Government Insurance Research Articles

Families' perceptions of consumer-grade, inexpensive oxygen saturation monitors.

We evaluated what proportion of families have a consumer-grade pulse oximeter, why they bought one, and how they choose to use it. We hypothesized that children followed in cardiorespiratory clinics would be more likely to have an oximeter than children attending a more general clinic. We carried out a cross-sectional study using a convenience sample of children attending a respirology, cardiology, or gastroenterology clinic at a children's hospital. Consenting guardians completed a survey. Two-hundred families completed the survey. Fifty-three (26.5%; 53/200) had an oximeter at home. The proportion of children attending a cardiorespiratory clinic who had an oximeter was higher than another clinic (p = 0.08), but 15.5% of children attending the latter also had access to one. Of devices not funded by government insurance, over 80% of devices were "fingertip" clamp-style oximeters, and 50% were purchased online. Most devices were used only when the child was ill (83.7%; 36/43). Only about 1/3 of families had received education about using an oximeter, and a similar proportion had compared their oximeter to a medical-grade device. Only 2.4% (1/42) respondents did not feel that their device was "somewhat" or "very" accurate. The oxygen saturation that would prompt seeking emergency care was similar to most pediatric acute care guidelines. Many children, particularly those with cardiorespiratory conditions, have access to consumer-grade pulse oximeters. Asking about the presence of an oximeter should be part of the pediatric history, and families responding affirmatively should be offered education.

Ad Hoc Adaptations to Climate Change in Coastal Communities

Climate change disproportionately impacts coastal residents in the United States. Existing studies document institutional efforts to adapt to sea level rise through projects like seawalls, beach nourishment, and property acquisitions to protect communities from rising seas. Such studies capture institutional adaptations, but do not include ad hoc adaptations by homeowners impacted by climate change. How are homeowners adapting to climate hazards? This paper analyzes ethnographic and interview data from 100 households in two coastal counties in North Carolina, a state with one of the most climate vulnerable shorelines in the country. This analysis of homeowner response considers ad hoc adaptations along the North Carolina coast. Results show that homeowners recognize climate hazards and regularly adapt on their own within the context of institutionally maintained flood protection infrastructure and transportation access to the places where they live. Residents are aware of and attempt to access support for home adaptations when programs or funds are available to them after disasters and do so with varying levels of success, though the more pervasive adaptations to chronic stress are not supported by government programs or insurance mechanisms. Ad hoc adaptations may provide short-term protection from climate hazards but have questionable long-term efficacy as sea levels rise and storm strength and frequency increases. Leaving communities and households to adapt on their own as chronic climate hazards outpace institutional response exacerbates existing inequalities by relying on residents with different levels of resources and agency to adapt.

Prevalence and Predictors of Food Insecurity among Adults with Type 1 Diabetes: Observational Findings from the 2022 Behavioral Risk Factor Surveillance System.

The majority of data on food insecurity in diabetes comes from samples of type 2 diabetes or youth with type 1 diabetes. This study screened for food insecurity among adults with type 1 diabetes in the 2022 Behavioral Risk Factor Surveillance Survey, which was the first year that respondents who endorsed diabetes were asked to indicate whether they had type 1 or type 2. One validated screening item asked, "During the past 12 months, how often did the food that you bought not last and you didn't have money to buy more?". Respondents who answered "always", "usually", "sometimes", or "rarely" were categorized as having a positive screen for food insecurity. Seventy-six percent of the sample was white/non-Hispanic. Over one-quarter screened positive for food insecurity. This prevalence is higher than some reports of food insecurity in type 1 diabetes but consistent with reports that include 'marginal' food security in the count of food-insecure individuals. White/non-Hispanics had a lower risk of a positive screen than minoritized respondents. Respondents reporting older age, lower educational attainment, not working, lower income, and receiving SNAP benefits had higher rates of a positive screen. Significant healthcare factors associated with a positive screen were receiving government insurance instead of private, not being able to afford to see a doctor, and worse general, physical, and mental health. In conclusion, rates of a positive screen for food insecurity among people with type 1 diabetes in this study were alarmingly high and associated with other socioeconomic indicators. Screening for food insecurity with appropriate instruments for samples with type 1 diabetes, across the U.S. and internationally, should be a priority.

Predictors of medical adherence following a bowel management program for youth and young adults with Spina Bifida.

To evaluate individual and community sociodemographic factors that predict bowel regimen adherence in youth and young adults with Spina Bifida (SB) following participation in a bowel management program (BMP). Participants were drawn from clinical cases seen through an International Center for Colorectal and Urogenital Care. Area deprivation index (ADI) scores were extracted from participant addresses and bowel regimen adherence data were collected from the electronic medical record (EMR). Participants' mean age was 8.06years old, 51.7% were male, 72.4% white, 37.9% Hispanic, 56.9% government insurance, 89.7% myelomeningocele, 15.5% non-adherent. Average neighborhood disadvantage was 5.19 (SD:2.83, range:1-10). After controlling for variables correlated with adherence (p < .20), every one decile higher neighborhood disadvantage score was associated with a 48% decrease in the odds of being adherent (OR = 0.52, p = .005, 95% CI: -101.90, -0.21). Our results suggest that neighborhood disadvantage is a strong predictor of medical adherence following a BMP, more so than other sociodemographic and health-related variables. These results may assist with identifying which individuals may be at higher risk for poor health outcomes due to neighborhood socioeconomic disadvantage and help health care systems intervene proactively.

Epidemiology, Outcomes, and Trend Analysis of Hospitalized Infants With Respiratory Syncytial Virus (RSV) Bronchiolitis From 1997 to 2019.

Background Most children with respiratory syncytial virus (RSV) infection have a self-limiting course that can be managed with supportive care, and hospitalization is uncommon. The objectives of this study were to evaluate the epidemiology, outcomes, associated comorbidities, and temporal trends in the prevalence of infants one to 24 months of age who required hospitalization for RSV infection in the United States of America from 1997 to 2019. Methods In this retrospective cross-sectional study, we utilized the Kids' Inpatient Database (KID) to investigate the prevalence and outcomes of RSV bronchiolitis within a large cohort of discharged patients from 1997 to 2019. We included children one to 24 months of age admitted with a diagnosis of RSV bronchiolitis. Neonates were excluded from the analysis. A chi-square for linear trend was used to analyze trends in the prevalence of RSV bronchiolitis hospitalization, the presence of complex chronic conditions (CCC), congenital heart disease (CHD), the use of non-invasive and invasive mechanical ventilation (NIV and IMV), and hospital mortality. Results There were a total of 566,786 infants aged one to 24 months hospitalized with RSV infection out of a total of 9,309,597 discharges during the eight-year cohort, with a hospital prevalence of 60.9 per 1000 discharges and a hospital mortality rate of 0.09% (95% confidence interval (CI): 0.08%-0.1%). There was no trend in hospitalization rates of RSV infections per 100,000 U.S. population during the study period, with a decrease in hospital mortality trend. Children with RSV bronchiolitis were more likely to have government insurance and reside in zip codes with the lowest income quartile. There was a significant seasonal and regional variation in RSV-related hospitalizations. The presence of CCC was identified in 2.4% of the RSV group compared to 5.1% of non-RSV discharges (odds ratio (OR): 0.46, 95% CI: 0.45-0.47; p<0.001). The prevalence of RSV among all discharges has significantly increased over the study period, rising from 51.6 cases per 1000 discharges in 1997 to 180.1 cases per 1000 discharges in 2019 (p<0.001). The prevalence of CCC and CHD among RSV patients has also shown an upward trend, with CCC cases increasing from 1,411 in 1997 to 2,795 in 2019 and CHD cases rising from 1,795 to 3,622 during the same period. The use of invasive mechanical ventilation, non-invasive ventilation, and extracorporeal membrane oxygenation has consistently increased over time. Additionally, complications such as the need for cardiopulmonary resuscitation have demonstrated a similar increasing trend, although they have remained overall low. However, population-based hospitalization rates showed no significant trend. Conclusions The hospitalization rates at a population level in the United States for RSV infection in children aged one to 24 months remained steady from 1997 to 2019, while hospital mortality rates showed a declining trend. There is an increased proportion of comorbid conditions and increased resource utilization in children with RSV. These findings are important for monitoring the effectiveness of preventive strategies for severe RSV infections.

Outpatient Factors Implicated in Timing of Delayed Elective Inguinal Hernia Repair in Premature Neonates: Single Center Analysis Brings Up a Touchy Issue and Balancing Metric

IntroductionAmong premature infants, the incidence of inguinal hernias (IH) has been reported to be as high as 10–30%. We performed this study to characterize the association between individual and systemic variables that may affect diagnosis to definitive operative repair of the premature neonatal IH in the outpatient setting. MethodsA single center cohort retrospective review analyzing IH repair in the premature neonatal (<37 GA) population was performed. Data was collected between 2013 and 2022. The cohort was defined as patients who underwent repair before the age of 1 and excluded patients with major medical comorbidities or underwent simultaneous major abdominal surgeries. ResultsOf the 836 premature neonates who underwent IH repair, the majority (73%) were repaired electively. Patients were characterized into risk cohorts a-priori. High-risk patients (HR, n = 43) were more likely to have Government insurance (67%). There was a significant difference in HR patient time to surgery between Government versus Commercial insurance, 10.6 versus 4.7 days, respectively (95% CI -11.09 to −0.4396, p = 0.0345). HR patients were also seen more frequently (clinic or emergency department) prior to operative repair (2.51 vs 1.72 95% CI –1.296% to −0.289%, p = 0.0021). A multivariate linear regression model demonstrated that risk class (p = 0.0244), touches (p < 0.0001), GA (p < 0.001), and prior authorization (p < 0.0001) were significantly associated with time to hernia repair. ConclusionsSystemic variables such as insurance type may increase average wait time for elective outpatient IH repair. This increase in wait time is associated with an increased number of healthcare visits. Therefore, timely access to surgical care prevents potential harm and may decrease health system burden. Type of StudyRetrospective comparative study/cohort study. Level of EvidenceIII.

Trends and Disparities in Next-Generation Sequencing in Metastatic Prostate and Urothelial Cancers

Targeted therapies based on underlying tumor genomic susceptible alterations have been approved for patients with metastatic prostate cancer (mPC) and advanced urothelial carcinoma (aUC). To assess trends and disparities in next-generation sequencing (NGS) testing among patients with mPC and aUC. This retrospective cohort study used an electronic health record-derived database to extract deidentified data of patients receiving care from US physician practices, hospital-affiliated clinics, and academic practices. Patients diagnosed with mPC or aUC between March 1, 2015, and December 31, 2022, were included. Social determinants of health evaluated by race and ethnicity, socioeconomic status (SES), region, insurance type, and sex (for aUC). The primary outcomes were (1) NGS testing rate by year of mPC and aUC diagnosis using Clopper-Pearson 2-sided 95% CIs and (2) time to NGS testing, which considered death as a competing risk. Cumulative incidence functions were estimated for time to NGS testing. Disparities in subdistributional incidence of NGS testing were assessed by race and ethnicity, SES, region, insurance type, and sex (for aUC) using the Fine-Gray modified Cox proportional hazards model, assuming different subdistribution baseline hazards by year of mPC and aUC diagnosis. A total of 11 927 male patients with mPC (167 Asian [1.6%], 1236 Black [11.6%], 687 Hispanic or Latino [6.4%], 7037 White [66.0%], and 1535 other [14.4%] among 10 662 with known race and ethnicity) and 6490 patients with aUC (4765 male [73.4%]; 80 Asian [1.4%], 283 Black [4.8%], 257 Hispanic or Latino [4.4%], 4376 White [74.9%], and 845 other [14.5%] among 5841 with known race and ethnicity) were eligible and included. Both cohorts had a median age of 73 years (IQR, 66-80 years), and most underwent NGS testing before first-line treatment in the mPC cohort (1502 [43.0%]) and before second-line treatment in the aUC cohort (1067 [51.3%]). In the mPC cohort, the rates of NGS testing increased from 19.0% in 2015 to 27.1% in 2022, but Black patients (hazard ratio [HR], 0.75; 95% CI, 0.67-0.84) and Hispanic or Latino patients (HR, 0.70; 95% CI, 0.60-0.82) were less likely to undergo NGS testing. Patients with mPC who had low SES (quintile 1: HR, 0.74 [95% CI, 0.66-0.83]; quintile 2: HR, 0.89 [95% CI, 0.80-0.99]), had Medicaid (HR, 0.53; 95% CI, 0.38-0.74) or Medicare or other government insurance (HR, 0.89; 95% CI, 0.82-0.98), or lived in the West (HR, 0.81; 95% CI, 0.70-0.94) also were less likely to undergo testing. In the aUC cohort, the NGS rate increased from 14.1% in 2015 to 46.6% in 2022, but Black patients (HR, 0.76; 95% CI, 0.61-0.96) and those with low SES (quintile 1: HR 0.77 [95% CI, 0.66-0.89]; quintile 2: HR, 0.87 [95% CI, 0.76-1.00]) or Medicaid (HR, 0.72; 95% CI, 0.53-0.97) or Medicare or other government insurance (HR, 0.88; 95% CI, 0.78-0.99) were less likely to undergo NGS testing. Patients with aUC living in the South were more likely to undergo testing (HR, 1.29; 95% CI, 1.12-1.49). These findings suggest that although NGS tumor testing rates improved over time, the majority of patients still did not undergo testing. These data may help with understanding current disparities associated with NGS testing and improving access to standard-of-care health care services.

Racial and ethnic disparities in severe maternal morbidity from pregnancy through 1-year postpartum

BACKGROUNDPrevious studies examining racial and ethnic disparities in severe maternal morbidity (SMM) have mainly focused on intrapartum hospitalization. There is limited information regarding the racial and ethnic distribution of SMM occurring in the antepartum and postpartum periods, including SMM occurring beyond the traditional 6 weeks postpartum period. OBJECTIVETo examine the racial and ethnic distribution of SMM during antepartum, intrapartum, and postpartum hospitalizations through 1-year postpartum, overall and stratified by maternal sociodemographic factors, and to estimate the percent increase in SMM by race and ethnicity and maternal sociodemographic factors within each racial and ethnic group after accounting for both antepartum and postpartum SMM through 1-year postpartum rather than just SMM occurring during the intrapartum hospitalization. STUDY DESIGNWe conducted a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008–2020. We examined the distribution of non-transfusion SMM and total SMM per 10,000 cases during antepartum, intrapartum, and postpartum hospitalizations through 365 days postpartum by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. We subsequently examined “SMM cases added” by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. The “SMM cases added” represent cases among unique individuals that are identified by considering the antepartum and postpartum periods but that would be missed if only the intrapartum hospitalization cases were included. RESULTSAmong 2,584,206 birthing individuals, a total of 37,112 (1.4%) individuals experienced non-transfusion SMM and 64,661 (2.5%) experienced any SMM during antepartum, intrapartum, and/or postpartum hospitalization. Black individuals had the highest rate of antepartum, intrapartum, and postpartum non-transfusion and total SMM followed by American Indian individuals. Asian individuals had the lowest rate of non-transfusion and total SMM during antepartum and postpartum hospitalizations while White individuals had the lowest rate of non-transfusion and total SMM during the intrapartum hospitalization. Black individuals were 1.9 times more likely to experience non-transfusion SMM during the intrapartum hospitalization than White individuals, which increased to 2.8 times during the antepartum period and to 2.5 times during the postpartum period. Asian and Hispanic individuals were less likely to experience SMM in the postpartum period than White individuals. Including antepartum and postpartum hospitalizations resulted in disproportionately more cases among Black and American Indian individuals than among White, Hispanic, and Asian individuals. The additional cases were also more likely to occur among individuals with lower educational levels and individuals on government insurance. CONCLUSIONRacial disparities in SMM are underreported in estimates that focus on the intrapartum hospitalization. Additionally, individuals with low socio-economic status bear the greatest burden of SMM occurring during the antepartum and postpartum periods. Approaches that focus on mitigating SMM during the intrapartum period only do not address the full spectrum of health disparities.El resumen está disponible en Español al final del artículo.

Prescribing patterns of statins and associated factors among type 2 diabetes mellitus patients in Africa: A systematic review and meta-analysis

BackgroundIn sub-Saharan African nations, there's a documented shortfall in the utilization of statins, despite established clinical guidelines advocating their use for reducing cardiovascular risks and overall mortality among Type 2 diabetes patients aged 40–75 years old. Most clinical guidelines recommend prescribing statins to individuals with type 2 diabetes to reduce the chances of cardiovascular disease. There is currently a lack of extensive research on statin utilization specifically for primary prevention of cardiovascular disease in Africa. Thus, this study aimed to assess the prescription patterns of statins for preventing cardiovascular disease in type 2 diabetes patients. MethodsThe findings of the review were presented following the guidelines outlined in the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-2020) checklist. We conducted searches on electronic databases including PubMed, EMBASE, Cochrane Library, Science Direct, African Journal Online, and Google Scholar. This systematic review and meta-analysis included articles that met specific inclusion criteria: observational studies such as cross-sectional, cohort, and case-control studies focusing on determinants, risk factors, or correlates associated with statin prescription within Africa. Only published articles up to June 2, 2024, published in English, and conducted in either community or healthcare facility settings were considered. Data import was initially conducted using Microsoft Excel, and statistical analysis was performed using STATA software. Cochran's Q test was employed to assess whether there was a significant variance in prevalence among the studies. Additionally, the I2 statistic was utilized to quantify the extent of heterogeneity. A funnel plot, a visual tool, was utilized to evaluate publication bias. ResultsThe search strategy resulted in 7695 published original articles. The full texts of the 89 papers were assessed for eligibility and quality. Moreover, some articles were rejected due to inaccuracies in the outcome variable. Ultimately, only ten studies focusing on the prevalence of statin prescription were examined. The research suggests that the pooled prevalence of statin prescription among Type 2 diabetic individuals in Africa is found to be 48.82% (95% CI: 35.41–63.24). Age greater than 65 years (AOR = 3.56, 95% CI: 1.70–7.45; I2 = 54.7%), comorbidity (AOR = 1.13, 95% CI: 0.27–4.63, I2 = 96.4%), dyslipidemia (AOR = 3.15, 95% CI: 1.54–6.44, I2 = 61.7%), DM duration greater than ten years (AOR = 1.36, 95% CI: 0.81–2.28, I2 = 77.3%), and government insurance (AOR = 8.85, 95% CI: 2.72–28.76, I2 = 81.5%) were factors associated with statin prescription among type 2 diabetic patients. ConclusionsIn general, the extent of statin prescriptions for individuals with type 2 diabetes who are eligible for statin therapy was below the target outlined by clinical practice guidelines. Being over 65 years old, having comorbidities, experiencing dyslipidemia, having type 2 diabetes for more than ten years, and having government insurance were all identified as independent factors predicting the prescription of statins. This finding is concerning and underscores the urgent need to enhance adherence to clinical practice guidelines for the well-being of this vulnerable population at high risk.

Intersectional collaboration and the development of prevention infrastructures: a qualitative study

PurposeInvesting in prevention could be of great benefit to public health. Especially for people with health risks, such as overweight, depressive symptoms, low social-economic status or people who experience loneliness or a sedentary lifestyle. In the Netherlands, different parties are responsible for financing and organising selective and indicated preventive interventions: the government, municipalities and health insurance companies. The aim of this study was two-fold: First, to describe the transition towards a sustainable prevention infrastructure. And second, to gain insight into barriers and facilitators associated with intersectoral collaboration regarding organising prevention for high-risk groups.Design/methodology/approachA longitudinal qualitative study was conducted among collaborative networks working together to build a prevention infrastructure. During a five-year study period, 86 semi-structured interviews were held. The COM-B model was used for data analysis.FindingsBarriers to intersectoral collaboration are: unknown (cost-)effectiveness, limited incentives to invest in collaboration, lack of clarity about responsibilities, differences in priorities and organisational culture between municipalities and health insurers. Facilitators are commitment, trust, sharing knowledge between parties, meeting regularly within the network and acknowledgement of mutual responsibilities. Also, national policy interventions targeted at the development of regional prevention infrastructures facilitated collaboration.Originality/valueThis study shows that collaboration regarding prevention is becoming increasingly common. It can be concluded that the transition towards a sustainable prevention infrastructure has started. The relationship between key stakeholders, like municipalities and health insurers, is generally stronger than it was five years ago. They have a better understanding of each other’s interests and expectations.

Combining developmental and sleep health measures for autism spectrum disorder screening: an ECHO study.

Sleep problems are reported for up to 80% of autistic individuals. We examined whether parsimonious sets of items derived from the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R) and the Brief Infant Sleep Questionnaire (BISQ) are superior to the standard M-CHAT-R in predicting subsequent autism spectrum disorder (ASD) diagnoses. Participants from 11 Environmental influences on Child Health Outcomes (ECHO) cohorts were included. We performed logistic LASSO regression models with 10-fold cross-validation to identify whether a combination of items derived from the M-CHAT-R and BISQ are superior to the standard M-CHAT-R in predicting ASD diagnoses. The final sample comprised 1552 children. The standard M-CHAT-R had a sensitivity of 44% (95% CI: 34, 55), specificity of 92% (95% CI: 91, 94), and AUROC of 0.726 (95% CI: 0.663, 0.790). A higher proportion of children with ASD had difficulty falling asleep or resisted bedtime during infancy/toddlerhood. However, LASSO models revealed parental reports of sleep problems did not improve the accuracy of the M-CHAT-R in predicting ASD diagnosis. While children with ASD had higher rates of sleep problems during infancy/toddlerhood, there was no improvement in ASD developmental screening through the incorporation of parent-report sleep metrics. Parental-reported sleep problems are common in autism spectrum disorder (ASD). We investigated whether the inclusion of parental-reports of infant/toddler sleep patterns enhanced the effectiveness of developmental screening for autism. We reported higher rates of difficulty falling asleep and resisting bedtime during infancy and toddlerhood among children later diagnosed with ASD; however, we did not find an improvement in ASD developmental screening through the incorporation of parent-report sleep metrics. In our sample, the standard M-CHAT-R had a sensitivity of 39% among children of mothers with government insurance compared with a sensitivity of 53% among children of mothers with employer-based insurance.

Experiences of Multiple Myeloma Patients With Treatment in the Palestinian Practice: A Multicenter Qualitative Study in a Resource-Limited Healthcare System.

Background Multiple myeloma is a crippling cancer that puts a significant strain on patients and their families alike. The long and exhausting treatment journey with the disease is challenging not only for patients but also for healthcare systems. This exploratory study was conducted to look into these patients' experiences with their treatment and explore their recommendations and views to improve the Palestinian healthcare system, which can be viewed as an evolving healthcare system within a resource-limited and developing country. Methods The consolidated criteria for reporting qualitative research (COREQ) checklist was used for conducting this multicenter exploratory qualitative study. A total number of eight patients with multiple myeloma who received treatment in the Palestinian healthcare system participated in semi-structured in-depth interviews. The semi-structured in-depth interviews followed a set interview schedule. Thematic analysis of the data was done using the qualitative interpretive description approach. Results A total of 5.48 h (329 min) of total interview time was analyzed. Among the patients, 6 (75%) were males, 5 (63.5%) lived in urban areas, 5 (62.5%) reported satisfaction with their household income, 6 (75%) underwent bone marrow transplantation, and all of them (100%) had governmental insurance. The qualitative data that emerged after analysis were classified into three major themes and multiple sub-themes. The three major themes were: (1) treatment side effects, (2) factors affecting treatment experience, and (3) recommendations to improve healthcare service. Conclusion The results of this qualitative study offer insight into how people with multiple myeloma view the healthcare system in Palestine and shed light on the variable and challenging experiences with their treatment, side effects, and communication with healthcare providers within the context of a resource-limited and developing country. Future research should involve hemato-oncology doctors and benefit from their expertise in the field.

Influence on surgical approach in hepatocholangiocarcinoma: A demographic and socioeconomic analysis.

e16280 Background: Hepatocholangiocarcinoma (HCC-CC) is a rare and aggressive malignancy of the liver that contains histopathological features of both hepatocellular carcinoma and cholangiocarcinoma. Surgery is the mainstay of treatment, and the surgical approaches used include radical hepatic resection, laparoscopic, and robotic surgery. There has yet to be a study that explores the impact of demographic features on the choice of surgical modality in patients with HCC-CC. The National Cancer Database (NCDB) was analyzed to determine the effects of demographic features on surgical modality and overall survival. Methods: A retrospective cohort analysis utilizing the NCDB included 2,449 patients diagnosed with HCC-CC (ICD-8180/3) between 2004-2020. Surgical modality was categorized into either open or minimally invasive by the preliminary treatment. Minimally invasive techniques included robotic-assisted and minimally invasive. Race, sex, age at diagnosis, income level, insurance used, distance from the facility, and the status of the facility as an academic center on the surgical modality were compared using Pearson Chi-squared tests or independent samples t-test as pertinent. Multivariate analysis with binary logistic regression was used to analyze the following categorical variables in relation to choice of surgical modality: race, sex, income, insurance, sex, and facility type. Surgical treatment modality on overall survival was analyzed by the Kaplan-Meier method. Exclusion criteria included missing data. Results: Most cases analyzed were White (75.8%), male (67.5%), and had government insurance as the primary payor at diagnosis (60.6%). Of the cases analyzed, 625 underwent surgery (25.5%). Patients who underwent minimally invasive surgery were more likely to be government-insured than patients who underwent open surgery (69.8% vs. 55.6%, P &lt; 0.05). Patients who underwent open surgery were younger on average (61.4 vs. 66.0 years, P &lt; 0.05). There was no significant difference in distance from residence to the treatment facility between the two surgical approaches. Multivariate analysis showed that patients treated at academic centers were less likely to receive minimally invasive surgery (28.1%) over open surgery (71.9%; P = 0.041, 95% CI 0.469-0.985) without statistical significance for race, sex, income, or insurance. The average survival time was significantly longer in open vs minimally invasive surgery (67.9 vs. 55.3 months, P &lt; 0.05). Conclusions: We identified that patients who underwent open surgery had significantly better overall survival with an average difference of 12.6 months. Even after accounting for other factors, the choice of surgical modality was significantly influenced by treatment at an academic institution. Patients receiving care at an academic facility are more likely to receive open surgery leading to overall increased survival.

Examining disparities in the receipt of curative treatment for hepatocellular cancer (HCC): A multicenter retrospective study from 2016-2023.

1582 Background: Prior studies suggested disparities in hepatocellular cancer (HCC) treatment and outcomes based on region, race, and socioeconomic status. After the implementation of the Affordable Care Act, including Michigan’s Medicaid Expansion in 2014, there’s increased interest in how these changes affect HCC care. The study examines factors influencing curative treatment receipt and existing disparities, as a step toward intervention strategies. Methods: This is a retrospective study of HCC patients at 6 community-based (4 university-affiliated) hospitals, in Michigan from Jan 2016-Sep 2023. Patients without imaging or histologic confirmation were excluded. Factors associated with receiving curative treatment were determined using both univariate and multivariable logistic regressions. Analysis was done using SPSS 28, with a p-value&lt;0.05 indicating statistical significance. Results: Of 680 HCC patients screened, 347 were analyzed. The mean age was 70 years, and 71% were male. 78.3% were White and 16.9% Black. 53.9% had private insurance and 35% had government insurance. Primary HCC etiologies were alcohol and hepatitis C virus (HCV) infection; 74.4% had cirrhosis. Barcelona Clinic Liver Cancer (BCLC) stages varied: A (10.6%), B (28.2%), C (36.4%), and D (24.8%). 59.4% underwent curative treatment (4.6% resection, 30.3% liver-directed, 13.3% systemic, 10.1% combination), while 38.3% had best supportive care. Univariate analysis identified many factors associated with receipt of curative treatment, including race (White&gt;Black), insurance (private&gt;government), earlier BCLC stages, ECOG 0/1/2, Child-Pugh A, lower MELD-Na score (mean=12), &lt;400 alpha-fetoprotein levels, and better liver function (Bilirubin, INR, albumin). Tumor characteristics, such as smaller size, absence of metastasis, and absence of portal vein thrombosis, were also associated with receipt of curative treatment. Overall, the one-year survival rate was 64% for those who had curative treatment and 35% for best supportive care. All with p-value&lt;0.05. Multivariable analysis showed Black patients (OR: 0.21, CI: 0.051-0.881) with larger tumors (OR:0.89, CI: 0.783-1.00) and lower albumin levels (OR:3.81, CI: 1.649-8.805) at presentation were less likely to receive curative treatment than White. Black patients were also diagnosed at a younger age (66.7 vs. 71.0 years, p=0.01), more advanced BCLC stages C/D (74% vs. 57%, p=0.04) on presentation, and HCV coinfection (58% vs. 32%, p&lt;0.001) than White. Median survival for Black and White were 757 days and 823 days, respectively (p=0.89). Conclusions: Black patients with larger tumors and low albumin are less likely to receive curative treatment than White. HCV coinfection in the Black population suggests a focus area for early intervention. Further investigation of HCC disparities across various settings is warranted.

Sociodemographic factors leading to preventable emergency department visits after bariatric surgery: a single-institution analysis

BackgroundAn important quality benchmark after bariatric surgery is 30-day emergency department (ED) visits. ObjectivesWe aimed to identify risk factors for ED visits not requiring readmission and thus deemed preventable. SettingUniversity Hospital. MethodsPatients who underwent a minimally invasive sleeve gastrectomy between 2017 and 2022 at a single institution were identified. Among these patients, those who presented to the ED within 30 days after surgery were matched 3:1 to controls. Sociodemographic and clinical variables were collected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database and the electronic medical record. Univariate conditional logistic regression analysis was performed to determine predictive factors of ED visits. ResultsOverall, 648 patients underwent sleeve gastrectomy, of which 53 (8.2%) presented to the ED within 30 days postoperatively without requiring readmission. Patients who presented to the ED were more likely to be unemployed (42% versus 24%, P = .04) and have government insurance (68% versus 41%, P = .001). Significant risk factors included lower versus upper socioeconomic bracket (odds ratio [OR] 3.6, P = .042), primary care physician (PCP) outside the health system versus within (OR 2.15, P = .032), greater number of PCP visits within the past year (OR 1.27, P < .001), and greater number of postoperative clinic phone calls (OR 2.04, P < .001). The number of ED visits within 1 year before surgery was a significant risk factor, with an OR of 1.44 for each visit (P < .001). ConclusionsModifiable and unmodifiable risk factors contribute to ED visits after bariatric surgery. Identifying these risk factors can aid in the development of quality improvement initiatives.

Access to palliative care in patients with multiple myeloma in the USA: A National Cancer Database (NCDB) analysis of years 2004-2020.

7563 Background: Palliative care (PC) can improve the quality of life for patients with multiple myeloma (MM). Despite its recognized importance, research gaps persist in understanding factors influencing PC accessibility and utilization, particularly in the diverse MM patient landscape in the real-world setting. This study explores potential associations between race, ethnicity, socioeconomic factors, and PC access for MM patients in the USA. Methods: Utilizing the NCDB, we identified 202,949 MM patients diagnosed from 2004 to 2020. Multivariate logistic regression analysis was conducted with SAS version 9.4, to determine independent factors predicting PC access. Results: Analysis of 202,949 MM patients revealed notable disparities for access to PC. Female patients exhibited lower PC odds (OR: 0.94, p &lt; 0.0001) compared to male patients, as did Black patients (OR: 0.80, p &lt; 0.0001) and other racial groups (OR: 0.84, p &lt; 0.0001) compared to White patients. Hispanic ethnicity was associated with lower PC utilization odds (OR: 0.84, p &lt; 0.0001) compared to non-Hispanics. Earlier years (2004-2007) showed higher PC odds (OR: 1.12, p &lt; 0.0001), while subsequent years (2008-2011, 2012-2015) exhibited lower odds (OR: 0.93, p = 0.0009; OR: 0.87, p &lt; 0.0001, respectively) compared to the most recent years (2016-2020). Academic settings had lower PC odds than non-academic facilities (OR: 0.78, p &lt; 0.0001). Insurance status varied, with no insurance (OR: 1.40, p &lt; 0.0001), Medicaid (OR: 1.17, p &lt; 0.0001), and other government insurance (OR: 1.38, p &lt; 0.0001) linked to higher PC odds compared to private insurance. Lower annual household incomes (&lt;$38,000, $38,000-$47,999, $48,000-$62,999) had increased PC odds compared to higher incomes (&gt;$63,000) (all p &lt; 0.0001). Areas with a higher percentage of individuals without a high school degree exhibited lower PC odds, notably 21% (OR: 0.83, p &lt; 0.0001) and 13.0%-20.9% (OR: 0.94, p = 0.0222) compared to &lt;7.0% without a high school degree. Greater distance (&gt;30 miles) reduced PC odds compared to shorter distance (&lt;10 miles) to treatment facility (OR: 0.83, p &lt; 0.0001). A Charlson-Deyo score of 1 increased PC odds compared to a score of 0 (OR: 1.12, p &lt; 0.0001). Conclusions: Our real-world analysis reveals substantial disparities in MM patients’ PC access and utilization. Female patients and minority groups (Blacks and Hispanics) face significant challenges. The dynamic trends over time and socioeconomic impacts underscore the need for integrating PC and targeted interventions for overall MM patient well-being. Our findings pave grounds for future prospective studies.

The positive impact of Medicaid expansion on melanoma stage at presentation.

1533 Background: This study aims to evaluate the impact of the Affordable Care Act Medicaid expansion on melanoma stage at presentation. Methods: 12,667 non-elderly patients (age 40-64) who were newly diagnosed with melanoma and known Medicaid expansion status were identified from The National Cancer Database. We excluded patients with private insurance, Medicare, or other government or unknown insurance. The time period for the cohort spanned from 2010 to 2020 which includes pre-expansion (2010-2013) and post-expansion periods (2014-2020). Year-to-year trend analysis and difference-in-difference (DID) analysis was performed to analyze tumor staging between states with Medicaid expansion (MES) and without Medicaid expansion (non-MES) before and after the expansion. Results: Out of the 12,667 melanoma patients (56% male, 95% white), 41% of patients were uninsured and 59% had Medicaid during 2010 to 2020. The percentage of patients without insurance decreased significantly from 51% in 2010 to 16% in 2020. There were 21% of patients with stage III and 18% with stage IV melanoma. The trend of melanoma stage at presentation over the study period was shown (Table). Notably, the stage IV melanoma at presentation decreased from 21% to 17% from 2010 to 2020 in MES. In contrast, stage IV melanoma at presentation increased from 20% to 23% over the same period of time in non-MES. After adjusting for confounders, DID analysis revealed a statistically significant decrease in stage IV melanoma at presentation (DID -0.04, p &lt; 0.001) as well as a statistically significant decrease in 3 year mortality (DID -0.05, p &lt; 0.001) between MES and non-MES before and after Medicaid expansion. In addition, the use of immunotherapy in stage IV melanoma in MES was significantly higher than non-MES (47% vs 41%, p &lt; 0.001). Conclusions: The findings reveal the positive impact of Medicaid expansion on melanoma stage at presentation and suggest that improved access to healthcare services can facilitate diagnosing early-stage melanoma and decreasing mortality rate. Despite these findings, there are still 16% of patients who still do not have insurance in 2020 which indicates that continued effort is needed to improve the outcomes of these uninsured patients.[Table: see text]

Out-of-Pocket Expenditure for Selected Surgeries in the Cardiology Department for Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), Private Health Insurance, and Uninsured Patients in a Tertiary Care Teaching Hospital in Karnataka, India.

Cardiovascular diseases are a major public health issue and the leading cause of mortality globally. The global economic burden of out-of-pocket expenditure (OOPE) for cardiovascular surgeries and procedures is substantial, with average costs being significantly higher than other treatments. This imposes a heavy economic burden. Government insurance schemes like Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) aim to enhance affordability and access to cardiac care. This retrospective study analyzed OOPE incurred for top cardiac surgeries under AB-PMJAY, private insurance, and uninsured patients at a tertiary care teaching hospital in Karnataka. Data of 1021 patients undergoing common cardiac procedures from January to July 2023 were analyzed using descriptive statistics (mean, median) and the Shapiro-Wilk test for normality. The study aims to evaluate financial risk protection offered by AB-PMJAY compared to private plans and inform effective policy-making in reducing the OOPE burden for surgeries in India. The study analyzed OOPE across 1021 patients undergoing any of four surgeries at a tertiary care teaching hospital in Karnataka. AB-PMJAY patients incurred zero OOPE across all surgeries. Uninsured patients faced the highest median OOPE, ranging from ₹1,15,292 (1390.57 USD) to ₹1,72,490 (2080.45 USD) depending on surgery type. Despite the presence of private insurance, the median out-of-pocket expenditure ranged from ₹1,689 (20.38 USD) to ₹68,788 (829.67 USD). Significant variations in OOPE were observed within different payment groups. Private insurance in comparison with AB-PMJAY had limitations like co-payments, deductibles, and limited coverage resulting in higher OOPE for patients. The results illustrate the efficacy of AB-PMJAY in reducing the financial burden and improving the affordability of cardiac procedures compared to private insurance. This emphasizes the significance of programmmes funded by the government in reducing the OOPE burden and ensuring equitable healthcare access. The comprehensive and particular estimates of OOPE for different surgical procedures, categorized by payment methods provide valuable information to guide the development of policies that aim to reduce OOPE and progress towarduniversal health coverage in India.

Study on Universal Health Coverage Scheme in India – The Stumper to Private Hospitals

Background Many governments have introduced health insurance schemes for the poor sections of society to save them from catastrophic health expenditure. Private hospitals play a key role in India, as they are in significant number in secondary and tertiary care services. Private hospitals have to fund their infrastructure, staff salaries from the revenue of previous year. In this study, we compared money received by a private medical college hospital bed through government insurance scheme patient and private paying patient. Methods Observational study, comparing money reimbursed for top ten procedures treated in private medical college hospitals by Ayushman Bharat (AB) fund and the price offered by a paying patient in similar bed. Results On average 600 patients received medical care through the AB scheme per month at our tertiary care super-specialty hospital. Highest numbers were seen in specialties like cardiovascular, and cancer treatments and infectious diseases under general medicine specialty. The costs considered were surgeon’s cost, medicines, devices, and hospitalization costs. The laparoscopic procedures were incurring a loss of 130%, knee replacements about 50%, coronary bypass grafting thankfully due to controlling of prices by central government is incurring a loss of 10%. The package amount offered accounts to 26–52% only of the costs incurred by the private hospitals. Conclusion The private academic hospitals need 25% to 50% more than current prices offered, across various procedures.

Race, partisanship, and the distinctiveness of vaccine hesitancy in health care attitudes

ABSTRACT Partisanship has served a dominant role in influencing public opinion on health reform in the United States in the past decade. Republicans are significantly less supportive than Democrats of expanding the Affordable Care Act and implementing broader government insurance provisions. With the onset of the pandemic, partisan divisions have also spilled over into polarized attitudes on public health measures to curb the spread of COVID-19 and vaccine uptake. The influence of partisanship should not be overstated, however, particularly when examining public opinion across racial groups. Black Americans were among the strongest proponents of health reform during the passage of the Affordable Care Act, and they remained strong supporters of Democratic-led proposals to expand health insurance access and of many public health measures to curb the spread of COVID-19. But high levels of Democratic partisanship alone cannot explain the dynamics of Black public opinion on vaccination, an issue for which Black Democrats consistently show more skepticism than white Democrats. Using multiple sources of nationally representative survey data from 2016 to 2022, this study illustrates how self-interest and racialized experiences with the government and the health care system help explain the distinctive racial divide in vaccination attitudes.