Variation in Health Care Access and Quality Among US States and High-Income Countries With Universal Health Insurance Coverage

Understanding the Link Between Retirement Timing and Cognition: A Scoping Review

Organization for Economic Co-operation and Development (OECD) countries have increased the age for full retirement benefits to alleviate financial pressures. Older age is linked to higher rates of cognitive impairment. Therefore, it is crucial for public policymakers to understand the relationship between retirement timing and cognition. The purpose of this scoping review was to review the retirement timing and cognition literature and to assess possible modifying factors. A search across three databases yielded a total of 10 studies. Five studies revealed mixed findings regarding the relationship between retirement timing and cognitive decline, with reported positive, negative, and null associations. In contrast, five studies found that later retirement age reduced the risk of dementia. More cross-sectional and longitudinal studies are needed to investigate modifiable factors such as job characteristics and leisure activities to clarify the mechanisms underlying the relationship between retirement timing and cognition.

U.S. dementia care spending by state: 2010-2019

INTRODUCTION

Dementia is the fourth largest cause of death for individuals 70 years of age and older in the United States, and it is tremendously costly. Existing estimates of the indirect costs of dementia are dated and do not report on differences across the United States.

METHODS

We used data from multiple surveys to create cost estimates and projections for informal dementia caregiving at the U.S. state level from 2010 through 2050.

RESULTS

In 2019, the annual replacement cost of informal caregiving was $42,422 per prevalent case, and the forgone wage cost was $10,677 per prevalent case. In 2019, it would have cost $230 billion to hire home health aides to provide all this care. If past trends persist, this cost is expected to grow to $404 billion per year in 2050.

DISCUSSION

The cost of informal care varied substantially by state and is expected to grow through at least 2050.

HIGHLIGHTS

In the United States in 2019, foregone wages due to informal dementia care was $58 billion. Replacing informal dementia care with health aides would have cost $230 billion. These costs vary dramatically by state, even when assessed per prevalent case. These costs are expected to nearly double by 2050.

Disparities in Health Insurance Among Middle Eastern and North African American Children in the US

OBJECTIVE

To estimate and compare the proportion of foreign-born Middle Eastern/North African (MENA) children without health insurance, public, or private insurance to foreign- and US-born White and US-born MENA children.

METHODS

Using 2000 to 2018 National Health Interview Survey data (N = 311 961 children) and 2015 to 2019 American Community Survey data (n = 1 892 255 children), we ran multivariable logistic regression to test the association between region of birth among non-Hispanic White children (independent variable) and health insurance coverage types (dependent variables).

RESULTS

In the NHIS and ACS, foreign-born MENA children had higher odds of being uninsured (NHIS OR = 1.50, 95%CI = 1.10-2.05; ACS OR = 2.11, 95%CI = 1.88-2.37) compared to US-born White children. In the ACS, foreign-born MENA children had 2.11 times higher odds (95%CI = 1.83-2.45) of being uninsured compared to US-born MENA children.

CONCLUSION

Our findings have implications for the health status of foreign-born MENA children, who are currently more likely to be uninsured. Strategies such as interventions to increase health insurance enrollment, updating enrollment forms to capture race, ethnicity, and nativity can aid in identifying and monitoring key disparities among MENA children.

Inequitable access to nonpharmacologic pain treatment providers among cancer-free U.S. adults

OBJECTIVE

Using evidence-based nonpharmacologic pain treatments may prevent opioid overuse and associated adverse outcomes. There is limited data on the impact of access-promoting social determinants of health (SDoH: education, income, transportation) on use of nonpharmacologic pain treatments. Our objective was to examine the relationship between SDoH and use of nonpharmacologic pain treatment providers. Our goal was to understand policy-actionable factors contributing to inequity in pain treatment.

METHODS

Based on Andersen's Health Utilization Model, this cross-sectional analysis of 2016-2019 Medical Expenditure Panel Survey data evaluated whether use of outpatient nonpharmacologic pain treatment providers is driven by enabling (i.e., advantageous socioeconomic resources) or need (i.e., perceived disability and diagnosed disease) factors. The study sample (unweighted n = 28,188) represented a weighted N = 81,912,730 noninstitutionalized, cancer-free, U.S. adults with pain interference. The primary outcome measured use of nonpharmacologic providers relative to exclusive prescription opioid use or no treatment (i.e., neither opioids nor nonpharmacologic). To quantify equitable access, we compared the variance-between access-promoting enabling factors versus medical need factors-that explained utilization.

RESULTS

Compared to enabling factors, need factors explained twice the variance predicting pain treatment utilization. Still, the adjusted odds of using nonpharmacologic providers instead of opioids alone were 39% lower among respondents identifying as Black (95% Confidence Interval [CI], 0.49-0.76) and respondents residing in the U.S. South (95% CI, 0.51-0.74). Higher education (95% CI, 1.72-2.79) and income (95% CI, 1.68-2.42) both facilitated using nonpharmacologic providers instead of opioids.

CONCLUSIONS

These findings highlight the substantial influence access-promoting SDoH have on pain treatment utilization.

Health Literacy Analytics of Accessible Patient Resources in Cardiovascular Medicine: What are Patients Wanting to Know?

Introduction

There remains an increasing utilization of internet-based resources as a first line of medical knowledge. Among patients with cardiovascular disease, these resources often are relied upon for numerous diagnostic and therapeutic modalities. However, the reliability of this information is not fully understood. The aim of this study was to provide a descriptive profile on the literacy quality, readability, and transparency of publicly available educational resources in cardiology.

Methods

The frequently asked questions and associated online educational articles on common cardiovascular diagnostic and therapeutic interventions were investigated using publicly available data from the Google RankBrain machine learning algorithm after applying inclusion and exclusion criteria. Independent raters evaluated questions for Rothwell's Classification and readability calculations.

Results

Collectively, 520 questions and articles were evaluated across 13 cardiac interventions, resulting in 3,120 readability scores. The sources of articles were most frequently from academic institutions followed by commercial sources. Most questions were classified as "Fact" at 76.0% (n = 395), and questions regarding "Technical Details" of each intervention were the most common subclassification at 56.3% (n = 293).

Conclusions

Our data show that patients most often are using online search query programs to seek information regarding specific knowledge of each cardiovascular intervention rather than form an evaluation of the intervention. Additionally, these online patient educational resources continue to not meet grade-level reading recommendations.

Trends in prostate cancer incidence among Black men in the Caribbean and the United States

BACKGROUND

Prostate cancer incidence is highest for Black men of the African diaspora in the United States and Caribbean. Recent changes in recommendations for prostate cancer screening have been shown to decrease overall prostate cancer incidence and increase the likelihood of late stage disease. However, it is unclear how trends in prostate cancer characteristics among high risk Black men differ by geographic region during the changes in screening recommendations.

METHODS

In this study, we used population-based prostate cancer registry data to describe age-adjusted prostate cancer incidence trends from 2008 to 2015 among Black men from six geographic regions. We obtained data on incident Black prostate cancer patients from six cancer registries (in the United States: Florida, Alabama, Pennsylvania, and New York; and in the Caribbean: Guadeloupe and Martinique). After age standardization, we used descriptive analyses to compare the demographics and tumor characteristics by cancer registry site. The Joinpoint regression program was used to compare the trends in incidence by site.

RESULTS

A total of 59,246 men were analyzed. We found the highest incidence rates (per 100,000) for prostate cancer in the Caribbean countries (181.99 in Martinique and 176.62 in Guadeloupe) and New York state (178.74). Incidence trends decreased significantly over time at all sites except Martinique, which also showed significantly increasing rates of late stage (III/IV) and Gleason score 7+ tumors.

CONCLUSIONS

We observed significant differences in prostate cancer incidence trends among Black men after major changes prostate screening recommendations. Future studies will examine the factors that differentially influence prostate cancer trends among the African diaspora.

Screening for Social Determinants of Health in the Pediatric Intensive Care Unit: Recommendations for Clinicians

Social determinants of health (SDoH) play a significant role in the health and well-being of children in the United States. Disparities in the risk and outcomes of critical illness have been extensively documented but are yet to be fully explored through the lens of SDoH. In this review, we provide justification for routine SDoH screening as a critical first step toward understanding the causes of, and effectively addressing health disparities affecting critically ill children. Second, we summarize important aspects of SDoH screening that need to be considered before implementing this practice in the pediatric critical care setting.

Association of Insurance Type With Inpatient Surgery 30-Day Complications and Costs

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.

COVID-19 Pandemic Impact on the Maternal Mortality in Kazakhstan and Comparison with the Countries in Central Asia

Maternal mortality ratio is one of the sensitive indicators that can characterize the performance of healthcare systems. In our study we aimed to compare the maternal mortality ratio in the Central Asia region from 2000 to 2020, determine its trends and evaluate the association between the maternal mortality ratio and Central Asia countries' total health expenditures. We also compared the maternal mortality causes before and during the pandemic in Kazakhstan. The data were derived from the public statistical collections of each Central Asian country. During the pre-pandemic period, Central Asian nations had a downward trend of maternal mortality. Maternal mortality ratio in Central Asian countries decreased by 38% from 47.3 per 100,000 live births in 2000 to 29.5 per 100,000 live births in 2020. Except for Uzbekistan, where this indicator decreased, all Central Asian countries experienced a sharp increase in maternal mortality ratio in 2020. The proportion of indirect causes of maternal deaths in Kazakhstan reached 76.3% in 2020. There is an association between the maternal mortality ratio in Central Asian countries and their total health expenditures expressed in national currency units (r max = -0.89 and min = -0.66, p < 0.01). The study revealed an issue in the health data availability and accessibility for research in the region. The findings suggest that there must be additional efforts from the local authorities to enhance the preparedness of Central Asian healthcare systems for the new public health challenges and to improve health data accessibility.

Variations in Medical Necessity Determinations Across Commercial Insurance Carriers for Prostate Cancer Procedures

PURPOSE

Variation in commercial insurance coverage may lead to disparity in access to quality cancer care. We evaluated commercial insurance coverage determinations to assess the degree of variation across a national sample.

METHODS AND MATERIALS

We identified the predominant carrier of commercial insurance in each state based on the 2020 US Government Accounting Office (GAO-21-34) report on insurance. For each state, publicly available medical policies from January 1, 2021 to January 31, 2021 were analyzed for coverage of 3 widely accepted procedures: hydrogel spacer, fluciclovine- positron emission tomography (PET), and intensity modulated radiation in low volume metastatic prostate cancer.

RESULTS

We analyzed 83 commercial medical policies across 51 states and District of Columbia. There was widespread variation in coverage policy. Hydrogel spacer was determined medically necessary in 9 states, mixed coverage in 8, not medically necessary in 22, and no available public policy in 12. Use of fluciclovine-PET required a minimum prostate specific antigen level of 2 ng/mL in 9 states, 1 ng/mL in 17, any minimum prostate specific antigen in 7, mixed coverage in 12, and no publicly available policy in 6. Intensity modulated radiation in low volume metastatic prostate cancer was medically necessary in 17 states, not necessary in 7, and not stated in 27. Insurance carriers often used external utilization management companies such as AIM-Healthcare and Evicore Healthcare. These determinations were more restrictive than carriers which did not use utilization management.

CONCLUSIONS

Commercial medical policies vary widely in medical necessity determinations for novel prostate cancer treatment procedures that are Food and Drug-approved and covered by Medicare. These data suggest a need for more consistent methodology for medical necessity determination to mitigate the current state where patients have unequal access to cancer procedures due to the location of residence and age.

Association between health care access and food insecurity among lower-income older adults with multiple chronic conditions in Washington State, USA

OBJECTIVE

Lower-income older adults with multiple chronic conditions (MCC) are highly vulnerable to food insecurity. However, few studies have considered how health care access is related to food insecurity among older adults with MCC. The aims of this study were to examine associations between MCC and food insecurity, and, among older adults with MCC, between health care access and food insecurity.

DESIGN

Cross-sectional study data from the 2019 Behavioral Risk Factor Surveillance System survey.

SETTING

Washington State, USA.

PARTICIPANTS

Lower-income adults, aged 50 years or older (n 2118). MCC was defined as having ≥ 2 of 11 possible conditions. Health care access comprised three variables (unable to afford seeing the doctor, no health care coverage and not having a primary care provider (PCP)). Food insecurity was defined as buying food that did not last and not having money to get more.

RESULTS

The overall prevalence of food insecurity was 26·0 % and was 1·50 times greater (95 % CI 1·16, 1·95) among participants with MCC compared to those without MCC. Among those with MCC (n 1580), inability to afford seeing a doctor was associated with food insecurity (prevalence ratio (PR) 1·83; 95 % CI 1·46, 2·28), but not having health insurance (PR 1·49; 95 % CI 0·98, 2·24) and not having a PCP (PR 1·10; 95 % CI 0·77, 1·57) were not.

CONCLUSIONS

Inability to afford healthcare is related to food insecurity among older adults with MCC. Future work should focus on collecting longitudinal data that can clarify the temporal relationship between MCC and food insecurity.

A Mixed-methods Assessment of the Impact of Insurance Issues on the Emotional and Physical Health of Patients With Inflammatory Bowel Disease

BACKGROUND

In patients with inflammatory bowel disease (IBD), failure to adhere to treatment regimens due to insurance issues can lead to disease complications. Our aim was to examine patients' perceptions of the impact of insurance issues on their health.

METHODS

Twenty-nine patients with IBD at a large US academic center and an insurance issue participated in a mixed-methods study. Retrospective chart review and an online questionnaire were completed to collect demographic information, IBD characteristics, and validated resilience scores. Semistructured interviews were completed for insurance experiences, which were coded independently by 2 coders for themes.

RESULTS

Twenty-nine patients completed the interview, and 24 completed the online survey. Sixteen had Crohn's disease, 13 had ulcerative colitis, and 66% were female. The most common insurance issue was lapsed insurance. Many experienced physical consequences, with 58% having flares, 14% undergoing surgery, and 14% developing antibodies. All emotional responses were negative, with the majority feeling stressed (38%). Providers were uninformed of insurance issues in 28% of cases. When asked about perceived resilience, 41% felt incapable of managing the situation, and 45% gave up trying to solve the problem. When asked how to improve going forward, 38% requested an easily accessible advocate to guide them.

CONCLUSIONS

A large proportion of our cohort chose not to inform their provider, felt incapable of managing on their own, and gave up on resolving their insurance issue. This highlights the need to consider restructuring the insurance system, to identify those at risk for insurance issues, and to make advocates available to avoid devastating consequences.

Varied Health Spending Growth Across US States Was Associated With Incomes, Price Levels, And Medicaid Expansion, 2000-19

Little is known about health care spending variation across the US for recent years. To estimate health spending by state and payer, we combined data from the government's State Health Expenditure Accounts, which have estimates through 2014, with other primary data on spending. In 2019 state-specific per person spending ranged from $7,250 to $14,500. After adjustment for inflation, annualized per person spending growth for each state ranged from 1.0 percent in Washington, D.C., to 4.2 percent in South Dakota between 2013 and 2019. The factors that explained the most variation across states were incomes (25.3 percent) and consumer prices (21.7 percent). Medicaid expansion was associated with increases in total spending per person, although the median of spending in expansion states showed slower growth in out-of-pocket spending than the median in nonexpansion states. Contemporary estimates of state health spending are valuable for tracking divergent expenditure trajectories in the US and assessing the associated factors.