Coverage Status Research Articles

Progress in reducing child mortality and stunting in India: an application of the Lives Saved Tool.

The Lives Saved Tool (LiST) has been used to estimate the impact of scaling up intervention coverage on undernutrition and mortality. Evidence for the model is largely based on efficacy trials, raising concerns of applicability to large-scale contexts. We modelled the impact of scaling up health programs in India between 2006 and 2016 and compared estimates to observed changes. Demographics, intervention coverage and nutritional status were obtained from National Family and Health Survey 2005–6 (NFHS-3) for the base year and NHFS-4 2015–16 for the endline. We used the LiST to estimate the impact of changes in coverage of interventions over this decade on child mortality and undernutrition at national and subnational levels and calculated the gap between estimated and observed changes in 2016. At the national level, the LiST estimates are close to the actual values of mortality for children <1 year and <5 years in 2016 (at 41 vs 42.6 and 50 vs 56.4, respectively, per 1000 live births). National estimates for stunting, wasting and anaemia at are also close to the actual values of NFHS-4. At the state level, actual changes were higher than the changes from the LiST projections for both mortality and stunting. The predicted changes using the LiST ranged from 33% to 92% of the actual change. The LiST provided national projections close to, albeit slightly below, actual performance over a decade. Reasons for poorer performance of state-specific projections are unknown; further refinements to the LiST for subnational use would improve the usefulness of the tool.

Gestational age, kindergarten-level literacy, and effect modification by maternal socio-economic and demographic factors.

Shorter gestational age at birth is associated with worse academic performance in childhood. Socio-economic and demographic factors that affect a child's development may modify the relationship between gestational age and later academic performance. The purpose of this study was to investigate socio-economic and demographic effect modification of gestational age's association with kindergarten-level literacy skills in a longitudinal Wisconsin birth cohort. We sampled 153145 singleton births (2007-2010) that linked to Phonological Awareness Literacy Screening-Kindergarten (PALS-K) scores (2012-2016 school years). PALS-K outcomes included meeting the screening benchmark (≥28 points, range 0-102 points) and the standardised score. Multivariable linear regressions of PALS-K outcomes on gestational age (completed weeks) included individual interactions for five maternal attributes measured at delivery: Medicaid coverage, education, age, race/ethnicity, and marital status. Each additional completed gestational week was associated with a 0.5 percentage point increase in the probability of meeting the PALS-K literacy benchmark. The benefit of an additional week of gestational age was 0.5 percentage points (95% confidence interval 0.3, 0.7 percentage points) greater for Medicaid-covered births (0.8 percentage points) relative to non-Medicaid births (0.3 percentage points). Relative to only completing high school, having college education weakened this association by 0.3-0.6 percentage points, depending on years in college. Similar but modest relations emerged with standardised scores. Socio-economic advantage as indicated by non-Medicaid coverage or higher levels of completed maternal education may diminish the cost of preterm birth on a child's kindergarten-level literacy skills.

An Analysis of Acculturation Status and Healthcare Coverage for the Needs of Mental Health Service Utilization among Latinos in Mississippi, Louisiana, and Alabama

Background: The use of mental health services by Latinos is only 7.3%, despite the high prevalence of depression rates of between 27.0% and 38.0% in the United States. Research is limited concerning Latinos’ acculturation status and healthcare coverage on mental healthcare service utilization in Mississippi, Louisiana, and Alabama. Therefore, the objective of this study is to examine the association of acculturation status and healthcare coverage with mental health service utilization in the Latino population. Methods: During 2011–2012, a Latino Community Health Needs Assessment was administered by a trained bilingual interviewer using participants’ preferred language. Four hundred and eleven community members and leaders participated in the study. Acculturation status and self-reported mental health service utilization were retrieved from the survey instrument. Multivariate logistic regression analyses were performed. Results: In multivariate logistic regression that included gender, education level, healthcare coverage, depression, and acculturation status, individuals with a high acculturation score (3–5) were 1.53 times more likely to utilize mental health services compared to those with a low acculturation score (0–2). Individuals with healthcare coverage were 2.75 times more likely to utilize mental health services compared to those with not having healthcare coverage. Healthcare coverage is only a significant determinant of mental health service utilization. Conclusions: This result underscores the importance of having healthcare coverage for the need of mental health service utilization. Future research should consider the impact of acculturation and healthcare coverage on mental health service utilization.

Vaccine Preventable Diseases and Vaccination Coverage in Aboriginal and Torres Strait Islander People, Australia, 2011–2015

This report complements the Vaccine Preventable Diseases and Vaccination Coverage reports produced biannually since 2000 by the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases in association with the Australian Institute of Health and Welfare. It integrates the available sources of routinely collected data relevant to the current status of vaccine preventable diseases and vaccine coverage in Aboriginal and Torres Strait Islander people in Australia. It aims to better inform Indigenous communities, Indigenous health care providers and planners of immunisation services of the current status and future needs for vaccine prevention in Indigenous people. The data presented here demonstrate that vaccination programs have had a significant impact on the health of Aboriginal and Torres Strait Islander people. Several areas are highlighted for further development of vaccination policy recommendations, in particular high rates of preventable hepatitis A and B, influenza and pneumococcal disease. Areas where more research is needed include means to more accurately monitor vaccination status, the applicability of meningococcal serogroup B vaccines when available, and effective ways of increasing vaccination coverage and timeliness of vaccination. Such issues need to be considered and implemented in full cooperation with Aboriginal and Torres Strait Islander people.

Opioid overdose knowledge among college students in a high overdose death state

ABSTRACTThe goal of this study was to investigate university students’ knowledge about the identification of opioid overdose and actions to take in an overdose emergency. A cross-sectional, anonymous, 36-item survey was developed and administered to West Virginia University (WVU) students. Overdose knowledge was assessed using the Opioid Overdose Knowledge Scale (OOKS). Demographic information, health insurance coverage status, previously receiving an opioid prescription, and knowledge about West Virginia Good Samaritan laws were also collected. Online survey responses were collected via REDCap. The study sample (n = 214) was 90% white, 72.5% female, had a mean age of 24.8 years, and over half previously received a prescription opioid (51.9%). Additionally, 6.5% reported witnessing an overdose in the past year, and 15.9% previously received naloxone training. Overall, our participants had an average score of 30.9 out of 45 on the OOKS. Participants who previously received naloxone training scored higher overall on the OOKS than participants who did not (p < .001). Similarly, participants who previously received a prescription for an opioid also scored higher than participants who had never had a previous prescription for an opioid (p < .001). University students’ knowledge suggests that previous exposure to opioid prescriptions and naloxone training increase a student’s knowledge about opioid overdose. This information is not surprising; however, this does make the case that students may benefit from brief overdose education programs that could be implemented across university health education curricula. However, a larger effort may need to be implemented to encourage students to participate in such programs.

Association Between Government Health Insurance Status and Physical Activity in American Youth.

Health insurance plans provide health programming access and affect physical activity levels in American youth, leading to health disparities in American children. The primary purpose of the current study was to investigate the relationship between health insurance status and physical activity level in American youth. A national, United States census weighted cross-sectional survey was performed analyzing 2002 noninstitutionalized children living in the United States between the ages of 10 to 18 years, equally split by age and sex, with state of residency and race/ethnicity proportional to the 2010 census distribution. Multiple linear regression was performed to investigate the relationship between insurance status and activity level (measured by HSS Pedi-FABS activity score) while controlling for relevant demographic and socioeconomic covariables. HSS Pedi-FABS activity scores were normally distributed with a mean of 15.4±8.5 points (of 30 possible points). Patients with an insurance status of "government/Medicaid," "other," or "none" each demonstrated significantly lower physical activity scores (14.2±8.5 vs. 13.6±9.0 vs. 10.1±8.5) than children with private insurance (16.5±8.2) (one-way ANOVA with Dunnett-adjusted pairwise comparisons, P<0.001), which remained statistically significant while controlling for Area Deprivation Index, age, gender, race/ethnicity, and Body Mass Index (β=-1.8, P<0.001). Government/Medicaid health insurance status and lack of health care coverage are associated with low levels of physical activity in American children, even while controlling for socioeconomic confounders. Collaborative work between health care providers and community/ school-based programs may be a reasonable approach to expanding access to recreation, organized sports, and physical activity for publicly and uninsured children. Level II-Prognostic Study.

Association of Medicaid Expansion With Health Insurance Coverage Among Persons With a Disability

Although nearly 1 in 5 persons in the United States has a physical or mental disability, little is known about the association of the Patient Protection and Affordable Care Act (ACA) with health insurance coverage among persons with a disability. To determine the association of Medicaid expansion with health insurance coverage among persons with a disability. Cross-sectional analysis of adults eligible for Medicaid expansion (aged 26-64 years with incomes up to 138% of the federal poverty level), using a triple-differences (difference-in-difference-in-difference) approach to compare the pre-ACA with post-ACA trend in health insurance rates by disability status between expansion and nonexpansion states using nationally representative, repeated cross-sectional sample data obtained from the American Community Survey in the United States from January 1, 2010, to December 31, 2016. Time was defined as either pre-ACA (January 1, 2010, to December 31, 2013) or post-ACA (January 1, 2014, to December 31, 2016). Treatment status was defined as whether a state implemented Medicaid expansion after January 1, 2014. States that expanded Medicaid between January 1, 2014, to December 31, 2016, were classified as the treatment group, and states that did not expand Medicaid during the study period were classified as the control group. Data were analyzed from December 12, 2018, to May 21, 2019. Self-reported health insurance coverage (uninsured, Medicaid, private) and self-reported disability status (≥1 condition limiting activity, including cognitive, ambulatory, self-care, independent living, and sensory difficulties). Of 2 549 376 Medicaid-eligible adults, 1 348 620 (52.9%) were female; 1 218 602 (47.8%) were non-Hispanic white, 497 128 (19.5%) were non-Hispanic black, 211 598 (8.3%) were Hispanic, and 206 499 (8.1%) were of other race/ethnicity; and 619 498 (24.3%) reported at least 1 disability. The percentage of persons without health insurance was greatest for persons without a disability who lived in a nonexpansion state before the ACA's Medicaid expansion provision went into effect (236 645 of 426 387 [55.5%]), and the smallest proportion of persons without health insurance was reported for persons with a disability living in an expansion state after the ACA went into effect (19 552 of 176 145 [11.1%]). Triple-differences analysis suggested that Medicaid expansion was associated with a decrease in the uninsured rate for both persons with a disability (7.1% - 16.2% = -9.1%) and without a disability (21.2% - 34.9% = -13.7%) and that Medicaid expansion was associated with a 4.6% decrease in the uninsurance rate for persons without a disability and a 2.6% decrease in persons with a disability (P < .001). Although Medicaid expansion was associated with an increase in Medicaid coverage for both persons with a disability (49.3% pre-ACA to 62.3% post-ACA; change, 13.0%) and persons without a disability (21.6% pre-ACA to 40.3% post-ACA; change, 17.7%), the triple difference-estimated Medicaid coverage was -4.7% for persons with a disability and 0.4% for persons without a disability, a difference of 5.1% (P < .001). Medicaid expansion was associated with a 3% higher private insurance rate for persons with a disability than for persons without a disability. Medicaid expansion appeared to be associated with lower uninsurance rates and higher Medicaid and private insurance coverage for persons with a disability. This study's findings suggest that the reduction in the uninsured rate and gains in Medicaid coverage were greater for persons without a disability than for persons with a disability.

Assessing the accuracy of survey reports of health insurance coverage using enrollment data.

To measure the accuracy of survey-reported data on features and type of health insurance coverage. Enrollment records from a private insurer were used as sample for primary survey data collection in spring of 2015 using the Current Population Survey health insurance module. A reverse record check study where households with individuals enrolled in a range of public and private health insurance plans (including the marketplace) were administered a telephone survey that included questions about general source of coverage (eg, employer), program name (eg, Medicaid), portal, premium, and subsidies. Survey data were matched back to enrollment records, which indicated coverage status at the time of the survey. Concordance between the records and survey data was assessed. Correct reporting of general source of coverage ranged from 77.8 percent to 98.3 percent across coverage type, premium ranged from 91.6 percent to 96.4 percent, and subsidy ranged from 83.0 percent to 91.0 percent. Using a conceptual algorithm to categorize coverage type resulted in sensitivity of 98.3 percent for employer-sponsored enrollees, and 70.6 percent-77.6 percent for the other coverage types, while specificity ranged from 93.9 percent to 99.4 percent across coverage types. Survey reports of features of coverage suggest they are viable items to include in an algorithm to categorize coverage type. Findings have implications beyond the CPS, particularly for marketplace enrollees.

2198-PUB: Real-World Risk Indicators of Impaired Awareness of Hypoglycemia in T2DM (InHypo-DM Study)

Further investigation into the real-world etiology of impaired awareness of hypoglycemia (IAH) in T2DM is needed. The present study aims to address this research gap by providing pragmatic, population-based insight into IAH and its risk indicators. A validated questionnaire (InHypo-DMPQ) was administered online to a nationally representative panel comprising Canadians (≥18 years) with T2DM taking insulin and/or secretagogues. Data were collected on respondents’ socio-demographic/clinical traits, self-reported hypoglycemia, and severity of IAH (no, moderate, and severe). Multivariable partial proportional odds (PPO) regression was used to identify the relevant risk indicators of moderate and severe IAH. Covariates were selected in consultation with the literature and clinical experts. A complete case analysis of 432 respondents (mean age: 53.0 (SD: 14.7) years; male: 56%) was undertaken. Of these individuals, 28% were classified with severe IAH, 66% with moderate IAH, and 6% with no IAH. Age, diabetes duration, A1C, total annual history of hypoglycemia (any type), therapeutic regimen, comorbidity status, gender, income, education, and drug coverage status were assessed for their influence on IAH severity. Based on the multivariable PPO model, a 5-year increase in diabetes duration decreased the adjusted odds of moderate or severe IAH, relative to no IAH, by 24% (95% CI: 12-35%, p&amp;lt;0.001). Moreover, the adjusted odds of severe IAH classification, versus no or moderate IAH, increased by a factor of 1.09 (95% CI: 1.02-1.15, p=0.008) for every 15 hypoglycemic events reported (in the past year). These results will help inform the improved management of IAH in real-world clinical settings. To reduce the risk of severe IAH in T2DM, clinical interventions should prioritize the reduction of hypoglycemic events. In particular, supporting patients with more recent T2DM diagnoses toward accurately recognizing their hypoglycemia symptoms may forestall the onset of IAH and related sequelae. Disclosure A. Ratzki-Leewing: None. S.B. Harris: Advisory Panel; Self; AstraZeneca, Janssen Pharmaceuticals, Inc., Lilly/Boehringer Ingelheim, Merck &amp; Co., Inc., Novo Nordisk A/S, Sanofi. Consultant; Self; AstraZeneca, Janssen Pharmaceuticals, Inc., Lilly/Boehringer Ingelheim, Merck &amp; Co., Inc., Novo Nordisk Inc., Sanofi. Research Support; Self; Abbott, AstraZeneca, Janssen Pharmaceuticals, Inc., Merck &amp; Co., Inc., Novo Nordisk A/S, Sanofi. Other Relationship; Self; Canadian Diabetes Association, Canadian Institutes of Health Research, The Lawson Foundation. N.H. Au: None. S. Webster-Bogaert: None. J.B. Brown: None. S.M. Reichert: Advisory Panel; Self; Abbott, AstraZeneca, Novo Nordisk Inc., Sanofi, Servier. Research Support; Self; Canadian Institutes of Health Research. Speaker's Bureau; Self; Abbott, AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck &amp; Co., Inc., Novo Nordisk Inc., Sanofi. B.L. Ryan: None. Funding Sanofi Canada

Left without being seen in a hybrid point of service collection model emergency department

ObjectiveThis study identifies reasons and predictors of LWBS and examines outcomes of patients in a model that uses “point-of-service” (POS) collection for low acuity patients. MethodsThis was a matched case-control study of all patients who left without being seen from the ED of a tertiary care center in Beirut Lebanon between June 2016 and May 2017. Matching was done for the ESI score, date and time (±2 h). A descriptive analysis and a bivariate analysis were conducted comparing patients who LWBS and those who completed their medical treatment. This was followed by a Logistic regression to identify predictors of LWBS. Results133 LWBS cases and 133 matched controls were enrolled in the study. Mean age for LWBS patients was (31.69 ± 15.29). The average reported wait time of LWBS patients was reported as 27.48 min (±25.09). Reasons for LWBS were; non-compensable status (66.9%), financial reasons (12.8%), long waiting times (12.8%), and others (8.3%). The majority of LWBS patients (81.2%) sought medical care after leaving the ED, and 8.3% of the LWBS patients represented to the ED after 48 h. Important predictors of LWBS included male gender, lower than undergraduate education level, waiting room time, non-compensable coverage status and fewer ED visits in the past year. ConclusionIn an ED setting with POS collection for low acuity patients, non-compensable coverage status was the strongest predictor for LWBS. Further studies are needed to assess the outcomes of patients who LWBS in this model of care.

Patterns of utilization and effects of hospital-specific factors on physical, occupational, and speech therapy for critically ill patients with acute respiratory failure in the USA: results of a 5-year sample

BackgroundTimely initiation of physical, occupational, and speech therapy in critically ill patients is crucial to reduce morbidity and improve outcomes. Over a 5-year time interval, we sought to determine the utilization of these rehabilitation therapies in the USA.MethodsWe performed a retrospective cohort study utilizing a large, national administrative database including ICU patients from 591 hospitals. Patients over 18 years of age with acute respiratory failure requiring invasive mechanical ventilation within the first 2 days of hospitalization and for a duration of at least 48 h were included.ResultsA total of 264,137 patients received invasive mechanical ventilation for a median of 4.0 [2.0–8.0] days. Overall, patients spent a median of 5.0 [3.0–10.0] days in the ICU and 10.0 [7.0–16.0] days in the hospital. During their hospitalization, 66.5%, 41.0%, and 33.2% (95% CI = 66.3–66.7%, 40.8–41.2%, 33.0–33.4%, respectively) received physical, occupational, and speech therapy. While on mechanical ventilation, 36.2%, 29.7%, and 29.9% (95% CI = 36.0–36.4%, 29.5–29.9%, 29.7–30.1%) received physical, occupational, and speech therapy. In patients receiving therapy, their first physical therapy session occurred on hospital day 5 [3.0–8.0] and hospital day 6 [4.0–10.0] for occupational and speech therapy. Of all patients, 28.6% (95% CI = 28.4–28.8%) did not receive physical, occupational, or speech therapy during their hospitalization. In a multivariate analysis, patients cared for in the Midwest and at teaching hospitals were more likely to receive physical, occupational, and speech therapy (all P < 0.05). Of patients with identical covariates receiving therapy, there was a median of 61%, 187%, and 70% greater odds of receiving physical, occupational, and speech therapy, respectively, at one randomly selected hospital compared with another (median odds ratio 1.61, 2.87, 1.70, respectively).ConclusionsPhysical, occupational, and speech therapy are not routinely delivered to critically ill patients, particularly while on mechanical ventilation in the USA. The utilization of these therapies varies according to insurance coverage, geography, and hospital teaching status, and at a hospital level.

PCN200 MEDICAID EXPANSION AND RACIAL INEQUITIES IN NEXT GENERATION SEQUENCING TESTING IN ONCOLOGY

Racial minorities in the United States have inferior cancer outcomes. For patients with cancer, next generation sequencing (NGS) informs treatment decisions; while NGS use is increasing, it is unclear whether uptake disparities exist. This study investigated changes in racial inequity in NGS testing of cancer patients following the 2014-onwards Medicaid coverage expansion ushered by the Patient Protection and Affordable Care Act (ACA) passage, comparing states with (36/50) and without expanded coverage status. Real-world patients with one of 10 cancer types and ≥2 documented visits from 1/1/2011 or 1/1/2013, depending on disease type, through 12/31/2017 in the Flatiron Health EHR-derived database were included in this exploratory retrospective study. Racial inequity was defined as the absolute percent difference in diagnosis-indexed NGS testing rates for black or African-American and white patients diagnosed in the time period. We compared the absolute percent difference in the pre-period (2011-2013) to the post-period (2014-2016) and to 2017 stratified by state Medicaid expansion status. Analyses were not adjusted for other covariates and potential confounders. We identified a cohort of 6,220 patients with abstraction-confirmed NGS testing (total N=49,915). Racial inequity in NGS testing use was observed in the pre-period (N=1,232) in Medicaid expansion and non-expansion states (-3.7% and -2.6% respectively). In the post-period (N=3,659), inequity dropped in expansion states (-1.6%) and grew in non-expansion states (-3.1%). Racial inequity in non-expansion states peaked in 2017 (16.9% vs 11.4%; Diff=-5.5%; N=637) while the racial inequity gap closed in expansion states in 2017 (17.6% vs 18.6%; Diff=1.0%; N=692). This hypothesis-generating study suggests Medicaid expansion may be associated with a reduction in racial inequity of NGS testing in cancer patients. Further research is needed to determine drivers and significance of NGS testing disparities.

Factors Affecting Delay in Filling Prescriptions for Dual Antiplatelet Therapy After Coronary Stenting

Dual antiplatelet therapy (DAPT) is critical in preventing stent thrombosis after percutaneous coronary intervention (PCI). Delays in DAPT after PCI have been associated with stent thrombosis, reinfarction, and death. Cases of death, stent thrombosis, and reinfarction at our institution have been attributed to patient delays in accessing DAPT on discharge after PCI. We sought to determine the proportion of patients that delay filling their discharge prescription for DAPT after PCI and factors that influence delays in DAPT prescription-filling. We reviewed all patients who received PCI at St Paul’s Hospital from April 1, 2015 to April 1, 2016 and determined the date of the first prescription filling of a P2Y12 antiplatelet agent after hospital discharge. The primary outcome was proportion of patients who delay filling their DAPT discharge prescription. Logistic regression analysis was performed to determine the relationship of various factors with delays in DAPT-filling. Six hundred fifty-one patients were included in the final analysis. Age, sex, and provincial drug coverage status were not associated with delays in DAPT prescription-filling. Distance of patient’s residence to St Paul’s Hospital was associated with a significant delay in DAPT prescription filling (adjusted odds ratio, 1.90; 95% confidence interval, 1.11-3.22). Hospital discharge processes to ensure timely access to DAPT after PCI should be established.

Bordetella pertussis: Vaccine Coverage and Immune Status among Children Under Five Years Old in Sana’a City, Yemen

Aims: This study was made to evaluate the immune response to pertussis among children under five years old by measuring the level of circulating Immunoglobulin G (IgG) antibodies against pertussis toxin (IgG-PT) after immunization with the primary series of DPT (DPT1-3) and then determining the coverage rates of universal childhood vaccines.&#x0D; Study Design: Cross-sectional laboratory study.&#x0D; Place and Duration of Study: Department of Medical Microbiology and Clinical Immunology, Faculty of Medicine and Health Sciences, Sana’a University, between June and October 2010.&#x0D; Methodology: A total of 345 children were randomly selected and investigated for universal childhood vaccination coverage rates; of these, 273 children who had received 3 full doses of DPT were studied for their pertussis immunological status. Blood samples were collected from the latter group and then tested for levels of IgG-PT by ELISA method. For assessment IgG-PT levels more than 24 units/ml were considered protected against pertussis. Data were analyzed according to gender and age groups.&#x0D; Results: The coverage rate of pertussis vaccine was 79.1%; only 71.4% of vaccinated children responded to the vaccine with mean level of 33 U/ml. A statistically significant difference was observed with respect to sero-protective IgG-PT between males and females (63.8% and 84.8% respectively, with χ2 =15, p=0.0001). Also, a statistically significant difference was observed with respect to sero-protective IgG-PT in different age groups, with older children (&gt;48 months) having a higher rate of antibodies than younger (13-24 months) (90% and 59.1% respectively, with χ2 =3.87, p=.04).&#x0D; Conclusion: We conclude that a considerable proportion of vaccinated children with a normal immune status were not serologically immune to pertussis. They remain to be reconsidered for either revaccination or booster doses due to lack of or inadequate response. Also, the rates of vaccine coverage for the main universal childhood vaccines are low.

DETERMINANTS OF OUT-OF-POCKET EXPENDITURE FOR HEALTH CARE: A SYSTEMATIC REVIEW

Background: Out-of-pocket (OOP) expenditure is a cost for health care that are paid by individuals at the time of treatment through user fees, co-payments and direct payments. It is the most common way of paying for health services in developing nations particularly in low and middle-income countries. OOP payments are typically perceived to be the most regressive instrument of health finance and high reliance to it create a significant financial barrier in accessing health care. Objectives: To assess the determinants of OOP expenditures for health care. Materials and Methods: Journal and articles related on determinants of OOP health expenditures were compiled using a major online database, PubMed and Science Direct. The search was limited to full-text papers published in English and studies conducted within the last 10 years (2007-2017). The selection of articles to be reviewed is done according to the PRISMA checklist. Result: The main determinants of OOP health expenditure identified were age, gender, place of living, education and income level, household size and presence of comorbidities. Other determinants were marital status, insurance status, payments for medical supplies and pharmaceuticals and distance to health facilities Conclusion: OOP payments is not an equitable nor efficient financing mechanism. A government need to formulate the best health financing mechanism to achieve a complete universal health coverage status. This review can help policy-makers in identifying the determinants of OOP, focussing on the mechanisms driving them, and formulate policy options for building stronger health financing mechanisms. Keywords: Determinants, Out-of-Pocket, Expenditure, Health Care

Market Access Analysis of Biologics and Small-Molecule Inhibitors for Inflammatory Bowel Disease Among US Health Insurance Policies

Background and AimsTreatment pathways for ulcerative colitis (UC) and Crohn’s disease (CD) are shifting to a more individualized, risk-stratified approach. The perception is that insurance policies may not have implemented this paradigm shift, particularly regarding access to newer agents. We evaluated patient access to advanced therapies by analyzing policy information from the Managed Markets Insight and Technology database.MethodsCoverage status as of December 2018 for all US lives was queried for adalimumab, infliximab, infliximab-dyyb, tofacitinib, ustekinumab, and vedolizumab by indication (UC and/or CD) and medical or pharmacy coverage benefit. Coverage status was classified by the number of biologic steps before access to specified drug as “No Biologic,” “1 Prior Biologic,” “2+ Prior Biologics,” “Not Covered.” Unknown lives were excluded from the analyses.ResultsCoverage analysis was available for approximately 302 million lives under each medical and pharmacy benefit. Our analysis indicates that approximately half of covered lives had access to all agents (except tofacitinib) as first-line therapy; two-thirds had access after one biologic exposure. Among newer agents, vedolizumab had the widest coverage. For indications of UC and CD, 81% of known lives had access to vedolizumab with no prior biologic exposure required (“No Biologic”), 95% after “No Biologic” + “1 prior Biologic.” Geographic variations were identified for coverage patterns.ConclusionsThis US-based healthcare policy analysis points to an increased access to advanced therapies for UC and CD. An individualized, risk-stratified treatment approach integrating advanced therapies, including those recently approved, into treatment pathways for UC and CD is feasible.

Relationship between health care insurance status, social determinants and prevalence of diabetes-related microvascular complications in patients with type 1 diabetes: a nationwide survey in Brazil.

To evaluate the relationship between social determinants, health care insurance status and occurrence of diabetes-related chronic complications (DRCC) in Brazilian patients with type 1 diabetes. A multicenter cross-sectional study conducted between August 2011 and August 2014 in 14 public clinics in 10 Brazilian cities. Data were obtained from 1760 patients, aged 29.9 ± 11.9 years, with diabetes duration of 15.5 ± 9.3 years; 55.9% female, 54.5% Caucasians, 69.7% were attended exclusively by the public Brazilian National Health Care System (BNHCS) and 30.3% had also private health care insurance. Patients' information was obtained through a questionnaire and a chart review form. The social determinants associated with having both private and public health care insurance were being employed, belonging to medium or high socioeconomic status, having more years of school attendance and having younger age. Regarding DRCC, patients that had private and public health care had lower rates of diabetic retinopathy and of any other DRCC. Chronic kidney disease was not associated with health care coverage status after adjusting for classical clinical risk factors. Brazilian patients with type 1 diabetes had better clinical control and lower rates of DRCC, mainly retinopathy, when also having private health care insurance. These patients presented less frequently predictors of chronic complications such as high levels of HbA1c and blood pressure. BNHCS should change the approach for screening DRCC such as diabetic retinopathy, using methods such as telemedicine that would lead to earlier diagnosis, better outcomes and will be cost-effective sometime after its implementation.

Social deprivation indexes and anti-influenza vaccination coverage in the elderly in Sardinia, Italy, with a focus on the Sassari municipality.

SummaryThe aim of the present study was to evaluate the relationship between social deprivation indexes and anti-influenza vaccination coverage in the elderly population (over 65 years old) in Sardinia.This relationship was first observed in a regional context. An already-known deprivation index was used, and its trivial relationship with anti-influenza vaccination coverage was evaluated. Secondly, the same relationship was assessed in the homogeneous area of the Municipality of Sassari. This required the adoption of an ad hoc deprivation index, which allowed us to stratify the population into deprivation groups and to correlate vaccination coverage with socio-economic variables.The results showed that regional anti-influenza vaccination coverage increased linearly as deprivation decreased. This trend was confirmed in the Municipality of Sassari. Pearson’s analysis highlighted factors that significantly correlate with vaccination coverage.In Sardinia, the relationship between anti-influenza vaccination coverage and socio-economic status is consistent with the international panorama, and highlights the necessity to implement interventions to promote vaccination coverage among the elderly.

Suitable oasis and cultivated land scales in arid regions based on ecological health

A suitable oasis scale and a cultivated land scale are important for water resources management in arid regions. This paper developed an approach to calculate a suitable oasis scale and a cultivated land scale by combining water-heat balance theory and wind-sand dynamics theory with ecological health assessment (i.e., WHBEHA model). The oasis effective vegetation coverage was determined using the wind-sand dynamics theory. The oasis ecological health was assessed by constructing the ecological health index system. This index system considered groundwater depth, ratio of farmland shelterbelt, vegetation coverage status, and occurrence frequency of strong winds as ecological health evaluation indicators and was illustrated using the middle reaches of Heihe River basin as the case study. The results of the proposed WHBEHA model revealed that the most suitable ecological and cultivated areas under different hydrologic years were 363–442 km2 and 1450–1767 km2 in the middle reaches of Heihe River basin. They summed up to the total suitable oasis areas were in the range of 1813–2209 km2. Status quo 2013 was a high flow year, according to WHBEHA, the scale of cultivated land in 2013 has exceeded the suitable scale, and should be reduced by 334 km2. Compared with the current oasis scale based on land-use and land-cover information and the oasis scales computed using oasis water-heat balance and oasis circle theory (WHBOCT), the proposed WHBEHA model is more suitable by considering the factors that affect the ecological health of arid regions. Furthermore, this study may provide a guideline for determining a sustainable socio-economic scale, especially cultivated scale in arid regions.

Antenatal care data sources and their policy and planning implications: a Palestinian example using the Lives Saved Tool

BackgroundPolicy making in healthcare requires reliable and local data. Different sources of coverage data for health interventions can be utilized to populate the Lives Saved Tool (LiST), a commonly used policy-planning tool for women and children’s health. We have evaluated four existing sources of antenatal care data in Palestine to discuss the implications of their use in LiST.MethodsWe identified all intervention coverage and health status indicators around the antenatal period that could be used to populate LiST. These indicators were calculated from 1) routine reported data, 2) a Multiple Indicator Cluster Survey (MICS), 3) paper-based antenatal records and 4) the eRegistry (an electronic health information system) for public clinics in the West Bank, Palestine for the most recent year available. We scaled coverage of each indicator to 90%, in public clinics only, and compared this to a no-change scenario for a seven-year period.ResultsEight intervention coverage and health status indicators needed to populate the antenatal section of LiST could be calculated from both paper-based antenatal records and the eRegistry. Only two could be calculated from routine reports and three from a national survey. Maternal lives saved over seven years ranged from 5 to 39, with percent reduction in the maternal mortality ratio (MMR) ranging from 1 to 6%. Pre-eclampsia management accounted for 25 to 100% of these lives saved.ConclusionsThe choice of data source for antenatal indicators will affect policy-based decisions when used to populate LiST. Although all data sources have their purpose, clinical data collected directly in an electronic registry during antenatal contacts may provide the most reliable and complete data to populate currently unavailable but needed indicators around specific antenatal care interventions.