Child and adolescent COVID-19 vaccination coverage by educational setting, United States

OBJECTIVES

The COVID-19 pandemic changed the setting of education for many children in the U.S. Understanding COVID-19 vaccination coverage by educational setting is important for developing targeted messages, increasing parents' confidence in COVID-19 vaccines, and protecting all children from severe effects of COVID-19 infection.

STUDY DESIGN/METHODS

Using data from the Household Pulse Survey (n = 25,173) collected from December 9-19, 2022, January 4-16, 2023, and February 1-13, 2023, this study assessed factors associated with COVID-19 vaccination and reasons for non-vaccination among school-aged children 5-11 and adolescents 12-17 by educational setting.

RESULTS

Among children 5-11 years, COVID-19 vaccination coverage was higher among those who received in-person instruction (53.7%) compared to those who were homeschooled (32.5%). Furthermore, among adolescents 12-17 years, COVID-19 vaccination coverage was higher among those who received in-person instruction (73.5%) or virtual/online instruction (70.1%) compared to those who were homeschooled (51.0%). Children and adolescents were more likely to be vaccinated if the parental respondent had been vaccinated compared to those who had not. Among children and adolescents who were homeschooled, main reasons for non-vaccination were concern about side effects (45.4-51.6%), lack of trust in COVID-19 vaccines (45.0-50.9%), and lack of trust in the government (32.7-39.2%).

CONCLUSIONS

Children and adolescents who were home-schooled during the pandemic had lower vaccination coverage than those who attended school in person, and adolescents who were home-schooled had lower vaccination coverage than those who received virtual instruction. Based on the reasons for non-vaccination identified in this study, increasing parental confidence in vaccines, and reducing barriers to access are important for supporting COVID-19 vaccination for school-age children.

Inability to Access Needed Medical Care Among Asian American, Native Hawaiian, and Pacific Islander Medicaid Enrollees

We examined self-reported inability to access to needed medical care and reasons for not accessing medical care among US-representative adult Medicaid enrollees, disaggregated across 10 Asian American, Native Hawaiian, and Pacific Islander ethnic groups. Chinese (-4.54 percentage points [PP], P < .001), Other Asian (-4.42 PP, P < .001), and Native Hawaiian (-4.36 PP, P < .001) enrollees were significantly less likely to report being unable to access needed medical care compared with non-Hispanic White enrollees. The most common reason reported was that a health plan would not approve, cover, or pay for care. Mitigating inequities may require different interventions specific to certain ethnic groups.

Antinociceptive and adverse effects of morphine:ketamine mixtures in rats

Prescription opioids are the gold standard for treating moderate to severe pain despite their well-documented adverse effects. Of all prescription medications, opioids are abused most widely, and fatal overdoses have reached epidemic levels. One strategy for improving the margin of safety of opioids is combining them with non-opioid drugs to decrease the opioid dose needed for pain relief, thereby reducing adverse effects that occur with larger doses. The N-methyl-D-aspartate receptor antagonist ketamine has been used safely as an analgesic but only under a very limited range of conditions. The current studies characterized the antinociceptive, behavioral suppressant, and gastrointestinal effects of morphine and ketamine alone and in mixtures to determine their interaction in 24 adult male Sprague-Dawley rats (n = 8 per assay). Given alone, both morphine and ketamine produced antinociception, decreased responding for food, and reduced gastrointestinal transit (i.e. produced constipation). The effects of morphine:ketamine mixtures generally were additive, except for the antinociceptive effects of 1:1 mixtures for which the difference in slope (i.e. non-parallel shift) between the observed and predicted effects suggested synergy at smaller doses and additivity at larger doses. The potency of morphine to produce constipation was not enhanced by administration of morphine:ketamine mixtures with antinociceptive effects. The nature of the interaction between morphine and ketamine for adverse effects such as dependence, withdrawal, abuse, or respiratory depression remains unknown but also might be related to the ratio of each drug in mixtures. It will be important to identify conditions that produce the largest potential therapeutic window in humans.

Use of and barriers to adopting standardized social risk screening tools in federally qualified health centers during the first year of the COVID-19 pandemic

OBJECTIVE

To describe the national rate of social risk factor screening adoption among federally qualified health centers (FQHCs), examine organizational factors associated with social risk screening adoption, and identify barriers to utilizing a standardized screening tool in 2020.

DATA SOURCE

2020 Uniform Data System, a 100% sample of all US FQHCs (N = 1375).

STUDY DESIGN

We used multivariable linear probability models to assess the association between social risk screening adoption and key FQHC characteristics. We used descriptive statistics to describe variations in screening tool types and barriers to utilizing standardized tools. We thematically categorized open-ended responses about tools and barriers.

DATA COLLECTION

None.

PRINCIPAL FINDINGS

In 2020, 68.9% of FQHCs screened patients for any social risk factors. Characteristics associated with a greater likelihood of screening adoption included having high proportions of patients best served in a language other than English (18.8 percentage point [PP] increase, 95% CI: 6.0, 31.6) and being larger in size (10.3 PP increase, 95% CI: 0.7, 20.0). Having higher proportions of uninsured patients (14.2 PP decrease, 95% CI: -25.5, -0.3) and participating in Medicaid-managed care contracts (7.3 PP decrease, 95% CI: -14.2, -0.3) were associated with lower screening likelihood. Among screening FQHCs, the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) was the most common tool (47.1%). Among non-screening FQHCs, common barriers to using a standardized tool included lack of staff training to discuss social issues (25.2%), inability to include screening in patient intake (21.7%), and lack of funding for addressing social needs (19.2%).

CONCLUSIONS

Though most FQHCs screened for social risk factors in 2020, various barriers have prevented nearly 1 in 3 FQHCs from adopting a screening tool. Policies that provide FQHCs with resources to support training and workflow changes may increase screening uptake and facilitate engagement with other sectors.

Health Insurance Coverage and Access to Care by Sexual Orientation During the COVID-19 Pandemic: United States, January 2021-February 2022

Objectives. To compare health insurance coverage and access to care by sex and sexual minority status during the COVID-19 pandemic and assess whether lack of insurance hindered access to care by sexual minority status. Methods. Using Behavioral Risk Factor Surveillance System data (January 2021-February 2022), we examined differences by sex and sexual orientation among 158 722 adults aged 18 to 64 years living in 34 states. Outcomes were health insurance coverage type and 3 access to care measures. Results. Sexual minority women were significantly more likely to be uninsured than were heterosexual women, and lack of insurance widened the magnitude of disparity by sexual minority status in all measures of access. Compared with heterosexual men with health insurance, sexual minority men with health insurance were significantly more likely to report being unable to afford necessary care. Conclusions. During the pandemic, 1 in 8 sexual minority adults living in 34 study states were uninsured. Among sexual minority women, lack of insurance widened inequities in access to care. There were inequities among sexual minority men with health insurance. Public Health Implications. Sexual minority adults may be disproportionately affected by the unwinding of the COVID-19 public health emergency and may require tailored efforts to mitigate insurance coverage loss. (Am J Public Health. 2024;114(1):118-128. https://doi.org/10.2105/AJPH.2023.307446).

CRISPR/Cas9 mutagenesis of the Arabidopsis GROWTH-REGULATING FACTOR (GRF) gene family

Genome editing in plants typically relies on T-DNA plasmids that are mobilized by Agrobacterium-mediated transformation to deliver the CRISPR/Cas machinery. Here, we introduce a series of CRISPR/Cas9 T-DNA vectors for minimal settings, such as teaching labs. Gene-specific targeting sequences can be inserted as annealed short oligonucleotides in a single straightforward cloning step. Fluorescent markers expressed in mature seeds enable reliable selection of transgenic or transgene-free individuals using a combination of inexpensive LED lamps and colored-glass alternative filters. Testing these tools on the Arabidopsis GROWTH-REGULATING FACTOR (GRF) genes, we were able to create a collection of predicted null mutations in all nine family members with little effort. We then explored the effects of simultaneously targeting two, four and eight GRF genes on the rate of induced mutations at each target locus. In our hands, multiplexing was associated with pronounced disparities: while mutation rates at some loci remained consistently high, mutation rates at other loci dropped dramatically with increasing number of single guide RNA species, thereby preventing a systematic mutagenesis of the family.

Structural Racism, Historical Redlining, and Incidence of Kidney Failure in US Cities, 2012-2019

SIGNIFICANCE STATEMENT

Residing in neighborhoods designated as grade D (hazardous) by the Home Owners' Loan Corporation (HOLC) under historical redlining-a discriminatory housing policy beginning in the 1930s-has been associated with present-day adverse health outcomes such as diabetes mortality. Historical redlining might underlie conditions in present-day neighborhoods that contribute to inequitable rates of kidney failure incidence, particularly for Black individuals, but its association with kidney disease is unknown. The authors found that among adults with incident kidney failure living in 141 metropolitan areas, residence in a historically redlined neighborhood rated grade D was associated with significantly higher kidney failure incidence rates compared with residence in a redlined grade A (best) neighborhood. These findings suggest that historical racist policies continue to affect current-day racial inequities in kidney health.

BACKGROUND

Historical redlining was a 1930s federally sponsored housing policy that permitted the Home Owners' Loan Corporation (HOLC) to develop color-coded maps and grade neighborhoods' mortgage lending risk on the basis of characteristics that included racial makeup. This practice has been associated with present-day health disparities. Racial inequities in kidney disease-particularly for Black individuals-have been linked to residential segregation and other structural inequities.

METHODS

Using a registry of people with incident kidney failure and digitized HOLC maps, we examined the association between residence in a historically redlined US census tract (CT) with a historical HOLC grade of D or hazardous) and present-day annual CT-level incidence of kidney failure incidence among adults in 141 US metropolitan areas, in 2012 through 2019.

RESULTS

Age-adjusted and sex-adjusted kidney failure incidence rates were significantly higher in CTs with a historical HOLC grade D compared with CTs with a historical HOLC grade of A or best (mean, 740.7 per million versus 326.5 per million, respectively, a difference of 414.1 per million). Compared with national averages of all adults in our sample, rates of kidney failure incidence were higher for Black adults in our study sample, irrespective of CT HOLC grade. Age-adjusted and sex-adjusted incidence rates for Black persons in CTs with a HOLC grade D were significantly higher than for Black persons residing in HOLC grade A CTs (mean, 1227.1 per million versus 1030.5 per million, respectively [a difference of 196.6 per million]).

CONCLUSIONS

Historical redlining is associated with present-day disparities in kidney failure incidence, demonstrating the legacy of historical racist policies on contemporary racial inequities in kidney health.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_08_24_JASN0000000000000165.mp3.

Inequities in Patient Access to Care Among Asian American, Native Hawaiian, and Pacific Islander Adults in Medicaid

BACKGROUND

Despite decades of advocacy for disaggregated data collection and reporting for Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) people, significant gaps remain in our ability to understand AA and NHPI individuals' access to care. We assess inequities in access to care measures between non-Hispanic White and AA and NHPI adult Medicaid enrollees.

METHODS

We used the 2014-15 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems, the first-and-only nationally representative sample of Medicaid enrollees. Our main outcomes were access to needed care, access to a personal doctor, timely access to a checkup, and timely access to specialty care. Using multivariable linear probability models, we assessed the relationship between racial/ethnic group and our outcomes, both in the aggregate and disaggregated into ten racial/ethnic groups, and adjusted for enrollee-level sociodemographic characteristics, health status, and state-level Medicaid expansion status.

RESULTS

In aggregate, AA and NHPI enrollees reported worse access to care than White enrollees on all four metrics (p < 0.001). The magnitude of disparities varied across the ten AA and NHPI ethnic groups. Disparities relative to White enrollees were particularly large in magnitude, roughly 1.5 to 2 times greater, for Chinese, Korean, and Vietnamese enrollees than for the aggregated AA and NHPI group.

CONCLUSIONS

Despite comparable insurance coverage, there were inequities in multiple access to care metrics between non-Hispanic White and AA and NHPI Medicaid enrollees. Collection of disaggregated health data on AA and NHPI patients reveals important variation in access to care by ethnic group.

Cutaneous Manifestations of Mycobacterium tuberculosis: A Literature Review

Tuberculosis is an ancient disease that humanity struggled with for centuries and continues to struggle with. The bacteria Mycobacterium tuberculosis often infects the lungs through respiratory transmission and manifests itself through various symptoms, including cutaneous infections. Cutaneous tuberculosis (CTB) comprises about 1% to 1.5% of all extrapulmonary manifestations and is often accompanied by polymorphous lesions, including papules, nodules, plaques, ulcers, gummas, and verrucous lesions. CTB is most commonly observed in low-income, HIV, and immunosuppressed populations, similar to intrapulmonary manifestations. The main pathogen for CTB is M. tuberculosis but less commonly with M. bovis and BCG vaccine, and the modes of transmission are largely classified into exogenous and endogenous CTB. Current treatment options for CTB include oral therapy of antibiotic medications such as rifampicin, streptomycin, ethambutol, isoniazid, and pyrazinamide, which is occasionally combined with surgical intervention.

Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial

BACKGROUND

An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown.

METHODS

The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units.

DISCUSSION

This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

Medicare Advantage Enrollment Among Beneficiaries With End-Stage Renal Disease in the First Year of the 21st Century Cures Act

Importance

Before 2021, most Medicare beneficiaries with end-stage renal disease (ESRD) were unable to enroll in private Medicare Advantage (MA) plans. The 21st Century Cures Act permitted these beneficiaries to enroll in MA plans effective January 2021.

Objective

To examine changes in MA enrollment among Medicare beneficiaries with ESRD after enactment of the 21st Century Cures Act overall and by race or ethnicity and dual-eligible status.

Design, Setting, and Participants

This cross-sectional time-trend study used data from Medicare beneficiaries with ESRD (both kidney transplant recipients and those undergoing dialysis) between January 2019 and December 2021. Data were analyzed between June and October 2022.

Exposures

21st Century Cures Act.

Main Outcomes and Measures

Primary outcomes were the proportion of Medicare beneficiaries with prevalent ESRD who switched from traditional Medicare to MA between 2020 and 2021 and those with incident ESRD who newly enrolled in MA in 2021. Individuals who stayed in traditional Medicare were enrolled in 2020 and 2021 and those who switched to MA were enrolled in traditional Medicare in 2020 and MA in 2021.

Results

Among 575 797 beneficiaries with ESRD in 2020 or 2021 (mean [SD] age, 64.7 [14.2] years, 42.2% female, 34.0% Black, and 7.7% Hispanic or Latino), the proportion of beneficiaries enrolled in MA increased from 24.8% (December 2020) to 37.4% (December 2021), a relative change of 50.8%. The largest relative increases in MA enrollment were among Black (72.8% relative increase), Hispanic (44.8%), and dual-eligible beneficiaries with ESRD (73.6%). Among 359 617 beneficiaries with TM and prevalent ESRD in 2020, 17.6% switched to MA in 2021. Compared with individuals who stayed in traditional Medicare, those who switched to MA had modestly more chronic conditions (6.3 vs 6.1; difference, 0.12 conditions [95% CI, 0.10-0.16]) and similar nondrug spending in 2020 (difference, $509 [95% CI, -$58 to $1075]) but were more likely to be Black (difference, 19.5 percentage points [95% CI, 19.1-19.9]) and have dual Medicare-Medicaid eligibility (difference, 20.8 percentage points [95% CI, 20.4-21.2]). Among beneficiaries who were newly eligible for Medicare ESRD benefits in 2021, 35.2% enrolled in MA.

Conclusions and Relevance

Results suggest that increases in MA enrollment among Medicare beneficiaries with ESRD were substantial the first year after the 21st Century Cures Act, particularly among Black, Hispanic, and dual-eligible individuals. Policy makers and MA plans may need to assess network adequacy, disenrollment, and equity of care for beneficiaries who enrolled in MA.

Neutrophils in Mycobacterium tuberculosis

Mycobacterium tuberculosis (M. tb) continues to be a leading cause of mortality within developing countries. The BCG vaccine to promote immunity against M. tb is widely used in developing countries and only in specific circumstances within the United States. However, current the literature reports equivocal data on the efficacy of the BCG vaccine. Critical within their role in the innate immune response, neutrophils serve as one of the first responders to infectious pathogens such as M. tb. Neutrophils promote effective clearance of M. tb through processes such as phagocytosis and the secretion of destructive granules. During the adaptative immune response, neutrophils modulate communication with lymphocytes to promote a strong pro-inflammatory response and to mediate the containment M. tb through the production of granulomas. In this review, we aim to highlight and summarize the role of neutrophils during an M. tb infection. Furthermore, the authors emphasize the need for more studies to be conducted on effective vaccination against M. tb.

Atypical Staphylococcal Septic Arthritis in a Native Hip: A Case Report and Review

Septic arthritis is a synovial fluid and joint tissue infection with significant morbidity and mortality risk if not diagnosed and treated promptly. The most common pathogen to cause septic arthritis is Staphylococcus aureus, a Gram-positive bacterium. Although diagnostic criteria are in place to guide the diagnosis of staphylococcal septic arthritis, there is a lack of adequate sensitivity and specificity. Some patients present with atypical findings which make it difficult to diagnose and treat in time. In this paper, we present the case of a patient with an atypical presentation of recalcitrant staphylococcal septic arthritis in a native hip complicated by uncontrolled diabetes mellitus and tobacco usage. We review current literature on diagnosing S. aureus septic arthritis, novel diagnostic technique performance to guide future research and assist clinical suspicion, and current S. aureus vaccine development for at-risk patients.

Narrow Dialysis Networks In Medicare Advantage: Exposure By Race, Ethnicity, And Dual Eligibility

The 21st Century Cures Act permitted people with end-stage renal disease (ESRD) to enroll in Medicare Advantage (MA) effective January 2021. It is imperative to understand the breadth of dialysis facility networks across MA contracts because most patients with ESRD need thrice-weekly dialysis to survive. In 2020 MA contracts' networks included a mean of 51 percent of dialysis facilities in their service areas. MA contracts with plans in a single state, with not-for-profit status, and with higher proportions of dually eligible enrollees with ESRD were significantly more likely to include less than or equal to 25 percent of dialysis facilities in their service area in network ("narrow networks") than contracts with plans in multiple states, with for-profit status, and with lower proportions of dually eligible enrollees with ESRD (by 12.9, 13.0, and 11.7 percentage points, respectively). Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native people with ESRD were enrolled in contracts with narrow networks of dialysis facilities at markedly higher rates than non-Hispanic White people with ESRD. In contrast, Black people with ESRD were less likely to be enrolled in a narrow-network contract. Policy makers should monitor and address the adequacy of dialysis facility networks in MA contracts, as well as disparities in enrollment in narrow-network plans.

Parental Immigration Status, Medicaid Expansion, And Supplemental Nutrition Assistance Program Participation

Anti-immigrant public policies and rhetoric during 2017-19 may have eroded enrollment in safety-net programs, such as the enrollment of children of immigrants in the Supplemental Nutrition Assistance Program (SNAP). At the same time, states' expansion of Medicaid through the Affordable Care Act may have mitigated erosion through coordinated enrollment across safety-net programs, including SNAP and Medicaid. We examined changes in SNAP participation rates by parental immigration status among low-income households in 2015-16 versus 2017-19 for differences by child race and ethnicity or state Medicaid expansion status. Relative to those among citizen children with US-born parents, SNAP participation rates among citizen children from mixed-status families and noncitizen children significantly decreased between 2015-16 and 2017-19, with the magnitude of disparity widening over time. Declines in SNAP participation were sharper for Hispanic and Latino children from mixed-status families, Hispanic and Latino noncitizen children, and noncitizen children residing in nonexpansion states. Findings are consistent with some policy makers' concerns of erosion in SNAP participation. Mechanisms that could be employed to help reverse these trends include policies, outreach strategies, and enrollment processes.

Medicaid Expansion and Medicare-Financed Hospitalizations Among Adult Patients With Incident Kidney Failure

Importance

Although Medicare provides health insurance coverage for most patients with kidney failure in the US, Medicare beneficiaries who initiate dialysis without supplemental coverage are exposed to substantial out-of-pocket costs. The availability of expanded Medicaid coverage under the Patient Protection and Affordable Care Act (ACA) for adults with kidney failure may improve access to care and reduce Medicare-financed hospitalizations after dialysis initiation.

Objective

To examine the implications of the ACA's Medicaid expansion for Medicare-financed hospitalizations, health insurance coverage, and predialysis nephrology care among Medicare-covered adults aged 19 to 64 years with incident kidney failure in the first year after initiating dialysis.

Design, Setting, and Participants

This cross-sectional study used a difference-in-differences approach to assess Medicare-financed hospitalizations among adults aged 19 to 64 years who initiated dialysis between January 1, 2010, and December 31, 2018, while covered by Medicare Part A (up to 5 years postexpansion). Data on patients were obtained from the Renal Management Information System's End Stage Renal Disease Medical Evidence Report, which includes data for all patients initiating outpatient maintenance dialysis regardless of health insurance coverage, treatment modality, or citizenship status, and these data were linked with claims data from the Medicare Provider Analysis and Review. Data were analyzed from January to August 2022.

Exposure

Living in a Medicaid expansion state.

Main Outcomes and Measures

Primary outcomes were number of Medicare-financed hospitalizations and hospital days in the first 3 months, 6 months, and 12 months after dialysis initiation. Secondary outcomes included dual Medicare and Medicaid coverage at 91 days after dialysis initiation and the presence of an arteriovenous fistula or graft at dialysis initiation for patients undergoing hemodialysis.

Results

The study population included 188 671 adults, with 97 071 living in Medicaid expansion states (mean [SD] age, 53.4 [9.4] years; 58 329 men [60.1%]) and 91 600 living in nonexpansion states (mean [SD] age, 53.0 [9.6] years; 52 677 men [57.5%]). In the first 3 months after dialysis initiation, Medicaid expansion was associated with a significant decrease in Medicare-financed hospitalizations (-4.24 [95% CI, -6.70 to -1.78] admissions per 100 patient-years; P = .001) and hospital days (-0.73 [95% CI, -1.08 to -0.39] days per patient-year; P < .001), relative reductions of 8% for both outcomes. Medicaid expansion was associated with a 2.58-percentage point (95% CI, 0.88-4.28 percentage points; P = .004) increase in dual Medicare and Medicaid coverage at 91 days after dialysis initiation and a 1.65-percentage point (95% CI, 0.31-3.00 percentage points; P = .02) increase in arteriovenous fistula or graft at initiation.

Conclusions and Relevance

In this cross-sectional study with a difference-in-differences analysis, the ACA's Medicaid expansion was associated with decreases in Medicare-financed hospitalizations and hospital days and increases in dual Medicare and Medicaid coverage. These findings suggest favorable spillover outcomes of Medicaid expansion to Medicare-financed care, which is the primary payer for patients with kidney failure.

Trends in Collection of Disaggregated Asian American, Native Hawaiian, and Pacific Islander Data: Opportunities in Federal Health Surveys

Collection of data for Asian American, Native Hawaiian, and Pacific Islander (AANHPI) persons that is disaggregated by ethnic subgroup may identify disparities that are not apparent in aggregated data. Using content analysis, we identified national population surveys administered by the US Department of Health and Human Services (HHS) and evaluated trends in the collection of disaggregated AANHPI data between 2011 and 2021. In 2011, 4 of 15 surveys (27%) collected disaggregated data for Asian American, 2 of 15 surveys (13%) collected data on Native Hawaiian, and 2 of 15 surveys (13%) collected disaggregated data for Pacific Islander people. By 2019, 14 of 21 HHS-administered surveys (67%) collected disaggregated data for Asian American (6 subgroups), 67% collected data on Native Hawaiian, and 67% collected disaggregated data on Pacific Islander (3 subgroups) people. Collection of disaggregated AANHPI data in HHS-administered surveys increased from 2011 to 2021, but opportunities to expand collection and reporting remain. Strategies include outreach with community organizations, increased language assistance, and oversampling approaches. Increased availability and reporting of these data can inform health policies and mitigate disparities. (Am J Public Health. 2022;112(10):1429-1435. https://doi.org/10.2105/AJPH.2022.306969).

Language barriers and postoperative opioid prescription use after total knee arthroplasty

Background

Patients with limited English proficiency (LEP) face difficulties in access to postoperative follow-up care, including post-discharge medication refills. However, prior studies have not examined how utilization of prescription pain medications after discharge from joint replacement surgeries differs between English proficient (EP) and LEP patients.

Objective

This study explored the relationship between English language proficiency and opioid prescription refill requests after hospital discharge for total knee arthroplasty (TKA).

Methods

This was an observational cohort study of patients ≥18 years of age who underwent TKA between January 2015 and December 2019 at a single academic center. LEP status was defined as not having English as the primary language and requesting an interpreter. Primary outcome variables included opioid pain medication refill requests between 0 and 90 days from discharge. Multivariable logistic regression modeling calculated the odds ratios of requesting an opioid refill.

Results

A total of 2148 patients underwent TKA, and 9.8% had LEP. Postoperative pain levels and rates of prior opioid use did not differ between LEP and EP patients. LEP patients were less likely to request an opioid prescription refill within 30 days (35.3% vs 52.4%, p < 0.001), 60 days (48.7% vs 61.0%, p = 0.004), and 90 days (54.0% vs 62.9%, p = 0.041) after discharge. In multivariable analysis, LEP patients had an odds ratio of 0.61 of requesting an opioid refill (95% CI, 0.41–0.92, p = 0.019) within 30 days of discharge. Having Medicare insurance and longer lengths of hospitalization were correlated with lower odds of 0–30 days opioid refills, while prior opioid use and being discharged home were associated with higher odds of opioid refill requests 0–30 days after discharge for TKA.

Conclusions

Language barriers may contribute to poorer access to postoperative care, including prescription medication refills. Barriers to postoperative care may exist at multiple levels for LEP patients undergoing surgical procedures.

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.

Variation in Usual Source of Care in Asian American, Native Hawaiian, and Other Pacific Islander Adult Medicaid Beneficiaries

BACKGROUND

Disparities in access to care between non-Hispanic White and Asian American, Native Hawaiian, and Pacific Islander (AANHPI) patients are often attributed to higher uninsurance rates among AANHPI patients. Less is known about variation among individuals with Medicaid health insurance coverage and among AANHPI subgroups.

OBJECTIVE

The objective of this study was to examine differences in access to care between White and AANHPI adult Medicaid beneficiaries, both in the aggregate and disaggregated into 9 ethnic subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Native Hawaiian, and Pacific Islander).

RESEARCH DESIGN

Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems data (2014-2015), a cross-sectional survey representative of all Medicaid beneficiaries.

SUBJECTS

A total of 126,728 White and 10,089 AANHPI Medicaid beneficiaries were included.

MEASURES

The study outcomes were: (1) having a usual source of care; and (2) reporting a health center or clinic as the usual site of care. Multivariable linear probability models assessed the relationship between race/ethnic subgroup and our outcomes, adjusting for sociodemographic characteristics and health status.

RESULTS

Compared with White beneficiaries, Korean beneficiaries were significantly less likely to report having a usual source of care [difference=-8.9 percentage points (PP), P =0.01], and Chinese (difference=8.4 PP, P =0.001), Native Hawaiian (difference=25.8 PP, P <0.001), and Pacific Islander (difference=22.2 PP, P =0.001) beneficiaries were significantly more likely to report a health center or clinic as their usual site of care.

CONCLUSIONS

Despite similar health insurance coverage, significant differences in access to care remain between White and AANHPI Medicaid beneficiaries. Disaggregated AANHPI data may reveal important variation in access to care and inform more targeted public policies.

Changes in Migration and Mortality Among Patients With Kidney Failure in Puerto Rico After Hurricane Maria

Importance

On September 20, 2017, one of the most destructive hurricanes in US history made landfall in Puerto Rico. Anecdotal reports suggest that many persons with kidney failure left Puerto Rico after Hurricane Maria; however, empirical estimates of migration and health outcomes for this population are scarce.

Objective

To assess the changes in migration and mortality among patients with kidney failure in need of dialysis treatment in Puerto Rico after Hurricane Maria.

Design, Setting, and Participants

This cross-sectional study used an interrupted time-series design of 6-month mortality rates and migration of 11 652 patients who received hemodialysis or peritoneal dialysis care in Puerto Rico before Hurricane Maria (before October 1, 2017) and/or during and after Hurricane Maria (on/after October 1, 2017). Data analyses were performed from February 12, 2019, to June 16, 2022..

Main Outcomes and Measures

Number of unique persons dialyzed in Puerto Rico per quarter; receipt of dialysis treatment outside Puerto Rico per quarter; and 6-month mortality rate per person-quarter for all persons undergoing dialysis.

Exposures

Hurricane Maria.

Results

The entire study sample comprised 11 652 unique persons (mean [SD] age, 59 [14.7] years; 7157 [61.6%] men and 4465 [38.4%] women; 10 675 [91.9%] Hispanic individuals). There were 9022 patients with kidney failure and dialysis treatment before and 5397 patients after Hurricane Maria. Before the hurricane, the mean quarterly number of unique persons dialyzed in Puerto Rico was 2834 per quarter (95% CI, 2771-2897); afterwards it dropped to 261 (95% CI, -348 to -175; relative change, 9.2%). The percentage of persons who had 1 or more dialysis sessions outside of Puerto Rico in the next quarter following a previous dialysis in Puerto Rico was 7.1% before Hurricane Maria (95% CI, 4.8 to 9.3). There was a significant increase of 5.8 percentage points immediately after the hurricane (95% CI, 2.7 to 9.0). The 6-month mortality rate per person-quarter was 0.08 (95% CI, 0.08 to 0.09), and there was a nonsignificant increase in level of mortality rates and a nonsignificant decreasing trend in mortality rates.

Conclusions and Relevance

The findings of this cross-sectional study suggest there was a significant increase in the number of people receiving dialysis outside of Puerto Rico after Hurricane Maria. However, no significant differences in mortality rates before and after the hurricane were found, which may reflect disaster emergency preparedness among dialysis facilities and the population with kidney failure, as well as efforts from other stakeholders.

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.

County-Level Dialysis Facility Supply and Distance Traveled to Facilities among Incident Kidney Failure Patients

Background

The availability of dialysis facilities and distance traveled to receive care can impact health outcomes for patients with newly onset kidney failure. We examined recent changes in county-level number of dialysis facilities between 2012 and 2019 and assessed the association between county-level dialysis facility supply and the distance incident kidney failure patients travel to receive care.

Methods

We conducted a cross-sectional study of 828,427 adult patients initiating in-center hemodialysis for incident kidney failure between January 1, 2012, and December 31, 2019. We calculated the annual county-level number of dialysis facilities, and counties were categorized as having zero, one, two, or three or more dialysis facilities at the time of treatment initiation. We then measured the distance traveled between a patient's home address and dialysis facility at treatment initiation (in miles) and evaluated the association between county-level number of dialysis facilities and distance traveled to initiate treatment.

Results

The average annual county-level number of facilities increased from 1.8 to 2.3 between 2012 and 2019. In our study period, 5% of incident adult kidney failure patients resided in a county that had zero dialysis facilities between 2012 and 2019. Compared with counties with three or more dialysis facilities, patients living in counties with no facilities in our study period traveled 14.3 miles (95% CI, 13.4 to 15.2) further for treatment.

Conclusions

Kidney failure patients in counties that had no dialysis facilities traveled further, limiting their access to dialysis. Counties with no dialysis facilities at the end of the study period were more rural and had higher poverty than other counties.

Every child, every day, back to play: the PICUstars protocol - implementation of a nurse-led PICU liberation program

BACKGROUND

As admissions to paediatric intensive care units (PICU) rise and mortality rates decline, the focus is shifting from survival to quality of survivorship. There is paucity of internationally accepted guidelines to manage complications like over-sedation, delirium, and immobility in the paediatric setting. These have a strong adverse impact on PICU recovery including healthcare costs and long-term functional disability. The A2F bundle (ABCDEF), or ICU Liberation, was developed to operationalise the multiple evidence-based guidelines addressing ICU-related complications and has been shown to improve clinical outcomes and health-care related costs in adult studies. However, there is little data on the effect of ICU Liberation bundle implementation in PICU.

METHODS

PICU-STARS will be a single centre before-and-after after trial and implementation study. It is designed to evaluate if the multidimensional, nurse-led ICU Liberation model of care can be applied to the PICU and if it is successful in minimising PICU-related problems in a mixed quaternary PICU. In a prospective baseline measurement, the present practises of care in the PICU will be assessed in order to inform the adaptation and implementation of the PICU Liberation bundle. To assess feasibility, implementation outcomes, and intervention effectiveness, the implementation team will use the Consolidated Framework for Implementation Research (CIFR) and process assessment (mixed methods). The implementation process will be evaluated over time, with focus groups, interviews, questionnaires, and observations used to provide formative feedback. Over time, the barriers and enablers for successful implementation will be analysed, with recommendations based on "lessons learned." All outcomes will be reported using standard descriptive statistics and analytical techniques, with appropriate allowance for patient differentials in severity and relevant characteristics.

DISCUSSION

The results will inform the fine-tune of the Liberation bundle adaptation and implementation process. The expected primary output is a detailed adaptation and implementation guideline, including clinical resources (and investment) required, to adopt PICU-STARS in other children's hospitals.

PATIENT AND PUBLIC INVOLVEMENT STATEMENT

The authors thank the PICU education and Liberation Implementation team, and our patients and families for their inspiration and valuable comments on protocol drafts. Results will be made available to critical care survivors, their caregivers, relevant societies, and other researchers.

TRIAL REGISTRATION

ACTRN, ACTRN382863 . Registered 19/10/2021 - Retrospectively registered.

STUDY STATUS

recruiting.

Screening for Social Risk at Federally Qualified Health Centers: A National Study

INTRODUCTION

Federally Qualified Health Centers serve 29.8 million low-income patients across the U.S., many of whom have unaddressed social risks. In 2019, for the first time, data on social risk screening capabilities were collected from every U.S. Federally Qualified Health Center. The objectives of this study were to describe the national rates of social risk screening capabilities across Federally Qualified Health Centers, identify organizational predictors of screening, and assess between-state heterogeneity.

METHODS

Using a 100% sample of U.S. Federally Qualified Health Centers (N=1,384, representing 29.8 million patients) from the 2019 Uniform Data System, the primary outcome was whether a Federally Qualified Health Center collected data on patients' social risk factors (yes/no). Summary statistics on the rates of social risk screening capabilities were generated in aggregate and by state. Linear probability models were then used to estimate the relationship between the probability of social risk screening and 7 key Federally Qualified Health Center characteristics (e.g., Federally Qualified Health Center size, Medicaid MCO contract, Medicaid accountable care organization presence). Data were analyzed in 2020‒2021.

RESULTS

Most (71%) Federally Qualified Health Centers collected social risk data, with a between-state variation. The most common screener was the Protocol for Responding to and Assessing Patients' Assets Risks and Experiences (43% of Federally Qualified Health Centers that screened), whereas 22% collected social risk data using a nonstandardized screener. After adjusting for other characteristics, Federally Qualified Health Centers with social risk screening capabilities served more total patients, were more likely to be located in a state with a Medicaid accountable care organization, and were less likely to have an MCO contract.

CONCLUSIONS

There has been widespread adoption of social risk screening tools across U.S. Federally Qualified Health Centers, but between-state disparities exist. Targeting social risk screening resources to smaller Federally Qualified Health Centers may increase the adoption of screening tools.

Comparison of mortality between Medicare Advantage and traditional Medicare beneficiaries with kidney failure

OBJECTIVES

To compare risk-adjusted 1-year mortality between Medicare Advantage (MA) and traditional Medicare (TM) enrollees with kidney failure who initiated dialysis.

STUDY DESIGN

Longitudinal analysis of mortality and enrollment data for Medicare beneficiaries.

METHODS

The study compared mortality between MA and TM enrollees with kidney failure who initiated dialysis in 2016, accounting for their enrollment switches between MA and TM during 12 months prior to dialysis initiation. Analyses were adjusted for risk scores and fixed effects for the month of dialysis initiation and county of residence.

RESULTS

The difference in risk-adjusted 1-year mortality between MA stayers (Medicare beneficiaries who were continuously enrolled in MA prior to dialysis initiation) and TM stayers (those who were continuously enrolled in TM prior to initiating dialysis) was -0.1 percentage points (95% CI, -1.0 to 0.8); however, the difference increased to -1.0 percentage points (95% CI, -3.2 to 1.2) when comparing TM-to-MA switchers (those who switched from TM to MA before initiation) with TM stayers, a comparison more prone to favorable selection bias given our finding that TM-to-MA switchers were healthier than MA stayers.

CONCLUSIONS

Among Medicare beneficiaries with kidney failure who initiated dialysis, risk-adjusted 1-year mortality rate is not different between MA and TM stayers. If there is remaining favorable selection in MA due to unobserved health status, our finding provides a lower-bound estimate of the MA impact on mortality among beneficiaries with kidney failure.

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.

A case report of cystoid macular edema, uveitis and vitreomacular traction in a patient taking Anastrozole

Purpose

To report a case of cystoid macular edema, uveitis, and vitreomacular traction in a patient with a history of breast cancer and taking anastrozole.

Observations

A 73-year-old female with a history of estrogen receptor-positive breast cancer and treatment with anastrozole presented with bilateral blurry vision, photophobia, and eye soreness. Optical coherence tomography (OCT) of both maculae revealed vitreomacular traction (VMT), an epiretinal membrane, cystoid macular edema (CME) in the right eye, and drusen without subretinal fluid bilaterally. Although later, macular OCT did show evidence of cystoid intraretinal spaces in the left eye as well. Fluorescein angiography showed bilateral petaloid leakage, bilateral slow disc leaking, as well as peripheral leakage in the right eye. Anastrozole was discontinued and, subsequent macular OCT showed release of VMT in the right eye, and eventual resolution of intraretinal cystoid spaces bilaterally.

Conclusions and importance

Stopping of anastrozole was associated in resolution of refractory CME in a patient on aromatase inhibitor therapy for breast cancer. It is therefore important to consider anastrozole and other aromatase inhibitor drugs as possible factors predisposing patients to the development of CME.

Changes in Hip Capsule Morphology after Arthroscopic Treatment for Femoroacetabular Impingement Syndrome with Periportal Capsulotomy are Correlated With Improvements in Patient-Reported Outcomes

PURPOSE

To assess the correlation between changes in hip capsule morphology with improvements in patient-reported outcome (PRO) scores after arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) using the periportal capsulotomy technique.

METHODS

Twenty-eight patients with cam morphology FAIS (without arthritis, dysplasia, or hypermobility) were prospectively enrolled before arthroscopic labral repair and femoroplasty through periportal capsulotomy (anterolateral/midanterior portals) without closure. Patients completed the Hip Disability and Osteoarthritis Outcomes Score (HOOS) and had nonarthrographic 3T magnetic resonance imaging (MRI) scans of the affected hip before and 1 year after surgery. Anterior capsule thickness, posterior capsule thickness, anterior-posterior capsule thickness ratio, and proximal-distal anterior capsule thickness ratio were measured on axial-oblique MRI sequences. Pearson correlation coefficients were calculated to determine the association between hip capsule morphology and PRO scores.

RESULTS

Postoperative imaging showed that for all 28 patients (12 female), labral repairs and capsulotomies had healed within 1 year of surgery. Analysis revealed postoperative decreases in anterior hip capsule thickness (1395.4 ± 508.4 mm³ vs 1758.4 ± 487.9 mm³; P = .003) and anterior-posterior capsule thickness ratio (0.92 ± 0.33 vs 1.12 ± 0.38; P = .02). Higher preoperative anterior-posterior capsule thickness ratio correlated with lower preoperative scores for HOOS pain (R = -0.43; P = .02), activities of daily living (ADL) (R = -0.43; P = .02), and sport (R = -0.38; P = .04). Greater decrease from preoperative to postoperative anterior-posterior capsule thickness ratio correlated with greater improvement for HOOS pain (R = -0.40; P = .04), ADL (R = -0.45; P = .02), and sport (R = -0.46; P = .02).

CONCLUSIONS

Periportal capsulotomy without closure demonstrates capsule healing by 1 year after arthroscopic FAIS treatment. Changes in hip capsule morphology including decreased anterior-posterior capsule thickness ratio after surgery may be correlated with improvements in patient pain, function, and ability to return to sports.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Despite National Declines In Kidney Failure Incidence, Disparities Widened Between Low- And High-Poverty US Counties

National estimates suggest that kidney failure incidence is declining in the US. However, whether this trend is evident in areas with socioeconomic disadvantage is unknown. We examined trends in kidney failure incidence by county-level poverty between 2000 and 2017 and divided the study period into period 1 (2000-05), period 2 (2006-11), and period 3 (2012-17). The magnitude of disparity in kidney failure incidence between high- and low-poverty counties increased from 42.8 more incident cases per million in high-poverty counties in period 1 to 100.1 more in period 3. Despite a national decline, kidney failure incidence increased in high-poverty counties, and disparities between high- and low-poverty counties widened from 2000 to 2017. Achieving the Department of Health and Human Services objective of reducing incident kidney failure cases by 25 percent by 2030 will require focused attention on preventing kidney failure in counties with higher poverty.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Initiation of Kidney Failure Treatment During the First 4 Months of the COVID-19 Pandemic

Importance

Persons with kidney failure require treatment (ie, dialysis or transplantation) for survival. The burden of the COVID-19 pandemic and pandemic-related disruptions in care have disproportionately affected racial and ethnic minority and socially disadvantaged populations, raising the importance of understanding disparities in treatment initiation for kidney failure during the pandemic.

Objective

To examine changes in the number and demographic characteristics of patients initiating treatment for incident kidney failure following the COVID-19 pandemic by race and ethnicity, county-level COVID-19 mortality rate, and neighborhood-level social disadvantage.

Design, Setting, and Participants

This cross-sectional time-trend study used data from US patients who developed kidney failure between January 1, 2018, and June 30, 2020. Data were analyzed between January and July 2021.

Exposures

COVID-19 pandemic.

Main Outcomes and Measures

Number of patients initiating treatment for incident kidney failure and mean estimated glomerular filtration rate (eGFR) at treatment initiation.

Results

The study population included 127 149 patients with incident kidney failure between January 1, 2018, and June 30, 2020 (mean [SD] age, 62.8 [15.3] years; 53 021 [41.7%] female, 32 932 [25.9%] non-Hispanic Black, and 19 835 [15.6%] Hispanic/Latino patients). Compared with the pre-COVID-19 period, in the first 4 months of the pandemic (ie, March 1 through June 30, 2020), there were significant decreases in the proportion of patients with incident kidney failure receiving preemptive transplantation (1805 [2.1%] pre-COVID-19 vs 551 [1.4%] during COVID-19; P < .001) and initiating hemodialysis treatment with an arteriovenous fistula (2430 [15.8%] pre-COVID-19 vs 914 [13.4%] during COVID-19; P < .001). The mean (SD) eGFR at initiation declined from 9.6 (5.0) mL/min/1.73 m2 to 9.5 (4.9) mL/min/1.73 m2 during the pandemic (P < .001). In stratified analyses by race/ethnicity, these declines were exclusively observed among non-Hispanic Black patients (mean [SD] eGFR: 8.4 [4.6] mL/min/1.73 m2 pre-COVID-19 vs 8.1 [4.5] mL/min/1.73 m2 during COVID-19; P < .001). There were significant declines in eGFR at initiation for patients residing in counties in the highest quintile of COVID-19 mortality rates (9.5 [5.0] mL/min/1.73 m2 pre-COVID-19 vs 9.2 [5.0] mL/min/1.73 m2 during COVID-19; P < .001), but not for patients residing in other counties. The number of patients initiating treatment for incident kidney failure was approximately 30% lower than projected in April 2020.

Conclusions and Relevance

In this cross-sectional study of US adults, the COVID-19 pandemic was associated with a substantially lower number of patients initiating treatment for incident kidney failure and treatment initiation at lower levels of kidney function during the first 4 months, particularly for Black patients and people living in counties with high COVID-19 mortality rates.

Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults

BACKGROUND

Low-income individuals without health insurance have limited access to health care. Medicaid expansions may reduce kidney failure incidence by improving access to chronic disease care.

METHODS

Using a difference-in-differences analysis, we examined the association between Medicaid expansion status under the Affordable Care Act (ACA) and the kidney failure incidence rate among all nonelderly adults, aged 19-64 years, in the United States, from 2012 through 2018. We compared changes in kidney failure incidence in states that implemented Medicaid expansions with concurrent changes in nonexpansion states during pre-expansion, early postexpansion (years 2 and 3 postexpansion), and later postexpansion (years 4 and 5 postexpansion).

RESULTS

The unadjusted kidney failure incidence rate increased in the early years of the study period in both expansion and nonexpansion states before stabilizing. After adjustment for population sociodemographic characteristics, Medicaid expansion status was associated with 2.20 fewer incident cases of kidney failure per million adults per quarter in the early postexpansion period (95% CI, -3.89 to -0.51) compared with nonexpansion status, a 3.07% relative reduction (95% CI, -5.43% to -0.72%). In the later postexpansion period, Medicaid expansion status was not associated with a statistically significant change in kidney failure incidence (-0.56 cases per million per quarter; 95% CI, -2.71 to 1.58) compared with nonexpansion status and the pre-expansion time period.

CONCLUSIONS

The ACA Medicaid expansion was associated with an initial reduction in kidney failure incidence among the entire, nonelderly, adult population in the United States; but the changes did not persist in the later postexpansion period. Further study is needed to determine the long-term association between Medicaid expansion and changes in kidney failure incidence.

Single Cell Transcriptomic Analyses Reveal the Impact of bHLH Factors on Human Retinal Organoid Development

The developing retina expresses multiple bHLH transcription factors. Their precise functions and interactions in uncommitted retinal progenitors remain to be fully elucidated. Here, we investigate the roles of bHLH factors ATOH7 and Neurog2 in human ES cell-derived retinal organoids. Single cell transcriptome analyses identify three states of proliferating retinal progenitors: pre-neurogenic, neurogenic, and cell cycle-exiting progenitors. Each shows different expression profile of bHLH factors. The cell cycle-exiting progenitors feed into a postmitotic heterozygous neuroblast pool that gives rise to early born neuronal lineages. Elevating ATOH7 or Neurog2 expression accelerates the transition from the pre-neurogenic to the neurogenic state, and expands the exiting progenitor and neuroblast populations. In addition, ATOH7 and Neurog2 significantly, yet differentially, enhance retinal ganglion cell and cone photoreceptor production. Moreover, single cell transcriptome analyses reveal that ATOH7 and Neurog2 each assert positive autoregulation, and both suppress key bHLH factors associated with the pre-neurogenic and states and elevate bHLH factors expressed by exiting progenitors and differentiating neuroblasts. This study thus provides novel insight regarding how ATOH7 and Neurog2 impact human retinal progenitor behaviors and neuroblast fate choices.

[The association between aeroallergenic structures and allergic rhinitis: a study on northern Vietnam]

Recently, there has been an increase in the number of patients with allergic rhinitis (AR) and the number of publications devoted to this problem is increasing. The main etiological factors of AR are pollen of trees, meadow and weeds, as well as mold spores, household allergens and epidermis of animals. Epidemiological studies have found that the prevalence and structure of AR are influenced by regional characteristics, such as the climatic and geographical and social characteristics of the region, and successively therapeutic and preventive algorithms in AR are also different.

AIM

To examine the phenotype of the incidence of AR in connection with the characteristics of aeroallergens under the influence of climatic and geographical conditions in northern Vietnam, to make a new contribution to knowledge about AR in Asia and to increase the effect of treatment and prevention in this territory.

MATERIALS AND RESEARCH METHODS

The study was conducted in the period from 06.2018 to 09.2018 on the basis of the ENT department of Thainguyen Central Hospital, Vietnam. A total of 556 patients with pathology of ENT organs aged 18 to 70 years were examined, 158 cases of chronic rhinitis were revealed. Among data from 158 patients, 64 patients were diagnosed with AR. We used otorhinolaryngological examination, a standard specific allergological examination and carried out aeropolyneological research in the city of the northern Vietnam, from 06.2018 to 06.2019.

RESULT

The aerobiological spectrum is dominated by pollen from the families Moraceae, Urticaceae, Poaceae, Acacia, Artemisia, fern spores and fungal spores from the genus Alternaria. Among patients with chronic rhinitis, 40% were diagnosed with AR, 98.44% of them year-round or perennial AR, with predominant sensitization to house dust mites and molds, much more often to plant pollen. Among 9 (14.06%) patients diagnosed with a polyp of the nasal cavity, 6 (9.37%) patients had increased levels of specific IgE in the blood to a mixture of molds. Sensitization in patients with AR with hypertrophy of the mucous membrane of the nasal cavity is predominant on house dust.

CONCLUSION

Predominantly, AR in northern Vietnam was year-round. Especially the connection between the formation of a polyp of the nasal cavity and hypersensitivity to fungal spores has been indicated, which may also indicate the role of social factors in further recommendations for the diagnosis, treatment and prevention of AR in patients living in North Vietnam.

Correlation of hip capsule morphology with patient symptoms from femoroacetabular impingement

The relationship between morphological characteristics of the hip capsule and patient symptoms in the setting of femoroacetabular impingement (FAI) is undefined. In this study, patients with symptomatic FAI prospectively underwent 3T magnetic resonance (MR) imaging of the affected hip and completed the hip disability and osteoarthritis outcome score (HOOS) to determine the correlation between hip capsule anatomy and patient symptoms. Anterior hip capsule volume, posterior capsule volume, anterior-posterior capsule volume ratio, and proximal-distal volume ratio in the anterior capsule were quantified and measured using axial-oblique intermediate-weighted 3D fast spin echo MR images. A total of 35 patients (35 hips) were included for analysis (mean age: 30.6 years; mean body mass index [BMI]: 24.9 kg/m² ; 57% male). The mean alpha angle was 62.2° ± 4.7°, the mean anterior hip capsule volume was 1705.1 ± 450.3 mm³ , the mean posterior hip capsule volume was 1284.8 ± 268.5 mm³ , the mean anterior to posterior capsule volume ratio was 1.1 ± 0.39, and the mean proximal to distal volume ratio of the anterior capsule was 0.65 ± 0.28. There was no correlation between age, gender, or BMI, and any hip capsule characteristics. Worse scores on the HOOS pain scale were correlated with increased anterior to posterior volume ratio (r = -.38; 95% confidence interval: -0.06 to -0.63). In conclusion, hip capsule morphology correlates with patient symptoms in the setting of FAI as increased anterior capsular volume, relative to posterior capsular volume, is associated with greater patient pain.

Receipt of Social Needs Assistance and Health Center Patient Experience of Care

INTRODUCTION

Community health centers often screen for and address patients' unmet social needs. This study examines the degree to which community health center patients report receiving social needs assistance and compares measures of access and quality between patients who received assistance versus similar patients who did not.

METHODS

A nationally representative sample of 4,699 nonelderly adults receiving care at community health centers from the 2014-2015 Health Resources and Services Administration Health Center Patient Survey was used, representing 12.6 million patients. The exposure-having "received social needs assistance"-was based on whether a patient received any community health center assistance accessing social programs (e.g., applying for government benefits) or basic needs (e.g., obtaining transportation, housing, food). Using logistic regression models with inverse probability of treatment weights, outcomes for patients who received social needs assistance with similar patients who did not were compared. Study outcomes, reported as absolute adjusted differences, included reporting a community health center as a usual source of care, reporting the emergency department as a usual source of care, perceived quality of care, and willingness to recommend the community health center to others. Data were analyzed in 2020.

RESULTS

Of the sample, 36% reported receiving social needs assistance, where the most common form of assistance was applying for government benefits. Relative to similar patients who did not receive social needs assistance, patients receiving assistance were significantly more likely to report a community health center as their usual source of care (adjusted difference=7.2 percentage points, 95% CI=2.2, 12.1) and to report perceived quality of care as "the best" (adjusted difference=11.1, 95% CI=5.4, 16.9). They were significantly less likely to report the emergency department as their usual source of care (adjusted difference= -4.2, 95% CI= -7.0, -1.3).

CONCLUSIONS

As community health centers and other providers consider providing social needs assistance to patients, these results suggest that doing so may be associated with improved access to and quality of care.

Unmet social needs among low-income adults in the United States: Associations with health care access and quality

OBJECTIVE

To describe social needs among low-income adults and estimate the relationship between level of unmet social needs and key indicators of health care access and quality.

DATA SOURCE

National survey data from 12 states from the 2017 Behavioral Risk Factor Surveillance System, which added a "Social Determinants of Health" Module in 2017.

STUDY DESIGN

We examined differences in eight measures of health care access and quality (eg, check-up in last 12 months, inability to see doctor due to cost, receipt of eye examination for diabetics) for low-income adults with 0, 1, 2-3, and 4+ unmet social needs based on 7 social needs measures. We used adjusted logistic regression models to estimate the association between level of unmet need and each outcome.

PRINCIPAL FINDINGS

Most common unmet social needs included not having enough money for balanced meals (33 percent) or food (32 percent). After adjusting for observable characteristics, higher levels of unmet social need were associated with poorer access and quality. Compared to those with no reported unmet needs, having 4+ unmet needs was significantly associated with reduced probability of having a yearly check-up (65 percent vs 78 percent, adjusted difference = -7.1 percentage points (PP)), receiving a flu vaccine (33 percent vs 42 percent, adjusted difference = -5.4 PP), having a personal doctor (74 percent vs 80 percent, adjusted difference = -3.1 PP), and having a foot (63 percent vs 80 percent, adjusted difference = -12.8 PP) or eye examination (61 percent vs 73 percent, adjusted difference = -12.6 PP) for diabetic patients, and increased probability of being unable to see a doctor due to cost (44 percent vs 9 percent, adjusted difference = 27.9 PP) and having diabetes affect the eyes (22 percent vs 19 percent, adjusted difference = 8.0 PP) at α = 0.05.

CONCLUSIONS

Higher levels of unmet social needs were associated with poorer access to and quality of care among low-income adults. Addressing social needs both inside and outside of health care settings may help mitigate these negative effects. Additional research on if and how to effectively do so is critical.

Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates

Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices’ successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

Effects of temperature and viscosity on miracidial and cercarial movement of Schistosoma mansoni: ramifications for disease transmission

Parasites with complex life cycles can be susceptible to temperature shifts associated with seasonal changes, especially as free-living larvae that depend on a fixed energy reserve to survive outside the host. The life cycle of Schistosoma, a trematode genus containing some species that cause human schistosomiasis, has free-living, aquatic miracidial and cercarial larval stages that swim using cilia or a forked tail, respectively. The small size of these swimmers (150-350 µm) dictates that their propulsion is dominated by viscous forces. Given that viscosity inhibits the swimming ability of small organisms and is inversely correlated with temperature, changes in temperature should affect the ability of free-living larval stages to swim and locate a host. By recording miracidial and cercarial movement of Schistosoma mansoni using a high-speed camera and manipulating temperature and viscosity independently, we assessed the role each factor plays in the swimming mechanics of the parasite. We found a positive effect of temperature and a negative effect of viscosity on miracidial and cercarial speed. Reynolds numbers, which describe the ratio of inertial to viscous forces exerted on an aquatic organism, were <1 across treatments. Q₁₀ values were <2 when comparing viscosity treatments at 20 °C and 30 °C, further supporting the influence of viscosity on miracidial and cercarial speed. Given that both larval stages have limited energy reserves and infection takes considerable energy, successful transmission depends on both speed and lifespan. We coupled our speed data with mortality measurements across temperatures and discovered that the theoretical maximum distance travelled increased with temperature and decreased with viscosity for both larval stages. Thus, our results suggest that S. mansoni transmission is high during warm times of the year, partly due to improved swimming performance of the free-living larval stages, and that increases in temperature variation associated with climate change might further increase transmission.

Asian American Access to Care in the Affordable Care Act Era: Findings from a Population-Based Survey in California

BACKGROUND

Though Asian Americans made gains in coverage following the Affordable Care Act (ACA), substantial variations in access to care remain across different ethnic subgroups. Several states are considering adoption of policies to collect health data for Asian Americans that is disaggregated by ethnic subgroup, which may identify disparities in access to care.

OBJECTIVE

We examined coverage and access to care between non-Hispanic White and Asian American adults following the ACA in California. We first compared outcomes in non-Hispanic White adults with all Asian Americans in our sample, and then evaluated whether we detect disparities when data is disaggregated into five of the most populous ethnic subgroups (Chinese, Korean, Filipino, Vietnamese, and Japanese).

DESIGN

Cross-sectional California Health Interview Survey data were collected between January 2014 and December 2016.

PARTICIPANTS

Our sample included 19,201 non-Hispanic White and 3077 Asian American non-elderly adults age 18 to 64 living in California.

MAIN MEASURES

Our outcomes were (1) being uninsured, (2) having a usual source of care, (3) delaying necessary medical care, and (4) delaying necessary prescription medications. Using multivariable logistic regression models, we examined our outcomes, adjusting for predisposing, enabling, need, and acculturation factors.

KEY RESULTS

Compared with non-Hispanic Whites, some subgroups of Asian Americans reported significantly worse access to care: disaggregated, adjusted analyses revealed that Koreans were significantly less likely to report a usual source of care (adjusted odds ratio [AOR] = 0.31, p < 0.01) relative to non-Hispanic Whites. Chinese (AOR = 0.42, p < 0.01) and Vietnamese (AOR = 0.34, p < 0.01) adults were significantly less likely to delay necessary care.

CONCLUSIONS

Disaggregated analyses identified differences in access to care for Asian American subgroups following the ACA. State policies to collect disaggregated health data for Asian Americans may reveal heterogeneity in experiences of care and inform specific policies to reduce disparities in access to care.

Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study

BACKGROUND

Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions.

OBJECTIVES

To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion.

DESIGN

A retrospective cohort study using explicit chart abstraction methods.

PARTICIPANTS

Three hundred women aged 30-80 presenting with breast lumps and 300 men and women aged 40-80 years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012-2016.

MAIN MEASURES

Rates and timing of test ordering and completion and patterns of visits and communications.

KEY RESULTS

At initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy; p < 0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1 month, versus 31% of patients with rectal bleeding (p < 0.01). By 1 year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists.

LIMITATIONS

The study relied on documented care, and findings may be most generalizable to academically affiliated institutions.

CONCLUSIONS

Diagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.

Lesbian, Gay, And Bisexual Adults Report Continued Problems Affording Care Despite Coverage Gains

The uninsurance rate among lesbian, gay, and bisexual (LGB) adults has dropped since the Affordable Care Act (ACA) and legalization of same-sex marriage. Less is known about whether disparities in access to care and health outcomes have narrowed in LGB adults compared to their straight peers in the post-ACA era. We used data from three waves of the Behavioral Risk Factor Surveillance System to examine access to a personal doctor, affordability of care, type of health insurance coverage, and self-reported health in LGB adults in the period January 2014-February 2017 in thirty-one states that implemented the system's sexual orientation module. Compared to straight adults, more LGB adults reported avoiding necessary care because of cost and worse self-reported health outcomes, even if they had health insurance. More LGB adults reported having individually purchased insurance, which suggests that the repeal of the ACA's individual mandate may create challenges in the affordability of necessary care.

Optimizing the use of androgen deprivation therapy in men with localized intermediate-risk prostate cancer in the era of modern dose-escalated radiation therapy

109

Background: While level one evidence has shown an overall survival (OS) advantage with the addition of androgen deprivation therapy (ADT) to radiotherapy (RT) for intermediate risk prostate cancer (PCa), the benefit in the era of modern dose escalation is controversial, especially given the heterogeneity within this risk group. We assessed the impact of adding ADT to high dose RT on OS for intermediate risk PCa stratified by number of intermediate risk factors (IRF). Methods: We identified 114,339 men with intermediate risk PCa (Gleason 7, clinical stage T1-2, PSA < 20 ng/mL) using the National Cancer Database. Men were stratified into the following subgroups based on the number of IRFs (Gleason 7, cT2b-c, PSA > 10-20 ng/mL): A) Gleason 3+4 and no other IRF, B) Gleason 4+3 and no other IRF, C) two IRFs, and D) three IRFs. The addition of ADT to dose-escalated external beam RT (DE-EBRT, ≥ 75.6 Gy), brachytherapy (BT), or combination EBRT+BT on OS was assessed within each subgroup using Kaplan-Meier and log-rank tests in propensity score-matched cohorts in all men and subsequently only in those with Charlson-Deyo comorbidity index (CDI) of zero. Results: There was no OS benefit with the addition of ADT to DE-EBRT, BT, or EBRT+BT in groups A, B, and C, even after limiting the cohort to men with CDI = 0. However, in group D, the addition of ADT to DE-EBRT was associated with a trend for OS improvement in patients with CDI = 0 only (8-year OS with and without ADT 68.3% and 62.4%, respectively, log-rank P= .07). Conversely, there was a trend for OS decrement with the addition of ADT to DE-EBRT in men with CDI ≥ 1 (8-year OS with and without ADT 61.8% and 67.5%, respectively, log-rank P= .06). There was no OS benefit of ADT in group D treated with BT or EBRT+BT, regardless of comorbidity status. Conclusions: The OS benefit of ADT in men with intermediate risk PCa may be limited to those with 3 IRFs and minimal comorbidities treated with DE-EBRT. If prospectively validated, extreme dose escalation achieved with BT (alone or in combination with EBRT) may obviate the addition of ADT in all men with intermediate risk disease, especially in an era of advanced molecular imaging.

Brachytherapy use for favorable-risk prostate cancer continues to decline in both academic and community centers despite superior survival compared to dose-escalated external beam radiation therapy

105

Background: Several studies have highlighted the decline in brachytherapy (BT) utilization for localized prostate cancer, possibly due to reduced reimbursement, decreased provider efficiency, and decline in operative training. We sought to evaluate the most contemporary trends in BT versus dose-escalated external beam radiation therapy (DE-EBRT) use, as well as its impact on survival. Methods: We identified 134,713 men in the National Cancer Database with favorable risk prostate cancer (Gleason 6-7, clinical stage T1-2, and PSA < 20 ng/mL) who were treated with BT or DE-EBRT alone from 2004 to 2014. Multivariable logistic regression was used to identify independent determinants of treatment modality. Overall survival (OS) was compared between modalities using Kaplan-Meier and log-rank tests in propensity score-matched cohorts adjusted for age, race, comorbidities, year of diagnosis, and treatment facility. Results: The 10-year OS rate was higher for BT compared to DE-EBRT (BT 74.5%, DE-EBRT 68.2%, P< .0001). However, consistent with prior analyses, BT use decreased significantly from 59.3% in 2004 to 34.7% in 2014 ( P value for trend < .0001), with a corresponding rise in EBRT. The rate of decline was similar in academic and community centers; however, BT was consistently more often utilized in the community (63% in 2004, 61% in 2014). On multivariable analysis, BT was least likely to be used in men who were black (vs. white or Asian), treated at an academic (vs. community) center, and insured by Medicaid (vs. Medicare or private). Conclusions: Nationally, despite its superior survival and cost-effectiveness, prostate brachytherapy continues to be superseded by DE-EBRT in favorable risk prostate cancer, especially in men treated at academic centers and insured by Medicaid, with striking racial disparities. Payment reform, patient/provider education, and more robust resident training in prostate brachytherapy are urgently needed to help reverse this trend and ensure equal access to this efficacious treatment modality.

Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients

IMPORTANCE

Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions.

OBJECTIVE

To evaluate the association of establishing team-based primary care with patient health care use and costs.

DESIGN, SETTING, AND PARTICIPANTS

We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018.

EXPOSURES

Practices participated in a 4-year learning collaborative that created and supported team-based primary care.

MAIN OUTCOMES AND MEASURES

Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care.

RESULTS

Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n = 51 155 [37.0%] vs n = 186 954 [46.6%]), more participants younger than 18 years (n = 337 931 [27.5%] vs n = 74 691 [18.6%]), higher Medicaid enrollment (n = 39 541 [28.6%] vs n = 81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P < .001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P = .03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P = .007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P = .009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P < .001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P = .003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P = .02).

CONCLUSIONS AND RELEVANCE

While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.