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Kwon Y, Roberts ET, Degenholtz HB, Jacobs BL, Sabik LM. Association of Medicare eligibility with access to and affordability of care among older cancer survivors. J Cancer Surviv 2024:10.1007/s11764-024-01562-x. [PMID: 38520599 DOI: 10.1007/s11764-024-01562-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/07/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE Older cancer survivors have substantial needs for ongoing care, but they may encounter difficulties accessing care due to cost concerns. We examined whether near-universal insurance coverage through Medicare-a key source of health insurance coverage in this population-is associated with improvements in care access and affordability among older cancer survivors around age 65. METHODS In a nationally representative sample of cancer survivors (aged 50-80) from 2006-2018 National Health Interview Survey, we employed a quasi-experimental, regression discontinuity design to estimate changes in insurance coverage, delayed/skipped care due to cost, and worries about or problems paying medical bills at age 65. RESULTS Medicare coverage sharply increased from 8.3% at age 64 to 98.2% at age 65, ensuring near-universal insurance coverage (99.5%). Medicare eligibility at age 65 was associated with reductions in delayed/skipped care due to cost (discontinuity, - 5.7 percentage points or pp; 95% CI, - 8.1, - 3.3; P < .001), worries about paying for medical bills (- 7.7 pp; 95% CI, - 12.0, - 3.2; P = .001), and problems paying medical bills (- 3.2 pp; 95% CI, - 6.1, - 0.2; P = .036). However, a sizable proportion reported any access or affordability problems (29.7%) between ages 66 and 80. CONCLUSIONS Near-universal Medicare coverage at age 65 was associated with a reduction-but not elimination-of access and affordability problems among cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS These findings reaffirm the role of Medicare in improving access and affordability for older cancer survivor and highlight opportunities for reforms to further alleviate financial burden of care in this population.
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Affiliation(s)
- Youngmin Kwon
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, A610 Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA.
| | - Eric T Roberts
- Department of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Howard B Degenholtz
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, A610 Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
| | - Bruce L Jacobs
- Department of Urology, Division of Health Services Research, University of Pittsburgh, School of Medicine, 3471 Fifth Ave, Suite 801, Pittsburgh, PA, 15213, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, A610 Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
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Wittman SR, Hoberman A, Mehrotra A, Sabik LM, Yabes JG, Ray KN. Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors. JAMA Netw Open 2024; 7:e242359. [PMID: 38483387 PMCID: PMC10940962 DOI: 10.1001/jamanetworkopen.2024.2359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/23/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Prior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care). Objective To compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs). Design, Setting, and Participants This retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022. Exposure Setting of telemedicine visit as PCP vs DTC. Main Outcomes and Measures The primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes. Results In total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]). Conclusions and Relevance Compared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.
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Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Bourne DS, Roberts ET, Sabik LM. Early impacts of the Pennsylvania Rural Health Model on potentially avoidable utilization. Health Aff Sch 2024; 2:qxae002. [PMID: 38313868 PMCID: PMC10836154 DOI: 10.1093/haschl/qxae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/08/2024] [Accepted: 01/17/2024] [Indexed: 02/06/2024]
Abstract
The Pennsylvania Rural Health Model (PARHM) is a novel alternative payment model for rural hospitals that aims to test whether hospital-based global budgets, coupled with delivery transformation plans, improve the quality of health care and health outcomes in rural communities. Eighteen hospitals joined PARHM in 3 cohorts between 2019 and 2021. This study assessed PARHM's impact on changes in potentially avoidable utilization (PAU)-a measure of admission rates policymakers explicitly targeted for improvement in PARHM. Using a difference-in-differences analysis and all-payer hospital discharge data for Pennsylvania hospitals from 2016 through 2022, we found no significant overall reduction in community-level PAU rates up to 4 years post-PARHM implementation, relative to changes in rural Pennsylvania communities whose hospitals did not join PARHM. However, heterogeneous treatment effects were observed across cohorts that joined PARHM in different years, and between critical access vs prospective payment system hospitals. These findings offer insight into how alternative payment models in rural health care settings may have heterogeneous impacts based on contextual factors and highlight the importance of accounting for these factors in proposed expansions of alternative payment models for rural health systems.
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Affiliation(s)
- Donald S Bourne
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA 15261, United States
| | - Eric T Roberts
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, and Leonard Davis Institute of Health Economics, Philadelphia, PA 19104, United States
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA 15261, United States
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Ramian H, Sun Z, Yabes J, Jacobs B, Sabik LM. Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds. JCO Oncol Pract 2024; 20:123-130. [PMID: 37590899 PMCID: PMC10827295 DOI: 10.1200/op.22.00851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/08/2023] [Accepted: 07/10/2023] [Indexed: 08/19/2023] Open
Abstract
Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.
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Affiliation(s)
- Haleh Ramian
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Zhaojun Sun
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Jonathan Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce Jacobs
- Department of Urology, Division of Health Services Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
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Abstract
BACKGROUND Data infrastructure for cancer research is centered on registries that are often augmented with payer or hospital discharge databases, but these linkages are limited. A recent alternative in some states is to augment registry data with All-Payer Claims Databases (APCDs). These linkages capture patient-centered economic outcomes, including those driven by insurance and influence health equity, and can serve as a prototype for health economics research. OBJECTIVES To describe and assess the utility of a linkage between the Colorado APCD and Colorado Central Cancer Registry (CCCR) data for 2012-2017. RESEARCH DESIGN, PARTICIPANTS, AND MEASURES This cohort study of 91,883 insured patients evaluated the Colorado APCD-CCCR linkage on its suitability to assess demographics, area-level data, insurance, and out-of-pocket expenses 3 and 6 months after cancer diagnosis. RESULTS The linkage had high validity, with over 90% of patients in the CCCR linked to the APCD, but gaps in APCD health plans limited available claims at diagnosis. We highlight the advantages of the CCCR-APCD, such as granular race and ethnicity classification, area-level data, the ability to capture supplemental plans, medical and pharmacy out-of-pocket expenses, and transitions in insurance plans. CONCLUSIONS Linked data between registries and APCDs can be a cornerstone of a robust data infrastructure and spur innovations in health economics research on cost, quality, and outcomes. A larger infrastructure could comprise a network of state APCDs that maintain linkages for research and surveillance.
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Affiliation(s)
- Cathy J. Bradley
- University of Colorado Cancer Center Aurora, CO
- Colorado School of Public Health, Department of Health Systems, Management, and Policy Aurora, CO
| | - Rifei Liang
- University of Colorado Cancer Center Aurora, CO
| | - Richard C. Lindrooth
- Colorado School of Public Health, Department of Health Systems, Management, and Policy Aurora, CO
| | - Lindsay M. Sabik
- University of Pittsburgh School of Public Health, Department of Health Policy and Management, Pittsburgh, PA
| | - Marcelo C. Perraillon
- University of Colorado Cancer Center Aurora, CO
- Colorado School of Public Health, Department of Health Systems, Management, and Policy Aurora, CO
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Reed KG, Sun Z, Yabes JG, Drake C, Ober N, Jacobs B, van Londen GJ, Bradley CJ, Sabik LM. Assessing characteristics of populations seen at Commission on Cancer facilities using Pennsylvania linked data. JNCI Cancer Spectr 2023; 7:pkad080. [PMID: 37788093 PMCID: PMC10627003 DOI: 10.1093/jncics/pkad080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/11/2023] [Accepted: 09/25/2023] [Indexed: 10/05/2023] Open
Abstract
Commission on Cancer (CoC) accreditation certifies facilities provide quality care. We assessed differences among patients who do and do not visit CoC facilities using Pennsylvania Cancer Registry data linked to facility records for patients diagnosed with cancer between 2018 and 2019 (n = 87 472). Predicted probabilities from multivariable logistic regression indicated patients in the most advantaged Area Deprivation Index quartiles were more likely to visit CoC facilities (78.0%, 95% confidence interval [CI] = 77.5% to 78.6%) compared with other quartiles. Urban patients (74.1%, 95% CI = 73.8% to 74.4%) were more likely than rural to be seen at a CoC facility (62.7%, 95% CI = 61.2% to 64.2%) as were Hispanic patients (88.0%, 95% CI = 86.7% to 89.3%) and non-Hispanic Black patients (79.1%, 95% CI = 78.1% to 80.0%) compared with White patients (72.0%, 95% CI = 71.7% to 72.4%). Differences in demographics suggest CoC data may underrepresent some groups, including low-income and rural patients.
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Affiliation(s)
- Kristine G Reed
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Shenandoah Oncology, Winchester, VA, USA
| | - Zhaojun Sun
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan G Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Coleman Drake
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nicole Ober
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bruce Jacobs
- Division of Health Services Research, Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Cathy J Bradley
- University of Colorado Comprehensive Cancer Center, Aurora, CO, USA
- Department of Health Systems, Management & Policy, Colorado School of Public Health, Aurora, CO, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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Mellor JM, McInerney M, Garrow RC, Sabik LM. The impact of Medicaid expansion on spending and utilization by older low-income Medicare beneficiaries. Health Serv Res 2023; 58:1024-1034. [PMID: 37011907 PMCID: PMC10480074 DOI: 10.1111/1475-6773.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older low-income Medicare beneficiaries. DATA SOURCES 2010-2018 Health and Retirement Study survey data linked to annual Medicare beneficiary summary files. STUDY DESIGN We estimated individual-level difference-in-differences models of total spending for inpatient, institutional outpatient, physician/professional provider services; inpatient stays, outpatient visits, physician visits; and Medicaid and Part A and B Medicare coverage. We compared changes in outcomes before and after Medicaid expansion in expansion versus nonexpansion states. DATA COLLECTION/EXTRACTION METHODS The sample included low-income respondents aged 69 and older with linked Medicare data, enrolled in full-year traditional Medicare, and residing in the community. PRINCIPAL FINDINGS ACA Medicaid expansion was associated with a 9.8 percentage point increase in Medicaid coverage (95% CI: 0.020-0.176), a 4.4 percentage point increase in having any institutional outpatient spending (95% CI: 0.005-0.083), and a positive but statistically insignificant 2.4 percentage point change in Part B enrollment (95% CI: -0.003 to 0.050, p = 0.079). CONCLUSIONS ACA Medicaid expansion was associated with more institutional outpatient spending among older low-income Medicare beneficiaries. Increased care costs should be weighed against potential benefits from increased realized access to care.
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Affiliation(s)
- Jennifer M. Mellor
- Department of EconomicsWilliam & MaryChancellors Hall, 300 James Blair DriveWilliamsburgVirginia23185USA
| | - Melissa McInerney
- Department of EconomicsTufts University, Joyce Cummings Center177 College AvenueMedfordMassachusetts02155USA
- National Bureau of Economic Research1050 Massachusetts AvenueCambridgeMassachusetts02138USA
| | - Renee C. Garrow
- Federal Reserve Board20th Street and Constitution Ave NWWashingtonDC20551USA
| | - Lindsay M. Sabik
- Department of Health Policy & ManagementUniversity of Pittsburgh School of Public Health130 DeSoto St., A610PittsburghPennsylvania15261USA
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McInerney M, Mellor JM, Ramamoorthy V, Sabik LM. Improving Identification of Medicaid Eligible Community-Dwelling Older Adults in Major Household Surveys with Limited Income or Asset Information. Health Serv Outcomes Res Methodol 2023; 23:416-432. [PMID: 37886716 PMCID: PMC10598802 DOI: 10.1007/s10742-022-00297-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022]
Abstract
Analysis of public policy affecting dual eligibles requires accurate identification of survey respondents eligible for both Medicare and Medicaid. Doing so for Medicaid is particularly challenging given the complex eligibility rules tied to income and assets. In this paper we provide guidance on how to best identify eligible respondents in household surveys that have limited income or asset information, such as the National Health Interview Survey (NHIS), American Community Survey (ACS), Current Population Survey (CPS), and Medical Expenditure Panel Survey (MEPS). We show how two types of errors-false negative and false positive errors-are impacted by incorporating limited income or asset information, relative to the commonly-used approach of solely comparing total income to the income threshold. With the 2018 Health and Retirement Study (HRS), which has detailed income and asset information, we mimic the income and asset information available in those other household surveys and quantify how errors change when imposing income or asset tests with limited information. We show that incorporating all available income and asset data results in the lowest number of errors and the lowest overall error rates. We recommend that researchers adjust income and impose the asset test to the fullest extent possible when imputing Medicaid eligibility for Medicare enrollees.
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Affiliation(s)
- Melissa McInerney
- Tufts University Department of Economics, Medford, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Jennifer M. Mellor
- William & Mary Department of Economics and Schroeder Center for Health Policy, Williamsburg, VA, USA
| | | | - Lindsay M. Sabik
- University of Pittsburgh School of Public Health Department of Health Policy and Management, Pittsburgh, PA, USA
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Kwon Y, Perraillon MC, Drake C, Jacobs BL, Bradley CJ, Sabik LM. Comparison of primary payer in cancer registry and discharge data. Am J Manag Care 2023; 29:455-462. [PMID: 37729528 DOI: 10.37765/ajmc.2023.89425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVES To determine agreement between variables capturing the primary payer at cancer diagnosis across the Pennsylvania Cancer Registry (PCR) and statewide facility discharge records (Pennsylvania Health Care Cost Containment Council [PHC4]) for adults younger than 65 years, and to specifically examine factors associated with misclassification of Medicaid status in the registry given the role of managed care. STUDY DESIGN Cross-sectional analysis of the primary cancer cases among adults aged 21 to 64 years in the PCR from 2010 to 2016 linked to the PHC4 facility visit records. METHODS We assessed agreement of payer at diagnosis (Medicare, Medicaid, private, other, uninsured, unknown) across data sources, including positive predictive value (PPV) and sensitivity, using the PHC4 records as the gold standard. The probability of misclassifying Medicaid in registry was estimated using multivariate logit models. RESULTS Agreement of payers was high for private insurance (PPV, 89.7%; sensitivity, 83.6%), but there was misclassification and/or underreporting of Medicaid in the registry (PPV, 80%; sensitivity, 58%). Among cases with "other" and "unknown" insurance, 73.8% and 62.1%, respectively, had private insurance according to the PHC4 records. Medicaid managed care was associated with a statistically significant increase of 12.6 percentage points (95% CI, 9.4-15.8) in the probability of misclassifying Medicaid enrollment as private insurance in the registry. CONCLUSIONS Findings suggest caution in conducting and interpreting research using insurance variables in cancer registries.
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Affiliation(s)
- Youngmin Kwon
- University of Pittsburgh School of Public Health, A610 Public Health, 130 DeSoto St, Pittsburgh, PA 15261.
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10
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Kudrick LD, Baddour K, Wu R, Fadel M, Snyder V, Neopaney A, Thomas TH, Sabik LM, Nilsen ML, Johnson JT, Ferris RL, Nouraie SM, Hass R, Mady LJ. Longitudinal Analysis of Caregiver Burden in Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2023; 149:681-689. [PMID: 37318816 PMCID: PMC10273129 DOI: 10.1001/jamaoto.2023.1283] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/21/2023] [Indexed: 06/16/2023]
Abstract
Importance Despite the critical role of caregivers in head and neck cancer (HNC), there is limited literature on caregiver burden (CGB) and its evolution over treatment. Research is needed to address evidence gaps that exist in understanding the causal pathways between caregiving and treatment outcomes. Objective To evaluate the prevalence of and identify risk factors for CGB in HNC survivorship. Design, Setting, and Participants This longitudinal prospective cohort study took place at the University of Pittsburgh Medical Center. Dyads of treatment-naive patients with HNC and their caregivers were recruited between October 2019 and December 2020. Eligible patient-caregiver dyads were 18 years or older and fluent in English. Patients undergoing definitive treatment identified a caregiver as the primary, nonprofessional, nonpaid person who provided the most assistance to them. Among 100 eligible dyadic participants, 2 caregivers declined participation, resulting in 96 enrolled participants. Data were analyzed from September 2021 through October 2022. Main Outcomes and Measures Participants were surveyed at diagnosis, 3 months postdiagnosis, and 6 months postdiagnosis. Caregiver burden was evaluated with the 19-item Social Support Survey (scored 0-100, with higher scores indicating more support), Caregiver Reaction Assessment (CRA; scored 0-5, with higher scores on 4 subscales [disrupted schedule, financial problems, lack of family support, and health problems] indicating negative reactions, and higher scores on the fifth subscale [self-esteem] indicating favorable influence); and 3-item Loneliness Scale (scored 3-9, with higher scores indicating greater loneliness). Patient health-related quality of life was assessed using the University of Washington Quality of Life scale (UW-QOL; scored 0-100, with higher scores indicating better QOL). Results Of the 96 enrolled participants, half were women (48 [50%]), and a majority were White (92 [96%]), married or living with a partner (81 [84%]), and working (51 [53%]). Of these participants, 60 (63%) completed surveys at diagnosis and at least 1 follow-up. Of the 30 caregivers, most were women (24 [80%]), White (29 [97%]), married or living with a partner (28 [93%]), and working (22 [73%]). Caregivers of nonworking patients reported higher scores on the CRA subscale for health problems than caregivers of working patients (mean difference, 0.41; 95% CI, 0.18-0.64). Caregivers of patients with UW-QOL social/emotional (S/E) subscale scores of 62 or lower at diagnosis reported increased scores on the CRA subscale for health problems (UW-QOL-S/E score of 22: CRA score mean difference, 1.12; 95% CI, 0.48-1.77; UW-QOL-S/E score of 42: CRA score mean difference, 0.74; 95% CI, 0.34-1.15; and UW-QOL-S/E score of 62: CRA score mean difference, 0.36; 95% CI, 0.14-0.59). Woman caregivers had statistically significant worsening scores on the Social Support Survey (mean difference, -9.18; 95% CI, -17.14 to -1.22). The proportion of lonely caregivers increased over treatment. Conclusions and Relevance This cohort study highlights patient- and caregiver-specific factors that are associated with increased CGB. Results further demonstrate the potential implications for negative health outcomes for caregivers of patients who are not working and have lower health-related quality of life.
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Affiliation(s)
- Lauren D. Kudrick
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Khalil Baddour
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard Wu
- Department of Otolaryngology–Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark Fadel
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Vusala Snyder
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Teresa H. Thomas
- Department of Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Marci L. Nilsen
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Jonas T. Johnson
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert L. Ferris
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Seyed M. Nouraie
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard Hass
- Population Health Science, College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
- Jefferson Center for Interprofessional Practice and Education, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Leila J. Mady
- Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Eom KY, Rothenberger SD, Jarlenski MP, Schoen RE, Cole ES, Sabik LM. Enrollee characteristics and receipt of colorectal cancer testing in Pennsylvania after adoption of the Affordable Care Act Medicaid expansion. Cancer Med 2023; 12:15455-15467. [PMID: 37329270 PMCID: PMC10417095 DOI: 10.1002/cam4.6168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer-related death in the U.S. Despite increased CRC screening rates, they remain low among low-income non-older adults, including Medicaid enrollees who are more likely to be diagnosed at advanced stages. OBJECTIVES Given limited evidence regarding CRC screening service use among Medicaid enrollees, we examined multilevel factors associated with CRC testing among Medicaid enrollees in Pennsylvania after Medicaid expansion in 2015. RESEARCH DESIGN Using the 2014-2019 Medicaid administrative data, we performed multivariable logistic regression models to assess factors associated with CRC testing, adjusting for enrollment length and primary care services use. SUBJECTS We identified 15,439 adults aged 50-64 years newly enrolled through Medicaid expansion. MEASURES Outcome measures include receiving any CRC testing and by modality. RESULTS About 32% of our study population received any CRC testing. Significant predictors for any CRC testing include being male, being Hispanic, having any chronic conditions, using primary care services ≤4 times annually, and having a higher county-level median household income. Being 60-64 years at enrollment, using primary care services >4 times annually, and having higher county-level unemployment rates were significantly associated with a decreased likelihood of receiving any CRC tests. CONCLUSIONS CRC testing rates were low among adults newly enrolled in Medicaid under the Medicaid expansion in Pennsylvania relative to adults with high income. We observed different sets of significant factors associated with CRC testing by modality. Our findings underscore the urgency to tailor strategies by patients' racial, geographic, and clinical conditions for CRC screening.
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Affiliation(s)
- Kirsten Y. Eom
- Department of Medicine at the MetroHealth System at Case Western Reserve UniversityClevelandOhioUSA
| | - Scott D. Rothenberger
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Marian P. Jarlenski
- Department of Health Policy & ManagementUniversity of Pittsburgh Graduate School of Public HealthPittsburghPennsylvaniaUSA
| | - Robert E. Schoen
- Division of Gastroenterology, Hepatology and Nutrition, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Evan S. Cole
- Department of Health Policy & ManagementUniversity of Pittsburgh Graduate School of Public HealthPittsburghPennsylvaniaUSA
| | - Lindsay M. Sabik
- Department of Health Policy & ManagementUniversity of Pittsburgh Graduate School of Public HealthPittsburghPennsylvaniaUSA
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12
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Miller DT, Sun Z, Grajales V, Pekala KR, Eom KY, Yabes J, Davies BJ, Sabik LM, Jacobs BL. Insurance Type and Area Deprivation Are Associated With Worse Overall Mortality for Patients With Muscle-invasive Bladder Cancer. Urology 2023; 177:81-88. [PMID: 37028521 DOI: 10.1016/j.urology.2023.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To examine the association of area-level socioeconomic status, rural-urban residence, and type of insurance with overall and cancer-specific mortality among patients with muscle-invasive bladder cancer. METHODS Using the Pennsylvania Cancer Registry, which collects demographic, insurance, and clinical information on every patient with cancer within the state, we identified all patients diagnosed with non-metastatic muscle-invasive bladder cancer between 2010 and 2016 based on clinical and pathologic staging. We used the Area Deprivation Index (ADI) as a surrogate for socioeconomic status and Rural-Urban Commuting Area codes to classify urban, large town, and rural communities. ADI was reported in quartiles, with 4 representing the lowest socioeconomic status. We fit multivariable logistic regression and Cox models to assess the relationship of these social determinants with overall and cancer-specific survival adjusting for age, sex, race, stage, treatment, rural-urban classification, insurance and ADI. RESULTS We identified 2597 patients with non-metastatic muscle-invasive bladder cancer. On multivariable analysis, Medicare (hazards ratio [HR] 1.15), Medicaid (HR 1.38), ADI 3 (HR 1.16) and ADI 4 (HR 1.21) were independent predictors of greater overall mortality (all P < 0.05). Female sex and receipt of non-standard treatment were associated with increased overall mortality and bladder cancer-specific mortality. There was no significant difference in both overall and cancer-specific survival between patients who were non-Hispanic White compared to non-White or between those from urban areas, large towns, or rural locations. CONCLUSION Lower socioeconomic status and Medicare and Medicaid insurance were associated with a greater risk of overall mortality while rural residence was not a significant factor. Implementation of public health programs may help reduce the gap in mortality for low SES at-risk populations.
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Affiliation(s)
- David T Miller
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Zhaojun Sun
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Valentina Grajales
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kelly R Pekala
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kirsten Y Eom
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Jonathan Yabes
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lindsay M Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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13
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Bradley CJ, Sabik LM, Liang R, Lindrooth RC, Perraillon MC. Treatment Disparities in Radiation and Hormone Therapy Among Women Covered by Medicaid vs Private Insurance in Cancer Registry and Claims Data. JAMA Health Forum 2023; 4:e230673. [PMID: 37145688 PMCID: PMC10163382 DOI: 10.1001/jamahealthforum.2023.0673] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
Importance Prior research has reported undertreatment among patients with cancer who are insured by Medicaid, but this finding may be due, in part, to incomplete data in cancer registries. Objective To compare disparities in radiation and hormone therapy between women with breast cancer covered by Medicaid and those with private insurance using the Colorado Central Cancer Registry (CCCR) and CCCR data supplemented with All Payer Claims Data (APCD). Design, Setting, and Participants This observational cohort study included women aged 21 to 63 years who received breast cancer surgery. We linked the CCCR and Colorado APCD to identify Medicaid and privately insured women who were newly diagnosed with invasive, nonmetastatic breast cancer between January 1, 2012, and December 31, 2017. In the radiation treatment analysis, we narrowed the sample to women who received breast-conserving surgery (Medicaid, n = 1408; private, n = 1984) and in the hormone therapy analysis, we selected women who were hormone-receptor positive (Medicaid, n = 1156; private, n = 1667). Main Outcomes and Measures We used logistic regression to estimate the likelihood of treatment within 12 months to assess whether the results varied between data sources. Results There were 3392 and 2823 participants in the radiation and hormone therapy cohorts, respectively. The mean (SD) age was 51.71 (8.30) years in the radiation therapy cohort, and 52.00 (8.16) years in the hormone therapy cohort. Among the participants, there were 140 (4%) and 105 (4%) who were Black non-Hispanic, 499 (15%) and 406 (14%) who were Hispanic, 2602 (77%) and 2190 (78%) were White, and 151 (4%) and 122 (4%) were other/unknown in the radiation and hormone therapy cohorts, respectively. A higher percentage of women were aged 50 years or younger in the Medicaid samples (40% vs 34% in the privately insured sample) and identified as non-Hispanic Black (about 7%) or Hispanic (approximately 24%). Treatment was underreported in both sources, but to a lesser extent in the APCD (2.5% and 2.0% for Medicaid and private insurance, respectively) compared with CCCR (19.5% and 13.3% for Medicaid and private insurance, respectively). Using CCCR data, Women with Medicaid insurance were 4 (95% CI, -8 to -1; P = .02) and 10 (95% CI, -14 to -6; P < .001) percentage points less likely to have a record of radiation and hormone therapy compared with privately insured women, respectively. Using combined CCCR and APCD, no statistically significant disparity was observed in radiation or hormone therapy between Medicaid-insured and privately insured women. Conclusions and Relevance Among women with breast cancer covered by Medicaid vs private insurance, cancer treatment disparities may be overestimated if based solely on cancer registry data.
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Affiliation(s)
- Cathy J Bradley
- University of Colorado Cancer Center, Aurora
- Colorado School of Public Health, Aurora
| | - Lindsay M Sabik
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Rifei Liang
- University of Colorado Cancer Center, Aurora
| | | | - Marcelo C Perraillon
- University of Colorado Cancer Center, Aurora
- Colorado School of Public Health, Aurora
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14
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Maganty A, Byrnes ME, Hamm M, Wasilko R, Sabik LM, Davies BJ, Jacobs BL. Barriers to rural health care from the provider perspective. Rural Remote Health 2023; 23:7769. [PMID: 37196993 DOI: 10.22605/rrh7769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION Rural populations routinely rank poorly on common health indicators. While it is understood that rural residents face barriers to health care, the exact nature of these barriers remains unclear. To further define these barriers, a qualitative study of primary care physicians practicing in rural communities was performed. METHODS Semistructured interviews were conducted with primary care physicians practicing in rural areas within western Pennsylvania, the third largest rural population within the USA, using purposively sampling. Data were then transcribed, coded, and analyzed by thematic analysis. RESULTS Three key themes emerged from the analysis addressing barriers to rural health care: (1) cost and insurance, (2) geographic dispersion, and (3) provider shortage and burnout. Providers mentioned strategies that they either employed or thought would be beneficial for their rural communities: (1) subsidize services, (2) establish mobile and satellite clinics (particularly for specialty care), (3) increase utilization of telehealth, (4) improve infrastructure for ancillary patient support (ie social work services), and (5) increase utilization of advanced practice providers. CONCLUSION There are numerous barriers to providing rural communities with quality health care. Barriers that are encountered are multidimensional. Patients are unable to obtain the care they need because of cost-related barriers. More providers need to be recruited to rural areas to combat the shortage and burnout. Advanced care-delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. Policy efforts should target all these aspects in order to appropriately address rural healthcare needs.
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Affiliation(s)
- Avinash Maganty
- Department of Urology, Dow Division of Health Services Research, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mary E Byrnes
- Department of Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Megan Hamm
- Qualitative, Evaluation, and Stakeholder Engagement Research Services, Center for Research on Healthcare's Data Center, University of Pittsburgh, PA, USA
| | - Rachel Wasilko
- Qualitative, Evaluation, and Stakeholder Engagement Research Services, Center for Research on Healthcare's Data Center, University of Pittsburgh, PA, USAQualitative, Evaluation, and Stakeholder Engagement Research Services, Center for Research on Healthcare's Data Center, University of Pittsburgh, PA, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Benjamin J Davies
- Department of Urology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bruce L Jacobs
- Department of Urology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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15
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Chun B, Ramian H, Jones C, Vasan R, Yabes JG, Davies BJ, Sabik LM, Jacobs BL. Changes in Urologic Cancer Surgical Volume and Length of Stay During the COVID-19 Pandemic in Pennsylvania. JAMA Netw Open 2023; 6:e239848. [PMID: 37097635 PMCID: PMC10130946 DOI: 10.1001/jamanetworkopen.2023.9848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Importance Disruptions in cancer surgery during the COVID-19 pandemic led to widespread deferrals and cancellations, creating a surgical backlog that presents a challenge for health care institutions moving into the recovery phase of the pandemic. Objective To describe patterns in surgical volume and postoperative length of stay for major urologic cancer surgery during the COVID-19 pandemic. Design, Setting, and Participants This cohort study identified 24 001 patients 18 years or older from the Pennsylvania Health Care Cost Containment Council database with kidney cancer, prostate cancer, or bladder cancer who received a radical nephrectomy, partial nephrectomy, radical prostatectomy, or radical cystectomy between the first quarter (Q1) of 2016 and Q2 of 2021. Postoperative length of stay and adjusted surgical volumes were compared before and during the COVID-19 pandemic. Main Outcomes and Measures The primary outcome was adjusted surgical volume for radical and partial nephrectomy, radical prostatectomy, and radical cystectomy during the COVID-19 pandemic. The secondary outcome was postoperative length of stay. Results A total of 24 001 patients (mean [SD] age, 63.1 [9.4] years; 3522 women [15%], 19 845 White patients [83%], 17 896 living in urban areas [75%]) received major urologic cancer surgery between Q1 of 2016 and Q2 of 2021. Of these, 4896 radical nephrectomy, 3508 partial nephrectomy, 13 327 radical prostatectomy, and 2270 radical cystectomy surgical procedures were performed. There were no statistically significant differences in patient age, sex, race, ethnicity, insurance status, urban or rural status, or Elixhauser Comorbidity Index scores between patients who received surgery before and patients who received surgery during the pandemic. For partial nephrectomy, a baseline of 168 surgeries per quarter decreased to 137 surgeries per quarter in Q2 and Q3 of 2020. For radical prostatectomy, a baseline of 644 surgeries per quarter decreased to 527 surgeries per quarter in Q2 and Q3 of 2020. However, the likelihood of receiving radical nephrectomy (odds ratio [OR], 1.00; 95% CI, 0.78-1.28), partial nephrectomy (OR, 0.99; 95% CI, 0.77-1.27), radical prostatectomy (OR, 0.85; 95% CI, 0.22-3.22), or radical cystectomy (OR, 0.69; 95% CI, 0.31-1.53) was unchanged. Length of stay for partial nephrectomy decreased from baseline by a mean of 0.7 days (95% CI, -1.2 to -0.2 days) during the pandemic. Conclusions and Relevance This cohort study suggests that partial nephrectomy and radical prostatectomy surgical volume decreased during the peak waves of COVID-19, as did postoperative length of stay for partial nephrectomy.
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Affiliation(s)
- Brian Chun
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Haleh Ramian
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Cameron Jones
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robin Vasan
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan G Yabes
- Urology Health Services Research Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Urology Health Services Research Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Urology Health Services Research Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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16
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Ray KN, Wittman SR, Yabes JG, Sabik LM, Hoberman A, Mehrotra A. Telemedicine Visits to Children During the Pandemic: Practice-Based Telemedicine Versus Telemedicine-Only Providers. Acad Pediatr 2023; 23:265-270. [PMID: 35589062 PMCID: PMC9666718 DOI: 10.1016/j.acap.2022.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In March 2020, regulatory and payment changes allowed "brick and mortar" pediatric practices to offer practice-based telemedicine for the first time, joining direct-to-consumer (DTC) telemedicine vendors in the ability to offer visits for common acute pediatric concerns via telemedicine. We sought to characterize the relative contribution of practice-based telemedicine versus commercial DTC telemedicine models in provision of children's telemedicine from 2018 through 2021. METHODS Using January 2018 to September 2021 data from Optum's de-identified Clinformatics® Data Mart Database, we identified telemedicine visits by children ≤17, excluding preventive visits and visits to specialists, emergency departments, and urgent care. Among included visits, we defined "telemedicine-only" providers as those with ≥80% of visits via telemedicine and practice-based telemedicine providers as those with ≤50% of visits via telemedicine. We then described the telemedicine visit volume and diagnoses for these categories overall and per 1000 children per month. RESULTS From January 2018 to February 2020, telemedicine-only providers accounted for 57,815 telemedicine visits (90.8%), while practice-based telemedicine accounted for 4192 telemedicine visits (6.6%). From March 2020 to September 2021, telemedicine-only providers accounted for 38,282 telemedicine visits (6.1%), while practice-based telemedicine accounted for 555,125 telemedicine visits (88.2%). Per month, telemedicine visits to practice-based telemedicine providers increased from pre-pandemic to pandemic periods (0.1 vs 12.9 visits per 1000 children/month), while telemedicine visits to telemedicine-only providers occurred at a similar rate from pre-pandemic to pandemic periods (0.92 vs 0.96 visits per 1000 children/month). CONCLUSIONS We observed a large increase in telemedicine visits during the pandemic, with the growth in visits exclusively occurring among visits to practice-based telemedicine providers as opposed to telemedicine-only providers.
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Affiliation(s)
- Kristin N Ray
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
| | - Samuel R Wittman
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Jonathan G Yabes
- Department of Medicine (J Yabes), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Lindsay M Sabik
- Department of Health Policy & Management ( L Sabik), University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pa
| | - Alejandro Hoberman
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Ateev Mehrotra
- Department of Health Care Policy (A Mehrotra), Harvard Medical School, Boston, Mass
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17
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Garrow R, Mellor JM, McInerney M, Sabik LM. Examining Medicaid Participation and Medicaid Entry Among Senior Medicare Beneficiaries With Linked Administrative and Survey Data. Med Care Res Rev 2023; 80:109-125. [PMID: 35730585 DOI: 10.1177/10775587221101297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Because Medicare beneficiaries can qualify for Medicaid through several pathways, duals who newly enroll in Medicaid may have experienced various financial and/or health changes that impact their Medicaid eligibility. Alternatively, new enrollment could reflect changes in awareness of the program among those previously eligible. Using monthly enrollment data linked to Health and Retirement Study survey data, we examine financial and health changes that occur around the time new Medicaid participants enter the program, and we compare those with changes experienced by both those continuously enrolled in Medicaid and those not enrolled. We find that Medicaid entry is often timed with a marked increase in out-of-pocket medical expenses, a substantial decrease in assets for some, and increases in activities of daily living (ADL) limitations. We also observe financial changes among persons continuously enrolled in Medicaid. Our results inform discussions about Medicaid eligibility policies and potential gaps in the protection that Medicaid offers from financial risk.
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18
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Bulls HW, Hamm M, Wasilko R, Cameron FDA, Belin S, Goodin BR, Liebschutz JM, Wozniak A, Sabik LM, Schenker Y, Merlin JS. "I Refused to Get Addicted to Opioids": Exploring Attitudes About Opioid Use Disorder in Patients With Advanced Cancer Pain and Their Support People. J Pain 2023:S1526-5900(23)00023-8. [PMID: 36709854 DOI: 10.1016/j.jpain.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/28/2022] [Accepted: 01/19/2023] [Indexed: 01/27/2023]
Abstract
Patients with advanced cancer are commonly prescribed opioids, yet patient attitudes about opioid risks (eg, opioid use disorder, or OUD) are understudied. Our objective was to use in-depth qualitative interviews to understand perceptions of opioid prescribing and OUD in patients with advanced, solid-tumor cancers and their support people. We conducted a qualitative study using a rigorous inductive, qualitative descriptive approach to examine attitudes about OUD in patients with advanced cancer (n = 20) and support providers (n = 11). Patients with cancer hold 2 seemingly distinct views: prescription opioids are addictive, yet OUD cannot happen to me or my loved one. Participants described general concerns about the addictive nature of prescription opioids ("My biggest concern… would just be the risk of getting addicted to the medication or even like, overdosing it"), while separating cancer pain management from OUD when considering prescription opioid risks and benefits ("They need to make sure they get the right ones, when they're taking it away from you."). Finally, participants identified personal characteristics and behaviors that they felt were protective against developing OUD (commonly control, willpower, and responsibility). This rigorous qualitative study demonstrates that patients with advanced cancer and their support people simultaneously hold concerns about the addictive nature of prescription opioids, while distancing from perceptions of OUD risks when using opioids for cancer pain management. Given high rates of opioid exposure during advanced cancer treatment, it is important to explore opportunities to promote a balanced understanding of prescription opioid use and OUD risks in this population. PERSPECTIVE: Though prescription opioids carry risk of OUD, there is little data to help guide patients with advanced cancer. Findings suggest that there is a need to develop new, innovative strategies to promote effective pain management and minimize opioid risks in this complex population.
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Affiliation(s)
- Hailey W Bulls
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania; Challenges in Managing and Preventing Pain Clinical Research Center (CHAMPP), University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Megan Hamm
- Qualitative, Evaluation, and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rachel Wasilko
- Qualitative, Evaluation, and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Flor de Abril Cameron
- Qualitative, Evaluation, and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shane Belin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Burel R Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Antoinette Wozniak
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lindsay M Sabik
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania; Challenges in Managing and Preventing Pain Clinical Research Center (CHAMPP), University of Pittsburgh, Pittsburgh, Pennsylvania
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19
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Wright B, Akiyama J, Potter AJ, Sabik LM, Stehlin GG, Trivedi AN, Wolinsky FD. Racial and Ethnic Disparities in Hospital-Based Care Among Dual Eligibles Who Use Health Centers. Health Equity 2023; 7:9-18. [PMID: 36744239 PMCID: PMC9892926 DOI: 10.1089/heq.2022.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 01/18/2023] Open
Abstract
Introduction Health center use may reduce hospital-based care among Medicare-Medicaid dual eligibles, but racial and ethnic disparities in this population have not been widely studied. We examined the extent of racial and ethnic disparities in hospital-based care among duals using health centers and the degree to which disparities occur within or between health centers. Methods We used 2012-2018 Medicare claims and health center data to model emergency department (ED) visits, observation stays, hospitalizations, and 30-day unplanned returns as a function of race and ethnicity among dual eligibles using health centers. Results In rural and urban counties, age-eligible Black individuals had more ED visits (7.9 [4.0, 11.7] and 13.7 [10.0, 17.4] per 100 person-years) and were more likely to experience an unplanned return (1.4 [0.4, 2.4] and 1 [0.4, 1.6] percentage points [pp]) than White individuals, but were less likely to be hospitalized (-3.3 [-3.9, -2.8] and -1.2 [-1.6, -0.9] pp). In urban counties, age-eligible Black individuals were 1.2 [0.9, 1.5] pp more likely than White individuals to have observation stays. Other racial and ethnic groups used the same or less hospital-based care than White individuals. Including state and health center fixed effects eliminated Black versus White disparities in all outcomes, except hospitalization. Results were similar among disability-eligible duals. Conclusion Racial and ethnic disparities in hospital-based care among dual eligibles are less common within than between health centers. If health centers are to play a more central role in eliminating racial and ethnic health disparities, these differences across health centers must be understood and addressed.
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Affiliation(s)
- Brad Wright
- Department of Family Medicine, UNC-Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA.,Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill, Chapel Hill, North Carolina, USA.,*Address correspondence to: Brad Wright, PhD, Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Suite 355, Columbia, SC 29208, USA,
| | - Jill Akiyama
- Department of Health Policy and Management, Gillings School of Public Health, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Andrew J. Potter
- Department of Political Science and Criminal Justice, California State University, Chico, California, USA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Grace G. Stehlin
- Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amal N. Trivedi
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Fredric D. Wolinsky
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA
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20
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Thomas TH, Bender C, Rosenzweig M, Taylor S, Sereika SM, Babichenko D, You KL, Terry MA, Sabik LM, Schenker Y. Testing the effects of the Strong Together self-advocacy serious game among women with advanced cancer: Protocol for the STRONG randomized clinical trial. Contemp Clin Trials 2023; 124:107003. [PMID: 36379436 PMCID: PMC9839496 DOI: 10.1016/j.cct.2022.107003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/27/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Women with advanced cancer experience significant barriers to achieving high-quality care and maximizing their physical and emotional health. Our novel serious game, Strong Together, aims to teach women with advanced cancer self-advocacy skills needed to improve their symptom burden, quality of life, and patient-centered care. METHODS This is a single-center, multi-site randomized clinical trial of the Strong Together intervention among 336 women within three months of an advanced breast or gynecologic cancer diagnosis. Randomization occurs to the 3-month Strong Together serious game or enhanced care as usual group. The aims are to: (1) evaluate the effects of the intervention on patient self-advocacy (primary outcome); (2) evaluate the effects of the intervention on quality of life, symptom burden, and patient-centered care (secondary outcomes); and (3) evaluate the behavioral and game mechanisms that influence the efficacy of the intervention. ELIGIBILITY CRITERIA female, age ≥ 18 years; diagnosis of advanced breast or gynecologic cancer within the past 3 months; Eastern Cooperative Oncology Group score of 0-2; English literacy; and ≥ 6-month life expectancy. Patient-reported outcome measures are collected at baseline, 3-months, and 6-months. CONCLUSION This protocol is the first large-scale intervention aimed at promoting self-advocacy in women with advanced cancer. Understanding the ability of serious games to impact patient outcomes provides critical information for researchers, clinicians, and stakeholders aiming to improve patient-centered care. TRIAL REGISTRATION NCT04813276.
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Affiliation(s)
- Teresa H Thomas
- University of Pittsburgh School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh 15261, PA, USA; Palliative Research Center (PaRC), University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh 15213, PA, USA.
| | - Catherine Bender
- University of Pittsburgh School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh 15261, PA, USA.
| | - Margaret Rosenzweig
- University of Pittsburgh School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh 15261, PA, USA; Palliative Research Center (PaRC), University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh 15213, PA, USA; University of Pittsburgh Medical Center Magee-Womens Hospital, 300 Halket Street, Pittsburgh 15213, PA, USA.
| | - Sarah Taylor
- University of Pittsburgh Medical Center Magee-Womens Hospital, 300 Halket Street, Pittsburgh 15213, PA, USA.
| | - Susan M Sereika
- University of Pittsburgh School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh 15261, PA, USA.
| | - Dmitriy Babichenko
- University of Pittsburgh School of Computing and Information, 135 North Bellefield Avenue, Pittsburgh 15213, PA, USA.
| | - Kai-Lin You
- University of Pittsburgh School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh 15261, PA, USA.
| | - Martha Ann Terry
- University of Pittsburgh School of Public Health, 130 De Soto Street, Pittsburgh 15261, PA, USA.
| | - Lindsay M Sabik
- University of Pittsburgh School of Public Health, 130 De Soto Street, Pittsburgh 15261, PA, USA.
| | - Yael Schenker
- Palliative Research Center (PaRC), University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh 15213, PA, USA; University of Pittsburgh School of Medicine, Division of General Internal Medicine, 200 Lothrop Street, Pittsburgh 15213, PA, USA.
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Wright B, Akiyama J, Potter AJ, Sabik LM, Stehlin GG, Trivedi AN, Wolinsky FD. Characterizing the Uptake of Newly Opened Health Centers by Individuals Dually Enrolled in Medicare and Medicaid. J Ambul Care Manage 2023; 46:2-11. [PMID: 36150035 PMCID: PMC9691473 DOI: 10.1097/jac.0000000000000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Federally qualified health centers (FQHCs) increasingly provide high-quality, cost-effective primary care to individuals dually enrolled in Medicare and Medicaid. However, not everyone can access an FQHC. We used 2012 to 2018 Medicare claims and federally collected FQHC data to examine communities where an FQHC first opened and determine which dual eligibles used it. Overall uptake was 10%, ranging from 6.6% among age-eligible urban residents to 14.8% among disability-eligible rural residents. Community-level uptake ranged from 0% to 76.4% (median = 5.5%; interquartile range = 2.8%-11.3%). Certain subpopulations of dual eligibles are significantly more likely to use FQHCs. Our findings should inform the targeting of future FQHC expansions.
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Affiliation(s)
- Brad Wright
- Department of Health Services Policy and Management, University of South Carolina, Columbia (Dr Wright); Department of Health Policy and Management, Gillings School of Public Health, UNC-Chapel Hill, Chapel Hill, North Carolina (Ms Akiyama); Department of Political Science & Criminal Justice, The California State University, Chico (Dr Potter); Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Sabik); The Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill, Chapel Hill, North Carolina (Ms Stehlin); Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island (Dr Trivedi); and Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City (Dr Wolinsky)
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22
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Pan Z, Dahman B, Bono RS, Sabik LM, Belgrave FZ, Yerkes L, Nixon DE, Kimmel AD. Brief Report: Physician Reimbursement and Retention in HIV Care: Racial Disparities in the US South. J Acquir Immune Defic Syndr 2023; 92:1-5. [PMID: 36184773 PMCID: PMC9742342 DOI: 10.1097/qai.0000000000003105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/17/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Retention in HIV care remains a national challenge. Addressing structural barriers to care may improve retention. We examined the association between physician reimbursement and retention in HIV care, including racial differences. METHODS We integrated person-level administrative claims (Medicaid Analytic eXtract, 2008-2012), state Medicaid-to-Medicare physician fee ratios (Urban Institute, 2008, 2012), and county characteristics for 15 Southern states plus District of Columbia. The fee ratio is a standardized measure of physician reimbursement capturing Medicaid relative to Medicare physician reimbursement across states. Generalized estimating equations assessed the association between the fee ratio and retention (≥2 care markers ≥90 days apart in a calendar year). Stratified analyses assessed racial differences. We varied definitions of retention, subsamples, and definitions of the fee ratio, including the fee ratio at parity. RESULTS The sample included 55,237 adult Medicaid enrollees with HIV (179,002 enrollee years). Enrollees were retained in HIV care for 76.6% of their enrollment years, with retention lower among non-Hispanic Black (76.1%) versus non-Hispanic White enrollees (81.3%, P < 0.001). A 10-percentage point increase in physician reimbursement was associated with 4% increased odds of retention (adjusted odds ratio 1.04, 95% confidence interval: 1.01 to 1.07). In stratified analyses, the positive, significant association occurred among non-Hispanic Black (1.08, 1.05-1.12) but not non-Hispanic White enrollees (0.87, 0.74-1.02). Findings were robust across sensitivity analyses. When the fee ratio reached parity, predicted retention increased significantly overall and for non-Hispanic Black enrollees. CONCLUSION Higher physician reimbursement may improve retention in HIV care, particularly among non-Hispanic Black individuals, and could be a mechanism to promote health equity.
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Affiliation(s)
- Zhongzhe Pan
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Rose S. Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Faye Z. Belgrave
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lauren Yerkes
- Virginia Department of Health, Richmond, Virginia, USA
| | - Daniel E. Nixon
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia, USA
| | - April D. Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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23
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Shafer PR, Dusetzina SB, Sabik LM, Platts-Mills TF, Stearns SC, Trogdon JG. High Deductible Health Plans and Use of Free Preventive Services Under the Affordable Care Act. Inquiry 2023; 60:469580231182512. [PMID: 37329296 DOI: 10.1177/00469580231182512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
The Affordable Care Act aimed to increase use of preventive services by eliminating cost-sharing to consumers. However, patients may be unaware of this benefit or they may not seek preventive services if they anticipate that the cost of potential diagnostic or treatment services will be too high, both more likely among those in high deductible health plans. We used nationally representative private health insurance claims (100% sample of IBM® MarketScan®) for the United States from 2006 to 2018, restricting the data to enrollment and claims for non-elderly adults who were enrolled for the full plan year. The cross-sectional sample (185 million person-years) is used to describe trends in preventive service use and costs from 2008 through 2016. The cohort sample (9 million people) focuses on the elimination of cost-sharing for certain high-value preventive services in late 2010, requiring continuous enrollment across 2010 and 2011. We examine whether HDHP enrollment is associated with use of eligible preventive services using semi-parametric difference-in-differences to account for endogenous plan selection. Our preferred model implies that HDHP enrollment was associated with a reduction of the post-ACA change in any use of eligible preventive services by 0.2 percentage points or 12.5%. Cancer screenings were unaffected but HDHP enrollment was associated with smaller increases in wellness visits, immunizations, and screening for chronic conditions and sexually transmitted infections. We also find that the policy was ineffective at reducing out-of-pocket costs for the eligible preventive services, likely due to implementation issues.
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Affiliation(s)
- Paul R Shafer
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, MA, USA
| | | | - Lindsay M Sabik
- School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Sally C Stearns
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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24
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Wittman SR, Yabes JG, Sabik LM, Kahn JM, Ray KN. Patient and Family Factors Associated with Use of Telemedicine Visits for Pediatric Acute Respiratory Tract Infections, 2018-2019. Telemed J E Health 2023; 29:127-136. [PMID: 35639360 PMCID: PMC9918348 DOI: 10.1089/tmj.2022.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background: Pediatric acute respiratory tract infections (ARTIs) were a common reason for commercial direct-to-consumer (DTC) telemedicine use before the COVID-19 pandemic, but the factors associated with this use are unknown. Objective: To identify child and family factors associated with use of commercial DTC telemedicine for ARTIs in 2018-2019. Methods: We performed a retrospective cohort analysis of claims data from the Optum Clinformatics® Data Mart Database. Among children with ARTI visits, we fitted logit models to examine child and family characteristics associated with DTC telemedicine use. Results: Of 660,725 children with ARTI visits, 12,944 (2.0%) had ≥1 commercial DTC telemedicine encounter. The odds of DTC telemedicine use were higher for children with age ≥12 years, lower parent educational attainment, higher household income, white non-Hispanic race/ethnicity, and residency in the West South Central census division. Conclusion: In 2018-2019, commercial DTC telemedicine use varied with child age, child race/ethnicity parent educational attainment, household income, and geography.
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Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Jeremy M. Kahn
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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25
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Bulls HW, Hamm M, Wasilko R, de Abril Cameron F, Belin S, Goodin BR, Liebschutz JM, Wozniak A, Sabik LM, Merlin JS, Schenker Y. Manifestations of Opioid Stigma in Patients With Advanced Cancer: Perspectives From Patients and Their Support Providers. JCO Oncol Pract 2022; 18:e1594-e1602. [PMID: 35878073 PMCID: PMC9835931 DOI: 10.1200/op.22.00251] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 01/16/2023] Open
Abstract
PURPOSE Stigma surrounding prescription opioids, or opioid stigma, is increasingly recognized as a barrier to effective and guideline-concordant cancer pain management. Patients with advanced cancer report high rates of pain and prescription opioid exposure, yet little is known about how opioid stigma may manifest in this population. METHODS We conducted in-depth qualitative interviews with 20 patients with advanced cancer and 11 support providers between March 2020, and May 2021. We took a rigorous inductive, qualitative descriptive approach to characterize how opioid stigma manifests in the lives of patients with advanced cancer. RESULTS Patients and their support providers described three primary manifestations of opioid stigma: (1) direct experiences with opioid stigma and discrimination in health care settings (eg, negative, stigmatizing interactions in pharmacies or a pain clinic); (2) concerns about opioid stigma affecting patient care in the future, or anticipated stigma; and (3) opioid-restricting attitudes and behaviors that may reflect internalized stigma and fear of addiction (eg, feelings of guilt). CONCLUSION This qualitative study advances our understanding of opioid stigma manifestations in patients with advanced cancer, as well as coping strategies that patients may use to alleviate their unease (eg, minimizing prescription opioid use, changing clinicians, and distancing from perceptions of addiction). In recognition of the costs of undermanaged cancer pain, it is important to consider innovative treatment strategies to address opioid stigma and improve pain management for patients with advanced cancer. Future research should examine opportunities to build an effective, multilevel opioid stigma intervention targeting patients, clinicians, and health care systems.
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Affiliation(s)
- Hailey W. Bulls
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- Challenges in Managing and Preventing Pain Clinical Research Center (CHAMPP), University of Pittsburgh, Pittsburgh, PA
| | - Megan Hamm
- Qualitative, Evaluation, and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Rachel Wasilko
- Qualitative, Evaluation, and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Flor de Abril Cameron
- Qualitative, Evaluation, and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Shane Belin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
| | - Burel R. Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Antoinette Wozniak
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- Challenges in Managing and Preventing Pain Clinical Research Center (CHAMPP), University of Pittsburgh, Pittsburgh, PA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
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Wright B, Akiyama J, Potter AJ, Sabik LM, Stehlin GG, Trivedi AN, Wolinsky FD. Health center use and hospital-based care among individuals dually enrolled in Medicare and Medicaid, 2012-2018. Health Serv Res 2022; 57:1045-1057. [PMID: 35124817 PMCID: PMC9441286 DOI: 10.1111/1475-6773.13946] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/19/2021] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To examine the relationship between federally qualified health center (FQHC) use and hospital-based care among individuals dually enrolled in Medicare and Medicaid. DATA SOURCES Data were obtained from 2012 to 2018 Medicare claims. STUDY DESIGN We modeled hospital-based care as a function of FQHC use, person-level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30-day unplanned returns. We stratified all models on the basis of eligibility and rurality. DATA EXTRACTION METHODS Our sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end-stage renal disease. PRINCIPAL FINDINGS After the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person-years among both age-eligible (-14.8 [-17.5, -12.1]; -6.6 [-7.5, -5.6]) and disability-eligible duals (-11.3 [-14.4, -8.3]; -6 [-7.4, -4.6]) as well as a lower probability of observation stays (-0.8 pp age-eligible; -0.4 pp disability-eligible) and unplanned returns (-2.1 pp age-eligible; -1.9 pp disability-eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person-years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability-eligible duals (a decrease of more than 60% compared with the pre-PPS period) and increases in the probability of hospitalization (1.1 pp age-eligible; 0.8 pp disability-eligible) and ACS hospitalization (0.5 pp age-eligible; 0.3 pp disability-eligible) (a decrease of roughly 50% compared with the pre-PPS period). CONCLUSIONS FQHC use is associated with reductions in hospital-based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.
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Affiliation(s)
- Brad Wright
- Department of Family MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jill Akiyama
- Department of Health Policy and ManagementUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Andrew J. Potter
- Department of Political Science and Criminal JusticeCalifornia State UniversityChicoCaliforniaUSA
| | - Lindsay M. Sabik
- Department of Health Policy and ManagementUniversity of Pittsburgh School of Public HealthPittsburghPennsylvaniaUSA
| | - Grace G. Stehlin
- Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Amal N. Trivedi
- Department of Health Services Policy and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Fredric D. Wolinsky
- Department of Health Management and PolicyUniversity of Iowa College of Public HealthIowa CityIowaUSA
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Oh NL, Potter AJ, Sabik LM, Trivedi AN, Wolinsky F, Wright B. The association between primary care use and potentially-preventable hospitalization among dual eligibles age 65 and over. BMC Health Serv Res 2022; 22:927. [PMID: 35854303 PMCID: PMC9295296 DOI: 10.1186/s12913-022-08326-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022] Open
Abstract
Background Individuals dually-enrolled in Medicare and Medicaid (dual eligibles) are disproportionately sicker, have higher health care costs, and are hospitalized more often for ambulatory care sensitive conditions (ACSCs) than other Medicare beneficiaries. Primary care may reduce ACSC hospitalizations, but this has not been well studied among dual eligibles. We examined the relationship between primary care and ACSC hospitalization among dual eligibles age 65 and older. Methods In this observational study, we used 100% Medicare claims data for dual eligibles ages 65 and over from 2012 to 2018 to estimate the likelihood of ACSC hospitalization as a function of primary care visits and other factors. We used linear probability models stratified by rurality, with subgroup analyses for dual eligibles with diabetes or congestive heart failure. Results Each additional primary care visit was associated with an 0.05 and 0.09 percentage point decrease in the probability of ACSC hospitalization among urban (95% CI: − 0.059, − 0.044) and rural (95% CI: − 0.10, − 0.08) dual eligibles, respectively. Among dual eligibles with CHF, the relationship was even stronger with decreases of 0.09 percentage points (95% CI: − 0.10, − 0.08) and 0.15 percentage points (95% CI: − 0.17, − 0.13) among urban and rural residents, respectively. Conclusions Increased primary care use is associated with lower rates of preventable hospitalizations for dual eligibles age 65 and older, especially for dual eligibles with diabetes and congestive heart failure. In turn, efforts to reduce preventable hospitalizations for this dual-eligible population should consider how to increase access to and use of primary care. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08326-2.
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Affiliation(s)
- N Loren Oh
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.,Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Andrew J Potter
- Department of Political Science & Criminal Justice, California State University, Chico, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Amal N Trivedi
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, USA
| | - Fredric Wolinsky
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
| | - Brad Wright
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA. .,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 590 Manning Dr. CB 7595, Chapel Hill, NC, 27599, USA.
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28
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Shih YCT, Sabik LM, Stout NK, Halpern MT, Lipscomb J, Ramsey S, Ritzwoller DP. Health Economics Research in Cancer Screening: Research Opportunities, Challenges, and Future Directions. J Natl Cancer Inst Monogr 2022; 2022:42-50. [PMID: 35788368 PMCID: PMC9255920 DOI: 10.1093/jncimonographs/lgac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/03/2022] [Indexed: 01/26/2023] Open
Abstract
Cancer screening has long been considered a worthy public health investment. Health economics offers the theoretical foundation and research methodology to understand the demand- and supply-side factors associated with screening and evaluate screening-related policies and interventions. This article provides an overview of health economic theories and methods related to cancer screening and discusses opportunities for future research. We review 2 academic disciplines most relevant to health economics research in cancer screening: applied microeconomics and decision science. We consider 3 emerging topics: cancer screening policies in national as well as local contexts, "choosing wisely" screening practices, and targeted screening efforts for vulnerable subpopulations. We also discuss the strengths and weaknesses of available data sources and opportunities for methodological research and training. Recommendations to strengthen research infrastructure include developing novel data linkage strategies, increasing access to electronic health records, establishing curriculum and training programs, promoting multidisciplinary collaborations, and enhancing research funding opportunities.
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Affiliation(s)
- Ya-Chen Tina Shih
- Correspondence to: Ya-Chen Tina Shih, PhD, Department of Health Services Research, Unit 1444, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030-4009, USA.
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Michael T Halpern
- Healthcare Delivery Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, and the Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Scott Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Institute, Seattle, WA, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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McInerney M, McCormack G, Mellor JM, Sabik LM. Association of Medicaid Expansion With Medicaid Enrollment and Health Care Use Among Older Adults With Low Income and Chronic Condition Limitations. JAMA Health Forum 2022; 3:e221373. [PMID: 35977244 PMCID: PMC9166222 DOI: 10.1001/jamahealthforum.2022.1373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/14/2022] [Indexed: 12/02/2022] Open
Abstract
Question Was the expansion of Medicaid to working-age adults under the Patient Protection and Affordable Care Act (ACA) associated with changes in Medicaid enrollment and health care use among older adults with low income and chronic condition limitations? Findings In this cross-sectional study of 7153 US adults 65 years or older with low income, ACA Medicaid expansion was associated with significant increases in the likelihood of Medicaid enrollment and outpatient health care use among those with chronic condition limitations. No associations were found between ACA Medicaid expansion and Medicaid enrollment and health care use among those without such limitations. Meaning In this study, expansion of Medicaid to working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were enrolled in Medicare. Importance Medicaid is an important source of supplemental coverage for older Medicare beneficiaries with low income. Research has shown that Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with increased Medicaid coverage for previously eligible older adults with low income, but there has been little research on whether their health care use increased or whether such changes differed by beneficiaries’ health status. Objective To assess whether the ACA Medicaid expansion to working-age adults was associated with increased Medicaid enrollment and health care use among older adults with low income with and without chronic condition limitations. Design, Setting, and Participants This cross-sectional study used data from the National Health Interview Survey from 2010 to 2017 for adults 65 years or older with low income (≤100% of the federal poverty level). Data were analyzed from November 2020 to March 2022. Exposure Residence in a state with Medicaid expansion for working-age adults. Main Outcomes and Measures The main outcomes were Medicaid coverage and health care use, measured by physician office visits and inpatient hospital care. Survey weights were used in calculating descriptive statistics and regression estimates. In multivariate analysis, difference-in-differences models were used to compare changes in outcomes over time between respondents in Medicaid expansion states and respondents in nonexpansion states. Results Of 21 859 adults included in the study, 7153 had chronic condition limitations (4983 [70.1%] female; mean [SD] age, 76.0 [0.1] years) and 14 706 did not have chronic condition limitations (9609 [66.3%] female; mean [SD] age, 74.85 [0.08] years). Of those with chronic condition limitations, 2707 (36.7%) were enrolled in Medicaid, 2816 (39.4%) had an office visit in the past 2 weeks, and 2152 (30.7%) used inpatient hospital care in the past year. Medicaid expansion was associated with differential increases in the likelihood of having Medicaid (4.92 percentage points; 95% CI, 0.25-9.60 percentage points; P = .04) and having an office visit in the past 2 weeks (5.31 percentage points; 95% CI, 0.10-10.51 percentage points; P = .046) compared with nonexpansion. There were no differential changes between expansion and nonexpansion states in receipt of inpatient hospital care (−0.62 percentage points; 95% CI, −5.39 to 4.14 percentage points; P = .79). Among adults without chronic condition limitations, 3159 (19.8%) were enrolled in Medicaid, and no differential changes between expansion and nonexpansion states in Medicaid enrollment (−0.24 percentage points; 95% CI, −3.06 to 2.57 percentage points; P = .86) or health care use were found. Conclusions and Relevance In this cross-sectional study, ACA Medicaid expansion for working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were dually eligible for Medicare and Medicaid.
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Affiliation(s)
- Melissa McInerney
- Department of Economics, Tufts University, Medford, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Grace McCormack
- Harvard Kennedy School, Harvard University, Cambridge, Massachusetts
| | - Jennifer M. Mellor
- Department of Economics, William & Mary, Williamsburg, Virginia
- Schroeder Center for Health Policy, William & Mary, Williamsburg, Virginia
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
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Bradley CJ, Sabik LM, Entwistle J, Stevens JL, Enewold L, Warren JL. Role of Medicaid in Early Detection of Screening-Amenable Cancers. Cancer Epidemiol Biomarkers Prev 2022; 31:1202-1208. [PMID: 35322273 DOI: 10.1158/1055-9965.epi-21-1077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/26/2021] [Accepted: 03/02/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This study examines the association between Medicaid enrollment, including through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), and distant stage for three screening-amenable cancers: breast, cervical, and colorectal. METHODS We use the Surveillance, Epidemiology, and End Results Cancer Registry linked with Medicaid enrollment data to compare patients who were Medicaid insured with patients who were not Medicaid insured. We estimate the likelihood of distant stage at diagnosis using logistic regression. RESULTS Medicaid enrollment following diagnosis was associated with the highest likelihood of distant stage. Medicaid enrollment through NBCCEDP did not mitigate the likelihood of distant stage disease relative to Medicaid enrollment prior to diagnosis. Non-Hispanic Black patients had a greater likelihood of distant stage breast and colorectal cancer. Residing in higher socioeconomic areas was associated with a lower likelihood of distant stage breast cancer. CONCLUSIONS Medicaid enrollment prior to diagnosis is associated with a lower likelihood of distant stage in screen amenable cancers but does not fully ameliorate disparities. IMPACT Our study highlights the importance of health insurance coverage prior to diagnosis and demonstrates that while targeted programs such as the NBCCEDP provide critical access to screening, they are not a substitute for comprehensive insurance coverage.
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Affiliation(s)
- Cathy J Bradley
- University of Colorado Cancer Center, Aurora, Colorado.,Colorado School of Public Health, Aurora, Colorado
| | - Lindsay M Sabik
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | | | | | - Lindsey Enewold
- Division of Cancer Control and Population Science, NCI, Bethesda, Maryland
| | - Joan L Warren
- Division of Cancer Control and Population Science, NCI, Bethesda, Maryland
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Pekala KR, Yabes JG, Bandari J, Yu M, Davies BJ, Sabik LM, Kahn JM, Jacobs BL. Corrigendum to ‘The centralization of bladder cancer care and its implications for patient travel distance’ [Urologic Oncology: Seminars and Original Investigations volume 39 (2021) 834.e.9–834.e.20/9680]. Urol Oncol 2022; 40:203-206. [DOI: 10.1016/j.urolonc.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Roberts ET, Mellor JM, McInerny MP, Sabik LM. Effects of a Medicaid dental coverage 'cliff' on dental care access among low-income Medicare beneficiaries. Health Serv Res 2022; 58:589-598. [PMID: 35362157 PMCID: PMC10154168 DOI: 10.1111/1475-6773.13981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/09/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate how an abrupt drop-off, or "cliff," in Medicaid dental coverage affects access to dental care among low-income Medicare beneficiaries. Medicaid is an important source of dental insurance for low-income Medicare beneficiaries, but beneficiaries whose incomes slightly exceed eligibility thresholds for Medicaid have fewer affordable options for dental coverage, resulting in a dental coverage cliff above these thresholds. DATA SOURCE Medicare Current Beneficiary Surveys (MCBS) from 2016-2019. STUDY DESIGN We used a regression discontinuity design to evaluate effects of this dental coverage cliff. This study design exploited an abrupt difference in Medicaid coverage above income eligibility thresholds in the Medicaid program for elderly and disabled populations. DATA COLLECTION The study included low-income community-dwelling Medicare beneficiaries surveyed in the MCBS whose incomes, measured in percentage points of the federal poverty level, were within ±75 percentage points of state-specific Medicaid income eligibility thresholds (n=7,508 respondent-years, which when weighted represented 26,776,719 beneficiary-years). PRINCIPAL FINDINGS Medicare beneficiaries whose income exceeded Medicaid eligibility thresholds were 5.0 percentage points more likely to report difficulty accessing dental care due to cost concerns or a lack of insurance than beneficiaries below the thresholds (95% CI: 0.2, 9.8; P=0.04)-a one-third increase over the proportion reporting difficulty below the thresholds (15.0%). CONCLUSIONS A Medicaid dental coverage cliff exacerbates barriers to dental care access among low-income Medicare beneficiaries. Expanding dental coverage for Medicare beneficiaries, particularly those who are ineligible for Medicaid, could alleviate barriers to dental care access that result from the lack of comprehensive dental coverage in Medicare.
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Affiliation(s)
- Eric T Roberts
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 DeSoto Street, Room A653, Pittsburgh, PA
| | | | - Melissa P McInerny
- Department of Economics Tufts University Braker Hall 8 Upper Campus Road Medford, MA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 DeSoto Street, Pittsburgh, PA
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Bradley CJ, Sabik LM. An ounce of prevention: Medicaid's role in reducing the burden of cancer in men with HIV. Cancer 2022; 128:1900-1903. [PMID: 35285936 DOI: 10.1002/cncr.34167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Cathy J Bradley
- Colorado School of Public Health, University of Colorado, Aurora, Colorado.,University of Colorado Comprehensive Cancer Center, Aurora, Colorado
| | - Lindsay M Sabik
- Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Sabik LM, Eom KY, Sun Z, Merlin JS, Bulls HW, Moyo P, Pruskowski JA, van Londen G, Rosenzweig M, Schenker Y. Patterns and Trends in Receipt of Opioids Among Patients Receiving Treatment for Cancer in a Large Health System. J Natl Compr Canc Netw 2022; 20:460-467.e1. [PMID: 35231900 PMCID: PMC10463265 DOI: 10.6004/jnccn.2021.7104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/18/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Given limited evidence on opioid prescribing among patients receiving treatment for cancer during the ongoing opioid epidemic, our objective was to assess predictors of and trends in opioid receipt during cancer treatment, including how patterns differ by type of cancer. METHODS Using cancer registry data, we identified patients with a first lifetime primary diagnosis of breast, colorectal, or lung cancer from 2013 to 2017 who underwent treatment within a large cancer center network. Cancer registry data were linked to electronic health record information on opioid prescriptions. We examined predictors of and trends in receipt of any opioid prescription within 12 months of cancer diagnosis. RESULTS The percentage of patients receiving opioids varied by cancer type: breast cancer, 35% (1,996/5,649); colorectal, 37% (776/2,083); lung, 47% (1,259/2,654). In multivariable analysis, opioid use in the year before cancer diagnosis was the factor most strongly associated with receipt of opioids after cancer diagnosis, with 4.90 (95% CI, 4.10-5.86), 5.09 (95% CI, 3.88-6.69), and 3.31 (95% CI, 2.68-4.10) higher odds for breast, colorectal, and lung cancers, respectively. We did not observe a consistent decline in opioid prescribing over time, and trends differed by cancer type. CONCLUSIONS Our findings suggest that prescription of opioids to patients with cancer varies by cancer type and other factors. In particular, patients are more likely to receive opioids after cancer diagnosis if they were previously exposed before diagnosis, suggesting that pain among patients with cancer may commonly include non-cancer-related pain. Heterogeneity and complexity among patients with cancer must be accounted for in developing policies and guidelines aimed at addressing pain management while minimizing the risk of opioid misuse.
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Affiliation(s)
- Lindsay M. Sabik
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management
| | - Kirsten Y. Eom
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management
| | - Zhaojun Sun
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management
| | - Jessica S. Merlin
- University of Pittsburgh School of Medicine, Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine
| | - Hailey W. Bulls
- University of Pittsburgh School of Medicine, Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine
| | - Patience Moyo
- Brown University School of Public Health, Department of Health Services, Policy, and Practice
| | | | - G.J. van Londen
- University of Pittsburgh School of Medicine, Department of Medicine, Divisions of Hematology-Oncology and Geriatric Medicine
| | - Margaret Rosenzweig
- University of Pittsburgh School of Nursing, Department of Acute & Tertiary Care
| | - Yael Schenker
- University of Pittsburgh School of Medicine, Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine
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Abstract
BACKGROUND State central cancer registries are an essential component of cancer surveillance and research that can be enriched through linkages to other databases. This study identified and described state central registry linkages to external data sources and assessed the potential for a more comprehensive data infrastructure with registries at its core. METHODS We identified peer-reviewed papers describing linkages to state central cancer registries in all 50 states, Washington, DC, and Puerto Rico, published between 2010 and 2020. To complement the literature review, we surveyed registrars to learn about unpublished linkages. Linkages were grouped by medical claims (public and private insurers), medical records, other registries (eg, human immunodeficiency virus/acquired immunodeficiency syndrome registries, birth certificates, screening programs), and data from specific cohorts (eg, firefighters, teachers). RESULTS We identified 464 data linkages with state central cancer registries. Linkages to cohorts and other registries were most common. Registries in predominately rural states reported the fewest linkages. Most linkages are not ongoing, maintained, or available to researchers. A third of linkages reported by registrars did not result in published papers. CONCLUSIONS Central cancer registries, often in collaboration with researchers, have enriched their data through linkages. These linkages demonstrate registries' ability to contribute to a data infrastructure, but a coordinated and maintained approach is needed to leverage these data for research. Sparsely populated states reported the fewest linkages, suggesting possible gaps in our knowledge about cancer in these states. Many more linkages exist than have been reported in the literature, highlighting potential opportunities to further use the data for research purposes.
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Affiliation(s)
- Cathy J. Bradley
- University of Colorado Cancer Center, Aurora, CO
- Colorado School of Public Health, Aurora, CO
| | | | - Lindsay M. Sabik
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | | | - Marcelo Perraillon
- University of Colorado Cancer Center, Aurora, CO
- Colorado School of Public Health, Aurora, CO
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Bradley CJ, Liang R, Jasem J, Lindrooth RC, Sabik LM, Perraillon MC. Cancer Treatment Data in Central Cancer Registries: When Are Supplemental Data Needed? Cancer Inform 2022; 21:11769351221112457. [PMID: 35923286 PMCID: PMC9340909 DOI: 10.1177/11769351221112457] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: We evaluated treatment concordance between the Colorado All Payer Claims Database (APCD) and the Colorado Central Cancer Registry (CCCR) to explore whether APCDs can augment registry data. We compare treatment concordance for breast cancer, an extensively studied site with an inpatient reporting source and select leukemias that are often diagnosed outpatient. Methods: We analyzed concordance by cancer type and treatment, patient demographics, reporting source, and health insurance, calculating the sensitivity, specificity, positive predictive values (PPV) and Kappa statistics. We estimated an adjusted logistic regression model to assess whether the APCD statistically significantly reports additional cancer-directed treatments. Results: Among women with breast cancer, 14% had chemotherapy treatments that were absent from the CCCR. Missing treatments were more common among women younger than age 50 (15%) and patients aged 75 and older (19%), rural residents (17%), and when the reporting source was outpatient (22%). Similar and more pronounced patterns for people with leukemia were observed. Concordance for oral treatments was lower for each cancer. Sensitivity and PPVs were high, with moderate Kappa statistics. The APCD was 5.3 percentage points less likely to identify additional treatments for breast cancer patients and 10 percentage points more likely to identify additional treatments when the reporting source was an outpatient facility. Conclusion: A robust data infrastructure is needed to investigate research questions that require population-level analyses, particularly for questions seeking to reduce health inequity and comparisons across payers, including Medicare Advantage and fee-for-service. APCD data are a step toward creating an infrastructure for cancer, particularly for patients who reside in rural areas and/or receive care from outpatient centers.
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Affiliation(s)
- Cathy J Bradley
- University of Colorado Cancer Center, Aurora, CO, USA
- Colorado School of Public Health, Aurora, CO, USA
| | - Rifei Liang
- University of Colorado Cancer Center, Aurora, CO, USA
| | - Jagar Jasem
- University of Colorado Cancer Center, Aurora, CO, USA
| | | | - Lindsay M Sabik
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Marcelo C Perraillon
- University of Colorado Cancer Center, Aurora, CO, USA
- Colorado School of Public Health, Aurora, CO, USA
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Cornelio N, McInerney MP, Mellor JM, Roberts ET, Sabik LM. Increasing Medicaid's Stagnant Asset Test For People Eligible For Medicare And Medicaid Will Help Vulnerable Seniors. Health Aff (Millwood) 2021; 40:1943-1952. [PMID: 34871073 DOI: 10.1377/hlthaff.2021.00841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Low-income Medicare beneficiaries rely on Medicaid for supplemental coverage but must meet income and asset tests to qualify. We examined states' income and asset tests for full-benefit Medicaid during the period 2006-18 and examined how alternative asset tests would affect eligibility for community-dwelling Medicare beneficiaries ages sixty-five and older. Most states have not updated the dollar limit of Medicaid's asset test since 1989, making the asset test increasingly restrictive in inflation-adjusted terms. We estimated that increasing Medicaid's asset limit by the Consumer Price Index, to Medicare Savings Program levels, or to $10,000 for individuals and $20,000 for couples would increase Medicaid eligibility by 1.7 percent, 4.4 percent, and 7.5 percent, respectively. Simplifying Medicaid's asset test to focus only on certain high-value assets would increase eligibility by 20.5 percent. Increasing asset limits would lessen restrictions on Medicaid eligibility that arise from stagnant asset tests, broadening eligibility for certain low-income Medicare beneficiaries and allowing them to retain higher, yet still modest, savings.
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Affiliation(s)
- Noelle Cornelio
- Noelle Cornelio is a doctoral student in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, in Pittsburgh, Pennsylvania
| | - Melissa Powell McInerney
- Melissa Powell McInerney is a professor in the Department of Economics, Tufts University, in Medford, Massachusetts
| | - Jennifer M Mellor
- Jennifer M. Mellor is the Paul R. Verkuil Professor of Economics and Public Policy in the Department of Economics and directs the Schroeder Center for Health Policy at William & Mary, in Williamsburg, Virginia
| | - Eric T Roberts
- Eric T. Roberts is an assistant professor in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
| | - Lindsay M Sabik
- Lindsay M. Sabik is an associate professor in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
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Perraillon MC, Liang R, Sabik LM, Lindrooth RC, Bradley CJ. The role of all-payer claims databases to expand central cancer registries: Experience from Colorado. Health Serv Res 2021; 57:703-711. [PMID: 34743320 DOI: 10.1111/1475-6773.13901] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the quality of a multiyear linkage between the Colorado all-payer claims database (APCD) and the Colorado Central Cancer Registry. DATA SOURCES Secondary 2012-2017 data from the APCD and the Colorado Cancer Registry. STUDY DESIGN Descriptive analysis of the proportion of cases captured by the linkage in relation to the cases reported by the registry. DATA COLLECTION/EXTRACTION METHODS We used probabilistic linkage to combine records from both data sources for all patients diagnosed with cancer. RESULTS We successfully linked 93% of the 146,884 patients in the registry. Approximately 63% of linked patients were perfect matches on five identifiers. Of partial matches, 81.6% were matched on four identifiers with missing or partial Social Security Numbers. The linkage rate was lower for uninsured patients at diagnosis (74.7%) or patients with private plans (89.4%) but close to 100% for Medicare and Medicaid enrollees. Most of the 29% of patients who did not have claims at the time of diagnosis were covered by private plans that may not submit claims. CONCLUSIONS APCD-registry linkages are a promising source of data to conduct population-based research from multiple payers. However, not all payers submit claims, and the quality of the data may vary by state.
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Affiliation(s)
- Marcelo C Perraillon
- Health Systems, Management & Policy, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rifei Liang
- University of Colorado Cancer Center, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lindsay M Sabik
- Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Richard C Lindrooth
- Health Systems, Management & Policy, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cathy J Bradley
- Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
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Sabik LM, Eom KY, Dahman B, Li J, van Londen GJ, Bradley CJ. Breast Cancer Treatment Following Health Reform: Evidence From Massachusetts. Med Care Res Rev 2021; 79:371-381. [PMID: 34467806 DOI: 10.1177/10775587211042532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are well-documented differences in breast cancer treatment by insurance status. Insurance expansions provide a context to assess the relationship between insurance and patterns of breast cancer care. We examine the association of Massachusetts health reform with use of breast conserving surgery, reconstruction, and adjuvant radiation using data from the Massachusetts Cancer Registry and Surveillance Epidemiology and End Results registries for 2001-2013 and a difference-in-differences approach. We observe statistically significant increases in breast conserving surgery among nonelderly women in Massachusetts relative to trends in states and age groups not affected by health reform. We also observe relative increases in reconstruction and adjuvant radiation, though trends in these outcomes were not the same across states prior to reform, limiting our ability to draw conclusions about the relationship between reform and these outcomes. Our results suggest that health reform was associated with some improvements in breast cancer treatment.
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Affiliation(s)
| | | | | | - Jie Li
- University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Cathy J Bradley
- University of Colorado Comprehensive Cancer Center, Aurora, CO, USA
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40
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Baddour K, Fadel M, Zhao M, Corcoran M, Owoc MS, Thomas TH, Sabik LM, Nilsen ML, Ferris RL, Mady LJ. The cost of cure: Examining objective and subjective financial toxicity in head and neck cancer survivors. Head Neck 2021; 43:3062-3075. [PMID: 34235804 DOI: 10.1002/hed.26801] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 06/15/2021] [Accepted: 06/28/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Little is documented regarding objective financial metrics and their impact on subjective financial toxicity in head and neck cancer (HNC) survivors. METHODS In a cross-sectional analysis, 71 survivors with available claims data for HNC-specific out-of-pocket expenses (OOPE) completed a survey including patient-reported, subjective financial toxicity outcome tools: the Comprehensive Score for financial Toxicity (COST) and the Financial Distress Questionnaire (FDQ). RESULTS Worse COST scores were significantly associated with lower earnings at survey administration (coefficient = 3.79; 95% CI 2.63-4.95; p < 0.001); loss of earnings after diagnosis (coefficient = 6.03; 95% CI 0.53-11.52; p = 0.032); and greater annual OOPE as a proportion of earnings [log10(Annual OOPE:Earnings at survey): coefficient = -5.66; 95% CI -10.28 to -1.04; p = 0.017]. Similar results were found with FDQ. CONCLUSION Financial toxicity is associated with particular socioeconomic characteristics which, if understood, would assist the development of pre-treatment screening tools to detect at-risk individuals and intervene early in the HNC cancer survivorship trajectory.
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Affiliation(s)
- Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mark Fadel
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Meng Zhao
- Strategic Analysis of Clinical Affairs, UPMC Insurance Services, Pittsburgh, Pennsylvania, USA
| | - Michael Corcoran
- Strategic Analysis of Clinical Affairs, UPMC Insurance Services, Pittsburgh, Pennsylvania, USA
| | - Maryanna S Owoc
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Teresa H Thomas
- Department of Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Marci L Nilsen
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Leila J Mady
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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41
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Singhal A, Alofi A, Garcia RI, Sabik LM. Medicaid adult dental benefits and oral health of low-income older adults. J Am Dent Assoc 2021; 152:551-559.e1. [PMID: 34176569 DOI: 10.1016/j.adaj.2021.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 02/13/2021] [Accepted: 03/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Older adults are keeping their natural teeth longer, spurring calls for dental coverage under Medicare. Although Medicare dental coverage would benefit all older adults, the poorest among them are already eligible for dental benefits through Medicaid. The authors examine the association between states' Medicaid adult dental benefits and dental care use and tooth loss among low-income older adults. METHODS Using the Behavioral Risk Factor Surveillance System data from 2014, 2016, and 2018, the authors examined adults 65 years or older. The outcomes examined included annual dental visit and partial and complete tooth loss. Poisson regressions were used to obtain risk ratios after adjusting for covariates. RESULTS States' Medicaid adult dental benefits were significantly associated with dental care use, with low-income older adults in states with no coverage having the lowest probability of visiting a dentist (risk ratio [RR], 0.83; 95% CI, 0.74 to 0.94), followed by emergency-only coverage (RR, 0.91; 95% CI, 0.84 to 0.98) and limited benefits (RR, 0.91; 95% CI, 0.85 to 0.98) relative to states with extensive benefits. There were no significant differences in either partial or complete tooth loss. CONCLUSIONS States' Medicaid adult dental benefits are significantly associated with dental visits among low-income seniors. Providing comprehensive dental benefits under Medicaid can improve access to dental care among low-income older adults. PRACTICAL IMPLICATIONS As the older adult patient population grows, the poorest older adults may face barriers to dental care in the absence of dental coverage. Dental professionals must engage in advocating for comprehensive dental coverage, especially for vulnerable populations.
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Pekala KR, Yabes JG, Bandari J, Yu M, Davies BJ, Sabik LM, Kahn JM, Jacobs BL. The centralization of bladder cancer care and its implications for patient travel distance. Urol Oncol 2021; 39:834.e9-834.e20. [PMID: 34162498 DOI: 10.1016/j.urolonc.2021.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/16/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the impact of centralized surgical and nonsurgical care (i.e., radiation and chemotherapy) on travel distances and survival outcomes for patients with advanced bladder cancer. Bladder cancer is a disease with high mortality for which treatment access is paramount and survival is superior in patients receiving surgery at high-volume centers. METHODS Using SEER-Medicare, we identified patients 66 years or older diagnosed with bladder cancer between 2004-2013. We categorized patients as treated with either surgical (i.e., radical cystectomy) or nonsurgical (i.e., radiation or chemotherapy) care. We fit a linear probability model to generate the predicted proportion of patients treated at the top quintile of volume over time and assessed travel distance, 1-year all-cause mortality, and 1-year bladder cancer-specific mortality over time. RESULTS A total of 6,756 and 10,383 patients underwent surgical and nonsurgical care, respectively. The percentage of patients treated at high-volume centers increased over the study period for both surgical care (53% to 62%) and nonsurgical care (47% to 55%), (both P< 0.001). Median travel distance increased (11.8 to 20.3 miles) for surgical care and (6.5 to 8.3 miles) for nonsurgical care, (both P < 0.001). The 1-year adjusted all-cause mortality and 1-year adjusted bladder-cancer specific mortality decreased significantly for both surgical and nonsurgical care (both P < 0.05). CONCLUSIONS Over time, centralization of surgical and nonsurgical care for bladder cancer patients increased, which was associated with increasing patient travel distance and decreased all-cause and bladder-cancer specific mortality.
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Affiliation(s)
| | - Jonathan G Yabes
- Center for Research on Health Care; Division of General Internal Medicine, Department of Medicine
| | | | | | | | - Lindsay M Sabik
- Center for Research on Health Care; Department of Health Policy and Management, Graduate School of Public Health
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology; Center for Research on Health Care
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Affiliation(s)
- Eric T Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health in Pittsburgh, PA (ETR, AEJ, LMS) in Pittsburgh, PA
| | - A Everette James
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health in Pittsburgh, PA (ETR, AEJ, LMS) in Pittsburgh, PA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health in Pittsburgh, PA (ETR, AEJ, LMS) in Pittsburgh, PA
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Roberts ET, Glynn A, Cornelio N, Donohue JM, Gellad WF, McWilliams JM, Sabik LM. Medicaid Coverage 'Cliff' Increases Expenses And Decreases Care For Near-Poor Medicare Beneficiaries. Health Aff (Millwood) 2021; 40:552-561. [PMID: 33819086 DOI: 10.1377/hlthaff.2020.02272] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100 percent but less than 200 percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8 percentage points just above the eligibility threshold for Medicaid (100 percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55 percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.
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Affiliation(s)
- Eric T Roberts
- Eric T. Roberts is an assistant professor in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, in Pittsburgh, Pennsylvania
| | - Alexandra Glynn
- Alexandra Glynn is a doctoral student in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
| | - Noelle Cornelio
- Noelle Cornelio is a doctoral student in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
| | - Julie M Donohue
- Julie M. Donohue is a professor and chair in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
| | - Walid F Gellad
- Walid F. Gellad is a core investigator at the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, and a professor of medicine in the Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - J Michael McWilliams
- J. Michael McWilliams is the Warren Alpert Foundation Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School and a professor of medicine and general internist at Brigham and Women's Hospital, in Boston, Massachusetts
| | - Lindsay M Sabik
- Lindsay M. Sabik is an associate professor in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
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Baddour K, Mady LJ, Schwarzbach HL, Sabik LM, Thomas TH, McCoy JL, Tobey A. Exploring caregiver burden and financial toxicity in caregivers of tracheostomy-dependent children. Int J Pediatr Otorhinolaryngol 2021; 145:110713. [PMID: 33882339 DOI: 10.1016/j.ijporl.2021.110713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Measure the prevalence of and factors associated with financial toxicity (FT) and caregiver burden in families of tracheostomy-dependent children. FT is defined as the objective and subjective patient-level impact of the costs of medical care and has been associated with lower quality of life, decreased compliance with treatment, and increased mortality. METHODS A medical record review was performed on all children with a tracheostomy tube placed from 2009 to 2018 at a tertiary children's hospital to identify and include children younger than 18 years old, not deceased, and not decannulated at the time of review. Eligible children's caregivers were contacted to fill out a 36-item questionnaire and three validated instruments: The Comprehensive Score for Financial Toxicity (COST) and the Financial Distress Questionnaire (FDQ), both addressed to the parent/primary caregiver, and the Burden Scale for Family Caregivers - short version (BSFC-s). RESULTS Of the 140 eligible tracheostomy patients identified, 45 caregivers (32.1%) returned the survey. The average COST score was 18 ± 1.7 with 73.3% of caregivers reporting high toxicity based on FDQ, and 75.6% having severe-to-very severe caregiver burden. Significant increase in FT was seen in households where an adult had to leave a paid position (p = 0.047) or work less (p = 0.002) because of their child's condition; or needed to omit some of the child's medical services or medications due to cost-prohibitive reasons (p<0.001). Financial toxicity was associated with caregiver burden (by BSFC-s) [r = -596; beta coefficient = -0.95, t(43) = -4.87, p<0.001] and financial distress (by FDQ; p<0.001). CONCLUSION Caregivers of children with medically complex, tracheostomy-dependent conditions suffer from FT and caregiver burden. As a result, harmful financial coping mechanisms such as missing necessary care components or forgoing prescribed treatments, may be adopted for cost-prohibitive reasons.
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Affiliation(s)
- Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Hannah L Schwarzbach
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Teresa H Thomas
- Department of Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jennifer L McCoy
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Allison Tobey
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Bono RS, Dahman B, Sabik LM, Yerkes LE, Deng Y, Belgrave FZ, Nixon DE, Rhodes AG, Kimmel AD. Human Immunodeficiency Virus-Experienced Clinician Workforce Capacity: Urban-Rural Disparities in the Southern United States. Clin Infect Dis 2021; 72:1615-1622. [PMID: 32211757 DOI: 10.1093/cid/ciaa300] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban-rural differences, in the Southern United States. METHODS We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009-2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region's HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban-rural differences. RESULTS We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P < .001) and practice in urban areas (96% vs 83%, P < .001) compared to non-HIV-experienced clinicians. The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range, 38.0), with no significant urban-rural differences. When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1000 diagnosed HIV cases (P < .001). CONCLUSIONS Significant urban-rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.
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Affiliation(s)
- Rose S Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lauren E Yerkes
- Division of Population Health Data, Virginia Department of Health, Richmond, Virginia, USA.,Division of Disease Prevention, Virginia Department of Health, Richmond, Virginia, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Faye Z Belgrave
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Daniel E Nixon
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Anne G Rhodes
- Division of Disease Prevention, Virginia Department of Health, Richmond, Virginia, USA
| | - April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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Hoehn RS, Rieser CJ, Phelos H, Sabik LM, Nassour I, Khan S, Kaltenmeier C, Paniccia A, Zureikat AH, Tohme ST. Medicaid expansion and the management of pancreatic cancer. J Surg Oncol 2021; 124:324-333. [PMID: 33939838 DOI: 10.1002/jso.26515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/02/2021] [Accepted: 04/16/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Medicaid expansion under the Affordable Care Act has improved access to screening and treatment for certain cancers. It is unclear how this policy has affected the diagnosis and management of pancreatic cancer. METHODS Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during two time periods: pre-expansion (2011-2012) and postexpansion (2015-2016). We investigated changes in cancer staging, treatment decisions, and surgical outcomes. RESULTS In this national cohort, pancreatic cancer patients in expansion states had increased Medicaid coverage relative to those in nonexpansion states (DID = 17.49, p < 0.01). Medicaid expansion also led to an increase in early-stage diagnoses (Stage I/II, DID = 4.71, p = 0.03), higher comorbidity scores among surgical patients (Charlson/Deyo score 0: DID = -13.69, p = 0.02), a trend toward more neoadjuvant radiation (DID = 6.15, p = 0.06), and more positive margins (DID = 11.69, p = 0.02). There were no differences in rates of surgery, postoperative outcomes, or overall survival. CONCLUSION Medicaid expansion was associated with improved insurance coverage and earlier stage diagnoses for Medicaid and uninsured pancreatic cancer patients, but similar surgical outcomes and overall survival. These findings highlight both the benefits of Medicaid expansion and the potential limitations of policy change to improve outcomes for such an aggressive malignancy.
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Affiliation(s)
- Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Caroline J Rieser
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Heather Phelos
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Nassour
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sidrah Khan
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christof Kaltenmeier
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alessandro Paniccia
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samer T Tohme
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Eom KY, van Londen GJ, Li J, Dahman B, Bradley C, Sabik LM. Changes in initiation of adjuvant endocrine therapy for breast cancer after state health reform. BMC Cancer 2021; 21:487. [PMID: 33933027 PMCID: PMC8088064 DOI: 10.1186/s12885-021-08149-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Socioeconomic differences in receipt of adjuvant treatment contribute to persistent disparities in breast cancer (BCA) outcomes, including survival. Adjuvant endocrine therapy (AET) substantially reduces recurrence risk and is recommended by clinical guidelines for nearly all women with hormone receptor-positive non-metastatic BCA. However, AET use among uninsured or underinsured populations has been understudied. The health reform implemented by the US state of Massachusetts in 2006 expanded health insurance coverage and increased the scope of benefits for many with coverage. This study examines changes in the initiation of AET among BCA patients in Massachusetts after the health reform. METHODS We used Massachusetts Cancer Registry data from 2004 to 2013 for a sample of estrogen receptor (ER)-positive BCA surgical patients aged 20-64 years. We estimated multivariable regression models to assess differential changes in the likelihood initiating AET after Massachusetts health reform by area-level income, comparing women from lower- and higher-income ZIP codes in Massachusetts. RESULTS There was a 5-percentage point (p-value< 0.001) relative increase in the likelihood of initiating AET among BCA patients aged 20-64 years in low-income areas, compared to higher-income areas, after the reform. The increase was more pronounced among younger patients aged 20-49 years (7.1-percentage point increase). CONCLUSIONS The expansion of health insurance in Massachusetts was associated with a significant relative increase in the likelihood of AET initiation among women in low-income areas compared with those in high-income areas. Our results suggest that expansions of health insurance coverage and improved access to care can increase the number of eligible patients initiating AET and may ameliorate socioeconomic disparities in BCA outcomes.
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Affiliation(s)
- Kirsten Y Eom
- Department of Health Policy and Management, University of Pittsburgh, 130 De Soto St, A663, Pittsburgh, PA, 15261, USA.
| | - G J van Londen
- Divisions of Hematology-Oncology and Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Jie Li
- Department of Health Policy and Management, University of Pittsburgh, 130 De Soto St, A663, Pittsburgh, PA, 15261, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, USA
| | - Cathy Bradley
- University of Colorado Comprehensive Cancer Center, Aurora, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, 130 De Soto St, A663, Pittsburgh, PA, 15261, USA
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Schenker Y, Hamm M, Bulls HW, Merlin JS, Wasilko R, Dawdani A, Kenkre B, Belin S, Sabik LM. This Is a Different Patient Population: Opioid Prescribing Challenges for Patients With Cancer-Related Pain. JCO Oncol Pract 2021; 17:e1030-e1037. [PMID: 33848194 DOI: 10.1200/op.20.01041] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Responses to the opioid epidemic in the United States, including efforts to monitor and limit prescriptions for noncancer pain, may be affecting patients with cancer. Oncologists' views on how the opioid epidemic may be influencing treatment of cancer-related pain are not well understood. METHODS We conducted a multisite qualitative interview study with 26 oncologists from a mix of urban and rural practices in Western Pennsylvania. The interview guide asked about oncologists' views of and experiences in treating cancer-related pain in the context of the opioid epidemic. A multidisciplinary team conducted thematic analysis of interview transcripts to identify and refine themes related to challenges to safe and effective opioid prescribing for cancer-related pain and recommendations for improvement. RESULTS Oncologists described three main challenges: (1) patients who receive opioids for cancer-related pain feel stigmatized by clinicians, pharmacists, and society; (2) patients with cancer-related pain fear becoming addicted, which affects their willingness to accept prescription opioids; and (3) guidelines for safe and effective opioid prescribing are often misinterpreted, leading to access issues. Suggested improvements included educational materials for patients and families, efforts to better inform prescribers and the public about safe and appropriate uses of opioids for cancer-related pain, and additional support from pain and/or palliative care specialists. CONCLUSION Challenges to safe and effective opioid prescribing for cancer-related pain include opioid stigma and access barriers. Interventions that address opioid stigma and provide additional resources for clinicians navigating complex opioid prescribing guidelines may help to optimize cancer pain treatment.
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Affiliation(s)
- Yael Schenker
- Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Megan Hamm
- Qualitative, Evaluation and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Hailey W Bulls
- Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jessica S Merlin
- Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rachel Wasilko
- Qualitative, Evaluation and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Alicia Dawdani
- Qualitative, Evaluation and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Balchandre Kenkre
- Qualitative, Evaluation and Stakeholder Engagement Services (QualEASE), Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA
| | - Shane Belin
- Palliative Research Center (PaRC) and Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lindsay M Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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50
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Hrebinko KA, Rieser C, Nassour I, Tohme S, Sabik LM, Khan S, Medich DS, Zureikat AH, Hoehn RS. Patient Factors Limit Colon Cancer Survival at Safety-Net Hospitals: A National Analysis. J Surg Res 2021; 264:279-286. [PMID: 33839343 DOI: 10.1016/j.jss.2021.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/05/2021] [Accepted: 03/04/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Safety-net hospitals serve a vital role in society by providing care for vulnerable populations. Existing data regarding oncologic outcomes of patients with colon cancer treated at safety-net hospitals are limited and variable. The objective of this study was to delineate disparities in treatment and outcomes for patients with colon cancer treated at safety-net hospitals. METHODS This retrospective cohort study identified 802,304 adult patients with colon adenocarcinoma from the National Cancer Database between 2004-2016. Patients were stratified according to safety-net burden of the treating hospital as previously described. Patient, tumor, facility, and treatment characteristics were compared between groups as were operative and short-term outcomes. Cox proportional hazards regression was utilized to compare overall survival between patients treated at high, medium, and low burden hospitals. RESULTS Patients treated at safety-net hospitals were demographically distinct and presented with more advanced disease. They were also less likely to receive surgery, adjuvant chemotherapy, negative resection margins, adequate lymphadenectomy, or a minimally invasive operative approach. On multivariate analysis adjusting for patient and tumor characteristics, survival was inferior for patients at safety-net hospitals, even for those with stage 0 (in situ) disease. CONCLUSION This analysis revealed inferior survival for patients with colon cancer treated at safety-net hospitals, including those without invasive cancer. These findings suggest that unmeasured population differences may confound analyses and affect survival more than provider or treatment disparities.
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Affiliation(s)
- Katherine A Hrebinko
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Caroline Rieser
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ibrahim Nassour
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Samer Tohme
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Sidrah Khan
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David S Medich
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amer H Zureikat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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