Associations Between Medicaid Expansion and Mental Health Among U.S. Racial and Ethnic Groups

OBJECTIVE

The authors examined associations between Medicaid expansion and self-reported mental health by race-ethnicity, focusing on lagged associations.

METHODS

This retrospective, cross-sectional study used 2011-2019 data from the Behavioral Risk Factor Surveillance System. The sample included low-income, childless adults ages 25-64 years. Difference-in-differences (DID) analysis was used to estimate associations between Medicaid expansion and self-reported mental health. Lagged associations were examined by separating the postexpansion period into proximal (2014-2016) and distal (2017-2019) periods.

RESULTS

In the overall sample (N=327,248), Medicaid expansion was associated with a reduction in the mean number of self-reported past-month poor mental health days (DID=-0.12, 95% CI=-0.21 to -0.03), after adjustment for covariates. The expansion was associated with significant reductions in past-month poor mental health days for the following groups: non-Hispanic White (DID=-0.18, 95% CI=-0.29 to -0.07), non-Hispanic Asian (DID=-1.15, 95% CI=-1.37 to -0.93), non-Hispanic other (DID=-0.62, 95% CI=-1.03 to -0.21), and Hispanic (DID=-0.48, 95% CI=-0.73 to -0.23). The non-Hispanic Black group had a significant increase in past-month poor mental health days (DID=0.27, 95% CI=0.06 to 0.49), and no significant change was noted for the American Indian or Alaska Native (AIAN) group. Improvements in mental health observed at the beginning of the policy implementation (proximal period) were not sustained over time for some racial-ethnic minority groups.

CONCLUSIONS

Although Medicaid expansion improved mental health for the overall sample, some racial-ethnic disparities were detected. The negative and insignificant associations for the non-Hispanic Black and AIAN groups, respectively, highlight the need to better understand why the Medicaid expansion affected racial-ethnic groups differently.

HIV testing and risk behaviors associated with depression in the United States

Given the high correlation between depression and HIV infection rates, our objective was to assess national rates for HIV testing and HIV risk behaviors among U.S. adults stratified by self-reports of depression. We conducted a cross-sectional study using data from the 2018-2020 Behavioral Risk Factor Surveillance System (BRFSS). We included respondents aged 18 years old and above with self-reported depression status (Sample size = 1,228,405). The primary outcomes included HIV testing and HIV-related risk behaviors. For respondents with prior HIV testing experience, we estimated the duration since the last HIV test. We applied a multivariable logistic regression model to analyze the correlation between depression and HIV testing or risk behaviors. The results showed people with depression had 51% higher odds of receiving HIV testing [adjusted odds ratio (AOR) = 1.51, 95% CI = 1.48, 1.55] and 51% higher odds of involvement in HIV risk behaviors [AOR = 1.51, 95% CI = 1.44, 1.58] after adjusting for covariates. Various socio-demographics and healthcare access variables were significantly associated with HIV testing and HIV risk behaviors. When comparing the average time from the last HIV test, people with depression had a shorter period compared to those without depression [Median time in months: 27.1 ± 0.45 vs. 29.3 ± 0.34]. Even though people with depression had higher rates of HIV testing, they still experienced long time periods (median = 2 + years) between HIV testing, which exceeded the recommended annual HIV testing for people at high risk from the Centers for Disease Control and Prevention.

Reproducibility of the medical cost estimation from the Medicare Current Beneficiary Survey: Comparing claims and survey

Background

The Medicare Current Beneficiary Survey (MCBS) limited-access data provides the unique opportunity to utilize administrative claims and adjusted survey data to investigate trends in utilization and medical expenditure across time. The adjusted survey data is a synthesized, matched version of the original survey data and claims. Researchers may choose adjusted survey data or original claims for cost evaluations according to their research purpose. However, limited research has examined methodological issues when estimating medical cost using different MCBS data sources.

Objective

The study objective was to examine the reproducibility of individual-level medical cost using both MCBS data sources: adjusted survey and claims data.

Methods

This serial cross-sectional study design analyzed 2006-2012 MCBS data. The sample included noninstitutionalized older Medicare beneficiaries (≥65 years old), with a cancer diagnosis and annually enrolled in Medicare Parts A, B, and D. The population was stratified by diabetes diagnosis. The primary outcome was annual medical cost. We investigated the discrepancies of medical cost estimated from the adjusted survey and original claims data. The agreement between cost estimates from the two sources in each year was determined using the Wilcoxon signed-rank test.

Results

A total of 4918 eligible Medicare beneficiaries were included in this study, and 26% of beneficiaries also had diabetes (N = 1275). Significant disagreements in cost estimates between adjusted survey and claims data were present regardless of disease complexity (with or without diabetes). Significant disagreements in medical cost estimates were present in most years, except in 2010 (p = 0.467) and 2011 (p = 0.098), for beneficiaries with cancer and diabetes (p < 0.001 for all). Significant disagreements in medical cost estimates were present in all years for beneficiaries with cancer without diabetes (p < 0.001 for all).

Conclusions

Based on discrepant cost estimates across data sources, researchers using MCBS to estimate costs should be cautious when using claims or adjusted survey data alone.

Diabetes management behaviors associated with depression in the U.S

BACKGROUND

There is a lack of nationally representative evidence from the U.S. investigating the relationships between depression and diabetes management behaviors. Our study aimed to assess the associations between diabetes management behaviors and depression status, and to compare U.S. population-level percentages of diabetes management behaviors among patients with and without depression.

METHODS

A cross-sectional study was conducted using population-based survey data to assess patient-reported variables retrospectively. We used the Behavioral Risk Factor Surveillance System (BRFSS) data and included states in the U.S. that continuously adopted the diabetes optional modules in 2013, 2015, 2017, and 2019. We included U.S. adults (≥ 18 years old) with self-reported diabetes in our analysis. Main outcomes were diabetes management behaviors (i.e., self-check for blood glucose and feet sores/irritation, regular diabetes clinical visit, HbA1c check, professional feet check, and dilated eye examination) and lifestyle behaviors (i.e., exercise, smoking, and alcohol consumption).

RESULTS

Among the 74,011 respondents with diabetes, patients with depression had a higher likelihood of performing routine HbA1c checks (adjusted odds ratio (AOR) = 1.12; 95% CI 1.01-1.23) but had a lower likelihood to perform regular self-check for blood glucose (AOR = 0.91; 95% CI 0.84-0.99), receive professional feet checks (AOR = 0.87; 95% CI 0.79-0.95), and receive a dilated eye examination (AOR = 0.89; 95% CI 0.82-0.98). For lifestyle behaviors, patients with depression were more likely to smoke (No smoking (AOR) = 0.65; 95% CI = 0.59-0.72) and less likely to engage in sufficient exercise time (AOR = 0.69; 95% CI 0.63-0.75). There were no significant associations between depression and other behaviors, including self-check for feet sores/irritation (AOR = 0.99; 95% CI 0.92-1.08), regular diabetes clinical visit (AOR = 1.03, 95% CI 0.94-1.13), and alcohol consumption (AOR = 1.01, 95% CI 0.92-1.10).

CONCLUSIONS

The association between depression status and diabetes management behaviors varied. People with depression were positively associated with HbA1c checks. However, less uptake of other behaviors may indicate the needs for improvement in diabetes management.

Can the LACE index help identify uninsured patients at risk of loss to follow-up during a pharmacist-led transitions of care program?

BACKGROUND

Uninsured patients are susceptible to being lost to follow-up (LTFU). In addition to being uninsured, follow-up is especially critical among this population during transitions of care when patients are discharged from the hospital setting back to home because follow-up care after discharge has been proven to prevent readmissions. The LACE tool has historically been used to predict readmissions, but the LACE tool has not been used to evaluate patients' risk of LTFU.

OBJECTIVE

To understand the potential translation of the LACE tool for use in uninsured patients' follow-up care, we assessed the association between LACE index scores and patients' risk of LTFU during a pharmacist-led transitions of care program for uninsured patients.

METHODS

Data were extracted from a randomized controlled trial implementing a pharmacist-led transitions of care program at an indigent care clinic. The study population included uninsured adult patients (>18 years old) who spoke English and attended a clinical visit with a pharmacist within 16 days after discharge from a community hospital. Analyses sought to determine factors associated with the patients' LTFU status.

RESULTS

Among 88 enrolled participants, 29 participants (32.95%) were LTFU. Thirty-two patients (36.4%) had a high LACE index score at baseline, indicating an increased risk of 30-day readmission. Of the remaining 56 patients (63.6%) with low-to-moderate LACE index scores, 54 (61.4%) had a moderate LACE index score, and only 2 (2.3%) had a low LACE index score. Uninsured patients with high LACE index scores had 70% lower odds of being LTFU than uninsured patients with low-to-moderate LACE index scores (exact odds ratio 0.297 [95% CI 0.081-0.947]).

CONCLUSION

The LACE index score was inversely related to the risk of LTFU during a pharmacist-led transitions of care program. Pharmacists may use the LACE tool to identify patients at high risk of LTFU.

Gelatin methacrylate/carboxybetaine methacrylate hydrogels with tunable crosslinking for controlled drug release

In this work, methacrylated gelatin (GelMA) based hydrogels were fabricated with carboxybetaine methacrylate (CBMA) to manipulate the properties of the gelatin-based hydrogels, since CBMA is a much smaller compound compared to gelatin. With the incorporation of CBMA, these hydrogels demonstrated better mechanical properties, a slower degradation rate, and a controlled drug release rate compared with the GelMA alone group. GelMA/CBMA hydrogels also showed good cell viability. As in the in vivo test, vascular endothelial growth factor (VEGF)-loaded GelMA/CBMA hydrogels displayed certain degrees of angiogenesis. These results indicate that GelMA/CBMA hydrogels are biocompatible, and the properties of GelMA/CBMA hydrogels can be easily tuned with the ratio of CBMA. These characteristics make the GelMA/CBMA hydrogel a promising material for drug delivery and tissue engineering.

Faecal occult blood screening: knowledge, attitudes, and practice in four Hong Kong primary care clinics

OBJECTIVES. To assess primary care patients for their awareness, knowledge, and attitude towards colorectal cancer and screening, to report on the uptake of faecal occult blood test screening and the results of screening, and explore predictors of screening uptake. DESIGN. Cross-sectional study. SETTING. Four primary care clinics in Hong Kong. PATIENTS. A total of 1664 patients aged 50 to 74 years attending the clinics in the period July 2006 to July 2007. MAIN OUTCOME MEASURES. Percentage of subjects who were aware that colorectal cancer is common and curable at an early stage, and who knew that faecal occult blood test or colonoscopy is useful for screening; relevant knowledge score; uptake rate of faecal occult blood testing; rate of testing positive; and factors predicting uptake. RESULTS. A total of 1645 questionnaires were collected. In all, 89% (95% confidence interval, 88-91%) were aware that colorectal cancer is common, 95% (94-96%) believed faecal occult blood test and colonoscopy are useful for screening, and 58% (56-61%) achieved a knowledge score of 50% or above. The uptake rate of the faecal occult blood test was 35%. Uptake was higher among those with a positive family history (odds ratio=1.57; 95% confidence interval, 1.08-2.27; P=0.02), those who were more aware that colorectal cancer is common (1.86; 1.29-2.69; P=0.001), and that colorectal cancer is potentially curable at an early stage (1.76; 1.32-2.36; P=0.0001). Rate of testing positive was 2.1% (95% confidence interval, 0.9-3.3%); no colorectal cancer was detected and the neoplasia detection rate (for cancers and adenomas) was 5.1 per 1000 subjects screened. CONCLUSIONS. Patients were aware that colorectal cancer is common in our community, and faecal occult blood test or colonoscopy is useful for screening. The uptake of screening was low, though relatively higher for those with a positive family history and greater awareness of the high frequency and potential for cure of colorectal cancer. Faecal occult blood test positivity rate was 2.1%, and neoplasia detection rate 5.1 per 1000 screened.

Biocompatibility of Fe(3)O(4) nanoparticles evaluated by in vitro cytotoxicity assays using normal, glia and breast cancer cells

In order to reveal the biocompatibility of Fe(3)O(4) nanoparticles and bipolar surfactant tetramethylammonium 11-aminoundecanoate cytotoxicity tests were performed as a function of concentration from low (0.1 microg ml(-1)) to higher concentration (100 microg ml(-1)) using various human glia, human breast cancer and normal cell lines. Cytotoxicity tests for human glia (D54MG, G9T, SF126, U87, U251, U373), human breast cancer (MB157, SKBR3, T47D) and normal (H184B5F5/M10, WI-38, SVGp12) cell lines exhibited almost nontoxicity and reveal biocompatibility of Fe(3)O(4) nanoparticles in the concentration range of 0.1-10 microg ml(-1), while accountable cytotoxicity can be seen at 100 microg ml(-1). The results of our studies suggest that Fe(3)O(4) nanoparticles coated with bipolar surfactant tetramethylammonium 11-aminoundecanoate are biocompatible and promising for bio-applications such as drug delivery, magnetic resonance imaging and magnetic hyperthermia.

Epidemiological study of diabetic retinopathy in a primary care setting in Hong Kong

OBJECTIVES

To estimate the prevalence and risk factors of diabetic retinopathy in type 2 diabetic patients, and to investigate the difference in retinopathy progression in patients with normal fundi or established retinopathy at baseline and the risk factors implicated in the progression.

DESIGN

Retrospective community-based study.

SETTING

Ten primary care clinics in Hong Kong.

PATIENTS

Type 2 diabetic patients; subsidiary analysis included subjects with more than one screening event.

MAIN OUTCOME MEASURES

Patient demographics, baseline prevalence, and risk factors of diabetic retinopathy; progression of retinopathy in patients with normal fundi and established retinopathy at baseline, and the associated risk factors.

RESULTS

A total of 6165 patients were recruited from January 1998 to May 2004. Primary analysis included 4423 patients with good-quality retinal photographs. The mean age of the patients was 60.36 years (standard deviation, 10.80 years; range, 28-94 years), the mean duration of diabetes was 4.71 years (standard deviation, 4.67 years; range, 0.1-40.6 years), and the mean level of glycated haemoglobin was 7.47% (standard deviation, 1.44%). The prevalence of retinopathy at baseline was 28.4%. Subsidiary analysis showed progression to sight-threatening retinopathy was more common in the group with baseline retinopathy than that without (7.9% vs 0.7%), and occurred at a faster rate (mean, 1.5 [range, 0.5-3.0] vs 2.0 [1.0-4.2] years). Logistic regression revealed that the level of glycated haemoglobin was positively associated with both the onset (P<0.001) and progression of retinopathy (P=0.03).

CONCLUSION

Optimal glycaemic control is important for reducing sight-threatening retinopathy. Close observation is required for patients with established retinopathy as progression occurs more rapidly.

The prevalence of microalbuminuria among patients with type II diabetes mellitus in a primary care setting: cross-sectional study

OBJECTIVES

To determine the prevalence of microalbuminuria among patients with type II diabetes mellitus in a primary care setting, and to study the association between various risk factors and the presence of microalbuminuria.

DESIGN

Cross-sectional community-based study.

SETTING

Four primary care clinics, Hong Kong.

PATIENTS

All patients with type II diabetes mellitus who regularly attended the clinics between May 2002 and March 2003.

MAIN OUTCOME MEASURES

Patients' demographic data, the proportion with microalbuminuria (measured using a spot urine test), and the association between this condition and risk factors for diabetic nephropathy (via correlation and multivariable logistic regression analysis).

RESULTS

The mean age of the 1161 patients in the sample population was 58.0 years. The mean duration of diabetes mellitus was 5.7 years, and the mean level of glycated haemoglobin was 7.4%. A total of 13.4% of the patients had microalbuminuria. Having the condition was significantly associated with advanced age, female sex, poor glycaemic control, and coexisting hypertension in both correlation and regression analyses. No significant association with ever smoking was found.

CONCLUSION

Early screening for incipient diabetic nephropathy and aggressive management of modifiable risk factors in a primary care setting may be important in optimising the renal outcome of patients with type II diabetes mellitus.

Rectal cancer mortality and total hardness levels in Taiwan's drinking water

The possible association between the risk of rectal cancer and hardness levels in drinking water from municipal supplies was investigated in a matched case-control study in Taiwan. All eligible rectal cancer deaths (986 cases) of Taiwan residents from 1990 through 1994 were compared with deaths from other causes (986 controls), and the hardness levels of the drinking water used by these residents were determined. Data on water hardness throughout Taiwan were collected from Taiwan Water Supply Corporation (TWSC). The control group consisted of people who died from other causes and the controls were pair matched to the cases by sex, year of birth, and year of death. The results show a significant negative relationship between drinking water hardness and rectal cancer mortality. Odds ratio and 95% confidence intervals were 1.24 (1.01-1. 55) and 1.38 (1.10-1.73), respectively, for exposure to moderately hard water and soft water compared with the use of hard water. Trend analyses showed an increasing odds ratio for rectal cancer with decreasing levels of hardness in drinking water. This is an important finding for the Taiwan water industry and human health.

Effects of indoor environmental factors on risk for acute otitis media in a subtropical area

The objective of this study was to examine the relationship between indoor environmental factors and acute otitis media in a subtropical area. A case-control study was performed using participants from a prevalence survey that included 219 school children with acute otitis media and 219 age- and gender-matched controls. The study was confined to 4164 primary school children aged 6-12 yr attending 8 primary schools in Kaohsiung rural municipalities who participated in a prevalence study of the health effects of an indoor environment. An acute otitis media case was defined as a child with acute symptoms (presenting with earache, fever, irritability, and/or discharge from the ear) diagnosed by a physician in the previous year. Controls selected from the same school did not have chronic or acute respiratory illness or an ear-related illness during the same period. Information regarding the home environment was obtained using a structured written questionnaire, completed by the parents of the children. Of the many indoor environmental factors included in this study, only living in a home with indications of dampness (mold, flooding, home dampness) showed an association with acute otitis media. It was concluded that dampness in the home is a new public health issue in subtropical areas.

Different regulation of the human thymidine kinase promoter in normal human diploid IMR-90 fibroblasts and HeLa cells

Transcriptional activation of the human thymidine kinase (hTK) promoter plays an important role in the cell cycle control of thymidine kinase expression. Using the luciferase reporter cotransfection assay, we found that the activity of the hTK promoter in IMR-90 normal human diploid fibroblasts was increased by the constitutively over-expressed cyclin A or cyclin E but not by cyclin D, suggesting that the former two cyclins may act as positive regulators for the hTK promoter. The sequence responsible for the transcriptional activation by cyclin E was identified to be located between -133 and -92 of the hTK promoter. Regulation of the hTK promoter in HeLa cells appeared to be different from that in IMR-90 fibroblasts. Firstly, the hTK promoter in HeLa was already highly activated and could not be further activated by ectopically expressed cyclin A or E. Secondly, the -133 to -92 region of the hTK promoter was important for the promoter strength in HeLa cells but not in IMR-90 cells. The steady-state levels of cyclins A and E were readily detected in HeLa cells but not in normal IMR-90 fibroblasts. Based on these results, we propose that the cellular environment of the HeLa cell allows the hTK promoter to stay fully activated for transcription regardless of ectopically expressed cyclin A or E and that transcriptional activation of thymidine kinase gene is deregulated in these tumor cells.