. Results Of the 1009 titles reviewed, 109 studies were screened by abstract, 23 were reviewed in full, and 7 studies met criteria for inclusion. Of the 5 studies investigating access, all 5 found disparities among postoperative physical therapy, orthopedic consult, and surgery, using Medicaid status as a proxy for income in addition to other income measures. Of the 3 studies analyzing outcomes, 2 found that low-SES patients had worse pain and function, again based on Medicaid status and other income measures. Education did not have a significant impact on outcomes, as per the 1 study that included it. No studies included measures of occupation or employment. Conclusion Patients of low SES face reduced access to cuff repair care and worse associated outcomes, despite federal and state government efforts to reduce health care disparity through health care reform. The small nature of this review reflects how measures of SES are often not examined in rotator cuff repair studies.
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Affiliation(s)
- Andrew P. Gatto
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Brian T. Feeley
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Drew A. Lansdown
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
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Kumar SR, Khatana SAM, Goldberg D. Impact of Medicaid Expansion on Liver-Related Mortality. Clin Gastroenterol Hepatol 2022; 20:419-426.e1. [PMID: 33278572 PMCID: PMC8672394 DOI: 10.1016/j.cgh.2020.11.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/25/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND & AIMS The Affordable Care Act provided the opportunity for states to expand Medicaid for low-income individuals. Not all states adopted Medicaid expansion, and the timing of adoption among expansion states varied. Prior studies have shown that Medicaid expansion improved mortality rates for several chronic conditions. Although there are data on the association between Medicaid expansion on insurance type among patients waitlisted for a liver transplant, there are no published data to date on its impact on liver disease-related mortality in the broader population. We therefore sought to evaluate the association between Medicaid expansion and state-level liver disease-related mortality using a quasi-experimental study design. METHODS We evaluated age-adjusted, state-level, liver disease-related mortality rates using the Centers for Disease Control and Prevention data. We fit multivariable linear regression models that accounted for sociodemographic, clinical, and access-to-care variables at the state level, and a difference-in-difference estimator to evaluate the association between Medicaid expansion and liver disease-related mortality. RESULTS In multivariable linear regression models, there was a significant association between Medicaid expansion and liver disease-related mortality (P = .02). Medicaid expansion was associated with 8.3 (95% CI, 1.6-15.1) fewer deaths from liver disease per 1,000,000 adult residents per year after Medicaid expansion compared with what would have been expected to occur if those states followed the same trajectory as nonexpansion states. The impact of Medicaid expansion translated to 870 fewer liver-related deaths per year in expansion states (4350 in the postexpansion study period from 2014 to 2018). CONCLUSIONS These data support the contention that Medicaid expansion has been associated with significantly decreased liver disease-related mortality. Universal Medicaid expansion could further decrease liver disease-related mortality in the United States.
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Affiliation(s)
- Smriti Rajita Kumar
- Department of Internal Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida.
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Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka RA, Yancy CW, Fonarow GC, DeVore AD, Bhatt DL, Peterson PN. Is the affordable care act medicaid expansion associated with receipt of heart failure guideline-directed medical therapy by race and ethnicity? Am Heart J 2022; 244:135-148. [PMID: 34813771 PMCID: PMC8727506 DOI: 10.1016/j.ahj.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/17/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Uninsurance is a known contributor to racial/ethnic health inequities. Insurance is often needed for prescriptions and follow-up appointments. Therefore, we determined whether the Affordable Care Act(ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment(GDMT) at discharge among patients hospitalized with heart failure(HF) by race/ethnicity. METHODS Using Get With The Guidelines-HF registry, logistic regression was used to assess odds of receiving GDMT(HF medications; education; follow-up appointment) in early vs non-adopter states before(2012 - 2013) and after ACA Medicaid Expansion(2014 - 2019) within each race/ethnicity, accounting for patient-level covariates and within-hospital clustering. We tested for an interaction(p-int) between GDMT and pre/post Medicaid Expansion time periods. RESULTS Among 271,606 patients(57.5% early adopter, 42.5% non-adopter), 65.5% were White, 22.8% African American, 8.9% Hispanic, and 2.9% Asian race/ethnicity. Independent of ACA timing, Hispanic patients were more likely to receive all GDMT for residing in early adopter states compared to non-adopter states (P <.0001). In fully-adjusted analyses, ACA Medicaid Expansion was associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients [before ACA:OR 0.40(95%CI:0.13,1.23); after ACA:OR 2.46(1.10,5.51); P-int = .0002], but this occurred in the setting of an immediate decline in prescribing patterns, particularly among non-adopter states, followed by an increase that remained lowest in non-adopter states. The ACA was not associated with receipt of GDMT for other racial/ethnic groups. CONCLUSIONS Among GWTG-HF hospitals, Hispanic patients were more likely to receive all GDMT if they resided in early adopter states rather than non-adopter states, independent of ACA Medicaid Expansion timing. ACA implementation was only associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients. Additional steps are needed for improved GDMT delivery for all.
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Affiliation(s)
- Khadijah K. Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Haolin Xu
- Department of Biostatistics and Bioinformatics, Duke University,
Durham, NC
| | - Nancy K. Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Elizabeth Calhoun
- Center for Population Science and Discovery, University of Arizona,
Tucson, AZ
| | | | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of
Medicine, Chicago, IL
| | - Gregg C. Fonarow
- Division of Cardiology, University of California Los Angeles,
CA
| | | | - Deepak L. Bhatt
- Division of Cardiovascular Medicine, Brigham and Women’s
Hospital Heart & Vascular Center, Harvard Medical School, Boston,
MA
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado, Anschutz Medical
Campus, Aurora, CO and Division of Cardiology, Denver Health Medical Center,
Denver, CO
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41
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Mohottige D, Boulware LE, Ford CL, Jones C, Norris KC. Use of Race in Kidney Research and Medicine: Concepts, Principles, and Practice. Clin J Am Soc Nephrol 2022; 17:314-322. [PMID: 34789476 PMCID: PMC8823929 DOI: 10.2215/cjn.04890421] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Black Americans and other racially and ethnically minoritized individuals are disproportionately burdened by higher morbidity and mortality from kidney disease when compared with their White peers. Yet, kidney researchers and clinicians have struggled to fully explain or rectify causes of these inequalities. Many studies have sought to identify hypothesized genetic and/or ancestral origins of biologic or behavioral deficits as singular explanations for racial and ethnic inequalities in kidney health. However, these approaches reinforce essentialist beliefs that racial groups are inherently biologically and behaviorally different. These approaches also often conflate the complex interactions of individual-level biologic differences with aggregated population-level disparities that are due to structural racism (i.e., sociopolitical policies and practices that created and perpetuate harmful health outcomes through inequities of opportunities and resources). We review foundational misconceptions about race, racism, genetics, and ancestry that shape research and clinical practice with a focus on kidney disease and related health outcomes. We also provide recommendations on how to embed key equity-enhancing concepts, terms, and principles into research, clinical practice, and medical publishing standards.
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Affiliation(s)
- Dinushika Mohottige
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina,Center for Community and Population Health Improvement, Duke Clinical and Translational Science Institute, Duke University School of Medicine, Durham, North Carolina
| | - L. Ebony Boulware
- Center for Community and Population Health Improvement, Duke Clinical and Translational Science Institute, Duke University School of Medicine, Durham, North Carolina,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Chandra L. Ford
- Department of Community Health Science, University of California, Los Angeles School of Public Health, Los Angeles, California,Center for the Study of Racism, Social Justice & Health, University of California, Los Angeles School of Public Health, Los Angeles, California
| | - Camara Jones
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia,Department of Epidemiology, Rollins School of Public Health at Emory University, Atlanta, Georgia,Department of Behavioral Sciences and Health Education, Rollins School of Public Health at Emory University, Atlanta, Georgia
| | - Keith C. Norris
- Center for the Study of Racism, Social Justice & Health, University of California, Los Angeles School of Public Health, Los Angeles, California,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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Zhao J, Han X, Nogueira L, Hyun N, Jemal A, Yabroff KR. Association of State Medicaid Income Eligibility Limits and Long-Term Survival After Cancer Diagnosis in the United States. JCO Oncol Pract 2022; 18:e988-e999. [PMID: 34995127 DOI: 10.1200/op.21.00631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To examine the association between historic state Medicaid income eligibility limits and long-term survival among patients with cancer. METHODS 1,449,144 adults age 18-64 years newly diagnosed with 19 common cancers between 2010 and 2013 were identified from the National Cancer Database. States' Medicaid income eligibility limits were categorized as ≤ 50%, 51%-137%, and ≥ 138% of federal poverty level (FPL). Survival time was measured from diagnosis date through December 31, 2017, for up to an 8-year follow-up. Multivariable Cox proportional hazards models with age as time scale were used to assess associations of eligibility limits and stage-specific survival, adjusting for the effects of sex, metropolitan statistical area, comorbidities, year of diagnosis, facility type and volume, and state. RESULTS Among patients with newly diagnosed cancer age 18-64 years, patients living in states with lower Medicaid income eligibility limits had worse survival for most cancers in both early and late stages, compared with those living in states with Medicaid income eligibility limits ≥ 138% FPL. A dose-response relationship was observed for most cancers with lower income limits associated with worse survival (13 of 17 cancers evaluated for early-stage cancers, and 11 of 17 cancers evaluated for late-stage cancers, and leukemia and brain tumors with P-trend < .05). CONCLUSION Lower Medicaid income eligibility limits were associated with worse long-term survival within stage; increasing Medicaid income eligibility may improve survival after cancer diagnosis.
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Affiliation(s)
- Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Leticia Nogueira
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Noorie Hyun
- Division of Biostatistics, Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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Ji X, Hu X, Castellino SM, Mertens AC, Yabroff KR, Han X. OUP accepted manuscript. JNCI Cancer Spectr 2022; 6:6522127. [PMID: 35699500 PMCID: PMC8877169 DOI: 10.1093/jncics/pkac006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/29/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Despite advances toward universal health insurance coverage for children, coverage gaps remain. Using a nationwide sample of pediatric and adolescent cancer patients from the National Cancer Database, we examined effects of the Affordable Care Act (ACA) implementation in 2014 with multinomial logistic regressions to evaluate insurance changes between 2010-2013 (pre-ACA) and 2014-2017 (post-ACA) in patients aged younger than 18 years (n = 63 377). All statistical tests were 2-sided. Following the ACA, the overall percentage of Medicaid and Children’s Health Insurance Program–covered patients increased (from 35.1% to 36.9%; adjusted absolute percentage change [APC] = 2.01 percentage points [ppt], 95% confidence interval [CI] = 1.31 to 2.71; P < .001), partly offset by declined percentage of privately insured (from 62.7% to 61.2%; adjusted APC = −1.67 ppt, 95% CI = −2.37 to −0.97; P < .001), leading to a reduction by 15% in uninsured status (from 2.2% to 1.9%; adjusted APC = −0.34 ppt, 95% CI = −0.56 to −0.12 ppt; P = .003). The largest declines in uninsured status were observed among Hispanic patients (by 23%; adjusted APC = −0.95 ppt, 95% CI = −1.67 to −0.23 ppt; P = .009) and patients residing in low-income areas (by 35%; adjusted APC = −1.22 ppt, 95% CI = −2.22 to −0.21 ppt; P = .02). We showed nationwide insurance gains among pediatric and adolescent cancer patients following ACA implementation, with greater gains in racial and ethnic minorities and those living in low-income areas.
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Affiliation(s)
- Xu Ji
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA
- Correspondence to: Xu Ji, PhD, Department of Pediatrics, Emory School of Medicine, Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, 2015 Uppergate Dr, Atlanta, GA 30322, USA (e-mail: )
| | - Xin Hu
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Sharon M Castellino
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Ann C Mertens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
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Everitt I, Freaney PM, Wang MC, Grobman WA, O’Brien MJ, Pool LR, Khan SS. Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth. Circ Cardiovasc Qual Outcomes 2022; 15:e008249. [PMID: 35041477 PMCID: PMC8820292 DOI: 10.1161/circoutcomes.121.008249] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Incidence of hypertensive disorders of pregnancy is increasing in the United States. Early detection is important to prevent adverse maternal and offspring outcomes. This ecological study evaluated changes in rates of hypertensive disorders of pregnancy among states that expanded Medicaid compared with states that did not expand Medicaid. METHODS A quasi-experimental analysis using difference-in-differences models compared changes in rates of hypertensive disorders of pregnancy in Medicaid expansion states relative to non-Medicaid expansion states from 2012 to 2019. Maternal data from singleton first live births to individuals aged 20 to 39 years were obtained from the National Center for Health Statistics. Outcomes of interest included age-adjusted rates of de novo hypertension in pregnancy (gestational hypertension or preeclampsia) and prepregnancy hypertension. RESULTS Data from 7 764 965 individuals with a singleton first live birth were analyzed from 17 states and Washington, DC that expanded Medicaid and 15 states that did not. Rates of de novo hypertension in pregnancy increased over the study period in both expansion (54.34 [95% CI, 48.25-60.43] to 74.87 [95% CI, 71.20-78.55] per 1000 births) and nonexpansion states (68.32 [95% CI, 61.02-75.62] to 84.79 [95% CI, 80.67-88.91] per 1000 births). In adjusted difference-in-differences analyses, expansion status was associated with a greater increase in rates of de novo hypertension in pregnancy (difference-in-differences coefficient, +8.18 [95% CI, 4.00-12.36] per 1000 live births) but a decline in rates of de novo hypertension in pregnancy complicated by low birth weight (-7.20 [95% CI, -13.71 to -0.70] per 1000 births with hypertensive disorders of pregnancy). In adjusted difference-in-differences analyses, there were no significant changes in rates of prepregnancy hypertension in expansion relative to nonexpansion states (+1.13 [95% CI, -0.09 to +2.35] per 1000 live births). CONCLUSIONS Between 2012 and 2019, states that expanded Medicaid had a significantly greater increase in rates of de novo hypertension, with some evidence of better outcomes among those with de novo hypertension diagnosed in pregnancy.
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Affiliation(s)
- Ian Everitt
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Priya M. Freaney
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael C. Wang
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - William A. Grobman
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Matthew J. O’Brien
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lindsay R. Pool
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sadiya S. Khan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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45
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Lee BP, Dodge JL, Terrault NA. Medicaid expansion and variability in mortality in the USA: a national, observational cohort study. THE LANCET PUBLIC HEALTH 2022; 7:e48-e55. [PMID: 34863364 PMCID: PMC10122976 DOI: 10.1016/s2468-2667(21)00252-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/18/2021] [Accepted: 11/01/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The expansion of the Medicaid public health insurance programme has varied by state in the USA. Longer-term mortality and factors associated with variability in outcomes after Medicaid expansion are under-studied. We aimed to investigate the association of state Medicaid expansion with all-cause mortality. METHODS This was a population-based, national, observational cohort study capturing all reported deaths among adults aged 25-64 years via death certificate data in the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database in the USA from Jan 1, 2010, to Dec 31, 2018. We obtained national demographic and mortality data for adults aged 25-64 years, and state-level demographics and 2010-18 mortality estimates for the overall population by linking federally maintained registries (CDC WONDER, Behavioral Risk Factor Surveillance System, Health Resources and Services Administration, US Census Bureau, and Bureau of Labor Statistics). States were categorised as Medicaid expansion or non-expansion states as classified by the Kaiser Family Foundation. Multivariable difference-in-differences analysis assessed the absolute difference in the annual, state-level, all-cause mortality per 100 000 adults after Medicaid expansion. FINDINGS Among 32 expansion states and 17 non-expansion states, Medicaid expansion was associated with reductions in all-cause mortality (-11·8 deaths per 100 000 adults [95% CI -21·3 to -2·2]). There was variability in changes in all-cause mortality associated with Medicaid expansion by state (ranging from -63·8 deaths per 100 000 adults [95% CI -134·1 to -42·9] in Delaware to 30·4 deaths per 100 000 adults [-39·8 to 51·4] in New Mexico). State-level proportions of women (-17·8 deaths per 100 000 adults [95% CI -26·7 to -8·8] for each percentage point increase in women residents) and non-Hispanic Black residents (-1·4 deaths per 100 000 adults [-2·4 to -0·3] for each percentage point increase in non-Hispanic Black residents) were associated with greater adjusted reductions in all-cause mortality among expansion states. INTERPRETATION After 4 years of implementation, Medicaid expansion remains associated with significant reductions in all-cause mortality, but reductions are variable by state characteristics. These results could inform policy makers to provide broad-based equitable improvements in health outcomes. FUNDING University of Southern California Research Center for Liver Diseases.
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Dani SS, Lone AN, Javed Z, Khan MS, Zia Khan M, Kaluski E, Virani SS, Shapiro MD, Cainzos-Achirica M, Nasir K, Khan SU. Trends in Premature Mortality From Acute Myocardial Infarction in the United States, 1999 to 2019. J Am Heart Assoc 2021; 11:e021682. [PMID: 34935456 PMCID: PMC9075205 DOI: 10.1161/jaha.121.021682] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Evaluating premature (<65 years of age) mortality because of acute myocardial infarction (AMI) by demographic and regional characteristics may inform public health interventions. Methods and Results We used the Centers for Disease Control and Prevention’s WONDER (Wide‐Ranging Online Data for Epidemiologic Research) death certificate database to examine premature (<65 years of age) age‐adjusted AMI mortality rates per 100 000 and average annual percentage change from 1999 to 2019. Overall, the age‐adjusted AMI mortality rate was 13.4 (95% CI, 13.3–13.5). Middle‐aged adults, men, non‐Hispanic Black adults, and rural counties had higher mortality than young adults, women, NH White adults, and urban counties, respectively. Between 1999 and 2019, the age‐adjusted AMI mortality rate decreased at an average annual percentage change of −3.4 per year (95% CI, −3.6 to −3.3), with the average annual percentage change showing higher decline in age‐adjusted AMI mortality rates among large (−4.2 per year [95% CI, −4.4 to −4.0]), and medium/small metros (−3.3 per year [95% CI, −3.5 to −3.1]) than rural counties (−2.4 per year [95% CI, −2.8 to −1.9]). Age‐adjusted AMI mortality rates >90th percentile were distributed in the Southern states, and those with mortality <10th percentile were clustered in the Western and Northeastern states. After an initial decline between 1999 and 2011 (−4.3 per year [95% CI, −4.6 to −4.1]), the average annual percentage change showed deceleration in mortality since 2011 (−2.1 per year [95% CI, −2.4 to −1.8]). These trends were consistent across both sexes, all ethnicities and races, and urban/rural counties. Conclusions During the past 20 years, decline in premature AMI mortality has slowed down in the United States since 2011, with considerable heterogeneity across demographic groups, states, and urbanicity. Systemic efforts are mandated to address cardiovascular health disparities and outcomes among nonelderly adults.
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Affiliation(s)
- Sourbha S Dani
- Division of Cardiology Lahey Hospital, and Medical CenterBeth Israel Lahey Health Burlington MA
| | - Ahmad N Lone
- Department of Cardiology Guthrie Health System/Robert Packer Hospital Sayre PA
| | - Zulqarnain Javed
- Division of Health Equity & Disparities Research, Center for Outcomes Research Houston Methodist Houston TX
| | - Muhammad S Khan
- Department of Cardiovascular Medicine Duke University Durham NC
| | - Muhammad Zia Khan
- Department of Cardiovascular Medicine West Virginia University Morgantown WV
| | - Edo Kaluski
- Department of Cardiology Guthrie Health System/Robert Packer Hospital Sayre PA
| | - Salim S Virani
- Michael E. DeBakey Veterans Affair Medical Center & Section of Cardiovascular Research Department of Medicine Baylor College of Medicine Houston TX
| | - Michael D Shapiro
- Section on Cardiovascular Medicine Wake Forest University School of Medicine Winston-Salem NC
| | - Miguel Cainzos-Achirica
- Center for Outcomes Research Houston Methodist Houston TX.,Department of CardiologyHouston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Khurram Nasir
- Division of Health Equity & Disparities Research, Center for Outcomes Research Houston Methodist Houston TX.,Department of CardiologyHouston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Safi U Khan
- Center for Outcomes Research Houston Methodist Houston TX
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Piña IL, Jimenez S, Lewis EF, Morris AA, Onwuanyi A, Tam E, Ventura HO. Race and Ethnicity in Heart Failure: JACC Focus Seminar 8/9. J Am Coll Cardiol 2021; 78:2589-2598. [PMID: 34887145 DOI: 10.1016/j.jacc.2021.06.058] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022]
Abstract
Heart failure (HF) affects >6 million Americans, with variations in incidence, prevalence, and clinical outcomes by race/ethnicity. Black adults have the highest risk for HF, with earlier age of onset and the highest risk of death and hospitalizations. The risk of hospitalizations for Hispanic patients is higher than White patients. Data on HF in Asian individuals are more limited. However, the higher burden of traditional cardiovascular risk factors, particularly among South Asian adults, is associated with increased risk of HF. The role of environmental, socioeconomic, and other social determinants of health, more likely for Black and Hispanic patients, are increasingly recognized as independent risk factors for HF and worse outcomes. Structural racism and implicit bias are drivers of health care disparities in the United States. This paper will review the clinical, physiological, and social determinants of HF risk, unique for race/ethnic minorities, and offer solutions to address systems of inequality that need to be recognized and dismantled/eradicated.
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Affiliation(s)
| | | | | | - Alanna A Morris
- Emory University, Atlanta, Georgia, USA. https://twitter.com/morrismd
| | | | - Edlira Tam
- Montefiore Medical Center, Bronx, New York, USA
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Berman AN, DeFilippis EM, Blankstein R. Role of Income-Lifting Social Programs in Reducing Years of Life Lost to Myocardial Infarction and Sudden Death-Reply. JAMA Cardiol 2021; 7:230-231. [PMID: 34910076 DOI: 10.1001/jamacardio.2021.5130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Adam N Berman
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Boston, Massachusetts
| | - Ersilia M DeFilippis
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Ron Blankstein
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Boston, Massachusetts
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Ayubcha C, Pouladvand P, Ayubcha S. A Quasi-Experimental Study of Medicaid Expansion and Urban Mortality in the American Northeast. Front Public Health 2021; 9:707907. [PMID: 34869142 PMCID: PMC8637894 DOI: 10.3389/fpubh.2021.707907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: To investigate the association of state-level Medicaid expansion and non-elderly mortality rates from 1999 to 2018 in Northeastern urban settings. Methods: This quasi-experimental study utilized a synthetic control method to assess the association of Medicaid expansion on non-elderly urban mortality rates [1999–2018]. Counties encompassing the largest cities in the Northeastern Megalopolis (Washington D.C., Baltimore, Philadelphia, New York City, and Boston) were selected as treatment units (n = 5 cities, 3,543,302 individuals in 2018). Cities in states without Medicaid expansion were utilized as control units (n = 17 cities, 12,713,768 individuals in 2018). Results: Across all cities, there was a significant reduction in the neoplasm (Population-Adjusted Average Treatment Effect = −1.37 [95% CI −2.73, −0.42]) and all-cause (Population-Adjusted Average Treatment Effect = −2.57 [95%CI −8.46, −0.58]) mortality rate. Washington D.C. encountered the largest reductions in mortality (Average Treatment Effect on All-Cause Medical Mortality = −5.40 monthly deaths per 100,000 individuals [95% CI −12.50, −3.34], −18.84% [95% CI −43.64%, −11.67%] reduction, p = < 0.001; Average Treatment Effect on Neoplasm Mortality = −1.95 monthly deaths per 100,000 individuals [95% CI −3.04, −0.98], −21.88% [95% CI −34.10%, −10.99%] reduction, p = 0.002). Reductions in all-cause medical mortality and neoplasm mortality rates were similarly observed in other cities. Conclusion: Significant reductions in urban mortality rates were associated with Medicaid expansion. Our study suggests that Medicaid expansion saved lives in the observed urban settings.
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Affiliation(s)
| | - Pedram Pouladvand
- Alfred I. DuPont Hospital for Children, Wilmington, NC, United States
| | - Soussan Ayubcha
- Marcus Institute of Integrative Health, Thomas Jefferson University, Philadelphia, PA, United States
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50
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Kumar SR, Goldberg DS. Medicaid Expansion and Enhanced Coverage of Direct Oral Antivirals: Improving Care for Patients With Liver Disease. Liver Transpl 2021; 27:1704-1705. [PMID: 34418271 DOI: 10.1002/lt.26276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/16/2021] [Indexed: 01/09/2023]
Affiliation(s)
- Smriti Rajita Kumar
- Department of Medicine, Thomas Jefferson University Hospitals, Philadelphia, PA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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