Care Enrollment Research Articles

Introducing and Evaluating the Effectiveness of Online Cognitive Behavior Therapy for Gambling Disorder in Routine Addiction Care: Comparative Cohort Study.

Several treatment-related challenges exist for gambling disorder, in particular at-scale dissemination in health care settings. This study describes the introduction of a newly developed internet-delivered cognitive behavioral therapy (iCBT) program for gambling disorder (GD), provided with therapist support in routine addiction care, in a nationally recruited sample in Sweden. The study details the introduction of the iCBT program, evaluates its effectiveness and acceptability, and compares registry outcomes among iCBT patients with other patients with GD at the clinic who received face-to-face psychological treatment as usual. The study site was the Stockholm Addiction eClinic, which offers digital interventions for addictive disorders in routine care. The iCBT program was introduced nationally for treatment-seeking patients through the Swedish eHealth platform. After approximately 2 years of routine treatment provision, we conducted a registry study, including ordinary patients in routine digital care (n=218), and a reference sample receiving face-to-face psychological treatment for GD (n=216). A statistically significant reduction in the Gambling Symptom Assessment Scale scores during the treatment was observed (B=-1.33, SE=0.17, P<.001), corresponding to a large within-group Cohen d effect size of d=1.39. The iCBT program was rated high for satisfaction. A registry-based survival analysis, controlling for psychiatric comorbidity, showed that patients receiving iCBT exhibited posttreatment outcomes (re-engagement in outpatient addiction care, receiving new psychiatric prescriptions, enrollment in psychiatric inpatient care, and care events indicative of contact with social services) similar to comparable patients who underwent face-to-face treatment-as-usual. A lack of randomized allocation notwithstanding, the iCBT program for GD evaluated in this study was well-received by patients in routine addiction care, was associated with the expected symptom decrease during treatment, and appears to result in posttreatment registry outcomes similar to face-to-face treatment. Future studies on treatment mechanisms and moderators are warranted. RR2-10.1186/s40814-020-00647-5.

Predicting Mental Health Care Enrollment and Treatment Uptake among Newly Arrived Refugees in U.S. Resettlement Programs.

This article examines variables that predict mental health care enrollment and engagement among refugees. The authors explore a mental health care model designed to identify mental health needs early among refugee arrivals that may interfere with adjustment and overall health outcomes using data from a Midwest refugee resettlement program. Using ecological models of mental distress and theories on help-seeking behaviors, the authors used logistic and count regressions to predict enrollment in mental health care services and utilization rates. Gender, nationality, and presenting problems were significant predictors of enrollment and length of engagement in services. The findings provide guidance to practitioners and resettlement agencies on refugee mental health and opportunities to increasing access and engagement in mental health care.

The interactive effect of maternity leaves and child care enrollment on maternal employment

This cross-country empirical research investigates the impact of maternity leaves and the child care enrollment rates on increasing maternal employment. By analyzing data from OECD countries with country-fixed effects, we find that the child care enrollment for 0–2 year olds increases the maternity employment rate. We confirm an inverted U-shaped relationship between the maternity leave duration and the maternity employment rate, as evidenced in prior studies. More interestingly, we find that an interaction term between child care enrollment and maternity leave duration is significantly positive, suggesting that two variables play a complement role in enhancing maternal employment rate. By examining the independent and complementary effects of extended maternity leave and child care enrollment rates, our study suggests that their combined use significantly enhances maternal employment rates, highlighting a complementary relationship that policymakers should consider to support working mothers effectively.

The safety of a dolutegravir (DTG)-based antiretroviral treatment (ART) regimen for pregnancy and birth outcomes in Ethiopia: evidence from multicenter cohort study

BackgroundA dolutegravir (DTG)-based antiretroviral regimen has been rolled out for pregnant women in low- and middle-income countries since 2020. However, available safety data are limited to a few clinical trials and observational studies. Hence, we present real-world pregnancy and birth outcome safety data from a large sample multicenter cohort study in Ethiopia.MethodsA retrospective cohort study was conducted in fourteen hospitals across Ethiopia from 2017 to 2022. HIV-infected pregnant women were followed from the date of prevention of mother-to-child transmission (PMTCT) care enrolment until the infant was 6–8 weeks old. The primary safety outcome was a composite of adverse pregnancy events comprising spontaneous abortion, intrauterine fetal death (IUFD) before onset of labor, preterm birth, and maternal death. Additionally, a composite adverse birth outcome was assessed, comprising intrapartum fetal demise, low birth weight, and neonatal death. Finally, a composite of adverse pregnancy or birth outcome was also investigated. The exposure of interest was the antiretroviral treatment (ART) regimen used during pregnancy for PMTCT of HIV.ResultsDuring the study period, 2643 women were enrolled in routine PMTCT care. However, 2490 (92.2%) participants were eligible for the study. A total of 136/1724 (7.9%, 95% CI: 6.7–9.3%) women experienced adverse pregnancy outcomes. Fewer women in the DTG-based group (5.4%, 95% CI: 3.7–7.5%) had adverse pregnancy outcomes than in the Efavirenz (EFV)-based group (8.3%, 95% CI: 6.6–10.3%), P = 0.004. After controlling for baseline differences, the DTG group had a 43% lower risk of adverse pregnancy outcomes (adjusted odd ratio (AOR), 0.57; 95% CI, 0.32–0.96%) and a 53% lower risk of preterm birth (AOR, 0.47; 95% CI, 0.22–0.98%) compared to the EFV group. A total of 103/1616 (6.4%, 95% CI: 5.2–7.7%) women had adverse birth outcomes. Although the difference was not statistically significant, fewer women in the DTG group (30/548; 5.5%, 95% CI: 3.7–7.7%) than in the EFV group (57/830; 6.9%, 95% CI: 5.2–8.8%) had adverse birth outcomes.ConclusionsIn this study, we observed that DTG-based regimens were associated with better pregnancy and birth outcome safety profiles, reaffirming the WHO recommendation. However, a prospective study is recommended to assess uncaptured maternal and perinatal adverse outcomes, such as congenital abnormalities, and infant growth and neurocognitive development.

Factors affecting physicians’ specialty selection: A demographic and socioeconomic perspective

Objectives: The medical field is advancing toward increasing specialization in knowledge, technology, and expertise. To meet the demands of quality health care, a practical, pragmatic, and well-balanced enrollment and distribution of physicians among specialties is crucial. The process of selecting a specialty as an ultimate future career is sensitive and conveys multidimensional implications on physicians, the health systems and society as a whole. Numerous complex and miscellaneous factors contribute to the development and adjustment of that decision that needs rigorous efforts to understand and hopefully control. Material and Methods: This is a cross-sectional and descriptive study, conducted through a comprehensive questionnaire encompassing demographic information, socioeconomic indicators, and components of the modified Kuppuswamy and MacArthur Scales. Data were collected using simple random sampling with considering design efficiency. Two-variable analysis with Pearson correlation and Chi-squared test was used to identify the associations and their significance. P &lt; 0.05 was considered statistically significant. Results: A total of 389 respondents completed the questionnaire: 58.87% females, 41.13% males. Among them, 67.8% were internship physicians, and 32.2% were general practitioners. The mean Kuppuswamy score was 15.17, and the mean subjective socioeconomic status (SES) score was 4.28. Female physicians presented a critical propensity toward choosing obstetrics and gynecology, and pediatrics as their primary future career (P ≤ 0.01), whereas male physicians were more willing to specialize in surgical specialties (P ≤ 0.01). Obstetrics, gynecology, and family medicine correlated with below-average Kuppuswamy scores (P = 0.010359), while surgical specialties correlated with higher scores (P &lt; 0.01). Physicians with above-average subjective SES scores preferred surgical specialties (P = 0.036596). Family medicine, obstetrics, gynecology, and pediatrics correlated with below-average subjective SES scores (P = 0.041828). Conclusion: Demographic and socioeconomic factors have a significant influence on physicians’ specialty preferences and selection.

Determinants of Late HIV Diagnosis and Advanced HIV Disease Among People Living with HIV in Tanzania.

About half of people infected with Human Immunodeficiency Virus (HIV) often present late for care, resulting in higher healthcare costs, undesired treatment outcomes, and ongoing HIV transmission. This study aimed to assess the prevalence and determinants of late HIV diagnosis and advanced HIV disease (AHD) in Tanzania. Data were obtained from the 2016-17 Tanzania HIV impact survey. We included 677 newly diagnosed people living with HIV. Late HIV diagnosis and AHD were defined as having a CD4 cell count below 350 cells/µL or 200 cells/µL at diagnosis, respectively. Bivariate and multivariable logistic regression models were fitted to identify the determinants of late HIV diagnosis or AHD. The mean age of the participants was 37.8 years (SD, 12.4). About two-thirds were women (62.6%). The prevalence of late HIV diagnosis was 42.4%, whereas the prevalence of AHD was 17.7%. Factors associated with late HIV diagnosis included age 31-40 years (adjusted odds ratio [aOR] = 1.72, 95% confidence interval [CI]: 1.14-2.60), age ≥41 years (aOR = 1.79, 95% CI: 1.16-2.76), male sex (aOR = 1.88, 95% CI: 1.29-2.73), and active syphilis infection (aOR=2.63, 95% CI: 1.20-5.76). Factors associated with AHD were age 31-40 years (aOR = 2.12, 95% CI: 1.18-3.81), age ≥41 years (aOR = 2.42, 95% CI: 1.32-4.41), male sex (aOR = 1.77, 95% CI: 1.09-2.87), formal education (aOR = 0.49, 95% CI: 0.30-0.81) and active syphilis infection (aOR = 2.49, 95% CI: 1.07-5.77). Late HIV diagnosis and AHD are prevalent among newly diagnosed people living with HIV in Tanzania. Specific subgroups are more likely to present late for HIV care, including middle-aged and older adults, men, illiterate individuals, and those with active syphilis and HIV co-infection. Therefore, we recommend expanding HIV testing services and implementing targeted interventions to improve early access and enrollment in HIV care.

Early Childhood Care Coordination Through 211: A Randomized Clinical Trial.

Early intervention services can improve outcomes for children with developmental delays. Health care providers, however, often struggle to ensure timely referrals and services. We tested the effectiveness of telephone-based early childhood developmental care coordination through 211 LA, a health and human services call center serving Los Angeles County, in increasing referral and enrollment in services. In partnership with 4 clinic systems, we recruited and randomly assigned children aged 12 to 42 months with upcoming well-child visits and without a known developmental delay, to intervention versus usual care. All children received developmental screening and usual clinic care. Intervention children also received telephone connection to a 211 LA early childhood care coordinator who made referrals and conducted follow-up. Primary outcomes at a 6-month follow-up included parent-reported referral and enrollment in developmental services. Secondary outcomes included referral and enrollment in early care and education (ECE). Logistic regression models were used to estimate the odds of outcomes, adjusted for key covariates. Of 565 families (282 intervention, 283 control), 512 (90.6%) provided follow-up data. Among all participants, more intervention than control children were referred to (25% vs 16%, adjusted odds ratio [AOR] 2.25, P = .003) and enrolled in (15% vs 9%, AOR 2.35, P = .008) ≥1 service, and more intervention than control children were referred to (58% vs 15%, AOR 9.06, P < .001) and enrolled in (26% vs 10%, AOR 3.75, P < .001) ECE. Telephone-based care coordination through 211 LA is effective in connecting young children to developmental services and ECE, offering a potentially scalable solution for gaps and disparities.

Community emergency medical services approaches to fall prevention: a systematic review

BackgroundFalls are a leading cause of morbidity and mortality among older adults in the USA. Current approaches to fall prevention often rely on referral by primary care providers or enrolment...

Has COVID-19 Changed the Incidence and Profile of Late Presenters for HIV Infection in Lodz, Polish Reference Centre, Poland?

Objectives: The aim of this study was to compare the prevalence and characteristics of HIV late presenters (LPs) and advanced LPs (aLPs) registered in the Lodz HIV centre during the COVID-19 pandemic (2020-2021) with those of the pre-pandemic period (2017-2019). Methods: A retrospective analysis was performed of the predictive factors associated with HIV LPs and aLPs based on multivariable logistic regression. The patient entry into specialist HIV care after diagnosis during the pandemic was analysed. Results: Of 121 newly diagnosed HIV infections during the pandemic, 49.6% had late presentation and 36.4% had advanced HIV disease (AHD). In the pre-pandemic period, out of 154 newly diagnosed patients, 58.4% were LPs and 38.3% were aLPs. Independent risk factors for HIV late presentation were older age (OR: 1.04, 95% CI: 1.01-1.076; p = 0.008), diagnosis in hospital (OR: 5.63, 95% CI: 2.87-11.05; p < 0.001) and negative VDRL as compared to positive VDRL (OR: 2.48, 95% CI: 1.19-5.15; p = 0.015). The same predictive factors were associated with aLPs: older age (OR: 1.07, 95% Cl 1.04-1.11; p < 0.001), HIV diagnosis in hospital (OR: 4.25, 95% CI 2.17-8.29; p < 0.001) and negative VDRL as compared to positive VDRL (OR: 4.95, 95% CI 1.87-13.10; p = 0.001). HIV diagnosis during the pandemic was not a risk factor for late presentation nor for advanced late presentation. However, the time between HIV diagnosis and the first visit to an HIV centre was statistically lower in the pre-pandemic period (p = 0.0048); the median lengths of time between the date of HIV testing, the first visit to the centre and the initiation of ART did not differ between these two periods in LPs and aLPs (p > 0.05). Conclusions: The COVID-19 pandemic did not change the prevalence or characteristics of late presentation and aLPs among newly diagnosed patients, nor did it extend the time to enrolment in HIV care or ART introduction in these groups.

Travel Distance and Spanish-Speaking are Associated with Delays in the Treatment of Cleft Palate.

Delayed repair of cleft palate is associated with worse speech outcomes. Social determinants of health may influence the timing of surgery; however, there are no population health investigations to evaluate factors such as travel distance, language barriers, and payer. This study sought to identify factors that may interfere with timely cleft palate repair. Retrospective cohort. National/multi-center. All cleft palate repairs within California were extracted from 2000-2021. The primary outcome was age at surgical repair, which was modeled with linear regression. Covariates included race, primary language, distance from patient home to hospital, socioeconomic status, primary payer, and managed care enrollment status. 11 260 patients underwent surgical repair of a cleft palate. Black race was associated with delayed repair (22 additional days, P = .004, 95% CI 67.00-37.7) along with Asian/Pacific-Islander race (11 additional days, P = .006, 95% CI 3.26-18.9) compared to white race. Spanish-speaking patients had significantly later cleft palate repairs by 19 days, (P < .001, 95% CI 10.8-27.7) compared with English-speaking. Further distances from the hospital were significantly associated with later cleft surgeries with out-of-state patients undergoing surgery 52 days later (P < .001, 95% CI 11.3-24.3). Managed care plans and Medi-Cal were significantly associated with earlier surgical repair compared with private insurance. Black, Asian Pacific Islander, and Spanish-speaking patients and greater distance traveled to hospital were associated with delayed cleft palate repairs. These results underscore the importance of addressing structural and social barriers to care to improve outcomes and reduce health disparities for patients with cleft palate.

An Age Group Comparison of Concurrent Hospice Care: A Cost-Effectiveness Analysis.

This study aimed to examine the cost-effectiveness of concurrent hospice care compared with standard care among pediatric patients of different age groups. Using a national Medicaid database of 18 152 pediatric patients enrolled in hospice care between 2011 and 2013, this study calculated and analyzed incremental cost-effectiveness ratios (ICERs) for concurrent care versus standard hospice care for children of 4 age categories: <1 year, 1 to 5 years, 6 to 14 years, and 15 to 20 years. The results indicated that the total Medicaid cost of hospice care was $3229 per patient per month (PPPM; SD, $8709) for those younger than 1 year, $4793 PPPM (SD, $8178) for those aged 1 to 5 years, $5411 PPPM (SD, $7456) for those aged 6 to 14 years, and $5625 PPPM (SD, $11459) for those aged 15 to 20 years. Incremental cost-effectiveness ratio values across all age groups showed that children enrolled in concurrent care had fewer live discharges but at a higher Medicaid cost of care as compared with those enrolled in standard hospice care. Concurrent hospice care was the most cost-effective in the age groups of <1 year and 1 to 5 years, with ICERs equal to $45 (95% confidence interval [CI], $23-$66) and $49 (95% CI, $8-$76), respectively. For the other older age groups, benefits of enrollment in concurrent care came at a much higher cost: in the age group of 6 to 14 years, ICER was equal to $217 (95% CI, $129-$217), and in the age group of 15 to 20 years, it was $107 (95% CI, $82-$183). Concurrent hospice is an effective way to reduce live discharges but has a higher total Medicaid cost than standard hospice care.

Medicaid spending and utilization of gene and RNA therapies for rare inherited conditions.

Gene and RNA therapies are promising treatments for many rare diseases. Pediatric populations that could benefit from these drugs are overrepresented among state Medicaid programs. Using Medicaid State Drug Utilization Data, we examined Medicaid spending and utilization of rare disease gene and RNA therapies. Between 2017 and 2022, the number of available gene and RNA therapies increased from 3 to 13, yearly Medicaid spending increased from $148.3 million to $879.7 million, and the number of yearly treatments (a proxy for number of patients) increased from 327 to 1638. Nearly all spending was attributed to spinal muscular atrophy (SMA) and Duchenne muscular dystrophy drugs. States participating in Medicaid pooled purchasing initiatives had 39% higher treatments per 100 000 enrollees with no differences in spending. Compared to states without a carve-out, states that carved SMA drugs out of managed Medicaid contracts had higher utilization (54%). Spending among carve-out states varied according to managed care enrollment, being higher for those with <80% of enrollees in managed care as compared with those with ≥80% of enrollees in managed care. This suggests that multi-state purchasing initiatives and managed care carve-outs can help increase access to gene and RNA therapies among Medicaid beneficiaries, but it is unclear if these strategies are effective at managing spending.

Development of diabetes complications within coordinated and structured primary health care: a 10-year retrospective cohort study in Germany.

Diabetes mellitus is a growing, costly, and potentially preventable public health issue. In 2004, Germany introduced the GP-centred healthcare programme to strengthen primary care. To assess the hazards of the most common diabetes-related complications in patients enrolled in GP-centred health care in comparison with usual primary care. A retrospective cohort study based on German claims data (4 million members) from 2011-2020. In total, 217 964 patients with diabetes were monitored from 2011-2020. Endpoints were blindness, amputation, myocardial infarction, stroke, coronary heart disease, dialysis, hypoglycaemia, and all-cause mortality. Cox proportional-hazards regression models were used for multivariable analysis and adjusted for sociodemographic, practice, and disease-specific characteristics. Compared with usual care (n = 98 609 patients), GP-centred health care (n = 119 355 patients) showed a relative risk reduction of blindness of 12%, and amputation of 20% over 10 years. The estimated impact of GP-centred health care on myocardial infarction, stroke, coronary artery disease, dialysis, and all-cause mortality is significantly favourable in comparison with usual care. However, the proportional risk of hypoglycaemia (+1.2%) in the interventional group is higher than in usual care. Enrolment in GP-centred health care appears to result in a consistent reduction of the relative risk of diabetes-related complications over 10 years. The significant difference in contrast to usual care may be explained by robust, structured primary care provision, including the diabetes disease management programme, and improved coordination and networking of care within primary and secondary care.

Racial and ethnicassociations with comprehensive cancer center access and clinical trial enrollment for acute leukemia.

Clinical trial participation at Comprehensive Cancer Centers (CCC) is inequitable for minoritized racial and ethnic groups with acute leukemia. CCCs care for a high proportion of adults with acute leukemia. It is unclear if participation inequities are due to CCC access, post-access enrollment, or both. We conducted a retrospective cohort study of adults with acute leukemia (2010-2019) residing within Massachusetts, the designated catchment area of the Dana-Farber/Harvard Cancer Center (DF/HCC). Individuals were categorized as non-Hispanic Asian (NHA), Black (NHB), White (NHW), Hispanic White (HW), or Other. Decomposition analyses assessed covariate contributions to disparities in (1) access to DF/HCC care and (2) post-access enrollment. Of 3698 individuals with acute leukemia, 85.9% were NHW, 4.5% HW, 4.3% NHB, 3.7% NHA, and 1.3% Other. Access was lower for HW (age- and sex-adjusted OR = 0.64, 95% CI = 0.45 to 0.90) and reduced post-access enrollment for HW (aOR = 0.54, 95% CI =0.34 to 0.86) and NHB (aOR = 0.60, 95% CI = 0.39 to 0.92) compared to NHW. Payor and socioeconomic status (SES) accounted for 25.2% and 21.2% of the +1.1% absolute difference in HW access. Marital status and SES accounted for 8.0% and 7.0% of the -8.8% absolute disparity in HW enrollment; 76.4% of the disparity was unexplained. SES and marital status accounted for 8.2% and 7.1% of the -9.1% absolute disparity in NHB enrollment; 73.0% of the disparity was unexplained. A substantial proportion of racial and ethnic inequities in acute leukemia trial enrollment at CCCs are from post-access enrollment, the majority of which was not explained by sociodemographic factors.

Long-term HIV care outcomes under universal HIV treatment guidelines: A retrospective cohort study in 25 countries.

While national adoption of universal HIV treatment guidelines has led to improved, timely uptake of antiretroviral therapy (ART), longer-term care outcomes are understudied. There is little data from real-world service delivery settings on patient attrition, viral load (VL) monitoring, and viral suppression (VS) at 24 and 36 months after HIV treatment initiation. For this retrospective cohort analysis, we used observational data from 25 countries in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium's Asia-Pacific, Central Africa, East Africa, Central/South America, and North America regions for patients who were ART naïve and aged ≥15 years at care enrollment between 24 months before and 12 months after national adoption of universal treatment guidelines, occurring 2012 to 2018. We estimated crude cumulative incidence of loss-to-clinic (CI-LTC) at 12, 24, and 36 months after enrollment among patients enrolling in care before and after guideline adoption using competing risks regression. Guideline change-associated hazard ratios of LTC at each time point after enrollment were estimated via cause-specific Cox proportional hazards regression models. Modified Poisson regression was used to estimate relative risks of retention, VL monitoring, and VS at 12, 24, and 36 months after ART initiation. There were 66,963 patients enrolling in HIV care at 109 clinics with ≥12 months of follow-up time after enrollment (46,484 [69.4%] enrolling before guideline adoption and 20,479 [30.6%] enrolling afterwards). More than half (54.9%) were females, and median age was 34 years (interquartile range [IQR]: 27 to 43). Mean follow-up time was 51 months (standard deviation: 17 months; range: 12, 110 months). Among patients enrolling before guideline adoption, crude CI-LTC was 23.8% (95% confidence interval [95% CI] 23.4, 24.2) at 12 months, 31.0% (95% CI [30.6, 31.5]) at 24 months, and 37.2% (95% [CI 36.8, 37.7]) at 36 months after enrollment. Adjusting for sex, age group, enrollment CD4, clinic location and type, and country income level, enrolling in care and initiating ART after guideline adoption was associated with increased hazard of LTC at 12 months (adjusted hazard ratio [aHR] 1.25 [95% CI 1.08, 1.44]; p = 0.003); 24 months (aHR 1.38 [95% CI 1.19, 1.59]; p < .001); and 36 months (aHR 1.34 [95% CI 1.18, 1.53], p < .001) compared with enrollment before guideline adoption, with no before-after differences among patients with no record of ART initiation by end of follow-up. Among patients retained after ART initiation, VL monitoring was low, with marginal improvements associated with guideline adoption only at 12 months after ART initiation. Among those with VL monitoring, VS was high at each time point among patients enrolling before guideline adoption (86.0% to 88.8%) and afterwards (86.2% to 90.3%), with no substantive difference associated with guideline adoption. Study limitations include lags in and potential underascertainment of care outcomes in real-world service delivery data and potential lack of generalizability beyond IeDEA sites and regions included in this analysis. In this study, adoption of universal HIV treatment guidelines was associated with lower retention after ART initiation out to 36 months of follow-up, with little change in VL monitoring or VS among retained patients. Monitoring long-term HIV care outcomes remains critical to identify and address causes of attrition and gaps in HIV care quality.

Georgia's Reinsurance Waiver Associated With Decreased Premium Affordability And Enrollment.

Sixteen states have used Section 1332 waivers to implement reinsurance programs that aim to reduce premiums and increase enrollment in the Affordable Care Act's health insurance Marketplaces. Although reinsurance programs have successfully reduced premiums for unsubsidized enrollees, little is known about how reinsurance affects Marketplace premiums, minimum cost of coverage, and enrollment for the large majority of Marketplace enrollees who receive premium subsidies. Using a difference-in-differences analysis of matched counties straddling Georgia's borders to examine Georgia's 2022 implementation of its reinsurance program, we found that reinsurance increased the minimum cost of enrolling in subsidized Marketplace coverage by approximately 30percent and decreased enrollment by roughly a third for Marketplace enrollees with incomes of 251-400percent of the federal poverty level. Marketplace reinsurance programs may have the unintended consequences of increasing the minimum cost of subsidized coverage and reducing enrollment. These outcomes are especially relevant in the present policy context of enhanced subsidies, which have substantially reduced the number of unsubsidized enrollees who would benefit most from reinsurance.

A retrospective cohort analysis of people living with HIV/AIDS enrolled in HIV care at a reference center in Antananarivo, Madagascar.

The impact of the "Treat all" policy on the individual and in terms of public health is closely related to early diagnosis and retention in care. Patient-level data are scarce in Madagascar. In this study, we aimed to describe the profile of a cohort of newly diagnosed people living with HIV/AIDS (PLHIV), identify their outcomes, and assess factors associated with attrition from care and advanced HIV disease (AHD) at presentation. We conducted a retrospective cohort study of PLHIV aged ≥15 years newly diagnosed at the University Hospital Joseph Raseta Befelatanana Antananarivo from 1 January 2010 to 31 December 2016. A total of 490 PLHIV were included in the cohort analysis. In total, 67.1% were male. The median age (interquartile range) at enrollment in care was 29 years (24-38). Overall, 36.1% of PLHIV were diagnosed with AHD at baseline. The proportion of patients with WHO stage IV at baseline increased significantly from 3.3% in 2010 to 31% in 2016 (p = 0.001 for trend). The probability of retention in care after the diagnosis at 12 months, 24 months, and 36 months was 71.8%, 65.5%, and 61.3%, respectively. Age ≥ 40 years (aHR: 1.55; 95% CI: 1.05-2.29; p = 0.026), low level of education (aHR:1.62; 95% CI: 1.11-2.36; p = 0,013), unspecified level of education (aHR:2.18; 95% CI: 1.37-3.47; p = 0.001) and unemployment (aHR:1.52; 95% CI: 1.07-2.16; p = 0.019) were independently associated with attrition from care. Factors associated with AHD at baseline were age ≥ 40 (aOR: 2.77; 95% CI: 1.38-5.57, p = 0.004), unspecified level of education (aOR: 3.80; 95% CI: 1.58-9.16, p = 0.003) and presence of clinical symptoms at baseline (aOR: 23.81; 95% CI: 10.7-52.98; p < 0.001). Sex workers were independently less likely to have an AHD at presentation (aOR: 0.23; 95% CI: 0.05-0.96, p = 0.044). Sociodemographic determinants influenced retention in care more than clinical factors. The presence of clinical symptoms and sociodemographic determinants were the main factors associated with AHD at baseline.

Assessing COVID-related concerns and their impact on antenatal and delivery care among pregnant women living with HIV in Kenya: a brief report

BackgroundSome studies indicate that pregnant Kenyan women were concerned about Coronavirus disease 2019 (COVID-19) exposure during maternity care. We assessed concern regarding COVID-19 exposure and any impact on antenatal care (ANC) enrollment and/or hospital delivery among pregnant women living with human immunodeficiency virus (HIV) in Kenya.MethodsData were collected from 1,478 pregnant women living with HIV enrolled in prevention of mother to child transmission of HIV (PMTCT) care at 12 Kenyan hospitals from October 2020 to July 2022. Surveys were conducted when women first presented for PMTCT services at the study hospital and asked demographic questions as well as items related to concerns about COVID-19. A 5-point Likert scale (strongly disagree to strongly agree) assessed concerns about COVID-19 exposure and travel challenges. Gestational age at PMTCT enrollment, number of ANC appointments attended, and delivery location were compared among women who expressed COVID-19 concerns and those who did not.ResultsFew women reported delaying antenatal care (4.7%), attending fewer antenatal care appointments (5.0%), or having concerns about a hospital-based delivery (7.7%) because of COVID-19. More (25.8%) reported travel challenges because of COVID-19. There were no significant differences in gestational age at enrollment, number of ANC appointments, or rates of hospital-based delivery between women with concerns about COVID-19 and those without,ConclusionFew pregnant women living with HIV expressed concerns about COVID-19 exposure in the context of routine ANC or delivery care. Women with and without concerns had similar care seeking behaviors. The recognized importance of routine ANC care and facility-based deliveries may have contributed to these positive pregnancy indicators, even among women who worried about COVID-19 exposure.Trial registrationwww.clinicaltrials.gov identifier NCT04571684.

Accuracy of Cancer Registry Primary Payer Information and Implications for Policy Research.

Cancer registry-based "primary payer at diagnosis" (PPDx) data are commonly used to evaluate the effect of insurance on cancer care outcomes, yet little is known about how well they capture Medicaid or Medicare enrollment. We linked the National Cancer Institute's Surveillance, Epidemiology, and End Results registry data to monthly Centers for Medicare and Medicaid Services (CMS) Medicaid and Medicare enrollment records, state-year Medicaid policy, and managed care enrollment. We selected adults aged 19-64 years diagnosed between 2007 and 2011. We used bivariate analyses to compare PPDx to CMS enrollment at diagnosis month and assessed underreporting rates by patient characteristics and state-year policy. PPDx reported 7.8% Medicare and 10.1% Medicaid, whereas CMS enrollment indicated 5.5% Medicare, 10.4% Medicaid, and 3.4% dual Medicare-Medicaid (N = 896,031). Positive predictive values for PPDx assignment to Medicaid and Medicare were 65.3% and 75.4%, with false negative rates of 52.0% and 33.8%, respectively. Medicaid underreporting was higher in low (56.5%) versus high (50.8%) poverty areas, for males (56.1%) versus females (48.9%), for Medicaid poverty expansion or waiver enrolled (63.8%) versus cash assistance-related eligibility (47.3%), and in states with large managed care enrollment (all P < 0.001). If Medicaid and Medicare enrollment data were used to edit PPDx, 12.0% of persons would switch primary payer assignment. Registry-reported PPDx fails to fully capture Medicaid and Medicare enrollment, which may result in biased estimates of insurance-related policy impacts. Enhancement with objective enrollment data could reduce measurement error and bias in estimates necessary to support policy assessment.

Prevalence of advanced HIV disease and associated factors among antiretroviral therapy naïve adults enrolling in care at public health facilities in Kampala, Uganda.

Despite adoption of the 'test-and-treat' strategy, a high proportion of antiretroviral therapy (ART) naïve people living with HIV (PLHIV) enrol in care with, and die of advanced HIV disease (AHD) in Uganda. In this study, we aimed to determine the prevalence of AHD among ART naïve adults enrolling in care and associated factors at selected public health facilities in Kampala, Uganda. From April to July 2022, we conducted a mixed-methods study at Kiswa Health Centre III, Kitebi Health Centre III, and Kawaala Health Centre IV. The study involved cross-sectional enrolment and evaluation of 581 participants, utilizing an interviewer-administered questionnaire and chart reviews. Modified Poisson regression was employed to identify factors associated with AHD, complemented by a qualitative component comprising fifteen in-depth interviews, with data analysed through thematic analysis. Overall, 35.1% (204/581) of the study participants had AHD. Being male [adjusted prevalence ratio (aPR): 1.4, 95% CI: 1.04-1.88] and aged 35-50 years (aPR: 1.81, 95% CI: 1.14-2.88) were associated with AHD. Participants with no personal health perception barriers had 37% lower odds of presenting to care with AHD (aPR: 0.63, 95% CI: 0.46-0.85). Qualitative findings indicated that individual factors, such as waiting until physical health deteriorated and initially opting for alternative therapies, took precedence in contributing to enrolment in care with AHD. Over one in every three ART naïve adults presents to public health facilities in Uganda with AHD. Male gender, age 35-50 years, and personal health perception barriers emerged as significant factors associated with AHD; emphasizing the need for targeted interventions to address these disparities and enhance early detection and engagement in care. Routine HIV testing should be emphasized and incentivized especially for men and persons aged 35-50 years.