Attitudes of Black American Christian church leaders toward Opioid Use Disorder, overdoses, and harm reduction: a qualitative study

Introduction

Black American Christian church leaders are trusted community members and can be invaluable leaders and planners, listeners, and counselors for Opioid Use Disorder (OUD) sufferers in the opioid overdose crisis disproportionately affecting the Black community. This qualitative study examines the extent to which the knowledge, attitudes, practices, and beliefs of Black American church leaders support medical and harm reduction interventions for people with OUD.

Methods

A semi-structured interview guide was used to conduct in-depth interviews of 30 Black Rhode Island church leaders recruited by convenience and snowball sampling.

Results

Thematic analysis of the interviews identified four themes: Church leaders are empathetic and knowledgeable, believe that hopelessness and inequity are OUD risk factors, are committed to helping people flourish beyond staying alive, and welcome collaborations between church and state.

Conclusion

Black American Christian church leaders are a critical resource in providing innovative and culturally sensitive strategies in the opioid overdose crisis affecting the Black American communities. As such, their views should be carefully considered in OUD policies, collaborations, and interventions in the Black American community.

The relationship of age and comorbid conditions to hospital and nursing home days in Medicaid recipients with HIV

OBJECTIVE

To determine how aging impacts health care utilization in persons with HIV (PWH) compared to persons without HIV (PWoH).

DESIGN

Matched case-control study.

METHODS

We studied Medicaid recipients in the United States, aged 18-64 years, from 2001 to 2012. We matched each of 270,074 PWH to three PWoH by baseline year, age, gender, and zip code. Outcomes were hospital and nursing home days per month (DPM). Comorbid condition groups were cardiovascular disease, diabetes, liver disease, mental health conditions, pulmonary disease, and renal disease. We used linear regression to examine the joint relationships of age and comorbid conditions on the two outcomes, stratified by sex at birth.

RESULTS

We found small excesses in hospital DPM for PWH compared with PWoH. There were 0.03 and 0.07 extra hospital DPM for females and males, respectively, and no increases with age. In contrast, excess nursing home DPM for PWH compared with PWoH rose linearly with age, peaking at 0.35 extra days for females and 0.4 extra days for males. HIV-associated excess nursing home DPM were greatest for persons with cardiovascular disease, diabetes, mental health conditions, and renal disease. For PWH at age 55, this represents an 81% increase in the nursing home DPM for males, and a 110% increase for females, compared PWoH.

CONCLUSIONS

Efforts to understand and interrupt this pronounced excess pattern of nursing home DPM among PWH compared to PWoH are needed and may new insights into how HIV and comorbid conditions jointly impact aging with HIV.

Comparing ambulatory commercial spending in Rhode Island and Massachusetts, 2016-2019

OBJECTIVE

To evaluate trends and drivers of commercial ambulatory spending and price variation.

DATA SOURCES AND STUDY SETTING

Commercial claims data from the Massachusetts and Rhode Island All-Payer Claims Databases from 2016 to 2019.

STUDY DESIGN

Observational study of spending in major ambulatory care settings. We calculated per member per year spending, average price, and utilization rates to consider drivers of spending, and constructed site-specific price indices to evaluate price variation.

DATA COLLECTION/EXTRACTION METHODS

We analyzed commercial claims data from All-Payer Claims Databases in the two states.

PRINCIPAL FINDINGS

Ambulatory spending levels in Massachusetts were 38.0% higher than those in Rhode Island in 2019. Overall utilization rates were similar, but Massachusetts had a 6.2 percentage point higher share of visits occurring in hospital outpatient departments (HOPD). Average prices were 31.5% higher in Massachusetts in 2016 and 36.4% higher in 2019. We observed extensive price variation in both states across both office and HOPD settings.

CONCLUSIONS

States seeking to address increases in health care spending, including those with cost growth benchmarks and rate review policies, should consider additional interventions that mitigate market failures in the establishment of commercial health care prices.

Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According to Topic and Demand?

HIV clinicians face increasing time constraints. Our objective was to describe the prevalence and quality of behavior change counseling within routine HIV visits and to explore whether clinicians may provide lower quality counseling when facing increased counseling demands. We audio-recorded and transcribed encounters between 205 patients and 12 clinicians at an urban HIV primary care clinic. We identified and coded episodes of behavior change counseling to determine clinicians' consistency with motivational interviewing (MI) and used multi-level regression to evaluate counseling quality changes with each additional topic. Clinician counseling for at least one behavior was indicated in 92% of visits (mean 2.5/visit). Behavioral topics included antiretroviral medication adherence (80%, n = 163), appointment adherence (54%, n = 110), drug use (46%, n = 95), tobacco use (45%, n = 93), unsafe sex (43%, n = 89), weight management (39%, n = 80), and alcohol use (35%, n = 71). Clinician counseling was most MI-consistent when discussing drug and tobacco use and least consistent for medication and appointment adherence, unsafe sex, and alcohol use. In multilevel analyses, clinician counseling was significantly less MI-consistent (β = - 0.14, 95% CI - 0.29 to - 0.001) with each additional behavior change counseling need. This suggests that HIV ambulatory care be restructured to allocate increased time for patients with greater need for behavior change.

Antiretroviral Therapy Use Was Not Associated with Stillbirth or Preterm Birth in an Analysis of U.S. Medicaid Pregnancies to Persons with HIV

Background

Using a U.S. based, nationally representative sample, this study compares stillbirth and preterm birth outcomes between women living with HIV (WWH) who did and did not use antiretroviral therapy (ART) during pregnancy, additionally assessing ART duration and regimen type.

Methods

Using 2001 to 2012 Medicaid Analytic eXtract (MAX) data from the 14 states with the highest prevalence of HIV. We estimated two, propensity score matched, multivariate logistic regression models for both outcomes of stillbirth and preterm birth: (1) any ART use and (2) the number of months on ART during pregnancy for ART users, adjusting for patient-level covariates.

Results

Only 34.6% of pregnancies among WWH had a history of ART use and among those, the proportions of stillbirth and preterm birth were 0.9% and 7.9%, respectively. Any ART use was not significantly associated with either outcome of stillbirth (marginal effects [MEs]: 0.06%, 95% confidence interval [CI]: -0.17 to 0.28) or preterm birth (ME: -0.12%, 95% CI: -0.79 to 0.55). For ART users, duration of ART was not significantly associated with either outcome. Black race was a strong independent predictor in both models (stillbirth: 0.80% and 0.84%, preterm birth: 4.19% and 3.76%). Neither protease inhibitor (PI) nor boosted PI regimens were more strongly associated with stillbirth or preterm birth than nucleoside reverse transcriptase inhibitor-based regimens.

Conclusion

ART use during pregnancy was low during this period. Our findings suggest that ART use and ART regimen are not associated, positively or negatively, with stillbirth or preterm birth for mothers with Medicaid. Additionally, our findings highlight a persisting need to address disparities in these outcomes for Black women.

How All-Payer Claims Databases (APCDs) Can be Used to Examine Changes in Professional Spending: Experience from the Rhode Island APCD

States are increasingly the focus of health care spending reform efforts given political deadlock at the federal level. Using the Rhode Island All-Payer Claims Database (APCD) from 2016 to 2019, a modified National Uniform Claim Committee (NUCC) provider taxonomy, and the 2021 Restructured BETOS Classification System (RBCS), we evaluate professional spending trends in commercial and Medicaid populations, identify specialties and clinical service categories driving trends, and examine price and volume contributions to spending changes. We found that professional spending from 2016-2019 in Medicaid is increasing faster than professional spending in commercial (5.2% vs. 2.7% annually). We also found that nurse practitioner and physician assistant evaluation and management (E&M), behavioral health services E&M, anesthesia, diagnostic radiology imaging, and orthopedic procedures were among the largest areas of spending increase during the study period in Rhode Island. Three-year trends showed heterogeneity in whether volume or price was primarily responsible for these spending increases.

Financial strain and depression in the U.S.: a scoping review

While the association between assets and depression has been established, less is known about the link between financial strain and depression. Given rising financial strain and economic inequity due to the COVID-19 pandemic, understanding the role that financial strain plays in shaping population depression in the United States is particularly salient. We conducted a scoping review of the peer-reviewed literature on financial strain and depression published from inception through January 19, 2023, in Embase, Medline via PubMed, and PsycINFO, PsycArticles, SocINDEX, and EconLit via Ebsco. We searched, reviewed, and synthesized the literature on longitudinal studies on financial strain and depression conducted in the United States. Four thousand and four unique citations were screened for eligibility. Fifty-eight longitudinal, quantitative articles on adults in the United States were included in the review. Eighty-three percent of articles (n = 48) reported a significant, positive association between financial strain and depression. Eight articles reported mixed results, featuring non-significant associations for some sub-groups and significant associations for others, one article was unclear, and one article reported no significant association between financial strain and depression. Five articles featured interventions to reduce depressive symptoms. Effective interventions included coping mechanisms to improve one's financial situation (e.g., mechanisms to assist in finding employment), to modify cognitive behavior (e.g., reframing mindset), and to engage support (e.g., engaging social and community support). Successful interventions were tailored to participants, were group-based (e.g., they included family members or other job seekers), and occurred over multiple sessions. While depression was defined consistently, financial strain was defined variably. Gaps in the literature included studies featuring Asian populations in the United States and interventions to reduce financial strain. There is a consistent, positive association between financial strain and depression in the United States. More research is needed to identify and test interventions that mitigate the ill effects of financial strain on population's mental health.

Mental health and ART adherence among adolescents living with HIV in Mozambique

Little is known about the mental health needs of adolescents living with HIV (ALWH) in Mozambique, including the potential relationship between mental health challenges and poor antiretroviral treatment (ART) adherence. We examined mental health problems (anxiety, depression, post-traumatic stress disorder [PTSD] symptoms and impairment) and their association with self-reported ART adherence among ALWH ages 15-19 in Nampula, Mozambique. The associations between each mental health problem area and sub-optimal adherence were estimated using logistic regression, controlling for age, education, and social support, with interaction by gender. Males had significantly higher anxiety (5.6 vs 4.3, p = 0.01), depression (5.8 vs 4.1, p = 0.005), and PTSD (13.3 vs 9.8, p = 0.02) symptoms and impairment (1.8 vs 0.56, p<0.0001) scores than females. Proportion reporting sub-optimal adherence (65%) did not differ by gender. Higher anxiety, depression, and PTSD symptom and impairment scores were significantly associated with higher odds of sub-optimal ART adherence in males but not females. Among Mozambican ALWH, mental health problems were prevalent and two-thirds had ART adherence less than 90%. Worse mental health was associated with increased odds of sub-optimal ART adherence in males but not females. Interventions are needed to address mental health problems and improve ART adherence in Mozambican ALWH, particularly among males.

Promoting patient-centered care within HIV care settings in sub-Saharan Africa

PURPOSE OF REVIEW

Patient centered care (PCC) in human immunodeficiency virus (HIV) care systems in sub-Saharan Africa (SSA) may improve outcomes for persons with HIV (PWH). We review the progress the region has made in promoting PCC and highlight some of the implementation challenges and potential areas of research.

RECENT FINDINGS

Studies show growing interest in promoting PCC across HIV care programs in SSA. Effective implementation of PCC, however, is hampered by: (1) lack of consensus on the conceptualization of PCC, including definition, frameworks, measures, and implementation strategies; (2) limited regional studies on the adoption and sustainability of PCC interventions; and (3) healthcare structural challenges including limited capital and human resources, poor provider-patient dynamics, high provider turnover, and lack of continuity in care. Recent studies in the region have focused on identifying key PCC domains addressable in resource limited settings, understanding the PCC experiences and expectations of PWH and their providers, and testing innovative interventions. We highlight the need for additional studies to address the existing gaps.

SUMMARY

We discuss the progress and challenges of implementing PCC in HIV care settings in SSA as well as the need for additional research to ensure that proposed PCC interventions have optimal impact.

Changes in Nursing Home Populations Challenge Practice and Policy

U.S. nursing homes (NH) have a growing prevalence of individuals with severe mental illness (SMI) and substance use disorders (SUD), and an associated increasing proportion of people under 65. We explored how Directors of Nursing (DONs) perceive challenges and strategies in caring for these populations. We conducted semi-structured telephone interviews with 32 DONs from diverse facilities around the U.S. Participants reported that people with SUD and SMI often present behavioral challenges requiring resource intensive responses, while regulations constrain optimal medication treatment. Younger individuals are considered more demanding of staff and impatient with traditional NH activities designed for older people. Some NHs report they screen out people with behavioral health disorders; they tend to be concentrated in NHs in economically disadvantaged communities. Individuals may remain in NHs because suitable settings for discharge are unavailable. These developments constitute a back door "re-institutionalization" of people with behavioral health disorders, and a growing crisis.

Children's Health Insurance Coverage and Parental Immigration Status: 2015-2019

BACKGROUND AND OBJECTIVES

Rhetoric and policies aimed at restricting immigration to the United States, such as those proposed during the Trump administration, may lead to reduced enrollment in Medicaid for children of immigrants, even those who were legally eligible. This study assessed how children's health insurance coverage changed before versus during the Trump administration by parental immigration status.

METHODS

Using American Community Survey data, we compared changes in rates of uninsurance and Medicaid enrollment for children in the United States before (2015 to 2016) versus during (2017 to 2019) the Trump administration. Children were categorized by parental immigration status: citizen children with US-born parents, citizen children with naturalized parents, children from mixed-status families, or noncitizen children.

RESULTS

The study population included 2 963 787 children between 2015 and 2019, representing approximately 64 million children annually. Throughout our study period, uninsurance rates for children from mixed-status families and noncitizen children were higher than citizen children with United States-born parents. Beginning in 2017, there were significant increases in uninsurance among children from mixed-status families (0.48 percentage points [PP], 95% confidence interval [CI]: 0.06 to 0.91) that increased to 1.48 PP (95% CI: 0.98 to 1.99) by 2019 when compared with concurrent trends among citizen children with US-born parents. Changes were accompanied by significant decreases in Medicaid enrollment by 2019 (-0.89 PP, 95% CI: -1.62 to -0.16).

CONCLUSIONS

There were substantial disparities in uninsurance rates by parental immigration status. Compared with citizen children with US-born parents, uninsurance rates among children from mixed-status families significantly increased between 2017 and 2019, with the magnitude of disparity widening over time.

Medicaid expansion, managed care plan composition, and enrollee experience

OBJECTIVES

To examine changes in plan composition and enrollee experience associated with Medicaid expansion among Medicaid managed care organization (MCO) enrollees.

STUDY DESIGN

Using 2012-2018 Adult Medicaid Consumer Assessment of Healthcare Providers and Systems surveys, we estimated changes in MCO enrollee characteristics and 4 outcomes: having access to needed care, having a personal doctor, having timely access to a checkup, and having timely access to specialty care.

METHODS

We estimated multivariable linear probability models comparing pre- vs postexpansion changes in expansion vs nonexpansion states. The postexpansion period was modeled as an event-study regression to account for changes over time. The coefficient of interest was a Medicaid expansion-by-year term.

RESULTS

Medicaid expansion was associated with statistically significant decreases in the proportion of female enrollees (-8.4 percentage points [PP]; P < .01) and increases in the proportion of enrollees who were aged 55 to 64 years (6.8 PP; P < .01) and were non-Hispanic White (4.4 PP; P < .01). Relative to enrollees in nonexpansion states, MCO enrollees in expansion states were significantly less likely to report access to a personal doctor (-1.6 PP; 95% CI, -3.0 to -0.1 PP) and less likely to report timely access to specialty care (-2.1 PP; 95% CI, -3.4 to -0.8 PP; P < .01) in the first year after expansion. Differences were not statistically significant by the second year post expansion. There were not significant changes in the other 2 outcomes.

CONCLUSIONS

State policy makers may need to account for the role that Medicaid expansion may have in changing Medicaid MCO enrollee composition to prevent unfair penalization on performance metrics.

Use of antiretroviral therapy in nursing home residents with HIV

BACKGROUND

Antiretroviral therapies (ARTs) are essential HIV care. As people living with HIV age and their presence in nursing homes (NHs) increases, it is critical to evaluate the quality of HIV care. We determine the rate of ART use and examine individual- and facility-level characteristics associated with no ART use in a nationally representative long-stay NH residents with HIV.

METHODS

This retrospective cohort study included all long-stay Medicare fee-for-service NH residents (2013-2016) with HIV who had a valid Minimum Data Set assessment. Residents were followed from long-stay qualification until death, Part D disenrollment, transfer from long-term care to another healthcare setting, or December 31, 2016. We identified individual and facility characteristics that were associated with non-use of ART using generalized estimating equation logistic regression.

RESULTS

Exactly 4171 eligible HIV+ residents from 2459 NHs were included in our study. Only 36% (1507 of 4171) received any ART regimen during an average of 11.6 months of observation. Older age, females, white race, receipt of Medicare skilled nursing benefits, and some major cardiometabolic comorbidities and mental health conditions were associated with non-ART use. Rates of non-ART use did not vary significantly by residents' end-of-life status (p = 0.21). Residents in facilities with a higher HIV concentration [adjusted odds ratio (adjOR) 3.42; 95% confidence interval (CI) 2.13-5.48] and an AIDS unit (adjOR 2.51; 95% CI 1.92-3.30) had higher odds of using an ART.

CONCLUSIONS AND IMPLICATIONS

The rate of ART use by HIV+ long-stay NH residents was low. Facilities' experience with HIV played an important role in ART receipt. Interventions to improve rates of ART use in NHs are urgently needed to ensure optimal health outcomes.

Methodological considerations on estimating medication adherence from self-report, electronic monitoring, and electronic healthcare databases using the TEOS framework

AIM

Measuring adherence to medication is complex due to the diversity of contexts in which medications are prescribed, dispensed, and used. The Timelines-Events-Objectives-Sources (TEOS) framework outlined a process to operationalize adherence. We aimed to develop practical recommendations for quantification of medication adherence using self-report (SR), electronic monitoring (EM), and electronic healthcare databases (EHD) consistent with the TEOS framework for adherence operationalization.

METHODS

An adherence methodology working group of the International Society for Medication Adherence (ESPACOMP) analysed implications of the process of medication adherence for all data sources and discussed considerations specific to SR, ED, and EHD regarding the information available on the prescribing, dispensing, recommended and actual use timelines, the four events relevant for distinguishing the adherence phases, the study objectives commonly addressed with each type of data, and the potential sources of measurement error and quality criteria applicable.

RESULTS

Four key implications for medication adherence measurement are common to all data sources: adherence is a comparison between two series of events (recommended and actual use); it refers to one or more specific medication(s); it applies to regular repeated events coinciding with known recommended dosing; and it requires separate measurement of the three adherence phases for a complete picture of patients' adherence. We propose recommendations deriving from these statements, and aspects to be considered in study design when measuring adherence with SR, EM and EHD using the TEOS framework.

CONCLUSION

The quality of medication adherence estimates is the result of several design choices that may optimize the data available.

Assets, stressors, and symptoms of persistent depression over the first year of the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has been accompanied by an increase in depression in U.S. adults. Previous literature suggests that having assets may protect against depression. Using a nationally representative longitudinal panel survey of U.S. adults studied in March and April 2020 and in March and April 2021, we found that (i) 20.3% of U.S. adults reported symptoms of persistent depression in Spring 2020 and Spring 2021, (ii) having more assets was associated with lower symptoms of persistent depression, with financial assets-household income and savings-most strongly associated, and (iii) while having assets appeared to protect persons-in particular those without stressors-from symptoms of persistent depression over the COVID-19 pandemic, having assets did not appear to reduce the effects of job loss, financial difficulties, or relationship stress on symptoms of persistent depression. Efforts to reduce population depression should consider the role played by assets in shaping risk of symptoms of persistent depression.

Wealth and depression: A scoping review

INTRODUCTION

The inverse relation between income and depression is well established. Less is understood about the relation between wealth and depression. We therefore conducted a scoping review to answer the question: What is known from the existing literature about the relation between wealth and depression?

METHODS

We searched for studies and articles in Medline (via PubMed), Embase, PsycINFO, PsycArticles, EconLit, and SocINDEX from inception through July 19, 2020. Ninety-six articles were included in our review. Key article characteristics were year of publication, sample size, country, study design, definition of depression, definition of wealth, and association between wealth and depression. Thirty-two longitudinal articles were included in a detailed charted review.

RESULTS

Depression was defined in a relatively standard manner across articles. In contrast, definitions and measurements of wealth varied greatly. The majority of studies in the full review (n = 56, 58%) and half of the studies in the longitudinal charted review (n = 16, 50%) reported an inverse relation between wealth and depression. The longitudinal charted review showed that (1) macro-economic events influenced depression, (2) wealth status influenced depression across the lifecourse, (3) wealth protected against depression in the face of stressors such as job loss, (4) subjective or psychosocial factors such as perception of wealth, relative comparison, and social status modified the relation between wealth and depression, and (5) savings interventions were successful in reducing depression and varied by context.

CONCLUSION

These findings suggest that wealth should be included in our consideration of the forces that shape mental health.

Racial And Ethnic Disparities In Patient Experience Of Care Among Nonelderly Medicaid Managed Care Enrollees

Medicaid managed care enrollees who are members of racial and ethnic minority groups have historically reported worse care experiences than White enrollees. Few recent studies have identified disparities within and between Medicaid managed care plans. Using 2014-18 data on 242,274 nonelderly Medicaid managed care enrollees in thirty-seven states, we examined racial and ethnic disparities in four patient experience metrics. Compared with White enrollees, minority enrollees reported significantly worse care experiences. Overall adjusted disparities for Black enrollees ranged between 1.5 and 4.5 percentage points; 1.6-3.9 percentage points for Hispanic or Latino enrollees; and 9.0-17.4 percentage points for Asian American, Native Hawaiian, or other Pacific Islander enrollees. Disparities were largely attributable to worse experiences by race or ethnicity within the same plan. For all outcomes, disparities were smaller in plans with the highest percentages of Hispanic or Latino enrollees, and for some outcomes, there were smaller disparities in plans with the highest percentages of Asian American, Native Hawaiian, or other Pacific Islander enrollees. Interventions to mitigate racial and ethnic inequities in care experiences include collection of comprehensive race and ethnicity data, adoption of health equity performance metrics, plan-level enrollee engagement, and multisectoral initiatives to dismantle structural racism.

HIV-Positive and HIV-Negative Women with Medicaid Have Similar Rates of Stillbirth and Preterm Birth

Introduction: Women living with human immunodeficiency virus (WLHIV) may face additional challenges and differential birth outcomes when compared with women without human immunodeficiency virus (HIV). There is limited research to date studying birth outcomes among a nationally representative sample of WLHIV. This study compares stillbirth and prematurity rates between HIV-positive (HIV+) and HIV-negative (HIV-) mothers in the Medicaid program. Methods: We used 12 years (2001-2012) of Medicaid Analytic eXtract data. We included Medicaid claims from the 14 states with the highest prevalence of HIV: California, Florida, Georgia, Illinois, Louisiana, Massachusetts, Maryland, North Carolina, New Jersey, New York, Ohio, Pennsylvania, Texas, and Virginia. Primary outcomes were stillbirth and preterm birth. We used logistic regression models adjusting for age, race, Medicaid coverage, eligibility, substance use, rurality, comorbidities, and state fixed effects to compare differences in rates for women with and without HIV. Results: Our study included a total of 33,078 HIV+ and 7,663,758 HIV- pregnancies from Medicaid enrollees between 2001 and 2012. The proportions of stillbirths and preterm births were higher for HIV+ when compared with HIV- mothers (0.9% vs. 0.7% and 8.0% vs. 6.6%, p < 0.0001). After adjusting for covariates, being HIV+ was not significantly associated with both stillbirth (odds ratio [OR]: 1.05) or prematurity (OR: 1.01). Black race was a strong independent predictor of both stillbirth and prematurity (OR: 1.99 and 1.51, p < 0.01). Rurality and substance abuse were not associated with either outcome. Conclusions: After adjustment for relevant covariates, maternal HIV infection was not associated with increased rates of stillbirth or preterm birth in the Medicaid program in the United States. It is imperative that we understand and eliminate the clinical, social, and contextual factors that are responsible for the strong association between black race and poor perinatal outcomes that we observe.

Association of Medicaid Expansion in Arkansas With Postpartum Coverage, Outpatient Care, and Racial Disparities

Importance

Non-Hispanic Black individuals are disproportionally covered by Medicaid during pregnancy and, compared with non-Hispanic White individuals, have higher rates of postpartum coverage loss and mortality. Expanded Medicaid coverage under the Affordable Care Act may have increased continuity of coverage and access to care in the critical postpartum period in expansion states.

Objective

To examine the association of Medicaid expansion in Arkansas with continuous postpartum coverage, postpartum health care use, and change in racial disparities in the study outcomes.

Design Setting and Participants

This cohort study with a difference-in-differences analysis compared persons with Medicaid and commercially financed childbirth, stratified by race, using Arkansas' All-Payer Claims Database for persons with a childbirth between 2013 and 2015. Race and ethnicity from birth certificate data were classified as Hispanic, non-Hispanic Black (hereafter Black), non-Hispanic White (hereafter White), and other (including Asian, Native American or Alaska Native, and Pacific Islander) or unknown race. Data were analyzed between June 2020 and August 2021.

Exposures

Medicaid-paid childbirth after January 1, 2014.

Main Outcomes and Measures

Continuous health insurance coverage and the number of outpatient visits during the first 6 months postpartum.

Results

A total of 60 990 childbirths (mean [SD] age of birthing person, 27 [5.3] years; 67% White, 22% Black, and 7% Hispanic) were included, among which 72.3% were paid for by Medicaid and 27.7% were paid for by a commercial payer. Medicaid expansion in Arkansas was associated with a 27.8 (95% CI, 26.1-29.5) percentage point increase in continuous insurance coverage and an increase in outpatient visits of 0.9 (95% CI, 0.7-1.1) during the first 6 months postpartum, representing relative increases of 54.9% and 75.0%, respectively. Racial disparities in postpartum coverage decreased from 6.3 (95% CI, 3.9-8.7) percentage points before expansion to -2.0 (95% CI, -2.8 to -1.2) percentage points after expansion. However, disparities in outpatient care between Black and White individuals persisted after Medicaid expansion (preexpansion difference, 0.4 [95% CI, 0.2-0.6] visits; postexpansion difference, 0.5 [95% CI, 0.4-0.6] visits).

Conclusions and Relevance

In this cohort study with a difference-in-differences analysis of 60 990 childbirths, Medicaid expansion was associated with higher rates of postpartum coverage and outpatient visits and lower racial and ethnic disparities in postpartum coverage. However, disparities in outpatient visits between Black and White individuals were unchanged. Additional policy approaches are needed to reduce racial and ethnic disparities in postpartum care.

The Relationship Between Medicare Advantage Star Ratings and Enrollee Experience

BACKGROUND

Medicare Advantage plans, private managed care plans that enrolled 34% of Medicare beneficiaries in 2019, received $6 billion in annual bonus payments on the basis of their performance on a 5-star rating system. Little is known, however, as to the extent these ratings adequately capture enrollee experience.

OBJECTIVES

To measure the effect of exposure to higher rated Medicare Advantage contracts on enrollee experience.

DESIGN

An instrumental variables analysis using MA contract consolidation as an exogenous shock to the quality of plan enrollees are exposed to.

PARTICIPANTS

A total of 345,897 MA enrollees enrolled in non-consolidated contracts and 21,405 enrollees who were consolidated.

MAIN MEASURES

The primary exposure was enrollee star rating, instrumented using contract consolidation. The primary outcomes were enrollee self-reported experience measures.

KEY RESULTS

There were no significant effects on increased star ratings on 23 of 27 outcomes. A one-star increase in contract star rating leads to a 5.4 percentage point increase in reporting that pain does not interfere with daily activities (95%CI 2.4, 8.4), and a 4.4 percentage reduction in the likelihood that a physician would talk to the enrollee about physical activity (95%CI: -7.8, -1.1, all p<0.05). A one-star increase in contract star rating led to an 8.4 percentage point reduction in achieving the top score on the received needed information index (95%CI: -16.4, -0.4), and a 1.8 percentage point reduction in responding with the lowest score for the overall rating of care (95%CI: -3.5, -0.1).

CONCLUSIONS

Exposure to a higher rated MA contract did not appreciably increase enrollee experience. Policymakers should consider reassessing how these ratings and associated bonus payments are currently calculated.

Higher Clinician-Patient Communication Is Associated With Greater Satisfaction With HIV Care

Provider-patient communication (PPC) skills are key in promoting patient satisfaction. Our study examined the relationship between clinician PPC skills and patient satisfaction with care among virally unsuppressed adult HIV patients in Busia County, Kenya. This cross-sectional study was conducted among 360 HIV patients on first line antiretroviral regimen and having a recent viral load ≥400 copies HIV RNA/ml. We conducted logistic regression analysis. The mean age of participants was 48.2 years [standard deviation (SD): 12.05]. Overall, the mean score on clinician PPC skills was 33.3 (SD: 9.0). A high proportion (85%) of participants reported satisfaction with the HIV care services. After adjusting for covariates, the odds of being satisfied with care increased by 19% (adjusted odds ratio: 1.19, 95% CI: 1.11-1.30) for every one unit increase in the clinician PPC skills score. Promoting good PPC skills may be key to improving patient satisfaction with HIV care.

Association of Patient-Reported Physician Awareness of Complementary Medicine, Medical Care Experience and Care Quality

The aim was to examine the association of patient-reported physician awareness of biological CAM use and patient perceptions of care experience and quality with a population-based study of patients with incident lung and colorectal cancer. This was a secondary data analysis using regression models. Outcomes of interest were patient reports of medical care experience and quality ratings. Among 716 patients who reported biological CAM use, 69% reported their physicians were aware of this. Patients who reported physician awareness of biological CAM use had higher adjusted scores for medical care experience ( + 5.4, 95%CI:2.3,8.6) and care quality ( + 3.6, 95%CI:−0.3, + 7.5). These associations suggest that physicians should be encouraged to inquire about biological CAM use.

Individual health behaviours to combat the COVID-19 pandemic: lessons from HIV socio-behavioural science

INTRODUCTION

COVID-19 parallels HIV in many ways. Socio-behavioural science has been critical in elucidating the context and factors surrounding individual levels of engagement with known effective prevention and treatment tools for HIV, thus offering important lessons for ongoing efforts to combat the COVID-19 pandemic.

DISCUSSION

Non-adherence to effective disease mitigation strategies (e.g. condoms for HIV and masks for COVID-19) can be attributed in part to prioritizing comfort, convenience and individual autonomy over public health. Importantly, misinformation can fuel denialism and conspiracies that discredit scientific knowledge and motivate nonadherence. These preferences and the extent to which individuals can act on their preferences may be constrained by the structures and culture in which they live. Both HIV and COVID-19 have been politicized and influenced by evolving recommendations from scientists, clinicians, policymakers and politically motivated organizations. While vaccines are vital for ending both pandemics, their impact will depend on availability and uptake. Four decades of experience with the HIV epidemic have shown that information alone is insufficient to overcome these challenges; interventions must address the underlying, often complex factors that influence human behaviour. This article builds from socio-behavioural science theory and describes practical and successful approaches to enable and support adherence to prevention and treatment strategies, including vaccine adoption. Key methods include reframing tools to enhance motivation, promoting centralized sources of trusted information, strategic development and messaging with and within key populations (e.g. through social media) and appealing to self-empowerment, altruism and informed decision making. Orchestrated evidence-based activism is needed to overcome manipulative politicization, while consistent transparent messaging around scientific discoveries and clinical recommendations are critical for public acceptance and support. Ultimately, the effectiveness of COVID-19 vaccines will depend on our ability to engender trust in the communities most affected.

CONCLUSIONS

Many lessons learned from socio-behavioural science in the HIV pandemic are applicable to the COVID-19 pandemic. Individual behaviour must be understood within its interpersonal and societal context to address the current barriers to adherence to disease-mitigating strategies and promote an effective response to the COVID-19 pandemic, which is likely to be endured for the foreseeable future.

Use of Antiretroviral Therapy for a US Medicaid Enrolled Pediatric Cohort with HIV

Appropriate antiretroviral therapy use in children with Human Immunodeficiency Virus (HIV) is essential for optimizing clinical outcomes and preventing HIV transmission. To describe and determine correlates of HIV antiretroviral therapy (ART) persistence and implementation for children and adolescents in the United States. We studied Medicaid enrollees (ages 2-19 years) with HIV in 14 states in 2011 and 2012. We defined non-persistence as a discontinuation of an ART regimen for at least 90 days, and calculated implementation as the proportion of days on ART while persistent. We used Cox proportional regression and logistic regression to determine characteristics associated with ART non-persistence and poor (< 90%) implementation, respectively. Among those with ≥ 1 year of observation (n = 8679), 55.7% never received ART. For ART recipients (n = 3849), 34.9% discontinued ART. Correlates of ART non-persistence included older age (e.g., 15-19 vs. 2-5 years [adjusted hazard ratio (aHR) 2.9, 95% CI 2.1-4.0]; females vs. males (aHR 1.2; 1.1-1.3); mental health conditions (aHR 1.3; 1.1-1.5), drug/alcohol abuse (aHR 1.2; 1.0-1.5) and HIV-related conditions (aHR 1.2; 1.0-1.4). Those with an outpatient visit were less likely to discontinue an ART (aHR 0.32; 0.28-0.36). During persistent episodes, 42.3% had poor ART implementation. Correlates of poor implementation included females vs. males (aOR 1.2; 95% CI 1.0-1.3), Black vs. White race (aOR 1.3; 95% CI 1.1-1.7) and Hispanic/Latino vs. White (aOR 1.3; 1.0-1.8). Among Medicaid youth with HIV, there were low rates of ART exposure, and ART discontinuation was common. Correlates of persistence and implementation differed, suggesting a need for varying clinical interventions to improve connection to care and ensuring ongoing engagement with ART use.

Strengthening data collection and use for quality improvement in primary care: the case of Costa Rica

Costa Rica is a bright spot of primary healthcare (PHC) performance, providing first-contact accessibility and continuous, comprehensive, coordinated, and patient-centered care to its citizens. Previous research hypothesized that strong data collection and use for quality improvement are central to Costa Rica's success. Using qualitative data from 40 interviews with stakeholders across the Costa Rican healthcare system, this paper maps the various data streams at the PHC level and delineates how these data are used to make decisions around insuring and improving the quality of PHC delivery. We describe four main types of PHC data: individual patient data, population health data, national healthcare delivery data, and local supplementary healthcare delivery data. In particular, we find that the Healthcare Delivery Performance Index-a ranking of the nation's 106 Health Areas using 15 quality indicators-is utilized by Health Area Directors to create quality improvement initiatives, ranging from education and coaching to optimization of care delivery and coordination. By ranking Health Areas, the Index harnesses providers' intrinsic motivation to stimulate improvement without financial incentives. We detail how a strong culture of valuing data as a tool for improving population health and robust training for personnel have enabled effective data collection and use. However, we also find that the country's complex data systems create unnecessary duplication and can inhibit efficient data use. Costa Rica's experience with data collection, analysis, and use for quality improvement hold important lessons for PHC in other public sector systems.

Association of Medicare Advantage Star Ratings With Racial, Ethnic, and Socioeconomic Disparities in Quality of Care

Importance

Medicare Advantage (MA) plans, which disproportionately enroll racial/ethnic minorities and persons with socioeconomic disadvantage, receive bonus payments on the basis of overall performance on a 5-star rating scale. The association between plans' overall quality and disparities in quality is not well understood.

Objective

To examine the association between MA star ratings and disparities in care for racial/ethnic minorities and enrollees with lower income and educational attainment.

Design Setting and Participants

This cross-sectional study included 1 578 564 MA enrollees from 454 contracts across the 2015 and 2016 calendar years. Data analyses were conducted between June 2019 and June 2020.

Exposures

Self-reported race and ethnicity and low socioeconomic status (SES) (defined by low income or less than a high school education) vs high SES (neither low income nor low educational attainment).

Main Outcomes and Measures

Performance on 22 measures of quality and satisfaction determined at the individual enrollee level, aggregated into simulated star ratings (scale, 2-5) stratified by SES and race/ethnicity.

Results

A total of 1 578 564 enrollees were included in this analysis (55.8% female; mean [SD] age, 71.4 [11.3] years; 65.8% White; 12.3% Black; 14.6% Hispanic). Enrollees with low SES had simulated stratified star ratings 0.5 stars lower (95% CI, 0.4-0.6 stars) than individuals with high SES in the same contract. Black and Hispanic enrollees had simulated star ratings that were 0.3 stars (95% CI, 0.2-0.4 stars) and 0.1 stars (95% CI, -0.04 to 0.2 stars) lower than White enrollees within the same contracts. Black enrollees had a 0.4-star lower rating (95% CI, 0.1-0.7 stars) in 4.5- to 5-star contracts and a no statistical difference in 2.0- to 2.5-star-rated contracts (difference, 0.3 stars; 95% CI, -0.02 to 0.7 stars). Hispanic enrollees had a 0.6-star lower simulated rating (95% CI, 0.2-1.0 stars) in 4.5- to 5-star contracts and no statistical difference in 2- to 2.5-star contracts (difference, -0.01 stars; 95% CI, -0.5 to 0.4 stars). There was low correlation between simulated ratings for enrollees of low SES and high SES (difference, 0.2 stars; 95% CI, 0.03-0.4 stars) and between simulated ratings for White and Black enrollees (difference, 0.4 stars; 95% CI, 0.3-0.5 stars) and White and Hispanic enrollees (difference, 0.3 stars; 95% CI, 0.2-0.4 stars). As the proportion of Black and Hispanic enrollees increased in a contract, racial/ethnic disparities in ratings decreased.

Conclusions and Relevance

In this cross-sectional study, simulated MA star ratings were only weakly correlated with those for enrollees of low SES in the same contract, and contracts with higher star ratings had larger disparities in quality. Measures of equity in MA plans' quality of care may be needed.

Demand for Essential Nonambulatory Neurosurgical Care Decreased While Acuity of Care Increased During the Coronavirus Disease 2019 (COVID-19) Surge

Background

In times of health resource reallocation, capacities must remain able to meet a continued demand for essential, nonambulatory neurosurgical acute care. This study sought to characterize the demand for and provision of neurosurgical acute care during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

This single-center cross-sectional observational analysis compared nonambulatory neurosurgical consult encounters during the peri-surge period (March 9 to May 31, 2020) with those during an analogous period in 2019. Outcomes included consult volume, distribution of problem types, disease severity, and rate of acute operative intervention.

Results

A total of 1494 neurosurgical consults were analyzed. Amidst the pandemic surge, 583 consults were seen, which was 6.4 standard deviations below the mean among analogous 2016–2019 periods (mean 873; standard deviation 45, P = 0.001). Between 2019 and 2020, the proportion of degenerative spine consults decreased in favor of spinal trauma (25.6% vs. 34% and 51.9% vs. 41.4%, P = 0.088). Among aneurysmal subarachnoid hemorrhage cases, poor-grade (Hunt and Hess grades 4–5) presentations were more common (30% vs. 14.8%, P = 0.086). A greater proportion of pandemic era consults resulted in acute operative management, with an unchanged absolute frequency of acutely operative consults (123/583 [21.1%] vs. 120/911 [13.2%], P < 0.001).

Conclusions

Neurosurgical consult volume during the pandemic surge hit a 5-year institutional low. Amidst vast reallocation of health care resources, demand for high-acuity nonambulatory neurosurgical care continued and proportionally increased for greater-acuity pathologies. In our continued current pandemic as well as any future situations of mass health resource reallocation, neurosurgical acute care capacities must be preserved.

Population-level changes in outcomes and Medicare cost following the introduction of new cancer therapies

OBJECTIVE

To examine the population-level impacts of the introduction of novel cancer therapies with high cost in the United States, using immunotherapies in advanced nonsmall cell lung cancer (NSCLC) as an example.

DATA SOURCES

Surveillance, Epidemiology, and End Results data in 2012-2015 linked to Medicare fee-for-service claims until 2016.

STUDY DESIGN

We examined population-level trends in treatment patterns, survival, and Medicare spending in patients diagnosed with advanced NSCLC, the leading cause of cancer death in the United States, between 2012 and 2015. We estimated the percentage of patients who received any antineoplastic therapy within two years of diagnosis, including novel immunotherapies. We compared the trends in overall survival and mean two-year Medicare spending per each patient before and after the introduction of immunotherapies in 2015.

DATA COLLECTION/EXTRACTION METHODS

Not Applicable.

PRINCIPAL FINDINGS

The percentage of patients treated with any antineoplastic therapy remained the same at 46.7% in 2012 and 2015, whereas the use of immunotherapies increased from 0% to 15.2%. The two-year survival rate and median survival increased by 3.3 percentage points (95% CI: 2.0, 4.5) and 0.4 months (CI: 0.0, 0.9), respectively, during the same period. The mean two-year total Medicare spending and outpatient spending per patient increased by $5735 (CI: 3479, 8040) and $7661 (CI: 5902, 9311), respectively, which were largely attributable to the increases in immunotherapy spending by $5806 (CI: 5165, 6459).

CONCLUSIONS

The introduction of lung cancer immunotherapies was accompanied by improvements in survival and increases in spending between 2012 and 2015 in the Medicare population. As novel immunotherapies and other target therapies continue to change the clinical management of various cancers, further efforts are needed to ensure their effective and efficient use, and to understand their population-level impacts in the United States.

Factors Associated With Antiretroviral Therapy Reinitiation in Medicaid Recipients With Human Immunodeficiency Virus

BACKGROUND

This study was conducted to examine patient characteristics associated with antiretroviral therapy (ART) reinitiation in Medicaid enrollees.

METHODS

This is a retrospective cohort study that uses Cox proportional hazard regression to examine the association between person-level characteristics and time from ART discontinuation to the subsequent reinitiation within 18 months.

RESULTS

There were 45 409 patients who discontinued ART, and 44% failed to reinitiate. More outpatient visits (3+ vs 0 outpatient visits: adjusted hazard ratio (adjHR), 1.56; 99% confidence interval [CI], 1.45-1.67) and hospitalization (adjHR, 1.18; 99% CI,1.16-1.20) during follow-up were associated with reinitiation.

CONCLUSIONS

Failure to reinitiate ART within 18 months was common in this sample. Care engagement was associated with greater ART reinitiation.

Higher Medicare Advantage Star Ratings Are Associated With Improvements In Patient Outcomes

Little is known about how well the Centers for Medicare and Medicaid Services' five-star rating system for the overall quality of Medicare Advantage (MA) contracts captures quality of care. Leveraging contract consolidation as a natural experiment to study the association between outcomes and insurer-initiated enrollee shifts to plans with higher-rated contracts, we found that enrollees experiencing a one-star MA rating increase were 20.8 percent less likely to voluntarily leave their plan to enroll in another plan or traditional Medicare. When hospitalized, they were 3.4 percent more likely to use a higher-quality hospital and 2.6 percent less likely to be readmitted within ninety days. Our findings suggest that MA star ratings may capture key domains of an MA plan's quality; however, the differences in outcomes that they capture might not all be clinically meaningful.

Reliability and Validity of a Brief Self-Report Adherence Measure among People with HIV Experiencing Homelessness and Mental Health or Substance Use Disorders

The study examines the reliability and validity of a 3-item self-report adherence measure among people with HIV (PWH) experiencing homelessness, substance use, and mental health disorders. 336 participants were included from nine sites across the US between September 2013 and February 2017. We assessed the validity of a self-report scale for adherence to antiretroviral therapy by comparing it with viral load (VL) abstracted from medical records at baseline, 6, 12, and 18 months. The items had high internal consistency (Cronbach's alpha coefficients at each time point were > 0.8). The adherence scale scores were higher in the group that achieved VL suppression compared to the group that did not. The c-statistic for the receiver-operating characteristic curves pooled across time points was 0.77 for each adherence sub-item and 0.78 for the overall score. The self-report adherence measure shows good internal consistency and validity that correlated with VL suppression in homeless populations.

Understanding the Relationship Between Nursing Home Experience With Human Immunodeficiency Virus and Patient Outcomes

BACKGROUND

As the population with human immunodeficiency virus (HIV) continues to age, the need for nursing home (NH) care is increasing.

OBJECTIVES

To assess whether NH's experience in treating HIV is related to outcomes.

RESEARCH DESIGN

We used claims and assessment data to identify individuals with and without HIV who were admitted to NHs in 9 high HIV prevalent states. We classified NHs into HIV experience categories and estimate the effects of NH HIV experience on patient's outcomes. We applied an instrumental variable using distances between each individual's residence and NHs with different HIV experience.

SUBJECTS

In all, 5,929,376 admissions for those without HIV and 53,476 admissions for residents with HIV.

MEASURES

Our primary outcomes were 30-day hospital readmissions, likelihood of becoming a long stay resident, and 180-day mortality posthospital discharge.

RESULTS

Residents with HIV tended to have poorer outcomes than residents without HIV, regardless of the NH they were admitted to. Residents with HIV admitted to high HIV experience NHs were more likely to be readmitted to the hospital than those admitted to NHs with lower HIV experience (19.6% in 0% HIV NHs, 18.7% in 05% HIV NHs and 22.9% in 5%-50% HIV NHs).

CONCLUSIONS

Residents with HIV experience worse outcomes in NHs than residents without HIV. Increased HIV experience was not related to improved outcomes.

TEOS: A framework for constructing operational definitions of medication adherence based on Timelines-Events-Objectives-Sources

AIMS

Managing adherence to medications is a priority for health systems worldwide. Adherence research is accumulating, yet the quality of the evidence is reduced by various methodological limitations. In particular, the heterogeneity and low accuracy of adherence measures have been highlighted in many literature reviews. Recent consensus-based guidelines advise on best practices in defining adherence (ABC) and reporting of empirical studies (EMERGE). While these guidelines highlight the importance of operational definitions in adherence measurement, such definitions are rarely included in study reports. To support researchers in their measurement decisions, we developed a structured approach to formulate operational definitions of adherence.

METHODS

A group of adherence and research methodology experts used theoretical, methodological and practical considerations to examine the process of applying adherence definitions to various research settings, questions and data sources. Consensus was reached through iterative review of discussion summaries and framework versions.

RESULTS

We introduce TEOS, a four-component framework to guide the operationalization of adherence concepts: (1) describe treatment as four simultaneous interdependent timelines (recommended and actual use, conditional on prescribing and dispensing); (2) locate four key events along these timelines to delimit the three ABC phases (first and last recommended use, first and last actual use); (3) revisit study objectives and design to fine-tune research questions and assess measurement validity and reliability needs, and (4) select data sources (e.g., electronic monitoring, self-report, electronic healthcare databases) that best address measurement needs.

CONCLUSION

Using the TEOS framework when designing research and reporting explicitly on these components can improve measurement quality.

Effects Of Medicaid Expansion On Postpartum Coverage And Outpatient Utilization

Timely postpartum care is associated with lower maternal morbidity and mortality, yet fewer than half of Medicaid beneficiaries attend a postpartum visit. Medicaid enrollees are at higher risk of postpartum disruptions in insurance because pregnancy-related Medicaid eligibility ends sixty days after delivery. We used Medicaid claims data for 2013-15 from Colorado, which expanded Medicaid under the Affordable Care Act, and Utah, which did not. We found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.

Patient and proxy reports regarding the experience of treatment decision-making in cancer care

OBJECTIVE

Shared decision-making, including the elicitation of patient preferences regarding treatment decisions, is considered part of high-quality cancer care. However, patients may not be able to self-report due to illness, and therefore proxy reports may be used. We sought to determine the difference between proxy and patient reports about patient decisions and preferences among patients who received or were scheduled for chemotherapy using data from a large, population-based survey of patients with incident lung or colorectal cancer.

METHODS

Of 3573 patients who received or were scheduled for chemotherapy, 3108 self-reported and 465 had proxies reporting on their behalf about preferred and actual decision roles regarding this treatment. Preferred and actual decision roles were assessed using the Control Preferences Scale, and categorized as shared, patient-controlled, or doctor-controlled. Multivariable logistic regression models were used to assess the association between patient and proxy responses and whether preferences were met. The models adjusted for sociodemographic and clinical variables and patient/proxy-reported health status.

RESULTS

Sixty-three percent of all respondents reported actual roles in decisions that matched their preferred roles (role attainment). Proxies and patients were similarly likely to report role attainment (65% vs 63%). In adjusted analyses, proxies were more likely report role attainment (OR = 1.27, 95%CI = 1.02-1.59), but this difference was smaller if health variables were excluded from the model (OR = 1.14, 95%CI = 0.92-1.41).

CONCLUSION

Most patients' preferences for treatment participation were met. Surveys from proxies appear to yield small differences on the reports of attainment of preferred treatment decision-making roles in cancer care vs surveys from patients.

Using electronic health records to identify candidates for human immunodeficiency virus pre-exposure prophylaxis: An application of super learning to risk prediction when the outcome is rare

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) protects high risk patients from becoming infected with HIV. Clinicians need help to identify candidates for PrEP based on information routinely collected in electronic health records (EHRs). The greatest statistical challenge in developing a risk prediction model is that acquisition is extremely rare.

METHODS

Data consisted of 180 covariates (demographic, diagnoses, treatments, prescriptions) extracted from records on 399 385 patient (150 cases) seen at Atrius Health (2007-2015), a clinical network in Massachusetts. Super learner is an ensemble machine learning algorithm that uses k-fold cross validation to evaluate and combine predictions from a collection of algorithms. We trained 42 variants of sophisticated algorithms, using different sampling schemes that more evenly balanced the ratio of cases to controls. We compared super learner's cross validated area under the receiver operating curve (cv-AUC) with that of each individual algorithm.

RESULTS

The least absolute shrinkage and selection operator (lasso) using a 1:20 class ratio outperformed the super learner (cv-AUC = 0.86 vs 0.84). A traditional logistic regression model restricted to 23 clinician-selected main terms was slightly inferior (cv-AUC = 0.81).

CONCLUSION

Machine learning was successful at developing a model to predict 1-year risk of acquiring HIV based on a physician-curated set of predictors extracted from EHRs.

An instrument to assess HIV-related knowledge and adjustment to HIV+ status, and their association with anti-retroviral adherence

Background

Findings on the association between health literacy and anti-retroviral (ARV) adherence are inconsistent. Health literacy is usually operationalized with simple tests of basic literacy, but more complex conceptions of health literacy include content knowledge. People living with chronic illness also conceptualize and experience illness in ways other than biomedical or mechanistic models of disease.

Objective

There are no instruments that comprehensively assess knowledge of people living with HIV concerning HIV disease and treatment; or psychological adjustment to being HIV+. Little is known about the relationship between factual knowledge, or positive identification as HIV+, and anti-retroviral (ARV) adherence.

Methods

Formative work with in-depth semi-structured interviews, and cognitive testing, to develop a structured instrument assessing HIV-related knowledge, and personal meanings of living with HIV. Pilot administration of the instrument to a convenience sample of 101 respondents.

Key results

Respondents varied considerably in their expressed need for in-depth knowledge, the accuracy of their understanding of relevant scientific concepts and facts about ARV treatment, and psychological adjustment and acceptance of HIV+ status. Most knowledge domains were not significantly related to self-reported ARV adherence, but accurate knowledge specifically about ARV treatment was (r = 0.25, p = .02), as was an adapted version of the Need for Cognition scale (r = .256, p = .012). Negative feelings about living with HIV (r = .33, p = .0012), and medication taking (r = .276, p = .008) were significantly associated with non-adherence.

Conclusion

The instrument may be useful in diagnosing addressable reasons for non-adherence, as a component of psychoeducational interventions, and for evaluation of such interventions.

Hazard of Cervical, Oropharyngeal, and Anal Cancers in HIV-Infected and HIV-Uninfected Medicaid Beneficiaries

BACKGROUND

Human immunodeficiency virus-infected (HIV⁺) individuals are disproportionately at risk for human papillomavirus (HPV)-associated cancers, but the magnitude of risk estimates varies widely. We conducted a retrospective study using a large U.S.-based cohort to describe the relationship between HIV infection and incident cervical, oropharyngeal, and anal cancers.

METHODS

Using 2001-2012 U.S. Medicaid data from 14 states, we matched one HIV⁺ to three HIV-uninfected (HIV^-) enrollees on sex, race, state, age, and year, and followed persons for up to 10 years. We developed Cox proportional hazards models comparing HIV⁺ to HIV^- for time to cancer diagnosis adjusted for demographic and comorbidity attributes.

RESULTS

Our cohorts included 443,592 women for the cervical cancer analysis, and 907,348 and 906,616 persons for the oropharyngeal and anal cancer analyses. The cervical cancer cohort had a mean age of 39 years and was 55% Black. The oropharyngeal and anal cancer cohorts were 50% male, had a mean age of 41 years, and were 51% Black. We estimated the following HRs: cervical cancer, 3.27 [95% confidence interval (CI), 2.82-3.80]; oropharyngeal cancer, 1.90 (95% CI, 1.62-2.23; both sexes), 1.69 (95% CI, 1.39-2.04; males), and 2.55 (95% CI, 1.86-3.50; females); and anal cancer, 18.42 (95% CI, 14.65-23.16; both sexes), 20.73 (95% CI, 15.60-27.56; males), and 12.88 (95% CI, 8.69-19.07; females).

CONCLUSIONS

HIV⁺ persons were at an elevated risk for HPV-associated cancers, especially anal cancer.

IMPACT

Medicaid claims data corroborate previous estimates based on registries and clinical cohorts.

Real-world use and survival outcomes of immune checkpoint inhibitors in older adults with non-small cell lung cancer

BACKGROUND

Limited data exist regarding the characteristics and survival outcomes of older adults with non-small cell lung cancer (NSCLC) who receive immune checkpoint inhibitors in routine oncology practice.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 1256 patients aged ≥65 years who were diagnosed with pathologically confirmed stage I to stage IV NSCLC between 2002 and 2015 and initiated nivolumab or pembrolizumab in 2016. We examined patient characteristics and overall survival from the time of immune checkpoint inhibitor initiation through December 31, 2017.

RESULTS

The median patient age at the time of immune checkpoint inhibitor initiatiton was 75.3 years (interquartile range, 8.5). A substantial percentage of patients were initially diagnosed with stage IV disease (42.6%) and had ≥2 comorbid conditions (48.7%). Using a claims-based proxy, 11.5% of patients had poor performance status and 12.6% had a history of autoimmune conditions. The median overall survival after initiation of immune checkpoint inhibitor was 9.3 months (95% CI, 8.5-10.5 months). The 1-year survival rate was 43.0% (95% CI, 40.2-45.7%). In multivariable analyses, multiple comorbid conditions, squamous histology, a history of nonplatinum doublet systemic therapy, recent radiotherapy, and a shorter time from initial diagnosis to treatment initiation were found to be statistically significantly associated with an increased hazard of death. Demographics, poor performance status, and prior autoimmune conditions were not significantly associated with the hazard of death.

CONCLUSIONS

Many older adults with NSCLC who initiated immune checkpoint inhibitors had multiple comorbidities, a history of autoimmune disease, or poor performance status. Factors associated with poor prognosis among patients with advanced NSCLC were also associated with worse survival in older adults treated with immune checkpoint inhibitors.

Architecting Process of Care: A randomized controlled study evaluating the impact of providing nonadherence information and pharmacist assistance to physicians

OBJECTIVE

To test the impact of connecting physicians, pharmacists, and patients to address medication nonadherence, and to compare different physician choice architectures.

DATA SOURCES AND STUDY SETTING

The study was conducted with 90 physicians and 2602 of their patients on medications treating chronic illness.

STUDY DESIGN

In this cluster randomized controlled trial, physicians were randomly assigned to an arm where the physician receives notification of patient nonadherence derived from real-time claims data, an arm where they receive this information and a pharmacist may contact patients either by default or by physician choice, and a control group. The primary outcome was resolving nonadherence within 30 days. We also considered physician engagement outcomes including viewing information about nonadherence and utilizing a pharmacist.

DATA COLLECTION

Physician engagement was constructed from metadata from the study website; adherence outcomes were constructed from medication claims.

PRINCIPAL FINDINGS

We see no differences between the treatment arms and control for the primary adherence outcome. The pharmacist intervention was 42 percentage points (95% CI: 28 pp-56 pp) more likely when it was triggered by default.

CONCLUSIONS

Access to a pharmacist and real-time nonadherence information did not improve patient adherence. Physician process of care was sensitive to choice architecture.

The Quality of Nursing Homes That Serve Patients With Human Immunodeficiency Virus

BACKGROUND/OBJECTIVES

As the national population of persons living with human immunodeficiency virus (HIV) ages, they will require greater postacute and long-term care use. Little is known about the quality of nursing homes (NHs) to which patients with HIV are admitted. In this study, we assess the association between the number of persons with HIV admitted annually to a given NH (HIV concentration) and that NH's quality outcomes.

DESIGN

A cross-sectional comparative study.

SETTING

NHs in nine states, from 2001 to 2012.

PARTICIPANTS

A total of 46 918 NH-years accounting for 67 301 admissions by patients with HIV.

MEASUREMENTS

We used 100% Medicaid Analytic Extract, Minimum Dataset 2.0 and 3.0, and Medicare claims from 2001 to 2012 from nine states to examine the association between HIV concentration and NH quality. Persons were classified as HIV positive on the basis of all available data sources, and a NH's percentage of new admissions with HIV was calculated (HIV concentration). We then compared differences in star ratings, rehospitalization rates, NH survey deficiencies, and restraint use by a NH's percentage of admissions with HIV, using linear random effects models.

RESULTS

After adjusting for NH characteristics, zip code characteristics, and state and year fixed effects, NHs with greater than 0% to 5% of admissions with HIV had a 0.6 lower star rating (P < .001), and a 0.4% percentage point higher 30-day rehospitalization rate (P < .01), compared to those with no HIV admissions. NHs with 5% to 50% of admissions with HIV had 7.0 more deficiencies (P < .001), a 0.1 lower star rating (P < .001), and a 1.5 percentage point higher rehospitalization rate (P < .001).

CONCLUSION

Persons with HIV were generally admitted to lower-quality NHs compared to persons without HIV. More efforts are needed to ensure that persons with HIV have access to high-quality NHs. J Am Geriatr Soc 67:2615-2621, 2019.

The association of provider and practice factors with HIV antiretroviral therapy adherence

OBJECTIVE

While antiretroviral therapy (ART) is essential to patients with HIV, there is substantial variation in adherence nationally. We assess how provider and practice factors contribute to successful HIV ART adherence.

DESIGN

We used Medicaid Analytic Extract claims from 2008 to 2012. We attributed patients with HIV to the provider that provided the plurality of HIV-related services or primary care in a given year and assigned these providers to a medical practice based on the National Provider Identifier registry file. We fit successive linear hierarchical models with patient, provider, and practice characteristics to partition the variation in adherence driven by each factor. Our unit of analysis was the patient-year.

SETTING

Fourteen US states with the highest HIV prevalence.

PARTICIPANTS

A total of 111 013 patient-years representing 60 496 Medicaid enrollees living with HIV attributed to 4930 providers and 1960 practices.

MAIN OUTCOME MEASURE

Percentage of year individual patients were adherent to an ART regimen.

RESULTS

Provider and practice random effects jointly explained 6.8% of variation in adherence with patient differences accounted for 45.2% of the variation. Patients seen by generalists and other specialists had a 1.6 [95% confidence interval (CI): 0.6-2.5] and 5.1 (95% CI: 4.1-6.1) percentage point greater adherence than those seen by infectious disease specialists (P < 0.001). Every additional year a patient saw the same provider was associated with a 6% increase in adherence (95% CI: 5.7-6.3).

CONCLUSION

There is substantial variation in ART adherence attributable to providers and practices and between provider specialties. To improve ART adherence for patients living with HIV, structural aspects of care should be considered.

Trends in medication adherence in HIV patients in the US, 2001 to 2012: an observational cohort study

INTRODUCTION

Adherence to antiretroviral therapy (ART) is essential to reduce HIV-related morbidity and mortality as well as the risk of virological failure and HIV transmission. We determined the trends in ART adherence during the periods of therapeutic advances, wider use of ART and greater attention to ART adherence. To understand the general trends in medication adherence, we compared ART adherence with medications for other common chronic conditions.

METHODS

A retrospective cohort study using Medicaid claims between 2001 and 2012 from 14 US states with the highest HIV prevalence. Medicaid is the largest source of care for HIV patients in the US. We identified Medicaid beneficiaries with HIV who initiated ART between 2001 and 2010 (n=23,343). Comparison groups included (1) HIV- persons who initiated a statin, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB), or metformin and (2) HIV+ persons who initiated these control medications while on and not on ART. We estimated adjusted odds of >90% medication implementation during the two years following initiation.

RESULTS

The proportion of HIV+ persons with >90% ART implementation increased from 33.5% in those who initiated in 2001 to 46.4% in 2005 and 52.4% in 2010. ART initiators in 2007 to 2010 had 53% increased odds of >90% implementation compared to those in 2001 to 2003 (adjusted OR 1.53, 99% CI: 1.34 to 1.75). Older age, male, White race, newer ART regimens and absence of substance use indicators were also associated with increased odds of >90% ART implementation. No or minimal improvements were found in the implementation of control medications in HIV- persons. For HIV- persons, the adjusted ORs comparing 2007-2010 to 2001-2003 were 1.06, 1.01 and 1.19 for statins, ACEI/ARB, metformin respectively. HIV+ persons who were on ART had, on average, 15.0 (SD: 4.2) and 16.1 (SD: 3.4) percentage points higher >90% implementation rates of concurrent statins, ACEI/ARB or metformin compared to HIV- persons and HIV+ persons who were not on ART respectively.

CONCLUSIONS

Adherence to ART substantially improved between 2001 and 2012. Nevertheless, the absolute rates of >90% implementation were low for all groups examined. Substantial disparities by age, sex and race were present, drawing attention to the need to continue to enhance medication adherence. Further studies are required to examine whether these trends and disparities persist in the most recent period.

Development and validation of an automated HIV prediction algorithm to identify candidates for pre-exposure prophylaxis: a modelling study

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is effective but underused, in part because clinicians do not have the tools to identify PrEP candidates. We developed and validated an automated prediction algorithm that uses electronic health record (EHR) data to identify individuals at increased risk for HIV acquisition.

METHODS

We used machine learning algorithms to predict incident HIV infections with 180 potential predictors of HIV risk drawn from EHR data from 2007-15 at Atrius Health, an ambulatory group practice in Massachusetts, USA. We included EHRs of all patients aged 15 years or older with at least one clinical encounter during 2007-15. We used ten-fold cross-validated area under the receiver operating characteristic curve (cv-AUC) with 95% CIs to assess the model's performance at identifying individuals with incident HIV and patients independently prescribed PrEP by clinicians. The best-performing model was validated prospectively with 2016 data from Atrius Health and externally with 2011-16 data from Fenway Health, a community health centre specialising in sexual health care in Boston (MA, USA). We calculated HIV risk scores (ie, probability of an incident HIV diagnosis) for every HIV-uninfected patient not on PrEP during 2007-15 at Atrius Health and assessed the distribution of scores for thresholds to determine possible candidates for PrEP in the three study cohorts.

FINDINGS

We included 1 155 966 Atrius Health patients from 2007-15 (150 [<0·1%] patients with incident HIV) in our development cohort, 537 257 Atrius Health patients in 2016 (16 [<0·1%] with incident HIV) in our prospective validation cohort, and 33 404 Fenway Health patients from 2011-16 (423 [1·3%] with incident HIV) in our external validation cohort. The best-performing algorithm was obtained with least absolute shrinkage and selection operator (LASSO) and had a cv-AUC of 0·86 (95% CI 0·82-0·90) for identification of incident HIV infections in the development cohort, 0·91 (0·81-1·00) on prospective validation, and 0·77 (0·74-0·79) on external validation. The LASSO model successfully identified patients independently prescribed PrEP by clinicians at Atrius Health in 2016 (cv-AUC 0·93, 95% CI 0·90-0·96) or Fenway Health (0·79, 0·78-0·80). HIV risk scores increased steeply at the 98th percentile. Using this score as a threshold, we prospectively identified 9515 (1·8%) of 536 384 patients at Atrius Health in 2016 and 4385 (15·3%) of 28 702 Fenway Health patients as potential PrEP candidates.

INTERPRETATION

Automated algorithms can efficiently identify patients at increased risk for HIV acquisition. Integrating these models into EHRs to alert providers about patients who might benefit from PrEP could improve prescribing and prevent new HIV infections.

FUNDING

Harvard University Center for AIDS Research, Providence/Boston Center for AIDS Research, Rhode Island IDeA-CTR, the National Institute of Mental Health, and the US Centers for Disease Control and Prevention.

Risk Factors for Early Disenrollment From Colorado's Affordable Care Act Marketplace

BACKGROUND

Midyear disenrollment from Marketplace coverage may have detrimental effects on continuity of care and risk pool stability of individual health insurance markets.

OBJECTIVE

The main objective of this study was to assess associations between insurance plan characteristics, individual and area-level demographics, and disenrollment from Marketplace coverage.

DATA

All payer claims data from individual market enrollees, 2014-2016.

STUDY DESIGN

We estimated Cox proportional hazards models to assess the relationship between plan actuarial value and Marketplace enrollment. The primary outcome was disenrollment from Marketplace coverage before the end of the year. We also calculated the proportion of enrollees who transitioned to other coverage after leaving the Marketplace, and identified demographic and area-level factors associated with early disenrollment. Finally, we compared monthly utilization rates between those who disenrolled early and those who maintained coverage.

RESULTS

Nearly 1 in 4 Marketplace beneficiaries disenrolled midyear. The hazard rate of disenrollment was 30% lower for individuals in plans receiving cost-sharing reductions and 21% lower for those enrolled in gold plans, compared with silver plans without cost-sharing subsidies. Young adults had a 70% increased hazard of disenrollment compared with older adults. Those who disenrolled midyear had greater hospital and emergency department utilization before disenrollment compared with those who maintained continuous coverage.

CONCLUSIONS

Plan generosity is significantly associated with lower disenrollment rates from Marketplace coverage. Reducing churning in Affordable Care Act Marketplaces may improve continuity of care and insurers' ability to accurately forecast the health care costs of their enrollees.

Nursing Home Residents by Human Immunodeficiency Virus Status: Characteristics, Dementia Diagnoses, and Antipsychotic Use

OBJECTIVES

Given an aging human immunodeficiency virus (HIV) population, we aimed to determine the prevalence of HIV for long-stay residents in US nursing homes (NHs) between 2001 and 2010 and to compare characteristics and diagnoses of HIV-positive (HIV+) and negative (HIV-) residents. Also, for residents with dementia diagnoses, we compared antipsychotic (APS) medication receipt by HIV status.

DESIGN

A cross-sectional comparative study.

SETTING

NHs in the 14 states accounting for 75% of persons living with HIV.

PARTICIPANTS

A total of 9 245 009 long-stay NH residents.

MEASUREMENTS

Using Medicaid fee-for-service claims data in the years 2001 to 2010, together with Medicare resident assessment and Chronic Condition Warehouse data, we identified long-stay (more than 89 days) NH residents by HIV status and dementia presence. We examined dementia presence by age groups and APS medication receipt by younger (aged younger than 65 years) vs older (aged 65 years or older) residents, using logistic regression.

RESULTS

Between 2001 and 2010, the prevalence of long-stay residents with HIV in NHs increased from 0.7% to 1.2%, a 71% increase. Long-stay residents with HIV were younger and less often female or white. For younger NH residents, rates of dementia were 20% and 16% for HIV+ and HIV- residents, respectively; they were 53% and 57%, respectively, for older residents. In adjusted analyses, younger HIV+ residents with dementia had greater odds of APS medication receipt than did HIV- residents (AOR = 1.3; 95% confidence interval [CI] = 1.2-1.4), but older HIV residents had lower odds (AOR = 0.9; 95% CI = 0.8-0.9).

CONCLUSION

The prevalence of long-stay HIV+ NH residents has increased over time, and given the rapid aging of the HIV population, this increase is likely to have continued. This study raises concern about potential differential quality of care for (younger) residents with HIV in NHs, but not for those aged 65 years and older. These findings contribute to the evidence base needed to ensure high-quality care for younger and older HIV+ residents in NHs.

Trends in Comorbid Conditions Among Medicaid Enrollees With HIV

Background

As antiretroviral therapy has become more effective, persons with HIV live longer and develop conditions that are characteristic of older populations. Understanding changes in comorbid conditions has important implications for the complexity and cost of care, particularly for Medicaid programs and their enrollees, which comprise about 40% of all persons with HIV. Thus, our objective was to examine trends in comorbid conditions for Medicaid enrollees with HIV.

Methods

Using 2001-2012 administrative claims data from the 14 states (NY, CA, FL, TX, MD, NJ, PA, IL, GA, NC, VA, LA, OH, MA) with the highest HIV prevalence, we identified 494 322 unique Medicaid enrollees with HIV, representing 5.8 million person-quarters after exclusions. We estimated changes over time in enrollee characteristics, proportions of enrollees with the 10 most common comorbid conditions, and number of comorbid conditions per enrollee.

Results

Over time, the average age for HIV Medicaid enrollees increased, and the proportion enrolled in a managed care plan also increased. In 2012, the highest proportion of enrollees exhibited evidence of hypertension (31%), psychiatric disease (26%), any liver disease (25%), and pulmonary disorder (23%). Nine of the 10 comorbid conditions increased over time, whereas HIV-related conditions declined. The largest adjusted relative increases in 2012 vs 2003 were observed for renal insufficiency (adjusted odds ratio [aOR], 2.20; P < .001), hyperlipidemia (aOR, 1.80; P < .001), and psychiatric disease (aOR, 1.45; P < .001).

Conclusions

Despite improvements in antiretroviral therapy and better control of patients' HIV, we found substantial increases in rates of comorbid conditions over time. These findings have important implications for the complexity and costs of clinical care and for state Medicaid programs.

Knowledge, Attitudes, and Confidence in Accountable Care Organization-Based Payment Models Among RI Physicians

Study Objective or Background: To assess Rhode Island (RI) physician knowledge, attitudes, and confidence to succeed in Accountable Care Organizations (ACOs). Study Design and Methods: We surveyed RI physicians' attitudes and beliefs about ACOs, including scales measuring Physician Knowledge (7 Multiple Choice and True/False items), Attitudes (8 Likert scale items), and Confidence (7 Likert Scale Items), and examined how physician characteristics related to these measures. Primary Results: The response rate was 6 percent (72/1183). Means (100-point scale) and standard deviations were calculated for Knowledge 65.3 (22), Attitudes for ACO participants 56.3 (13.2) and ACO non-participants 42.7 (14.3), and Confidence 32.4 (25.9). Primary care physicians had higher Attitudes compared with specialists among ACO participants (60.2 vs. 51.8, p=.047) and ACO non-participants (48.2 vs. 34.4, p=.030). Principal Conclusions: RI Physicians have low scores in Knowledge, Attitudes, and Confidence scales in ACOs. Primary care physicians have more positive Attitudes about ACOs than specialists. This study is limited by its low response rate. [Full article available at http://rimed.org/rimedicaljournal-2019-03.asp].