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Katzman DK. Understanding Healthcare Inequities in Publicly Insured Youth With Eating Disorders. J Adolesc Health 2024; 74:1061-1063. [PMID: 38762247 DOI: 10.1016/j.jadohealth.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/14/2024] [Accepted: 02/29/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Debra K Katzman
- Division of Adolescent Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; The Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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Goff SL, Shieh MS, Lindenauer PK, Ash AS, Krishnan JA, Geissler KH. Differences in Health Care Utilization for Asthma by Children with Medicaid versus Private Insurance. Popul Health Manag 2024; 27:105-113. [PMID: 38574325 PMCID: PMC11001504 DOI: 10.1089/pop.2023.0244] [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: 04/06/2024] Open
Abstract
Asthma is the most common chronic disease in children, disproportionately affects families with lower incomes, and is a leading reason for acute care visits and hospitalizations. This retrospective cohort study used the Massachusetts All Payer Claims Database (2014-2018) to examine differences in acute care utilization and quality of care for asthma between Medicaid- and privately insured children in Massachusetts. Outcomes included acute care use (emergency department [ED] or hospitalization), ED visits with asthma, routine asthma visits, and filled prescriptions for asthma medications. Multivariable logistic regression was used to account for differences in demographics, ZIP codes, health status, and asthma severity. Overall, 10.0% of Medicaid-insured children and 5.6% of privately insured were classified as having asthma. Among 317,596 child-year observations for children with asthma, 64.4% were insured by Medicaid. Medicaid-insured children had higher rates of any acute care use (50.4% vs. 30.0%) and ED visits with an asthma diagnosis (27.2% vs. 13.3%) compared to privately insured children. Only 65.4% of Medicaid enrollees had at least one routine asthma visit compared to 74.3% of privately insured children. Most children received at least one asthma medication (88.6% Medicaid vs. 83.3% privately insured), but a higher percentage of Medicaid-insured children received at least one rescue medication (84.0% vs. 73.7%), and a lower percentage of Medicaid-insured (46.1% vs. 49.2%) received a controller medication. These results suggest that opportunities for improvement in childhood asthma persist, particularly for children insured by Medicaid.
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Affiliation(s)
- Sarah L. Goff
- Department of Health Promotion and Policy, School of Public Health & Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Meng-Shiou Shieh
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts-Chan Medical School—Baystate, Springfield, Massachusetts, USA
| | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts-Chan Medical School—Baystate, Springfield, Massachusetts, USA
- Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - Arlene S. Ash
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Jerry A. Krishnan
- Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, Illinois, USA
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois Chicago, Chicago, Illinois, USA
- Institute for Healthcare Delivery Design, University of Illinois Chicago, Chicago, Illinois, USA
| | - Kimberley H. Geissler
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts-Chan Medical School—Baystate, Springfield, Massachusetts, USA
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Arakelyan M, Freyleue SD, Schaefer AP, Austin AM, Moen EL, O'Malley AJ, Goodman DC, Leyenaar JK. Rural-urban disparities in health care delivery for children with medical complexity and moderating effects of payer, disability, and community poverty. J Rural Health 2024; 40:326-337. [PMID: 38379187 PMCID: PMC10954394 DOI: 10.1111/jrh.12827] [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: 06/12/2023] [Revised: 11/22/2023] [Accepted: 02/02/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE Children with medical complexity (CMC) may be at increased risk of rural-urban disparities in health care delivery given their multifaceted health care needs, but these disparities are poorly understood. This study evaluated rural-urban disparities in health care delivery to CMC and determined whether Medicaid coverage, co-occurring disability, and community poverty modified the effects of rurality on care delivery. METHODS This retrospective cohort study of 2012-2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire included CMC <18 years. Health care delivery measures (ambulatory clinic visits, emergency department visits, acute care hospitalizations, total hospital days, and receipt of post-acute care) were compared for rural- versus urban-residing CMC in multivariable regression models, following established methods to evaluate effect modification. FINDINGS Of 112,475 CMC, 7307 (6.5%) were rural residing and 105,168 (93.5%) were urban residing. A total of 68.9% had Medicaid coverage, 33.9% had a disability, and 39.7% lived in communities with >20% child poverty. In adjusted analyses, rural-residing CMC received significantly fewer ambulatory visits (risk ratio [RR] = 0.95, 95% confidence interval [CI]: 0.94-0.96), more emergency visits (RR = 1.12, 95% CI: 1.08-1.16), and fewer hospitalization days (RR = 0.90, 95% CI = 0.85-0.96). The estimated modification effects of rural residence by Medicaid coverage, disability, and community poverty were each statistically significant. Differences in the odds of having a hospitalization and receiving post-acute care did not persist after incorporating sociodemographic and clinical characteristics and interaction effects. CONCLUSIONS Rural- and urban-residing CMC differed in their receipt of health care, and Medicaid coverage, co-occurring disabilities, and community poverty modified several of these effects. These modifying effects should be considered in clinical and policy initiatives to ensure that such initiatives do not widen rural-urban disparities.
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Affiliation(s)
- Mary Arakelyan
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Seneca D Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Erika L Moen
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - David C Goodman
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - JoAnna K Leyenaar
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
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Wang CP, Zylberberg HM, Borman ZA, Engelman S, Yanes R, Hirten RP, Sands BE, Cohen BL, Ungaro RC, Rao BB. Impact of Care in an Interdisciplinary Inflammatory Bowel Disease Specialty Clinic on Outcomes in Patients Insured with Medicaid. J Clin Gastroenterol 2023; 57:908-912. [PMID: 36149668 PMCID: PMC10033461 DOI: 10.1097/mcg.0000000000001769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 08/29/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) patients are known to benefit from care delivered in a specialized, interdisciplinary setting. We aimed to evaluate the impact of this model on health outcomes, quality metrics, and health care resource utilization (HRU) in IBD patients insured with Medicaid. MATERIALS AND METHODS In July 2017, IBD patients at our tertiary hospital were transitioned from a fellows' general gastroenterology (GI) clinic to a fellows' interdisciplinary IBD clinic. IBD patients were included if they were insured with Medicaid, had at least 1 visit in the general GI clinic between July 1, 2016 and June 30, 2017, and at least 1 visit between July 1, 2017 and June 30, 2018 in the IBD clinic. Characteristics related to patients' IBD course, overall health care maintenance, and HRU were compared. RESULTS A total of 170 patients (51% male, mean age 39 y) were included. After the transition to the IBD clinic, use of corticosteroids (37% vs. 25%; P =0.004) and combination therapy were significantly lower (55% vs. 38%; P =0.0004), although use of high-dose biologics numerically increased (58.5% vs. 67%; P =0.05). Posttransition, patients showed significantly lower levels of mean C-reactive protein ( P =0.04). After the transition, patients attended significantly fewer outpatient GI visits ( P =0.0008) but were more often seen by other health care specialists ( P =0.0003), and experienced a numeric decrease in HRU with fewer emergency department visits, hospitalizations, and surgeries. CONCLUSIONS Care in an interdisciplinary, IBD specialty setting is associated with significantly decreased corticosteroid use, decreased C-reactive protein levels, and improved access to ancillary services in Medicaid patients.
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Affiliation(s)
| | - Haley M Zylberberg
- Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | | | | | | | | | | | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH 44195
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Correa-Agudelo E, Ding L, Beck AF, Brokamp C, Altaye M, Kahn RS, Mersha TB. Understanding racial disparities in childhood asthma using individual- and neighborhood-level risk factors. J Allergy Clin Immunol 2022; 150:1427-1436.e5. [PMID: 35970309 PMCID: PMC9887733 DOI: 10.1016/j.jaci.2022.07.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/16/2022] [Accepted: 07/11/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Racial disparities in childhood asthma outcomes result from a complex interplay of individual- and neighborhood-level factors. OBJECTIVES We sought to examine racial disparities in asthma-related emergency department (ED) visits between African American (AA) and European American (EA) children. METHODS This is a retrospective study of patients younger than 18 years who visited the ED at Cincinnati Children's for asthma from 2009 to 2018. The outcome was number of ED visits during a year. We assessed 11 social, economic, and environmental variables. Mediation and mixed-effects analyses were used to assess relationships between race, mediators, and number of ED visits. RESULTS A total of 31,114 children (46.1% AA, 53.9% EA) had 186,779 asthma-related ED visits. AA children had more visits per year than EA children (2.23 vs 2.15; P < .001). Medicaid insurance was associated with a 7% increase in rate of ED visits compared with commercial insurance (1.07; 95% CI, 1.03-1.1). Neighborhood socioeconomic deprivation was associated with an increased rate of ED visits in AA but not in EA children. Area-level particulate matter with diameter less than 2.5 μm, pollen, and outdoor mold were associated with an increased rate of ED visits for both AA and EA children (all P < .001). Associations between race and number of ED visits were mediated by insurance, area-level deprivation, particulate matter with diameter less than 2.5 μm, and outdoor mold (all P < .001), altogether accounting for 55% of the effect of race on ED visits. Race was not associated with number of ED visits (P = .796) after accounting for mediators. CONCLUSIONS Racial disparities in asthma-related ED visits are mediated by social, economic, and environmental factors, which may be amenable to interventions aimed at improving outcomes and eliminating inequities.
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Affiliation(s)
- Esteban Correa-Agudelo
- Divisions of Asthma Research, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Lili Ding
- Divisions of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Andrew F Beck
- Divisions of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio; Divisions of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Cole Brokamp
- Divisions of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Mekibib Altaye
- Divisions of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Robert S Kahn
- Divisions of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Tesfaye B Mersha
- Divisions of Asthma Research, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio.
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Molino AR, Minnick MLG, Jerry-Fluker J, Karita Muiru J, Boynton SA, Furth SL, Warady BA, Ng DK. Health and Dental Insurance and Health Care Utilization Among Children, Adolescents, and Young Adults With CKD: Findings From the CKiD Cohort Study. Kidney Med 2022; 4:100455. [PMID: 35518833 PMCID: PMC9062328 DOI: 10.1016/j.xkme.2022.100455] [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] [Indexed: 11/05/2022] Open
Abstract
Rationale & Objective To understand the association between health and dental insurance status and health and dental care utilization, and their relationship with disease severity in a population with childhood-onset chronic kidney disease (CKD). Study Design Observational cohort study. Settings & Participants Nine hundred fifty-three participants contributing 4,369 person-visits (unit of analysis) in the United States enrolled in the Chronic Kidney Disease in Children (CKiD) Study from 2005 to 2019. Exposures Health insurance (private vs public vs none) and dental insurance (presence vs absence) self-reported at annual visits. Outcomes Self-reported suboptimal health care utilization in the past year, defined separately as not visiting a private physician, visiting the emergency room, visiting the emergency room at least twice, being hospitalized, and self-reported suboptimal dental care utilization over the past year, defined as not receiving dental care. Analytical Approach Repeated measures Poisson regression models were fit to estimate and compare utilization by insurance type and disease severity at the prior visit. Additional unadjusted and adjusted models were fit, as well as models including interactions between insurance and Black race, maternal education, and income. Results Those with public health insurance were more likely to report suboptimal health care utilization across the CKD severity spectrum, and lack of dental insurance was strongly associated with lack of dental care. These relationships varied depending on strata of socioeconomic status and race but the effect measure modification was not significant. Limitations Details of insurance coverage were unavailable; reasons for emergency care or type of private physician visited were unknown. Conclusions Pediatric nephrology programs may consider interventions to help direct supportive resources to families with public insurance who are at higher risk for suboptimal utilization of care. Insurance providers should identify areas to expand access for families of children with CKD.
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Affiliation(s)
- Andrea R. Molino
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria Lourdes G. Minnick
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Judith Jerry-Fluker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jacqueline Karita Muiru
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sara A. Boynton
- Department of Pediatrics, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Susan L. Furth
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Bradley A. Warady
- Department of Pediatrics, Division of Nephrology, Children’s Mercy Kansas City, Kansas City, MO
| | - Derek K. Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Chronic Kidney Disease in Children Study
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pediatrics, Division of Nephrology, Children’s Mercy Kansas City, Kansas City, MO
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Afolabi T, Fairman KA. Association of Asthma Exacerbation Risk and Physician Time Expenditure With Provision of Asthma Action Plans and Education for Pediatric Patients. J Pediatr Pharmacol Ther 2022; 27:244-253. [PMID: 35350158 DOI: 10.5863/1551-6776-27.3.244] [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: 04/30/2021] [Accepted: 07/14/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To provide information about factors underlying provision of asthma action plans (AAPs) to a minority of pediatric patients with asthma, assess whether risk of exacerbation acts on provision of AAP and asthma education directly, suggesting targeting to highest-risk patients, or indirectly by influencing physician-patient interaction time. METHODS This study was a retrospective cross-sectional analysis of a nationally representative sample of physician office visits that consisted of patients aged 2 to 18 years with asthma. Exacerbation risk comprised proxy indicators of control and severity. Direct and time-mediated effects of exacerbation risk on provision of AAP and education were calculated from logistic regression models. RESULTS Asthma action plans were provided in 14.3% of visits, education in 23.9%. Total direct effects of exacerbation risk (ORs = 3.88-4.69) far exceeded indirect, time-mediated effects (both ORs = 1.03) on AAPs. Direct effects on education were similar but smaller. After adjusting for risk, physician time expenditure of ≥30 minutes was associated with nearly doubled odds of providing AAP or education (ORs = 1.90-1.99). Visits that included allied health professionals alongside physician care were significantly associated with all 4 outcomes in multivariate analyses (ORs = 3.06-5.28). CONCLUSIONS Exacerbation risk has a strong, direct association with AAP provision in pediatric asthma, even controlling for physician time expenditure. Provision of AAP and education to pediatric patients with asthma may be facilitated by increasing available time for office visits and involving allied health professionals.
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Affiliation(s)
- Titilola Afolabi
- Midwestern University College of Pharmacy-Glendale (TA, KAF), Glendale, AZ.,Phoenix Children's Hospital (TA), Phoenix, AZ
| | - Kathleen A Fairman
- Midwestern University College of Pharmacy-Glendale (TA, KAF), Glendale, AZ
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Mayfield CA, Geraci M, Dulin M, Eberth JM, Merchant AT. Social and demographic characteristics of frequent or high-charge emergency department users: A quantile regression application. J Eval Clin Pract 2021; 27:1271-1280. [PMID: 33511747 DOI: 10.1111/jep.13537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Heavy users of the emergency department (ED) are a heterogeneous population. Few studies have captured the social and demographic complexity of patients with the largest burden of ED use. Our objective was to model associations between social and demographic patient characteristics and quantiles of the distributions of ED use, defined as frequent and high-charge. METHODS We conducted a cross-sectional analysis of electronic health and billing records of 99 637 adults residing in an urban North Carolina county who visited an ED within Atrium Health, a large integrated health care system, in 2017. Mid-quantile and standard quantile regression models were used for count and continuous responses, respectively. Frequent and high-charge use outcomes were defined as the median (0.50) and upper quantiles (0.75, 0.95, 0.99) of the outcome distributions for total billed ED visits and associated charges during the study period. Patient characteristic predictors were: insurance coverage (Medicaid, Medicare, private, uninsured), total visits to ambulatory care during the study period (0, 1, >1), and patient demographics: age, gender, race, ethnicity, and living in an underprivileged community called a public health priority area (PHPA). RESULTS Results showed heterogeneous relationships that were stronger at higher quantiles. Having Medicaid or Medicare insurance was positively associated with ED visits and ED charges at most quantiles. Racial and geographic disparities were observed. Black patients had more ED visits and lower ED charges than their White counterparts at most quantiles of the outcome distributions. Patients living in PHPAs, had lower charges than their counterparts at the median but higher charges at the 0.95 and 0.99 quantiles. CONCLUSIONS The relationships between patient characteristics and frequent and high-charge use of the ED vary based on the level of use. These findings can be used to inform targeted interventions, tailored policy, and population health management initiatives.
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Affiliation(s)
- Carlene A Mayfield
- Department of Community Health, Atrium Health, Charlotte, North Carolina, USA
| | - Marco Geraci
- MEMOTEF Department, School of Economics, Sapienza, University of Rome, Rome, Italy.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Michael Dulin
- Academy for Population Health Innovation, University of North Carolina Charlotte and Mecklenburg County Health Department, Charlotte, North Carolina, USA
| | - Jan M Eberth
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,Rural and Minority Health Research Center, University of South Carolina, Arnold School of Public Health, Columbia, South Carolina, USA
| | - Anwar T Merchant
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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Redmond C, Akinoso-Imran AQ, Heaney LG, Sheikh A, Kee F, Busby J. Socioeconomic disparities in asthma health care utilization, exacerbations, and mortality: A systematic review and meta-analysis. J Allergy Clin Immunol 2021; 149:1617-1627. [PMID: 34673047 DOI: 10.1016/j.jaci.2021.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prior studies investigating the effect of socioeconomic status (SES) on asthma health care outcomes have been heterogeneous in the populations studied and methodologies used. OBJECTIVE We sought to systematically synthesize evidence investigating the impact of SES on asthma health care utilization, exacerbations, and mortality. METHODS We searched Embase, Medline, and Web of Science for studies reporting differences in primary care attendance, exacerbations, emergency department attendance, hospitalization, ventilation/intubation, readmission, and asthma mortality by SES. Study quality was assessed using the Newcastle Ottawa Scale, and meta-analyses were conducted using random-effects models. We conducted several prespecified subgroup analyses, including by health care system (insurance based vs universal government funded) and time period (before vs after 2010). RESULTS A total of 61 studies, comprising 1,145,704 patients, were included. Lower SES was consistently associated with increased secondary health care utilization including emergency department attendance (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), hospitalization (OR, 1.63; 95% CI, 1.34-1.99), and readmission (OR, 1.31; 95% CI, 1.19-1.44). Substantial associations were also found between SES and ventilation/intubation (OR, 1.76; 95% CI, 1.13-2.73), although there was no association with primary care attendances (OR, 0.79; 95% CI, 0.51-1.24). We found evidence of borderline significance for increased exacerbations (OR, 1.18; 95% CI, 0.98-1.42) and mortality (OR, 1.12; 95% CI, 0.92-1.37) among more deprived groups. There was no convincing evidence that disparities were associated with country-level health care funding models or that disparities have narrowed over time. CONCLUSIONS Patients with a lower SES have substantially increased secondary care health care utilization. We found evidence suggestive of increased exacerbations and mortality risk, although CIs were wide. These disparities have been consistently reported worldwide, including within countries offering universally funded health care systems. Systematic review registration: CRD42020173544.
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Affiliation(s)
- Charlene Redmond
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, United Kingdom
| | - Abdul Qadr Akinoso-Imran
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, United Kingdom
| | - Liam G Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, United Kingdom
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Frank Kee
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, United Kingdom
| | - John Busby
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, United Kingdom.
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10
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Marye S. Health insurance, pediatric asthma, and emergency department usage. Public Health Nurs 2021; 38:931-940. [PMID: 34020508 DOI: 10.1111/phn.12926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/23/2021] [Accepted: 04/23/2021] [Indexed: 11/28/2022]
Abstract
This study synthesized current research on the relationships between type of insurance and emergency department usage for children with asthma in the United States. Thematic analysis is in the context of the Affordable Care Act (ACA). A systematic mapping review yielded 20 articles published in the last 10 years on topics of insurance, emergency department usage, and pediatric asthma. Analysis indicates continued trends of increased emergency department use among asthmatic children since enactment of the ACA, running counter to the goal of fiscal efficiency for the healthcare system and reduction of health inequities. Barriers to care persist, particularly among communities of color, despite provisions to improve access to primary and preventive care. Inadequate access to primary care is associated with poor adherence among asthmatic children with public insurance. Those with health insurance through their parents' employer experience barriers due to cost-sharing expenses. This leads to increased asthma severity and low medication adherence, resulting in the need for emergency care. A disconnect between increased health insurance coverage and utilization of primary care in some populations implies unmet service needs that warrant further investigation. Findings inform policymakers and public health leaders of persistent health inequities resulting in preventable emergency department usage.
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DeGuzman PB, Huang G, Lyons G, Snitzer J, Keim-Malpass J. Rural Disparities in Early Childhood Well Child Visit Attendance. J Pediatr Nurs 2021; 58:76-81. [PMID: 33370620 DOI: 10.1016/j.pedn.2020.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Children should attend well child visits (WCVs) during early childhood so that developmental disorders may be identified as early as possible, so treatment can begin. The aim of this research was to determine if rurality impacts access to WCV during early childhood, and if altering rurality measurement methods impacts outcomes. DESIGN AND METHODS We utilized a longitudinal correlational design with early childhood data gathered from the Virginia All Payer Claims Database, which contains claims data from Medicaid and the majority of Virginia commercial insurance payers (n = 6349). WCV attendance was evaluated against three rurality metrics: a traditional metric using Rural-Urban Commuting Area codes, a developed land variable, and a distance to care variable, at a zip code level. RESULTS Two of the rurality methods revealed that rural children attend fewer WCVs than their urban counterparts, (67% vs. 50% respectively, using a traditional metric; and a 0.035 increase in WCV attendance for every percent increase in developed land). Differences were attenuated by insurance payer; children with Medicaid attend fewer WCVs than those with private insurance. CONCLUSIONS Young children in rural Virginia attend fewer WCVs than their non-rural counterparts, placing them at higher risk for missing timely developmental disorder screenings. The coronavirus disease pandemic has been associated with an abrupt and significant reduction in vaccination rates, which likely indicates fewer WCVs and concomitant developmental screenings. Pediatric nurses should encourage families of young children to develop a plan for continued WCVs, so that early identification of developmental disorders can be achieved.
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Affiliation(s)
- Pamela B DeGuzman
- University of Virginia School of Nursing, VA, United States of America.
| | - Guoping Huang
- University of Virginia School of Architecture, Department of Urban and Environmental Planning, United States of America
| | - Genevieve Lyons
- University of Virginia School of Medicine, Department of Public Health Sciences, United States of America
| | - Joseph Snitzer
- University of Virginia School of Architecture, Department of Urban and Environmental Planning, United States of America
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12
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Tejwani V, Chang HY, Tran AP, Naber JA, Gutzwiller FS, Winders TA, Khurana S, Sumino K, Mosnaim G, Moloney RM. A multistakeholder Delphi consensus core outcome set for clinical trials in moderate-to-severe asthma (coreASTHMA). Ann Allergy Asthma Immunol 2021; 127:116-122.e7. [PMID: 33781936 DOI: 10.1016/j.anai.2021.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/09/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Treatments for long-term control of asthma have improved and include a promising but expensive class of biologic therapies. However, the clinical trials evaluating these and other novel treatments have used a variety of different outcomes to evaluate efficacy. The evolution of asthma care calls for a re-examination of outcomes that are most important to patients and other stakeholders. OBJECTIVE To develop a core set of outcomes to be measured in phase 3 and phase 4 clinical drug trials in patients with moderate-to-severe asthma. METHODS We used a robust and in-depth multistakeholder consensus process bringing together patients, clinicians, regulators, payers, health technology assessors, researchers, and product developers to reach consensus on outcomes. We used a modified Delphi method to reach consensus, an approach adapted from the Core Outcome Measures in Effectiveness Trials Initiative aligned with contemporary methodological standards for core outcome set development. RESULTS The following outcomes were included in the final core set: severe asthma exacerbation, change in asthma control, asthma-specific or severe asthma-specific quality of life, asthma-specific hospital stay (ie, >24-hour stays at any level of care) or admission, and asthma-specific emergency department visit. CONCLUSION These 5 outcomes represent a minimum set of core outcomes for use in phase 3 and phase 4 clinical drug trials in moderate-to-severe asthma. Consistent collection of these outcomes as minimum, independent of whether additional heterogeneous primary or secondary outcomes are included, will allow for meaningful comparisons of the effect of asthma therapies across clinical trials.
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Affiliation(s)
- Vickram Tejwani
- Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland.
| | | | - Annie P Tran
- Center for Medical Technology Policy, Baltimore, Maryland
| | | | | | | | - Sandhya Khurana
- Pulmonary and Critical Care Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Kaharu Sumino
- Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Giselle Mosnaim
- Pulmonary, Allergy and Critical Care, NorthShore University HealthSystem, Evanston, Illinois
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13
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Chang JC, Knight AM, Lawson EF. Patterns of Healthcare Use and Medication Adherence among Youth with Systemic Lupus Erythematosus during Transfer from Pediatric to Adult Care. J Rheumatol 2021; 48:105-113. [PMID: 32007936 DOI: 10.3899/jrheum.191029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Youth with systemic lupus erythematosus (SLE) transferring from pediatric to adult care are at risk for poor outcomes. We describe patterns of rheumatology/nephrology care and changes in healthcare use and medication adherence during transfer. METHODS We identified youth ages 15-25 with SLE using US private insurance claims from Optum's deidentified Clinformatics Data Mart. Rheumatology/nephrology visit patterns were categorized as (1) unilateral transfers to adult care within 12 months, (2) overlapping pediatric and adult visits, (3) lost to followup, or (4) continuing pediatric care. We used negative binomial regression and paired t tests to estimate changes in healthcare use and medication possession ratios (MPR) after the last pediatric (index) visit. We compared MPR between youth who transferred and age-matched peers continuing pediatric care. RESULTS Of the 184 youth transferred out of pediatric care, 41.8% transferred unilaterally, 31.5% had overlapping visits over a median of 12 months before final transfer, and 26.6% were lost to followup. We matched 107 youth continuing pediatric care. Overall, ambulatory care use decreased among those lost to followup. Acute care use decreased across all groups. MPR after the index date were lower in youth lost to followup (mean 0.24) compared to peers in pediatric care (mean 0.57, p < 0.001). CONCLUSION Youth with SLE with continuous private insurance coverage do not use more acute care after transfer to adult care. However, a substantial proportion fail to see adult subspecialists within 12 months and have worse medication adherence, placing them at higher risk for adverse outcomes.
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Affiliation(s)
- Joyce C Chang
- J.C. Chang, MD, MSCE, Division of Rheumatology, and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA;
| | - Andrea M Knight
- A.M. Knight, MD, MSCE, Division of Rheumatology, and SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Erica F Lawson
- E.F. Lawson, MD, Division of Rheumatology, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
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14
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Mahesri M, Schneeweiss S, Globe D, Mutebi A, Bohn R, Achebe M, Levin R, Desai RJ. Clinical outcomes following bone marrow transplantation in patients with sickle cell disease: A cohort study of US Medicaid enrollees. Eur J Haematol 2020; 106:273-280. [PMID: 33155319 DOI: 10.1111/ejh.13546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Bone marrow transplantation (BMT) is currently the only curative therapy available for patients with sickle cell disease (SCD), but clinical outcomes in routine care are not well understood. We describe the rates of vaso-occlusive crises (VOCs), transplant complications, and mortality in SCD patients after BMT. METHODS A cohort study of SCD patients who underwent BMT was designed using US Medicaid claims data (2000-2013). RESULTS A total of 204 SCD patients undergoing BMT were identified with a mean (SD) age of 10.6 (7.3) years, with 52.9% male and 67.6% African American. The overall VOC rate was 0.99 per person-year (95% CI: 0.91-1.07) over a median follow-up time of 2.1 years (IQR: 0.8-4.3 years). A total of 138 (67.6%) remained free of VOCs. The mortality rate was 1.7 (95% CI: 0.9-3.1) per 100 person-years, transplant-related complications occurred among 113 (55.4%) patients with an incidence rate of 38.2 (95% CI: 31.7-45.9) per 100 person-years, while 47 (23%) patients had GvHD with an incidence rate of 8.0 (95% CI: 6.0-10.7) per 100 person-years. CONCLUSION Two thirds of the BMT recipients remained VOC-free over 2 years of follow-up, but transplant-related complications, including GvHD occurred with high frequency. This highlights a continuing unmet need for alternative curative interventions in SCD.
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Affiliation(s)
- Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | | | - Alex Mutebi
- Vertex Pharmaceuticals Inc., Boston, MA, USA
| | | | - Maureen Achebe
- Hematology Division, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
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15
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Bozigar M, Lawson AB, Pearce JL, King K, Svendsen ER. A Bayesian spatio-temporal analysis of neighborhood pediatric asthma emergency department visit disparities. Health Place 2020; 66:102426. [PMID: 33011491 DOI: 10.1016/j.healthplace.2020.102426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/17/2020] [Accepted: 08/17/2020] [Indexed: 11/25/2022]
Abstract
Asthma disparities have complex, neighborhood-level drivers that are not well understood. Consequently, identifying particular contextual factors that contribute to disparities is a public health goal. We study pediatric asthma emergency department (ED) visit disparities and neighborhood factors associated with them in South Carolina (SC) census tracts from 1999 to 2015. Leveraging a Bayesian framework, we identify risk clusters, spatially-varying relationships, and risk percentile-specific associations. Clusters of high risk occur in both rural and urban census tracts with high probability, with neighborhood-specific associations suggesting unique risk factors for each locale. Bayesian methods can help clarify the neighborhood drivers of health disparities.
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Affiliation(s)
- Matthew Bozigar
- Division of Epidemiology, Department of Public Health Sciences, College of Graduate Studies, Medical University of South Carolina, Charleston, SC, United States.
| | - Andrew B Lawson
- Division of Biostatistics, Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - John L Pearce
- Division of Environmental Health, Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Kathryn King
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, SC, United States; School-Based Health, Center for Telehealth, Medical University of South Carolina, Charleston, SC, United States.
| | - Erik R Svendsen
- Division of Environmental Health, Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
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16
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Desai RJ, Mahesri M, Globe D, Mutebi A, Bohn R, Achebe M, Levin R, Schneeweiss S. Clinical outcomes and healthcare utilization in patients with sickle cell disease: a nationwide cohort study of Medicaid beneficiaries. Ann Hematol 2020; 99:2497-2505. [DOI: 10.1007/s00277-020-04233-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023]
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Lack S, Kinser PA. The modification of three vulnerability theories to assist nursing practice for school-age children with severe asthma. J SPEC PEDIATR NURS 2020; 25:e12280. [PMID: 31749322 DOI: 10.1111/jspn.12280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/01/2019] [Accepted: 11/06/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE Severe asthma is an inflammatory illness associated with adverse health outcomes and behaviors in children, such as decreased quality of life, impaired sleep, and increased medical costs and morbidity. CONCLUSIONS Children with severe asthma frequently exhibit a cycle of health and behaviors which contribute to these adverse health outcomes, consisting of decreased physical activity, increased stress, and increased airway inflammation and asthma exacerbations. School-age children, in particular, are a vulnerable population because they not only rely on others for their care but also suffer from a chronic illness and are at risk for unequal healthcare access and health outcomes. PRACTICE IMPLICATIONS Currently, there is no one nursing theory that adequately addresses the vulnerability, cycle of health and behaviors, and adverse health outcomes of children with severe asthma. By integrating key concepts from three vulnerability theories and presenting a modified conceptual framework, this paper aims to demonstrate how the use of this new conceptual framework may assist nurses in evaluating the unique needs of school-age children with severe asthma to provide best practices and develop appropriate interventions.
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Affiliation(s)
- Sharon Lack
- School of Nursing, Virginia Commonwealth University, Richmond, Virginia
| | - Patricia A Kinser
- School of Nursing, Virginia Commonwealth University, Richmond, Virginia
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18
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Axelrad JE, Sharma R, Laszkowska M, Packey C, Rosenberg R, Lebwohl B. Increased Healthcare Utilization by Patients With Inflammatory Bowel Disease Covered by Medicaid at a Tertiary Care Center. Inflamm Bowel Dis 2019; 25:1711-1717. [PMID: 30989212 PMCID: PMC7327156 DOI: 10.1093/ibd/izz060] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Low socioeconomic status has been linked with numerous poor health outcomes, but data are limited regarding the impact of insurance status on inflammatory bowel disease (IBD) outcomes. We aimed to characterize utilization of healthcare resources by IBD patients based on health insurance status, using Medicaid enrollment as a proxy for low socioeconomic status. METHODS We retrospectively identified adult patients with IBD engaged in a colorectal cancer surveillance colonoscopy program from July 2007 to June 2017. Our primary outcomes included emergency department (ED) visits, inpatient hospitalizations, biologic infusions, and steroid exposure, stratified by insurance status. We compared patients who had ever been enrolled in Medicaid with all other patients. RESULTS Of 947 patients with IBD, 221 (23%) had been enrolled in Medicaid. Compared with patients with other insurance types, patients with Medicaid had higher rates of ever being admitted to the hospital (77.6% vs 42.6%, P < 0.0001) or visiting the ED (90.5% vs 38.4%, P < 0.0001). When adjusted for sex, age at first colonoscopy, and ethnicity, patients with Medicaid had a higher rate of inpatient hospitalizations (Rate ratio [RR] 2.95; 95% CI 2.59-3.36) and ED visits (RR 4.24; 95% CI 3.82-4.70) compared to patients with other insurance. Patients with Medicaid had significantly higher prevalence of requiring steroids (62.4% vs 37.7%, P < 0.0001), and after adjusting for the same factors, the odds of requiring steroids in the patients with Medicaid was increased (OR 3.77; 95% CI 2.53-5.62). CONCLUSIONS Medicaid insurance was a significant predictor of IBD care and outcomes. Patients with Medicaid may have less engagement in IBD care and seek emergency care more often.
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Affiliation(s)
- Jordan E Axelrad
- Inflammatory Bowel Disease Center, Division of Gastroenterology, NYU Langone Health, New York, USA
| | - Rajani Sharma
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA,Address correspondence to: Rajani Sharma, MD, 630 West 168 Street, Box 83, P&S 3 Floor, Room 3–401, New York, NY 10032 ()
| | - Monika Laszkowska
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA
| | - Christopher Packey
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA
| | - Richard Rosenberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, USA
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Fishman E, Crawford G, DeVries A, Hackell J, Haynes K, Helm M, Wall E, Agiro A. Association between early-childhood antibiotic exposure and subsequent asthma in the US Medicaid population. Ann Allergy Asthma Immunol 2019; 123:186-192.e9. [PMID: 31158472 DOI: 10.1016/j.anai.2019.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/16/2019] [Accepted: 05/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although socioeconomically disadvantaged children have an increased risk of asthma, the association between early-childhood antibiotics and the incidence of asthma among such children has had limited study. OBJECTIVE To examine the association between antibiotic fills in the first 2 years of life and risk of developing asthma among children enrolled in Medicaid plans. METHODS This retrospective cohort study of children with continuous medical and pharmacy coverage from birth to 2.5 years of age was performed from July 1, 2012, to November 31, 2018. We excluded children with a diagnosis of asthma before 2.5 years of age. Hazard ratios (HRs) and 95% CIs were estimated from Cox proportional hazards regression models. Covariates included sex, preterm birth, cesarean delivery, and mother's asthma status. RESULTS There were 79,582 children in the study cohort of whom 29,931 (37.6%) had 0 antibiotic prescriptions filled, 27,403 (34.4%) had 1 or 2 prescriptions filled, and 22,248 (28.0%) had 3 or more prescriptions filled. A total of 2381 new cases of asthma were observed in 89,545 person-years of follow-up. After adjustment, receipt of 1 or 2 antibiotics was associated with an increased risk of developing asthma, relative to 0 antibiotics (HR, 1.34; 95% CI, 1.21-1.49), and receipt of 3 or more antibiotics was associated with greater increased risk relative to 0 antibiotics (HR, 1.71; 95% CI, 1.54-1.90). After adjustment, the absolute risk of developing asthma by age 4.0 years increased from 2.7% (0 antibiotics) to 3.6% (1-2 antibiotics) and 4.5% (≥3 antibiotics). CONCLUSION Antibiotic prescriptions filled in the first 2 years of life were associated with an increased risk of asthma diagnosis from 2.5 to 5 years of age in a Medicaid population.
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Affiliation(s)
| | | | | | | | | | - Mark Helm
- Childhood Health Associates of Salem, Salem, Oregon
| | - Eric Wall
- University of Washington Neighborhood Clinics, Seattle, Washington
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20
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Lee AS, McGarry L, Bowen DK, Tasian GE. Patient Characteristics Associated With Completion of 24-hour Urine Analyses Among Children and Adolescents With Nephrolithiasis. Urology 2019; 127:102-106. [PMID: 30796989 DOI: 10.1016/j.urology.2019.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/01/2019] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To inform the development of strategies to improve adherence to guidelines, we sought to identify characteristics of pediatric patients with nephrolithiasis associated with completing 24-hour urine analyses. MATERIALS AND METHODS We performed a retrospective cohort study of patients with nephrolithiasis aged 3-18years treated in a large pediatric healthcare system from May 2012 to May 2017. Multivariable Cox models were fit to estimate the association between patient characteristics and completion of a 24-hour urine analysis. RESULTS Among 623 patients, 317 (50.9%) completed a 24-hour urine collection. Median age was 14.4years (interquartile range [IQR] 10.5, 16.3). In adjusted analyses, age at diagnosis (hazard ratio [HR] 1.03; 95% confidence interval [CI] 1.01-1.07), renal colic on presentation (HR 1.72; 95% CI 1.15-2.58), and family history of nephrolithiasis (HR 1.50; 95% CI 1.17-1.93) were associated with an increased likelihood of completion of a 24-hour urine. Public/government assistance insurance (HR 0.68; 95% CI 0.48-0.96) was associated with decreased likelihood of completing a 24-hour urine. CONCLUSION Patients who had prior painful experiences with stones (renal colic), and potential better understanding of nephrolithiasis (family history, older age on presentation) were more likely to complete a 24-hour urine. Those patients with public insurance/government assistance were less likely to complete a 24-hour urine. These results can be used to develop strategies to improve pediatric patients' adherence to completing 24-hour urine collections.
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Affiliation(s)
- Albert S Lee
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA
| | - Laura McGarry
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA
| | - Diana K Bowen
- Division of Urology, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gregory E Tasian
- Department of Surgery, Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.
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Perry R, Braileanu G, Palmer T, Stevens P. The Economic Burden of Pediatric Asthma in the United States: Literature Review of Current Evidence. PHARMACOECONOMICS 2019; 37:155-167. [PMID: 30315512 PMCID: PMC6386052 DOI: 10.1007/s40273-018-0726-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Asthma is a chronic respiratory disease that is widespread throughout the US population and disproportionately affects children. This literature review aimed to identify recent information regarding the economic burden of pediatric asthma in the US. MEDLINE, EMBASE, Econlit, and PsycINFO databases and gray literature sources were searched from January 2012 to January 2018 to capture relevant publications. Publications reporting on healthcare resource utilization and/or healthcare costs of pediatric asthma were included (n = 8). Total direct costs of pediatric asthma were US$5.92 billion in 2013. Average annual costs per child ranged from US$3076 to US$13612. Across studies, pharmacy (US$1027-2120), inpatient (US$337-2016) and outpatient (US$1049-8039) costs were the primary contributors to healthcare costs. Inpatient and emergency department (ED) visits exerted a high economic burden. For instance, the national annual cost of asthma-related hospitalizations was estimated at US$1.59 billion in 2009, while estimates of costs-per-hospitalization (2010) and charges-per-discharge (2009) were US$3600 and US$8406, respectively. The total cost of ED visits to Medicaid was estimated at US$272 million in 2010. In a mixed-insurance population, ED cost estimates ranged from US$152 to US$172 annually per patient. Invariably, costs for children with asthma were significantly greater than for children without. Pediatric asthma imposes a significant economic burden to the US healthcare system. Children with asthma have significantly higher healthcare resource utilization and costs than children without asthma.
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Affiliation(s)
| | | | | | - Paul Stevens
- OMRON Healthcare Europe B.V., Hoofddorp, The Netherlands.
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22
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Pan IW, Lam S, Clarke DF, Shih YCT. Insurance transitions and healthcare utilization for children with refractory epilepsy. Epilepsy Behav 2018; 89:48-54. [PMID: 30384099 DOI: 10.1016/j.yebeh.2018.09.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/27/2018] [Accepted: 09/27/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of the study is to investigate the association between insurance transitions and healthcare utilization among children with refractory epilepsy. METHODS We applied published algorithms to identify the study cohort of children with a diagnosis of refractory epilepsy who were treated between 10/1/2013 and 9/30/2014 at 36 children's hospitals in the United States. Insurance transition was defined as having any change in the type of primary payer from the first date of diagnosis to the date of the last visit at the same hospital. Univariate and multilevel multivariable analytical methods were used in the study. RESULTS Among 3488 children hospitalized with refractory epilepsy, rates of insurance transitions at 1, 2, and 5 years of refractory epilepsy diagnosis were 8.1%, 14%, and 29.9%, respectively. Patients whose primary payer at diagnosis was Private or Others were more likely to experience insurance transitions than patients whose primary payer was Medicaid. Younger children were associated with a higher risk of insurance transitions than older children. The high intensity of insurance transitions was associated with a higher number of emergency department and inpatient visits. CONCLUSIONS Insurance transitions interrupted the continuity of medical care for children with refractory epilepsy and were associated with more frequent hospitalizations and emergency department visits, which then translated to higher healthcare costs. Medicaid provided stable insurance coverage and is critically important for these patients and should be the main focus for policies aiming to minimize insurance transitions and optimize healthcare delivery.
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Affiliation(s)
- I-Wen Pan
- Baylor College of Medicine, Department of Neurosurgery, 7200 Cambridge St, Houston, TX 77030, United States of America; Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St, Houston, TX 77030, United States of America.
| | - Sandi Lam
- Baylor College of Medicine, Department of Neurosurgery, 7200 Cambridge St, Houston, TX 77030, United States of America; Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St, Houston, TX 77030, United States of America.
| | - Dave Fitzgerald Clarke
- Baylor College of Medicine, Department of Pediatrics, Neurology and Developmental Neuroscience Section, 6701 Fannin St, Houston, TX 77030, United States of America; Texas Children's Hospital, Department of Neurology, Epilepsy Center, 6701 Fannin St, Houston, TX 77030, United States of America.
| | - Ya-Chen Tina Shih
- University of Texas MD Anderson Cancer Center, Department of Health Services Research, 1155 Pressler St., Houston, TX 77030, United States of America.
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Chen AJ, Hwang V, Law PY, Stewart JM, Chao DL. Factors Associated with Non-compliance for Diabetic Retinopathy Follow-up in an Urban Safety-Net Hospital. Ophthalmic Epidemiol 2018; 25:443-450. [PMID: 30081686 DOI: 10.1080/09286586.2018.1504311] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE Diabetic retinopathy (DR) is the leading cause of preventable blindness in working-aged adults, and compliance in ophthalmic follow-up appointments is critical to prevent vision loss. However, barriers to follow-up care have not been well studied, especially in socio-economically disadvantaged groups. We investigated the risk factors for non-compliance to DR follow-up appointments in a safety-net county hospital. METHODS Two hundred and nine patients who were treated for DR at the Zuckerberg San Francisco General Hospital retina clinic between 1 July 2015 and 30 January 2016 were enrolled in the study. Multivariate logistic regression analysis of demographic and medical information was used to determine independent risk factors for non-compliance to DR follow-up appointments. RESULTS The mean patient age was 58 years. Sixty-three percent (132/209) of patients were male; the mean haemoglobin A1c level was 8.5 (SD 0.14). Forty-six percent (97/209) of patients attended <80% of their DR follow-up appoinments. Independent risk factors for non-compliance after multivariate logistic regression analysis were diabetic foot involvement [OR: 2.40, 95% CI: (1.04-5.55)] and foot/kidney involvement [OR: 3.79 (1.35-10.5)], history of major depressive disorder (MDD) [OR: 2.11 (1.05-4.26), and having Medi-Cal [OR: 5.01 (2.00-12.5)] or SF Health insurance [OR: 6.79 (2.14-21.5)]. CONCLUSIONS AND RELEVANCE In conclusion, this is the first study to identify diabetic end organ damage and MDD as independent risk factors for non-compliance in DR follow-up appointments. It is important that health care providers identify these patient subsets and increase efforts to more deliberately encourage follow-up in these high-risk patient groups for DR.
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Affiliation(s)
- Allison J Chen
- a Shiley Eye Institute, Department of Ophthalmology , University of California , San Diego , California , USA
| | - Vicky Hwang
- b Department of Ophthalmology , University of California , San Francisco , California , USA
| | - Pui Yee Law
- b Department of Ophthalmology , University of California , San Francisco , California , USA
| | - Jay M Stewart
- b Department of Ophthalmology , University of California , San Francisco , California , USA
| | - Daniel L Chao
- a Shiley Eye Institute, Department of Ophthalmology , University of California , San Diego , California , USA
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24
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Zablotsky B, Black LI. Concordance between survey reported childhood asthma and linked Medicaid administrative records. J Asthma 2018; 56:285-295. [PMID: 29771597 DOI: 10.1080/02770903.2018.1455854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Agreement between administrative and survey data has been shown to vary by the condition of interest and there is limited research dedicated to parental report of asthma among children. The current study assesses the concordance between parent-reported asthma from the National Health Interview Survey (NHIS) with Medicaid administrative claims data among linkage eligible children from the NHIS. METHODS Medicaid Analytic eXtract (MAX) files from the Centers for Medicare & Medicaid Services (CMS) (years 2000-2005) were linked to participants of the NHIS (years 2001-2005). Concordance measures were calculated to assess overall agreement between a claims-based asthma diagnosis and a survey-based asthma diagnosis. Structural equation modeling was used to assess the association between demographic, service utilization, and co-occurring conditions factors and agreement. RESULTS Percent agreement between the two data sources was high (90%) with a prevalence-adjusted bias-adjusted kappa of 0.80 and Cohen's kappa of 0.55. Agreement varied by demographic characteristics, service utilization characteristics, and the presence of allergies and other health conditions. Structural equation modeling results found the presence of a series of co-occurring conditions, namely allergies, resulted in significantly lower agreement after controlling for demographics and service utilization. CONCLUSIONS There was general agreement between asthma diagnoses reported in the NHIS when compared to medical claims. Discordance was greatest among children with co-occurring conditions.
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Affiliation(s)
| | - Lindsey I Black
- a National Center for Health Statistics , Hyattsville , MD , USA
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Increased healthcare utilisation among atopic children in a general practice database: a nested index-control study. BJGP Open 2018; 2:bjgpopen18X101349. [PMID: 30564702 PMCID: PMC6181076 DOI: 10.3399/bjgpopen18x101349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 11/20/2017] [Indexed: 12/02/2022] Open
Abstract
Background Atopic eczema, asthma, and allergic rhinitis (AR) create a serious burden on general practice resources. Aim To investigate the use of general practice resources (that is, consultation visits, telephone contacts, and home visits) in children with physician-diagnosed atopic disorders (ADs). Design & setting In a nested index-control study design, all children (here defined as individuals aged 2–18 years) listed in a representative general practice database were selected in 2014. Method Children diagnosed with ADs were matched on age and sex with non-atopic controls within the same practice. For all the different groups, the number and frequency of children contacting the GP were calculated. Results Of the children with atopic eczema (n = 15 202), 80% consulted the GP in 2014 (controls = 67%). Of the children with asthma (n = 7754), 80% consulted the GP (controls = 65%), and for children with AR (n = 6710), this was 82% (controls = 66%). Of the children with all three ADs, 91% consulted the GP (controls = 68%). On average, a child with atopic eczema contacted the GP 2.8 times/year (controls = 1.9); for children with asthma, the contact frequency was 3.0 (controls = 1.9); and for AR, 3.2 (controls = 1.9). For children with all three ADs, the contact frequency was 4.3 (controls = 2.0). Consultations related to the ADs investigated only explain a smaller part of the increased healthcare utilisation in atopic children. Conclusion Atopic children use more general practice resources compared to non-atopic children, yet frequently for morbidity or other health-related questions not related to one of the ADs.
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Gelzer AD, Gao W, Keleti D, Donia T, Megargell L, Kreitman J, Michael KE. Multifaceted interventions improve medication adherence and reduce acute hospitalization rates in medicaid patients prescribed asthma controllers. J Asthma 2018; 56:190-199. [PMID: 29565708 DOI: 10.1080/02770903.2018.1439954] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To measure the effectiveness of managed care-led interventions in Medicaid subjects with asthma on medication adherence and acute hospitalization in Pennsylvania. METHODS A total of 3589 members (age range, 5-64 years) served by two Pennsylvania-based Medicaid managed care plans (southeastern Pennsylvania [SEPA] and Lehigh-Capital/New West Pennsylvania [LCNWPA]) with low adherence rates (proportion of days covered [PDC]; 20%-67%) for asthma controller prescription fills in 2012 were guided through a care continuum by a comprehensive asthma strategy, consisting of adherence-improvement interventions (grouped as general intervention [GI] or personalized intervention [PI] for higher-risk subjects). Medication adherence and acute hospitalization rates (emergency department [ED] and inpatient [IP]) were compared at baseline versus one-year post-intervention using paired t-test or signed-rank tests. Repeated measures analysis of variances detected the interaction effect of time by intervention group after controlling for sociodemographic covariates. RESULTS Member profiles in SEPA (n = 2 796) and LCNWPA (n = 793) were racially and ethnically distinct. Both cohorts experienced statistically significant improvements in mean PDC rate (+4.9% and +7.2%; p = 0.01 and p = 0.03, respectively), accompanied by significant reductions in ED visits (asthma-related: -23.0% and -17.5%, respectively; p < 0.01), and IP admissions (asthma-related: -37.1% and -40.0%, respectively; p < 0.01). The PI subcohorts showed significantly greater improvements in mean PDC versus GI subcohorts (p ≤ 0.04), whereas acute hospitalization rates were statistically comparable in the SEPA cohort, despite its greater asthma burden. CONCLUSIONS Managed care-led interventions can effectively improve medication adherence and reduce acute hospitalizations in high-risk Medicaid populations.
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Affiliation(s)
- Andrea D Gelzer
- a Medical Executive Management, AmeriHealth Caritas , Philadelphia , PA , USA
| | - Wanzhen Gao
- b Corporate Informatics, AmeriHealth Caritas , Philadelphia , PA , USA
| | - David Keleti
- c Corporate Clinical Services, AmeriHealth Caritas , Philadelphia , PA , USA
| | - Thomas Donia
- a Medical Executive Management, AmeriHealth Caritas , Philadelphia , PA , USA
| | - Lauren Megargell
- d Pharmacy Clinical Intelligence, PerformRx , Philadelphia , PA , USA
| | - Jeffrey Kreitman
- e Pharmacy Management, AmeriHealth Caritas , Philadelphia , PA , USA
| | - Karen E Michael
- a Medical Executive Management, AmeriHealth Caritas , Philadelphia , PA , USA
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An American Thoracic Society/National Heart, Lung, and Blood Institute Workshop Report: Addressing Respiratory Health Equality in the United States. Ann Am Thorac Soc 2018; 14:814-826. [PMID: 28459618 DOI: 10.1513/annalsats.201702-167ws] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Health disparities related to race, ethnicity, and socioeconomic status persist and are commonly encountered by practitioners of pediatric and adult pulmonary, critical care, and sleep medicine in the United States. To address such disparities and thus progress toward equality in respiratory health, the American Thoracic Society and the National Heart, Lung, and Blood Institute convened a workshop in May of 2015. The workshop participants addressed health disparities by focusing on six topics, each of which concluded with a panel discussion that proposed recommendations for research on racial, ethnic, and socioeconomic disparities in pulmonary, critical care, and sleep medicine. Such recommendations address best practices to advance research on respiratory health disparities (e.g., characterize broad ethnic groups into subgroups known to differ with regard to a disease of interest), risk factors for respiratory health disparities (e.g., study the impact of new tobacco or nicotine products on respiratory diseases in minority populations), addressing equity in access to healthcare and quality of care (e.g., conduct longitudinal studies of the impact of the Affordable Care Act on respiratory and sleep disorders), the impact of personalized medicine on disparities research (e.g., implement large studies of pharmacogenetics in minority populations), improving design and methodology for research studies in respiratory health disparities (e.g., use study designs that reduce participants' burden and foster trust by engaging participants as decision-makers), and achieving equity in the pulmonary, critical care, and sleep medicine workforce (e.g., develop and maintain robust mentoring programs for junior faculty, including local and external mentors). Addressing these research needs should advance efforts to reduce, and potentially eliminate, respiratory, sleep, and critical care disparities in the United States.
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Rank M, Landman N, Harootunian G, Winscott M, Jain N, Frey K, Wilson G, Drewek R, Parra-Roide L, Wilson C, Smoldt R, Cortese D. Variability in asthma quality and costs in children with different Medicaid insurance plans in Maricopa County. J Asthma 2018; 56:152-159. [PMID: 29451814 DOI: 10.1080/02770903.2018.1432644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To describe the variation in asthma quality and costs among children with different Medicaid insurance plans. METHODS We used 2013 data from the Center for Health Information and Research, which houses a database that includes individuals who have Medicaid insurance in Arizona. We analyzed children ages 2-17 years-old who lived in Maricopa County, Arizona. Asthma medication ratio (AMR, a measure of appropriate asthma medication use), outpatient follow-up within 2 weeks after asthma-related hospitalization (a measure of continuity of care), asthma-related hospitalizations, and all emergency department (ED) visits were the primary quality metrics. Direct costs were reported in 2013 $US dollars. We used one-way analysis of variance to compare the health plans for AMR and per member cost (total, ER, and hospital), and the chi-squared test for the outpatient follow-up measure. We used coefficient of variation to identify variation of each measure across all individuals in the study. RESULTS In 2013, 90,652 children in Maricopa County were identified as having asthma. The average patient-weighted AMR for children with persistent asthma was 0.35, well short of the goal of ≥0.70, and only 36% of hospitalized asthma patients had outpatient follow-up within 2 weeks of hospitalization. AMR, total costs, and ED costs varied significantly (p <.0001) when comparing health plans while hospital costs and outpatient follow-up showed no significant variation. CONCLUSIONS Targeting appropriate medication use for asthma may help reduce variation, improve outcomes, and increase healthcare value for children with asthma and Medicaid insurance in the US.
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Affiliation(s)
- Matthew Rank
- a Division of Allergy , Asthma and Clinical Immunology, Mayo Clinic , Scottsdale , AZ , USA.,b Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester , MN , USA.,c Division of Pulmonology , Phoenix Children's Hospital , Phoenix , AZ , USA
| | - Natalie Landman
- d Arizona State University Healthcare Delivery and Policy Program, Arizona State University , Scottsdale , AZ , USA
| | - Gevork Harootunian
- e Center for Health Information and Research, College of Health Solutions, Arizona State University , Phoenix , AZ , USA
| | - Michelle Winscott
- f Department of Family Medicine , Mayo Clinic , Scottsdale , AZ , USA
| | - Neil Jain
- g San Tan Allergy and Asthma , Gilbert , AZ , USA
| | | | - Gena Wilson
- c Division of Pulmonology , Phoenix Children's Hospital , Phoenix , AZ , USA
| | - Rupali Drewek
- c Division of Pulmonology , Phoenix Children's Hospital , Phoenix , AZ , USA
| | | | | | - Robert Smoldt
- d Arizona State University Healthcare Delivery and Policy Program, Arizona State University , Scottsdale , AZ , USA
| | - Denis Cortese
- d Arizona State University Healthcare Delivery and Policy Program, Arizona State University , Scottsdale , AZ , USA
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Ménard S, Jbilou J, Lauzier S. Family caregivers' reported nonadherence to the controller medication of asthma in children in Casablanca (Morocco): Extent and associated factors. J Asthma 2018; 55:1362-1372. [PMID: 29336706 DOI: 10.1080/02770903.2017.1414235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Recent statistics show a relatively high prevalence of asthma among Moroccan children and a weak control over their symptoms. To our knowledge, no research has been carried out to document adherence to the controller treatment in this population. This study aims 1) to assess the extent of children's nonadherence to the controller treatment of asthma in an urban region of Morocco as reported by a family caregiver, and 2) to identify the associated factors. METHODS We conducted a cross-sectional study among caregivers of asthmatic children (2-12 years old) in different health and education facilities of Casablanca-Settat. We administered face-to-face questionnaires incorporating validated instruments (Medication Adherence Rating Scale-Asthma (MARS-A), Beliefs about Medicines Questionnaire (BMQ), Asthma Knowledge Questionnaire). Univariate and multivariate log-binomial regressions evaluating the association between several factors and reported nonadherence were performed (prevalence ratios (PR) and 95% confidence intervals (CI)). RESULTS Through two public hospitals, three private medical clinics, and one private school, 103 caregivers were recruited. Low adherence to the controller treatment of asthma was reported by 48% of the caregivers (MARS-A <45). In the multivariate model, caregivers with the lowest level of knowledge about asthma were almost three times more likely to report low adherence compared to caregivers with the highest level (PR = 2.93; 95% CI: 1.14-7.52). CONCLUSIONS This study highlights the finding that low adherence is widespread in this context and also the importance of targeting caregivers' knowledge of asthma for interventions.
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Affiliation(s)
- Sandra Ménard
- a Department of Social and Preventive Medicine, Faculty of Medicine , Laval University , Quebec , QC , Canada
| | - Jalila Jbilou
- b Research Professor, Centre de formation médicale du Nouveau-Brunswick , Moncton , NB , Canada ; Associate Professor, School of Psychology, Université de Moncton , Monction , NB , Canada
| | - Sophie Lauzier
- c Researcher, Population Health and Optimal Health Practices Research Unit, CHU de Québec-Université Laval Research Center , QC , Canada ; Assistant Professor, Faculty of Pharmacy, Laval University , Quebec , QC , Canada
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Hilton R, Zheng Y, Fitzpatrick A, Serban N. Uncovering Longitudinal Health Care Behaviors for Millions of Medicaid Enrollees: A Multistate Comparison of Pediatric Asthma Utilization. Med Decis Making 2018; 38:107-119. [PMID: 29029580 PMCID: PMC5764816 DOI: 10.1177/0272989x17731753] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND This study introduces a framework for analyzing and visualizing health care utilization for millions of children, with a focus on pediatric asthma, one of the major chronic respiratory conditions. METHODS The data source is the 2005 to 2012 Medicaid Analytic Extract claims for 10 Southeast states. The study population consists of Medicaid-enrolled children with persistent asthma. We translate multiyear, individual-level medical claims into sequences of discrete utilization events, which are modeled using Markov renewal processes and model-based clustering. Network analysis is used to visualize utilization profiles. The method is general, allowing the study of other chronic conditions. RESULTS The study population consists of 1.5 million children with persistent asthma. All states have profiles with high probability of asthma controller medication, as large as 60.6% to 90.2% of the state study population. The probability of consecutive asthma controller prescriptions ranges between 0.75 and 0.95. All states have utilization profiles with uncontrolled asthma with 4.5% to 22.9% of the state study population. The probability for controller medication is larger than for short-term medication after a physician visit but not after an emergency department (ED) visit or hospitalization. Transitions from ED or hospitalization generally have a lower probability into physician office (between 0.11 and 0.38) than into ED or hospitalization (between 0.20 and 0.59). CONCLUSIONS In most profiles, children who take asthma controller medication do so regularly. Follow-up physician office visits after an ED encounter or hospitalization are observed at a low rate across all states. Finally, all states have a proportion of children who have uncontrolled asthma, meaning they do not take controller medication while they have severe outcomes.
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Affiliation(s)
- Ross Hilton
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology
| | - Yuchen Zheng
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology
| | | | - Nicoleta Serban
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology
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Alcala E, Cisneros R, Capitman JA. Health care access, concentrated poverty, and pediatric asthma hospital care use in California's San Joaquin Valley: A multilevel approach. J Asthma 2017; 55:1253-1261. [PMID: 29261336 DOI: 10.1080/02770903.2017.1409234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND California's San Joaquin Valley is a region with a history of poverty, low health care access, and high rates of pediatric asthma. It is important to understand the potential barriers to care that challenge vulnerable populations. OBJECTIVE The objective was to describe pediatric asthma-related utilization patterns in the emergency department (ED) and hospital by insurance coverage as well as to identify contributing individual-level indicators (age, sex, race/ethnicity, and insurance coverage) and neighborhood-level indicators of health care access. METHODS This was a retrospective study based on secondary data from California hospital and ED records 2007-2012. Children who used services for asthma-related conditions, were aged 0-14 years, Hispanic or non-Hispanic white, and resided in the San Joaquin Valley were included in the analysis. Poisson multilevel modeling was used to control for individual- and neighborhood-level factors. RESULTS The effect of insurance coverage on asthma ED visits and hospitalizations was modified by the neighborhood-level percentage of concentrated poverty (RR = 1.01, 95% CI = 1.01-1.02; RR = 1.03, 95% CI = 1.02-1.04, respectively). The effect of insurance coverage on asthma hospitalizations was completely explained by the neighborhood-level percentage of concentrated poverty. CONCLUSIONS Observed effects of insurance coverage on hospital care use were significantly modified by neighborhood-level measures of health care access and concentrated poverty. This suggests not only an overall greater risk for poor children on Medi-Cal, but also a greater vulnerability or response to neighborhood social factors such as socioeconomic status, community cohesiveness, crime, and racial/ethnic segregation.
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Affiliation(s)
- Emanuel Alcala
- a Department of Public Health, School of Social Sciences, Humanities, and Arts , University of California, Merced , California , USA.,b College of Health and Human Services , Central Valley Health Policy Institute, California State University , Fresno , California , USA
| | - Ricardo Cisneros
- a Department of Public Health, School of Social Sciences, Humanities, and Arts , University of California, Merced , California , USA
| | - John A Capitman
- b College of Health and Human Services , Central Valley Health Policy Institute, California State University , Fresno , California , USA
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Veeranki SP, Ohabughiro MU, Moran J, Mehta HB, Ameredes BT, Kuo YF, Calhoun WJ. National estimates of 30-day readmissions among children hospitalized for asthma in the United States. J Asthma 2017; 55:695-704. [PMID: 28837382 DOI: 10.1080/02770903.2017.1365888] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Previous single-center studies have reported that up to 40% of children hospitalized for asthma will be readmitted. The study objectives are to investigate the prevalence and timing of 30-day readmissions in children hospitalized with asthma, and to identify factors associated with 30-day readmissions. METHODS Data (n = 12,842) for children aged 6-18 years hospitalized for asthma were obtained from the 2013 Nationwide Readmission Database (NRD). The primary study outcome was time to readmission within 30 days after discharge attributable to any cause. Several predictors associated with the risk of admission were included: patient (age, sex, median household income, insurance type, county location, and pediatric chronic complex condition), admission (type, day, emergency services utilization, length of stay (LOS), and discharge disposition), and hospital (ownership, bed size, and teaching status). Cox's proportional hazards model was used to identify predictors. RESULTS Of 12,842 asthma-related index hospitalizations, 2.5% were readmitted within 30-days post-discharge. Time to event models identified significantly higher risk of readmission among asthmatic children aged 12-18 years, those who resided in micropolitan counties, those with >4-days LOS during index hospitalization, those who were hospitalized in an urban hospital, who had unfavorable discharge (hazard ratio 2.53, 95% confidence interval 1.33-4.79), and those who were diagnosed with a pediatric complex chronic condition, respectively, than children in respective referent categories. CONCLUSION A multi-dimensional approach including effective asthma discharge action plans and follow-up processes, home-based asthma education, and neighborhood/community-level efforts to address disparities should be integrated into the routine clinical care of asthma children.
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Affiliation(s)
- Sreenivas P Veeranki
- a Department of Preventive Medicine and Community Health , University of Texas Medical Branch , Galveston , TX , USA
| | - Michael U Ohabughiro
- b School of Medicine , University of Texas Medical Branch , Galveston , TX , USA
| | - Jacob Moran
- a Department of Preventive Medicine and Community Health , University of Texas Medical Branch , Galveston , TX , USA
| | - Hemalkumar B Mehta
- c Department of Surgery , University of Texas Medical Branch , Galveston , TX , USA
| | - Bill T Ameredes
- d Division of Pulmonary Critical Care & Sleep Medicine, Department of Internal Medicine , University of Texas Medical Branch , Galveston , TX , USA
| | - Yong-Fang Kuo
- a Department of Preventive Medicine and Community Health , University of Texas Medical Branch , Galveston , TX , USA
| | - William J Calhoun
- d Division of Pulmonary Critical Care & Sleep Medicine, Department of Internal Medicine , University of Texas Medical Branch , Galveston , TX , USA
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Hilton RP, Zheng Y, Serban N. Modeling Heterogeneity in Healthcare Utilization Using Massive Medical Claims Data. J Am Stat Assoc 2017; 113:111-121. [PMID: 30294054 DOI: 10.1080/01621459.2017.1330203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We introduce a modeling approach for characterizing heterogeneity in healthcare utilization using massive medical claims data. We first translate the medical claims observed for a large study population and across five years into individual-level discrete events of care called utilization sequences. We model the utilization sequences using an exponential proportional hazards mixture model to capture heterogeneous behaviors in patients' healthcare utilization. The objective is to cluster patients according to their longitudinal utilization behaviors and to determine the main drivers of variation in healthcare utilization while controlling for the demographic, geographic, and health characteristics of the patients. Due to the computational infeasibility of fitting a parametric proportional hazards model for high-dimensional, large sample size data we use an iterative one-step procedure to estimate the model parameters and impute the cluster membership. The approach is used to draw inferences on utilization behaviors of children in the Medicaid system with persistent asthma across six states. We conclude with policy implications for targeted interventions to improve adherence to recommended care practices for pediatric asthma.
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Affiliation(s)
- Ross P Hilton
- H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology
| | - Yuchen Zheng
- H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology
| | - Nicoleta Serban
- H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology
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Al Sallakh MA, Vasileiou E, Rodgers SE, Lyons RA, Sheikh A, Davies GA. Defining asthma and assessing asthma outcomes using electronic health record data: a systematic scoping review. Eur Respir J 2017; 49:49/6/1700204. [DOI: 10.1183/13993003.00204-2017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/09/2017] [Indexed: 01/25/2023]
Abstract
There is currently no consensus on approaches to defining asthma or assessing asthma outcomes using electronic health record-derived data. We explored these approaches in the recent literature and examined the clarity of reporting.We systematically searched for asthma-related articles published between January 1, 2014 and December 31, 2015, extracted the algorithms used to identify asthma patients and assess severity, control and exacerbations, and examined how the validity of these outcomes was justified.From 113 eligible articles, we found significant heterogeneity in the algorithms used to define asthma (n=66 different algorithms), severity (n=18), control (n=9) and exacerbations (n=24). For the majority of algorithms (n=106), validity was not justified. In the remaining cases, approaches ranged from using algorithms validated in the same databases to using nonvalidated algorithms that were based on clinical judgement or clinical guidelines. The implementation of these algorithms was suboptimally described overall.Although electronic health record-derived data are now widely used to study asthma, the approaches being used are significantly varied and are often underdescribed, rendering it difficult to assess the validity of studies and compare their findings. Given the substantial growth in this body of literature, it is crucial that scientific consensus is reached on the underlying definitions and algorithms.
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Makhinova T, Barner JC, Richards KM, Rascati KL. Asthma Controller Medication Adherence, Risk of Exacerbation, and Use of Rescue Agents Among Texas Medicaid Patients with Persistent Asthma. J Manag Care Spec Pharm 2016; 21:1124-32. [PMID: 26679962 PMCID: PMC10401995 DOI: 10.18553/jmcp.2015.21.12.1124] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adherence to asthma long-term controller medications is one of the key drivers to improve asthma management among patients with persistent asthma. While suboptimal use of controller medications has been found to be associated with more frequent use of oral corticosteroids (OCS), few studies exist regarding the relationship between adherence to controller therapy and the use of short-acting beta2-agonists (SABAs). A better understanding of the association between adherence to asthma controller agents and use of reliever medications will help health care providers and decision makers enhance asthma management. OBJECTIVE To determine if there is a relationship between asthma controller adherence, risk of exacerbation requiring OCS, and use of asthma rescue agents. METHODS Texas Medicaid claims data from January 1, 2008, to August 31, 2011, were retrospectively analyzed. Continuously enrolled patients aged 5-63 years with a primary diagnosis of asthma (ICD-9-CM code 493) and with 4 or more prescription claims for any asthma medication in 1 year (persistent asthma) were included. The index date was the date of the first asthma controller prescription, and patients were followed for 1 year. The primary outcome variables were SABA (dichotomous: less than 6 vs. ≥ 6) and OCS (continuous) use. The primary independent variable was adherence (proportion of days covered [PDC]) to asthma long-term controller medications. Covariates included demographics and nonstudy medication utilization. Multivariate logistic and linear regression analyses were employed to address the study objective. RESULTS The study sample (n = 32,172) was aged 15.0 ± 14.5 years, and adherence to controller therapy was 32.2% ± 19.7%. The mean number of SABA claims was 3.7 ± 3.1, with most patients having 1-5 claims (73.2%), whereas 19.4% had ≥ 6 SABA claims. The mean number of OCS claims was 1.0 ± 1.4. Adherent (PDC ≥ 50%) patients were 96.7% (OR = 1.967; 95% CI = 1.826-2.120) more likely to have ≥ 6 SABA claims when compared with nonadherent (PDC less than 50%) patients (P less than 0.001). As for OCS use, adherent patients had 0.11 fewer claims compared with nonadherent patients (P less than 0.001). Importantly, patients with ≥ 6 SABA claims had 0.7 more OCS claims compared with patients with less than 6 claims for SABA (P less than 0.001). The odds of having ≥ 6 SABA claims were higher for concurrent dual therapy users, older age, males, African Americans and higher number of nonstudy medications (P less than 0.001). Dual therapy users, younger age, Hispanic ethnicity, and higher number of nonstudy medications were associated with an increase in OCS use (P less than 0.005). CONCLUSIONS Adherence to long-term controller medications was suboptimal among patients with asthma. Adherent patients had fewer OCS claims, indicating that adherence to controller therapy is critical in preventing asthma exacerbations requiring OCS use. Although there was a positive relationship between adherence to long-term controller medication and SABA use, increased SABA use served as a predictor of increased OCS use, which indicates poor asthma control. Health care providers should be aware of OCS and SABA use among patients who are both adherent and nonadherent to asthma controller medications.
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Affiliation(s)
- Tatiana Makhinova
- The University of Texas at Austin, 2409 University Ave., STOP A1930, Austin, TX 78712-1120.
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Hammer-Helmich L, Linneberg A, Thomsen SF, Tang L, Glümer C. Health service use among children with and without eczema, asthma, and hay fever. Clin Epidemiol 2016; 8:341-349. [PMID: 27695364 PMCID: PMC5028076 DOI: 10.2147/clep.s111960] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Atopic diseases, for example, eczema, asthma, and hay fever, are among the most common chronic diseases of childhood. Knowledge on health service use among children with atopic disease is limited. This study aimed to investigate the total use and costs of health services for children with and without eczema, asthma, and hay fever in a Danish general population. METHODS We conducted a health survey with four complete birth cohorts from the City of Copenhagen. Individual questionnaire data on eczema, asthma, and hay fever for children aged 3, 6, 11, and 15 years were linked to register information on use and costs of health services and prescribed medication and parental education. In total 9,720 children participated (50.5%). RESULTS We found increased health service use (number of additional consultations per year [95% confidence interval]) among children with current eczema symptoms (1.77 [1.29-2.26]), current asthma symptoms (2.53 [2.08-2.98]), and current hay fever symptoms (1.21 [0.74-1.67]), compared with children without these symptoms. We also found increased use of prescribed medication and most subtypes of health services. Current asthma symptoms and current eczema symptoms, but not current hay fever symptoms, increased the health service costs with at least €300 per year per child. CONCLUSION Children with eczema, asthma, and hay fever used health services and prescribed medication more than children without these diseases.
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Affiliation(s)
- Lene Hammer-Helmich
- Research Center for Prevention and Health, The Capital Region of Denmark, Copenhagen; Department of Real World Evidence and Epidemiology, H. Lundbeck A/S, Valby
| | - Allan Linneberg
- Research Center for Prevention and Health, The Capital Region of Denmark, Copenhagen; Department of Clinical Experimental Research, Rigshospitalet; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen
| | - Simon Francis Thomsen
- Department of Dermatology, Bispebjerg Hospital; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Line Tang
- Research Center for Prevention and Health, The Capital Region of Denmark, Copenhagen
| | - Charlotte Glümer
- Research Center for Prevention and Health, The Capital Region of Denmark, Copenhagen; Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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Tan X, Feng X, Chang J, Higa G, Wang L, Leslie D. Oral antidiabetic drug use and associated health outcomes in cancer patients. J Clin Pharm Ther 2016; 41:524-31. [PMID: 27453485 DOI: 10.1111/jcpt.12430] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 07/06/2016] [Indexed: 12/19/2022]
Affiliation(s)
- X. Tan
- School of Pharmacy; West Virginia University; Morgantown WV USA
| | - X. Feng
- School of Pharmacy; West Virginia University; Morgantown WV USA
| | - J. Chang
- School of Pharmacy; University of Texas; El Paso TX USA
| | - G. Higa
- School of Pharmacy; West Virginia University; Morgantown WV USA
| | - L. Wang
- Public Health Sciences; Penn State University College of Medicine; Hershey PA USA
| | - D. Leslie
- Public Health Sciences; Penn State University College of Medicine; Hershey PA USA
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Pan Y, Chen S, Chen M, Zhang P, Long Q, Xiang L, Lucas H. Disparity in reimbursement for tuberculosis care among different health insurance schemes: evidence from three counties in central China. Infect Dis Poverty 2016; 5:7. [PMID: 26812914 PMCID: PMC4729161 DOI: 10.1186/s40249-016-0102-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/09/2015] [Indexed: 11/10/2022] Open
Abstract
Background Health inequity is an important issue all around the world. The Chinese basic medical security system comprises three major insurance schemes, namely the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Cooperative Medical Scheme (NCMS). Little research has been conducted to look into the disparity in payments among the health insurance schemes in China. In this study, we aimed to evaluate the disparity in reimbursements for tuberculosis (TB) care among the abovementioned health insurance schemes. Methods This study uses a World Health Organization (WHO) framework to analyze the disparities and equity relating to the three dimensions of health insurance: population coverage, the range of services covered, and the extent to which costs are covered. Each of the health insurance scheme’s policies were categorized and analyzed. An analysis of the claims database of all hospitalizations reimbursed from 2010 to 2012 in three counties of Yichang city (YC), which included 1506 discharges, was conducted to identify the differences in reimbursement rates and out-of-pocket (OOP) expenses among the health insurance schemes. Results Tuberculosis patients had various inpatient expenses depending on which scheme they were covered by (TB patients covered by the NCMS have less inpatient expenses than those who were covered by the URBMI, who have less inpatient expenses than those covered by the UEBMI). We found a significant horizontal inequity of healthcare utilization among the lower socioeconomic groups. In terms of financial inequity, TB patients who earned less paid more. The NCMS provides modest financial protection, based on income. Overall, TB patients from lower socioeconomic groups were the most vulnerable. Conclusion There are large disparities in reimbursement for TB care among the three health insurance schemes and this, in turn, hampers TB control. Reducing the gap in health outcomes between the three health insurance schemes in China should be a focus of TB care and control. Achieving equity through integrated policies that avoid discrimination is likely to be effective. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0102-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yao Pan
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China. .,The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Shanquan Chen
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.
| | - Manli Chen
- School of Management, Hubei University of Chinese Medicine, Wuhan, China.
| | - Pei Zhang
- Yichang Center for Disease Control and Prevention, Yichang, China.
| | - Qian Long
- Duke Global Health Institute, Duke University, Durham, NC, USA. .,Global Health Research Center, Duke Kunshan University, Kunshan, China.
| | - Li Xiang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China.
| | - Henry Lucas
- Institute of Development Studies, Sussex University, Brighton, UK.
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Rivera-Hernandez M, Galarraga O. Type of Insurance and Use of Preventive Health Services Among Older Adults in Mexico. J Aging Health 2015; 27:962-82. [PMID: 25804897 PMCID: PMC4720256 DOI: 10.1177/0898264315569457] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The main purpose of this article was to assess the differences between Seguro Popular (SP) and employer-based health insurance in the use of preventive services, including screening tests for diabetes, cholesterol, hypertension, cervical cancer, and prostate cancer among older adults at more than a decade of health care reform in Mexico. METHOD Logistic regression models were used with data from the Mexican Health and Nutrition Survey, 2012. RESULTS After adjusting for other factors influencing preventive service utilization, SP enrollees were more likely to use screening tests for diabetes, cholesterol, hypertension, and cervical cancer than the uninsured; however, those in employment-based and private insurances had higher odds of using preventive care for most of these services, except Pap smears. DISCUSSION Despite all the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in health care access and utilization still exist in Mexico.
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Affiliation(s)
| | - Omar Galarraga
- Department of Health Services, Policy and Practice Brown University, Providence, RI, USA
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Tan X, Marshall VD, Anderson RT, Donohoe J, Camacho F, Balkrishnan R. Adjuvant therapy use among Appalachian breast cancer survivors. Medicine (Baltimore) 2015; 94:e1071. [PMID: 26131828 PMCID: PMC4504563 DOI: 10.1097/md.0000000000001071] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
There is a paucity of literature systemically examining the effects of access to cancer care resources on adjuvant endocrine therapy (AET) use behaviors, especially in underserved regions such as the Appalachian region in the United States, where gaps in healthcare access are well documented. The objectives of this study were to explore AET adherence and persistence in Appalachia, delineate the effects of access to care cancer on adherence/persistence, and evaluate the influences of adherence and persistence on overall survival.A retrospective cohort study from 2006 to 2008 was conducted among female breast cancer survivors living in the Appalachian counties of 4 states (PA, OH, KY, and NC). We linked cancer registries to Medicare claims data and included patients with invasive, nonmetastatic, hormone-receptor-positive breast cancer who received guideline-recommended AET. Medication adherence was defined as corresponding to a Medication Possession Ratio (MPR) ≥0.8 and logistic regression was utilized to assess predictors of adherence. Medication nonpersistence was defined as the discontinuation of drugs after exceeding a 60-day medication gap, and multivariate adjusted estimates of nonpersistence were obtained using the Cox proportional hazards (PH) model.About 31% of the total 428 patients were not adherent to AET, and 30% were not persistent over an average follow-up period of 421 days. Tamoxifen, relative to aromatase inhibitors, was associated with higher odds of adherence (odds ratio = 2.82, P < 0.001) and a lower risk of nonpersistence (hazard ratio = 0.40, P < 0.001). Drug-related side effects like pain may be an important factor leading to nonadherence and early discontinuation. In addition, aromatase inhibitor (AI) adherence and persistence were significantly influenced by out-of-pocket drug costs, dual eligibility status, and coverage gaps. Nonadherence to and nonpersistence with AET were associated with higher risks of all-cause mortality.Our findings of suboptimal AET adherence/persistence in Appalachia as well as positive associations between AET adherence/persistence and overall survival outcomes further underscore the importance of ensuring appropriate AET use in this population to reduce breast cancer mortality disparities. Our findings also suggest that intervention strategies focusing on individualized treatment and medication-related factors may improve adjuvant treatment use.
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Affiliation(s)
- Xi Tan
- From Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, West Virginia (XT); Department of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan, Ann Arbor, Michigan (VDM); Department of Public Health Services, School of Medicine, University of Virginia, Charlottesville, Virginia (RTA, FC, RB); Mountain-Pacific Quality Health, Helena, Montana (JD)
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Patel MR, Caldwell CH, Song PXK, Wheeler JRC. Patient perceptions of asthma-related financial burden: public vs. private health insurance in the United States. Ann Allergy Asthma Immunol 2014; 113:398-403. [PMID: 25091716 PMCID: PMC4177455 DOI: 10.1016/j.anai.2014.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/01/2014] [Accepted: 07/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Given the complexity of the health insurance market in the United States and the confusion that often stems from these complexities, patient perception about the value of health insurance in managing chronic disease is important to understand. OBJECTIVE To examine differences between public and private health insurance in perceptions of financial burden with managing asthma, outcomes, and factors that explain these perceptions. METHODS Secondary analysis was performed using baseline data from a randomized clinical trial that were collected through telephone interviews with 219 African American women seeking services for asthma and reporting perceptions of financial burden with asthma management. Path analysis with multigroup models and multiple variable regression analyses were used to examine associations. RESULTS For public (P < .001) and private (P < .01) coverage, being married and more educated were indirectly associated with greater perceptions of financial burden through different explanatory pathways. When adjusted for multiple morbidities, asthma control, income, and out-of-pocket expenses, those with private insurance used fewer inpatient (P < .05) and emergency department (P < .001) services compared with those with public insurance. When also adjusted for health insurance, greater financial burden was associated with more urgent office visits (P < .001) and lower quality of life (P < .001). CONCLUSION African American women who perceive asthma as a financial burden regardless of health insurance report more urgent health care visits and lower quality of life. Burden may be present despite having and being able to generate economic resources and health insurance. Further policy efforts are indicated and special attention should focus on type of coverage.
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Affiliation(s)
- Minal R Patel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan.
| | - Cleopatra H Caldwell
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Peter X K Song
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - John R C Wheeler
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan
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