Medicaid Analytic eXtract Research Articles

Hydroxychloroquine early in pregnancy and risk of birth defects

BackgroundHydroxychloroquine is generally considered safe in pregnancy for the treatment of rheumatic conditions, but studies have been too small to evaluate teratogenicity. Quantifying the risk of congenital malformations associated with early pregnancy exposure to hydroxychloroquine is important in both the context of its ongoing use for rheumatological disorders and its potential future use for coronavirus disease 2019 prophylaxis, for which a number of clinical trials are ongoing despite initial trials for coronavirus disease 2019 treatment having been negative.ObjectiveThe study objective was to evaluate the risk of major congenital malformations associated with exposure to hydroxychloroquine during the first trimester of pregnancy, the period of organogenesis.Study DesignWe performed a population-based cohort study nested in the Medicaid Analytic eXtract (MAX, 2000–2014) and IBM MarketScan Research Database (MarketScan, 2003–2015). The source cohort included 2045 hydroxychloroquine-exposed pregnancies and 3,198,589 pregnancies not exposed to hydroxychloroquine continuously enrolled in their respective insurance program for 3 months before the last menstrual period through at least 1 month after delivery; infants were enrolled for at least 3 months after birth. We compared the risk of congenital malformations in women using hydroxychloroquine during the first trimester of pregnancy with that of those not using hydroxychloroquine, restricting the cohort to women with rheumatic disorders and using propensity score matching to control for indication, demographics, medical comorbidities, and concomitant medications (1867 hydroxychloroquine-exposed pregnancies and 19,080 pregnancies not exposed to hydroxychloroquine). The outcomes considered included major congenital malformations diagnosed during the first 90 days after delivery and specific malformation types for which there were at least 5 exposed events: oral cleft, cardiac, respiratory, gastrointestinal, genital, urinary, musculoskeletal, and limb defects.ResultsOverall, 54.8 per 1000 infants exposed to hydroxychloroquine were born with a major congenital malformation versus 35.3 per 1000 unexposed infants, corresponding to an unadjusted relative risk of 1.51 (95% confidence interval, 1.27–1.81). Patient characteristics were balanced in the restricted, propensity score–matched cohort. The adjusted relative risk was 1.26 (95% confidence interval, 1.04–1.54); it was 1.33 (95% confidence interval, 1.08–1.65) for a daily dose of ≥400 mg and 0.95 (95% confidence interval, 0.60–1.50) for a daily dose of <400 mg. Among the different malformation groups considered, more substantial increases in the risk of oral clefts, respiratory anomalies, and urinary defects were observed, although estimates were imprecise. No pattern of malformation was identified.ConclusionOur findings suggest a small increase in the risk of malformations associated with first-trimester hydroxychloroquine use. For most patients with autoimmune rheumatic disorders, the benefits of treatment during pregnancy will likely outweigh this risk. If hydroxychloroquine were shown to be effective for coronavirus disease 2019 prophylaxis in ongoing trials, the risk of malformations would need to be balanced against such benefits.

Association Between Congenital Cytomegalovirus and the Prevalence at Birth of Microcephaly in the United States

Congenital cytomegalovirus (cCMV) has received far less clinical and public health attention as a teratogenic infection than the Zika virus epidemic. However, cCMV may be responsible for a large fraction of microcephaly cases in the United States. To evaluate the association between cCMV and the prevalence at birth of microcephaly in the United States. This population-based cohort study included pregnant women and their newborns identified in 2 insurance claims databases from the United States: Medicaid Analytic eXtract (January 1, 2000, to December 31, 2013) and IBM Research MarketScan, a database for employer-sponsored private health insurance (January 1, 2011, to September 30, 2015). All pregnancies that resulted in live births in women with full health benefits were included. Analysis began June 2016 and ended May 2020. Congenital cytomegalovirus infection documented in inpatient or outpatient newborn claims records. The primary outcome was microcephaly at birth documented in inpatient or outpatient newborn and/or maternal claims records. Cases with chromosomal abnormalities or neural tube defects were excluded. The association between cCMV and microcephaly was estimated in the pooled cohort using prevalence ratios (PRs) and 95% CIs. In the pooled cohort of 2 338 580 pregnancies (2 075 410 pregnancies [88.7%] were among women younger than 35 years), 336 infants (0.014%) had a cCMV diagnosis. The prevalence of microcephaly among newborns with and without a cCMV diagnosis was 655 and 2.8 per 10 000 live births, respectively (PR, 232; 95% CI, 154-350). After restricting to CMV-tested newborns (572 [0.024%]) to correct for preferential testing of infants with microcephaly, the PR was 15 (95% CI, 5.2-41). However, this PR is biased if other cCMV-related outcomes (eg, hearing loss) trigger testing because cCMV prevalence in tested infants, with ([46%]) or without microcephaly (22 of 559 [3.9%]), would overestimate that in the source population. Therefore, the prevalence of cCMV in overall infants with microcephaly (22 of 669 [3.2%]) was compared with that from an external unbiased sample of US infants screened at birth (449 of 100 332 [0.45%]) to estimate a PR of 7.4 (95% CI, 4.8-11.5) as a conservative lower bound. Congenital cytomegalovirus infection increases the prevalence of microcephaly at birth by at least 7-fold. Prevention of CMV infection during pregnancy might substantially reduce the number of newborns with microcephaly and other cCMV-related outcomes in the United States.

Vaso-occlusive crises and costs of sickle cell disease in patients with commercial, Medicaid, and Medicare insurance – the perspective of private and public payers

Aim To characterize vaso-occlusive crises (VOCs) and describe healthcare costs among commercially-insured, Medicaid-insured, and Medicare-insured patients with sickle cell disease (SCD). Materials and methods The IBM Truven Health MarketScan Commercial (2000–2018), Medicaid Analytic eXtract (2008–2014), and Medicare Research Identifiable Files (2012–2016) databases were used to identify patients with ≥2 SCD diagnoses. Study measures were evaluated during a 12-month follow-up period, stratified by annual number of VOCs (i.e. 0, 1, and ≥2). Results Among 16,092 commercially-insured patients (mean age = 36.7 years), 35.3% had 1+ VOCs. Mean annual total all-cause healthcare costs were $15,747, $27,194, and $64,555 for patients with 0, 1, and 2+ VOCs, respectively. Total all-cause healthcare costs were mainly driven by inpatient (0 VOC = 31.0%, 1 VOC = 53.1%, 2+ VOCs = 65.4%) and SCD-related costs (0 VOC = 56.4%, 1 VOC = 78.4%, 2+ VOCs = 93.9%). Among 18,287 Medicaid-insured patients (mean age = 28.5 years, fee-for-service = 50.2%), 63.9% had 1+ VOCs. Mean annual total all-cause healthcare costs were $16,750, $29,880, and $64,566 for patients with 0, 1, and 2+ VOCs, respectively. Inpatient costs (0 VOC = 37.2%, 1 VOC = 64.3%, 2+ VOCs = 72.9%) and SCD-related costs (0 VOC = 60.9%, 1 VOC = 73.8%, 2+ VOCs = 92.2%) accounted for a significant proportion of total all-cause healthcare costs. Among 15,431 Medicare-insured patients (mean age = 48.2 years), 55.1% had 1+ VOCs. Mean annual total all-cause healthcare costs were $21,877, $29,250, and $58,308 for patients with 0, 1, and ≥2 VOCs, respectively. Total all-cause healthcare costs were mainly driven by inpatient (0 VOC = 47.9%, 1 VOC = 54.9%, 2+ VOCs = 67.5%) and SCD-related costs (0 VOC = 74.9%, 1 VOC = 84.4%, 2+ VOCs = 95.3%). Limitations VOCs managed at home were not captured. Analyses were descriptive in an observational setting; thus, no causal relationships can be inferred. Conclusions A high proportion of patients experienced VOCs across payers. Furthermore, inpatient and SCD-related costs accounted for a significant proportion of total all-cause healthcare costs, which increased with VOC frequency.

Validation of algorithms to estimate gestational age at birth in the Medicaid Analytic eXtract-Quantifying the misclassification of maternal drug exposure during pregnancy.

Accurate ascertainment of gestational age (GA) has been a challenge in perinatal epidemiologic research. To date, no study has validated GA algorithms in Medicaid Analytic eXtract (MAX). We linked livebirths of mothers enrolled in Medicaid ≥30 days after delivery in 1999-2010 MAX to state birth certificates. We used clinical/obstetric estimate of gestation on the birth certificates as gold standard to validate claims-based GA algorithms. We calculated the proportions of deliveries with algorithm-estimated GA within 1-/2-weeks of the gold standard, the sensitivity, specificity, and positive/negative predictive value (PPV/NPV) of exposure to select medications during specific gestation windows, and quantified the impact of exposure misclassification on hypothetical relative risk (RR) estimates. We linked 1 336 495 eligible deliveries. Within 1-week agreement was 77%-80% overall and 47%-56% for preterm deliveries. The trimester-specific drug exposure status had high sensitivities and PPVs (88.5%-98.5%), and specificities and NPVs (>99.0%). Assuming a hypothetical RR of 2.0, bias associated with exposure misclassification during first trimester ranged from 10% to 40% under non-differential/differential misclassification assumptions. Claims-based GA algorithms had good agreement with the gold standard overall, but lower agreement among preterm deliveries, potentially resulting in biased risk estimated for pregnancy exposure evaluations.

Association of Selective Serotonin Reuptake Inhibitors With the Risk of Type 2 Diabetes in Children and Adolescents

Concerns exist that use of selective serotonin reuptake inhibitors (SSRIs) increases the risk of developing type 2 diabetes (T2D) in adults, but evidence in children and adolescents is limited. In the absence of a randomized clinical trial, evidence must be generated using real-world data. To evaluate the safety of SSRI use in children and adolescents with respect to the associated risk of T2D. This cohort study of patients aged 10 to 19 years with a diagnosis for an SSRI treatment indication was conducted within the nationwide Medicaid Analytic eXtract (MAX; January 1, 2000, to December 31, 2014) and the IBM MarketScan (January 1, 2003, to September 30, 2015) databases. Data were analyzed from November 1, 2018, to December 6, 2019. New users of an SSRI medication and comparator groups with no known metabolic adverse effects (no antidepressant exposure, bupropion hydrochloride exposure, or psychotherapy exposure). Within-class individual SSRI medications were compared with fluoxetine hydrochloride. Incident T2D during follow-up. Intention-to-treat effects were estimated using Cox proportional hazards regression models, adjusting for confounding through propensity score stratification. As-treated effects to account for continuous treatment were estimated using inverse probability weighting and marginal structural models. A total of 1 582 914 patients were included in the analysis (58.3% female; mean [SD] age, 15.1 [2.3] years). The SSRI-treated group included 316 178 patients in the MAX database (publicly insured; mean [SD] age, 14.7 [2.1] years; 62.2% female) and 211 460 in the MarketScan database (privately insured; mean [SD] age, 15.8 [2.3] years; 63.9% female) with at least 2 SSRI prescriptions filled, followed up for a mean (SD) of 2.3 (2.0) and 2.2 (1.9) years, respectively. In publicly insured patients, initiation of SSRI treatment was associated with a 13% increased hazard of T2DM (intention-to-treat adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.22) compared with untreated patients. The association strengthened for continuous SSRI treatment (as-treated aHR, 1.33; 95% CI, 1.21-1.47), corresponding to 6.6 (95% CI, 4.2-10.4) additional cases of T2D per 10 000 patients treated for at least 2 years. Adjusted HRs were lower in privately insured patients (intention-to-treat aHR, 1.01 [95% CI, 0.84-1.23]; as-treated aHR, 1.10 [95% CI, 0.88-1.36]). Findings were similar when comparing SSRI treatment with psychotherapy (publicly insured as-treated aHR, 1.44 [95% CI, 1.25-1.65]; privately insured as-treated aHR, 1.21 [95% CI, 0.93-1.57]), whereas no increased risk was observed compared with bupropion treatment publicly insured as-treated aHR, 1.01 [95% CI, 0.79-1.29]; privately insured as-treated aHR, 0.87 [95% CI, 0.44-1.70]). For the within-class analysis, no medication had an increased hazard of T2D compared with fluoxetine. These findings suggest that children and adolescents initiating SSRI treatment may be at a small increased risk of developing T2D, particularly publicly insured patients. The magnitude of association was more modest than previously reported, and the absolute risk was small. The potential small risk should be viewed in relation to the efficacy of SSRIs for its major indications in young patients.

Gabapentin in pregnancy and the risk of adverse neonatal and maternal outcomes: A population-based cohort study nested in the US Medicaid Analytic eXtract dataset.

Despite the widespread use, only sparse information is available on the safety of gabapentin during pregnancy. We sought to evaluate the association between gabapentin exposure during pregnancy and risk of adverse neonatal and maternal outcomes. Using the United States Medicaid Analytic eXtract (MAX) dataset, we conducted a population-based study of 1,753,865 Medicaid-eligible pregnancies between January 2000 and December 2013. We examined the risk of major congenital malformations and cardiac defects associated with gabapentin exposure during the first trimester (T1), and the risk of preeclampsia (PE), preterm birth (PTB), small for gestational age (SGA), and neonatal intensive care unit admission (NICUa) associated with gabapentin exposure early, late, or both early and late in pregnancy. Gabapentin-unexposed pregnancies served as the reference. We estimated relative risks (RRs) and 95% confidence intervals (CIs) using fine stratification on the propensity score (PS) to control for over 70 confounders (e.g., maternal age, race/ethnicity, indications for gabapentin, other pain conditions, hypertension, diabetes, use of opioids, and specific morphine equivalents). We identified 4,642 pregnancies exposed in T1 (mean age = 28 years; 69% white), 3,745 exposed in early pregnancy only (28 years; 67% white), 556 exposed in late pregnancy only (27 years; 60% white), and 1,275 exposed in both early and late pregnancy (29 years; 75% white). The reference group consisted of 1,744,447 unexposed pregnancies (24 years; 40% white). The adjusted RR for major malformations was 1.07 (95% CI 0.94-1.21, p = 0.33) and for cardiac defects 1.12 (0.89-1.40, p = 0.35). Requiring ≥2 gabapentin dispensings moved the RR to 1.40 (1.03-1.90, p = 0.03) for cardiac defects. There was a higher risk of preterm birth among women exposed to gabapentin either late (RR, 1.28 [1.08-1.52], p < 0.01) or both early and late in pregnancy (RR, 1.22 [1.09-1.36], p < 0.001), SGA among women exposed to gabapentin early (1.17 [1.02-1.33], p = 0.02), late (1.39 [1.01-1.91], p = 0.05), or both early and late in pregnancy (RR, 1.32 [1.08-1.60], p < 0.01), and NICU admission among women exposed to gabapentin both early and late in pregnancy (RR, 1.35 [1.20-1.52], p < 0.001). There was no higher risk of preeclampsia among women exposed to gabapentin after adjustment. Study limitations include the potential for residual confounding and exposure misclassification. In this large population-based study, we did not find evidence for an association between gabapentin exposure during early pregnancy and major malformations overall, although there was some evidence of a higher risk of cardiac malformations. Maternal use of gabapentin, particularly late in pregnancy, was associated with a higher risk of PTB, SGA, and NICUa.

Is the Generosity of Medicaid Home and Community‐Based Services Associated with Community Discharge from Skilled Nursing Facilities?

Research ObjectiveWhile most older adults receiving post‐acute care in skilled nursing facilities (SNFs) prefer to return home, many remain as nursing home (NH) long‐stayers due to lack of sufficient supports in the community. Discharge from SNF to the community may be particular challenging for Medicare‐Medicaid dually enrolled SNF users. Medicaid home and community‐based services (HCBS) have been expanding in the last few decades and could be an important source of community support for duals. The objective of this study was to examine whether the generosity of Medicaid HCBS is related to community discharge for dual SNF users.Study DesignNational Medicare enrollment and claims data, Medicaid Analytic eXtract (MAX), Minimum Data Set, and facility/county‐level public available data between 2010 and 2013 were linked. Eligible Medicare‐Medicaid dual beneficiaries and their SNF post‐acute admissions were identified. Generosity of Medicaid HCBS was measured at the county level based on MAX data and included metrics for breadth (ie, proportion of duals using HCBS services) and intensity (ie, average HCBS spending per user). Outcome was community discharge within 100 days of SNF admission (dichotomous). A linear probability model with SNF fixed‐effects and robust standard errors was estimated to examine the relationship between the likelihood of community discharge and HCBS generosity, accounting for individual‐level covariates (eg, sociodemographic characteristic, characteristics of index hospital stay, history of hospitalization, functioning status, and comorbidities). We further stratified the analysis by age, type of index hospitalization, and presence of Medicaid lesser‐of policy, a cost‐sharing policy that limits the reimbursement received by SNFs for taking care of duals.Population StudiedCommunity‐dwelling older duals with fee‐for‐service (FFS) Medicare and Medicaid benefits who were newly admitted to SNFs for post‐acute care between October 1, 2010, and September 30, 2013 (N = 224 236).Principal FindingsHCBS breadth and intensity varied substantially across counties and over time. Overall, 49.4% of the identified dual SNF residents were discharged to community within 100 days of SNF admission. After accounting for covariates and SNF fixed‐effects, we found that a 10 percentage‐point increase in HCBS breadth led to a 0.66 percentage‐point increase (P &lt; 0.01) in the likelihood of discharge among older dual SNF users, but we did not detect a significant relationship between HCBS intensity and community discharge. Stratified analyses suggested a positive relationship between community discharge and HCBS breadth only among duals over 85 years old (1.49 percentage‐point, P &lt; 0.01), and among those who had medical (vs surgical) index hospitalization (0.70 percentage‐point, P &lt; 0.05). A stronger effect was found for states without Medicaid lesser‐of policy (2.26 percentage‐point, P &lt; 0.05), compared to states with such a policy (0.53 percentage‐point, P &lt; 0.05).ConclusionsWe found that higher HCBS breadth but not intensity was related to a higher likelihood of community discharge with a relatively small effect size. The potentially meaningful effect was found among subgroups including the oldest old, people had medical index hospitalization, and states without Medicaid lesser‐off policy.Implications for Policy or PracticeWhile the effect of HCBS breadth on facilitating community discharge is modest in general, tailored HCBS policies to increase the coverage for targeted populations or in certain regions may be more effective in promoting community discharge.Primary Funding SourceNational Institutes of Health.

Does Medicaid Hcbs Generosity Influence Nursing Home Placement for Dually Eligible Adrd Patients?

Research ObjectiveOlder adults with Alzheimer’s disease and related dementias (ADRD) often receive informal care to support their community living. As the disease progresses, the physical and emotional toll it exacts on caregivers may become unsustainable, and nursing home (NH) placement may become necessary. Medicaid Home and Community‐Based Services (HCBS) programs provide various types of services to support community living for Medicaid enrollees, which may reduce or delay NH placement for ADRD patients. This study aimed to examine the relationship between Medicaid HCBS generosity and the likelihood of NH placement for duals with ADRD, and their level of functional impairment at NH admission.Study DesignNational Medicare data, Medicaid Analytic eXtract (MAX), and MDS 3.0 for CY2010‐2013 were linked. Eligible Medicare‐Medicaid dual beneficiaries with ADRD were identified and followed for up to a year. Based on MAX data, two measures of HCBS generosity were constructed at the county level for older duals with ADRD: (a) breadth (ie, proportion of duals who used HCBS services); and (b) intensity (ie, average HCBS spending per user). Outcomes included NH placement during the follow‐up year (dichotomous) and the level of physical impairment (ie, activities of daily living [ADL, 0‐28 point scale], categorized into low, moderate, and severe impairment) at the time of NH admission. A linear probability model with county random‐effects and robust standard errors was estimated to examine the relationship between the likelihood of NH placement and HCBS generosity, accounting for individual (eg, sociodemographic characteristic, prior hospitalizations, and comorbidities) and county‐level covariates (eg, median household income, female labor participation). A multinomial logistic model was estimated to examine the relationship between HCBS generosity and ADL impairment among those who were admitted to NHs.Population StudiedCommunity‐dwelling older dual beneficiaries with ADRD who were enrolled in fee‐for‐service Medicaid between October 1, 2010, and December 31, 2012 (N = 365 310).Principal FindingsConsiderable variation in county‐level HCBS breadth and intensity was observed. 17.1% of duals with ADRD had NH placement within one year. After accounting for individual and county level covariates, we found that a 10 percentage‐point increase in HCBS breadth among individuals with ADRD was associated with 1.1 percentage point reduction (P &lt; 0.01) in the likelihood of NH placement. Among individuals with NH placement, greater HCBS intensity was related to a higher level of impairment at NH admission ($100 increase in HCBS intensity led to 1.03 and 1.04 times the likelihood of having moderate or severe physical impairment [P &lt; 0.01]). Greater HCBS breadth was associated with less physical impairment (10 percentage‐point increase led to 0.93 and 0.91 times the likelihood of having moderate or severe physical impairment [P &lt; 0.01]).ConclusionsAmong community‐dwelling duals with ADRD, Medicaid HCBS breadth was associated with a lower likelihood of NH placement, and HCBS intensity was associated with greater physical impairment at NH admission.Implications for Policy or PracticeInvestment in Medicaid HCBS may prevent or delay NH placement among community‐dwelling older adults with ADRD. More research is needed to identify how the utilization of different HCBS services may affect NH placement.Primary Funding SourceNational Institutes of Health.

Hcbs Service Intensity and Nursing Home Placement for Patients with Alzheimer's Disease and Related Dementias: Does Race Matter?

Research ObjectiveTo explore racial differences in the nursing home (NH) placement among Medicare‐Medicaid dual‐eligible home and community‐based service (HCBS) users with Alzheimer's disease and related dementias (ADRD), and determine the extent to which HCBS generosity may be influential.Study DesignThe following 2010‐2013 national data were linked at the individual level: Medicaid Analytic eXtract (MAX) Personal Summary (PS) file and Other Therapy (OT) file, the Minimum Data Set (MDS) 2.0/3.0 and Medicare Beneficiary Summary File and MedPAR.Dually eligible fee‐for‐service Medicare and Medicaid beneficiaries were identified using MBSF. Diagnosis of ADRD was based on the MBSF chronic condition file. New users were defined as those who did not have HCBS episodes in a prior 30‐day look‐back period, based on the OT records.The outcome variable was any NH admission within one year after the HBCS use, defined based on the MDS data. The main variables of interest were race (ie, white, black, other), the intensity of HCBS among ADRD population at the county level (the average monthly spending per HCBS user with ADRD in a county, based on MAX PS file), and the interaction terms between the intensity of ADRD and race. A linear probability model with county fixed‐effect and robust standard errors were estimated, accounting for individual covariates (eg, demographic characteristics, chronic conditions, prior use of institutional care).Population Studied1 527 974 new users of HCBS with ADRD during CY2010 to 2013.Principal FindingsThe intensity of HCBS among individuals with ADRD varies widely across counties, the 25th percentile, median, and the 75th percentile was $654, $827, and $1099, respectively. The overall NH admission rate among HCBS users with ADRD was 67%, 55%, and 36% for whites, blacks, and others, respectively. After accounting for individual covariates, whites continued to exhibit a higher NH admission rate, as compared with two other race groups. However, while a higher intensity of HCBS reduced the likelihood of NH placement for whites, it increased the risk among blacks. NH admission rate for blacks was 7.2 percentage points (P &lt; 0.01) lower than for whites in a county with a median HCBS monthly spending. A one hundred dollars increase in monthly HCBS spending was associated with a 0.3 percentage points (P &lt; 0.01) decrease in admission rate among whites, but a 0.3 percentage points (P &lt; 0.01) increase among blacks.ConclusionsOur findings suggest that among dual‐eligible HCBS users with ADRD, whites were more likely to have NH admission within 1 year than non‐whites. Moreover, higher intensity of HCBS in a county was associated with lower a NH admission rate among whites, but a higher rate among blacks.Implications for Policy or PracticeStates have been promoting the use of HCBS as the means of rebalancing the cost of traditional institutional care while allowing more people to remain living in the community. However, the expansion of HCBS may have differential impact on NH admission risk for whites and blacks. Better understanding of racial differences in care needs is critical to inform the State Medicaid program design.Primary Funding SourceNational Institutes of Health.

Is Being Home Good for Your Health? Outcomes of Medicaid Home‐ and Community‐Based Long‐Term Care Relative to Nursing Home Care

Research ObjectiveExpanding home‐ and community‐based services (HCBS) as an alternative to nursing home care has become a priority for many state Medicaid programs. Whereas low‐income people with long‐term care needs used to have little choice but to move to a nursing home if they needed extensive assistance funded by Medicaid, now more than half of all Medicaid long‐term care funding goes to HCBS, with substantial variation by state and county. This shift in policy was motivated by widespread consumer preferences to avoid institutionalization and the hope that HCBS would save Medicaid money relative to nursing home care.However, these dramatic policy changes are being made on the basis of surprisingly little evidence about the outcomes of HCBS. HCBS inevitably involves a lower intensity of care than nursing home care and shifts some of the burden of care to untrained caregivers. Recent descriptive evidence shows higher hospitalization rates among HCBS users than nursing home residents, but descriptive correlations may suffer from selection bias. Our study provides the first plausibly causal national estimates of health outcomes for recipients of Medicaid HCBS relative to nursing home care and explores possible mechanisms for the effect.Study DesignWe use 2005 and 2012 Medicaid Analytic Extract (MAX) data set, a national compilation of Medicaid claims, in a longitudinal instrumental variables framework. We combine the MAX data with Medicare claims to identify hospital admissions, our main outcome variable, and with state and county data on the percent of individuals receiving HCBS versus nursing home care. To address the endogeneity of HCBS receipt, we instrument for it using the county percentage of nonelderly long‐term care users who receive HCBS. The percentage of nonelderly users is highly predictive of HCBS use for an elderly beneficiary, but because the instrument was derived from a separate population, the exclusion restriction is unlikely to be violated.Population StudiedOlder adults (65+) dually enrolled in Medicaid and Medicare. We also examine heterogeneity of the effects by race/ethnicity and the presence of dementia.Principal FindingsHCBS users have 13 percentage‐point higher annual rates of hospitalization than their nursing home counterparts when selection bias is addressed, with an even larger difference among those with dementia. These differences exist within as well as across counties, ruling out differences in state policy or county‐level health infrastructure as primary explanations. Differences are smaller for those receiving more intensive HCBS. Furthermore, we find significant disparities by race, with blacks using HCBS at higher rates than whites but experiencing higher rates of hospitalization.ConclusionsShifting long‐term care for older adults from nursing homes to HCBS, while well motivated, results in the unintended consequence of substantially higher hospitalization rates and potentially exacerbates disparities by race. The intensity of services may be inadequate for some HCBS recipients.Implications for Policy or PracticeHospitalizations are costly to Medicare but also to the HCBS recipient in terms of stress and risks. Although consumer preferences to remain at home may outweigh poor outcomes of HCBS, the full costs and benefits need to be considered. HCBS outcomes—not just expansion—need more attention.Primary Funding SourceNational Institutes of Health.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders.

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs' perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010-2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

Medical Resource Use and Costs of Treating Sickle Cell-related Vaso-occlusive Crisis Episodes: A Retrospective Claims Study.

BackgroundThe study investigated the economic burden of vaso-occlusive crisis (VOC) among sickle cell disease (SCD) patients, through assessment of overall utilization and costs and costs per VOC episode (regarding the number of VOC episodes and health care setting, respectively).MethodsUsing the Medicaid Analytic Extracts database, the first SCD-related diagnosis claim (index claim) between June 1, 2009–December 31, 2012 was identified among eligible adults. Patients were required to have continuous medical and pharmacy benefits for 6 months pre- and 12 months post-index. Discrete VOC claims identified within a 3-day gap were combined as a single VOC episode. Annual all-cause and SCD-related medical resources and costs were identified and stratified by number of VOC episodes during the 1-year follow-up period. Health care costs per VOC episode were also examined, stratified by care setting.ResultsEnrollees included 8521 eligible patients with a mean age of 32.88 years (SD=12.21). Of these, 66.5% had a Charlson Comorbidity index (CCI) score of 0 (no comorbidities) and 67.3% were female. The average total medical costs were US$34 136 (median=US$12 691) annually, and SCD accounted for 60% of the total costs (mean=US$20 206, median=US$1204). Patients with >3 episodes had the highest annual SCD-related costs (mean=US$58 950) across all settings. Health care resource utilization (HCRU) and costs increased substantially as the number of VOC episodes increased. This study was limited to observation of associations rather than causal inference, and by possible coding and identification discrepancies and the restricted generalizability of the population.ConclusionsVOC has a severe impact on medical resource use and costs among the adult SCD population. Further research among broader study populations is needed to facilitate the reduction of VOC episodes and thereby improve clinical and economic outcomes for SCD patients.

Human Immunodeficiency Virus-Experienced Clinician Workforce Capacity: Urban-Rural Disparities in the Southern United States.

Human immunodeficiency virus (HIV)-experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban-rural differences, in the Southern United States. We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009-2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region's HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban-rural differences. We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P < .001) and practice in urban areas (96% vs 83%, P < .001) compared to non-HIV-experienced clinicians. The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range, 38.0), with no significant urban-rural differences. When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1000 diagnosed HIV cases (P < .001). Significant urban-rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.

Oral fluconazole use in the first trimester and risk of congenital malformations: population based cohort study.

ObjectiveTo examine the risk of congenital malformations associated with exposure to oral fluconazole at commonly used doses in the first trimester of pregnancy for the treatment of vulvovaginal candidiasis.DesignPopulation based cohort study.SettingA cohort of pregnancies publicly insured in the United States, with data from the nationwide Medicaid Analytic eXtract 2000-14.ParticipantsPregnancies of women enrolled in Medicaid from three or more months before the last menstrual period to one month after delivery, and infants enrolled for three or more months after birth.InterventionsUse of fluconazole and topical azoles was established by requiring one or more prescriptions during the first trimester of pregnancy.Main outcome measuresRisk of musculoskeletal malformations, conotruncal malformations, and oral clefts (primary outcomes), associated with exposure to oral fluconazole, diagnosed during the first 90 days after delivery, were examined.ResultsThe study cohort of 1 969 954 pregnancies included 37 650 (1.9%) pregnancies exposed to oral fluconazole and 82 090 (4.2%) pregnancies exposed to topical azoles during the first trimester. The risk of musculoskeletal malformations was 52.1 (95% confidence interval 44.8 to 59.3) per 10 000 pregnancies exposed to fluconazole versus 37.3 (33.1 to 41.4) per 10 000 pregnancies exposed to topical azoles. The risks of conotruncal malformations were 9.6 (6.4 to 12.7) versus 8.3 (6.3 to 10.3) per 10 000 pregnancies exposed to fluconazole and topical azoles, respectively; risks of oral clefts were 9.3 (6.2 to 12.4) versus 10.6 (8.4 to 12.8) per 10 000 pregnancies, respectively. The adjusted relative risk after fine stratification of the propensity score was 1.30 (1.09 to 1.56) for musculoskeletal malformations, 1.04 (0.70 to 1.55) for conotruncal malformations, and 0.91 (0.61 to 1.35) for oral clefts overall. Based on cumulative doses of fluconazole, the adjusted relative risks for musculoskeletal malformations, conotruncal malformations, and oral clefts overall were 1.29 (1.05 to 1.58), 1.12 (0.71 to 1.77), and 0.88 (0.55 to 1.40) for 150 mg of fluconazole; 1.24 (0.93 to 1.66), 0.61 (0.26 to 1.39), and 1.08 (0.58 to 2.04) for more than 150 mg up to 450 mg of fluconazole; and 1.98 (1.23 to 3.17), 2.30 (0.93 to 5.65), and 0.94 (0.23 to 3.82) for more than 450 mg of fluconazole, respectively.ConclusionsOral fluconazole use in the first trimester was not associated with oral clefts or conotruncal malformations, but an association with musculoskeletal malformations was found, corresponding to a small adjusted risk difference of about 12 incidents per 10 000 exposed pregnancies overall.

Black and White Patients With Inflammatory Bowel Disease Show Similar Biologic Use Patterns With Medicaid Insurance

Prior studies have identified racial disparities in the treatment and outcomes of inflammatory bowel disease (IBD). These disparities could be secondary to differences in biology, care delivery, or access to appropriate therapy. The primary aim of this study was to compare medication use among Medicaid-insured black and white patients with IBD, given uniform access to gastroenterologists and therapies. We analyzed Medicaid Analytic eXtract data from 4 states (California, Georgia, North Carolina, and Texas) between 2006 and 2011. We compared the use of IBD-specific therapies, including analyses of postoperative therapy among patients with Crohn disease (CD). We performed bivariate analyses and multivariable logistic regression, adjusting for potential confounders. We identified 14,735 patients with IBD (4672 black [32%], 8277 with CD [58%]). In multivariable analysis, there was no significant difference in the odds of anti-tumor necrosis factor use by race for CD (adjusted odds ratio [aOR] = 1.13; 95% confidence interval [CI], 0.99-1.28] or ulcerative colitis (aOR = 1.12; 95% CI, 0.96-1.32). Black patients with CD were more likely than white patients to receive combination therapy (aOR = 1.50; 95% CI, 1.15-1.96), and black patients were more likely than white patients to receive immunomodulator monotherapy after surgery for CD (31% vs 18%; P = 0.004). In patients with Medicaid insurance, where access to IBD-specific therapy should be similar for all individuals, there was no significant disparity by race in the utilization of IBD-specific therapies. Disparities in IBD treatment discussed in prior literature seem to be driven by socioeconomic or other issues affecting access to care.

Prevalence and Correlates of Food Allergy Among Medicaid-Enrolled United States Children.

The objective of this study is to provide a comprehensive epidemiological profile detailing food allergy (FA) prevalence and related correlates among Medicaid-enrolled children. The 2012 Medicaid Analytic eXtract person-level 100% files for 50 states and the District of Columbia were analyzed. The analytic sample of 23,825,160 included all children ages 0 to 19 years as of January 1, 2012 who were continuously enrolled in Medicaid in 2012. The prevalence of FA was measured using International Classification of Diseases, Ninth Revision, Clinical Modification codes and compared with other atopic conditions (atopic dermatitis, allergic rhinitis, and asthma). Logistic regression was used to evaluate child characteristics associated with FA. The prevalence of FA among Medicaid-enrolled children was less than 1% (0.6%). State-level prevalence ranged from a high of 1.4% in Alaska to a low of 0.2% in Nevada. Race and ethnicity were associated with FA such that Asian, Black, and Pacific Islander/Native Hawaiian children had a higher odds of FA, while Hispanic and Native American children had 15% and 24% lower odds of FA, respectively, compared with White children. Compared with estimates of parent-reported, physician-diagnosed FA in the general population, the claims-based prevalence of FA among Medicaid-enrolled children is substantially lower. Racial and ethnic differences are consistent with the general population. The findings signal a need to better understand reasons for these differences including awareness, access to care, and service utilization patterns in this population.

Effects of State-level Medicaid Expansion on Veterans Health Administration Dual Enrollment and Utilization: Potential Implications for Future Coverage Expansions.

The objective of this study was to examine how pre-Affordable Care Act (ACA) state-level Medicaid expansions affect dual enrollment and utilization of Veterans Health Administration (VA) and Medicaid-funded care. We employed difference-in-difference analysis to determine the association between pre-ACA Medicaid expansions in New York and Arizona in 2001 and VA utilization. Participants' dual enrollment in Medicaid and VA, the distribution of their annual hospital admissions and emergency department (ED) visits between VA and Medicaid were dependent variables. We controlled for age, race, sex, disease burden, distance to VA facilities and income-based eligibility for VA services. Secondary data collected from 1999 to 2006 in 2 states expanding Medicaid and 3 demographically similar nonexpansion states. We obtained residency, enrollment and utilization data from VA's Corporate Data Warehouse and Medicaid Analytic Extract files. For low-income Veterans, Medicaid expansion was associated with increased dual enrollment of 4.87 percentage points (99% confidence interval: 4.48-5.25), a 4.63-point decline in VA proportion of admissions (-5.87 to -3.38), and a 11.70-point decrease in the VA proportion of ED visits (-13.06 to -10.34). Results also showed increases in the number of total (VA plus Medicaid) annual per-capita hospitalizations and ED visits among the group of VA enrollees most likely to be eligible for expansion. This study shows slight usage shifts when Veterans gain access to non-VA care. It highlights the need to overcome care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional expansions of public health insurance programs such as Medicare-for-All.

Validation of algorithms to identify adverse perinatal outcomes in the Medicaid Analytic Extract database.

The Medicaid Analytic eXtract (MAX) is a health care utilization database from publicly insured individuals that has been used for studies of drug safety in pregnancy. Claims-based algorithms for defining many important maternal and neonatal outcomes have not been validated. To validate claims-based algorithms for identifying selected pregnancy outcomes in MAX using hospital medical records. The medical records of mothers who delivered between 2000 and 2010 within a single large healthcare system were linked to their claims in MAX. Claims-based algorithms for placental abruption, preeclampsia, postpartum hemorrhage, small for gestational age, and noncardiac congenital malformation were defined. Fifty randomly sampled cases for each outcome identified using these algorithms were selected, and their medical records were independently reviewed by two physicians to confirm the presence of the diagnosis of interest; disagreements were resolved by a third physician reviewer. Positive predictive values (PPVs) and 95% confidence intervals (CIs) of the claims-based algorithms were calculated using medical records as the gold standard. The linked cohort included 10,899 live-birth pregnancies. The PPV was 92% (95% CI, 82%-97%) for placental abruption, 82% (95% CI, 70%-91%) for preeclampsia, 74% (95% CI, 61%-85%) for postpartum hemorrhage, 92% (95% CI, 82%-97%) for small for gestational age, and 86% (95% CI, 74%-94%) for noncardiac congenital malformation. Across the perinatal outcomes considered, PPVs ranged between 74% and 92%. These PPVs can inform bias analyses that correct for outcome misclassification.

Maternal and fetal outcomes following exposure to duloxetine in pregnancy: cohort study

ObjectiveTo evaluate the risk of adverse maternal and infant outcomes following in utero exposure to duloxetine.DesignCohort study nested in the Medicaid Analytic eXtract for 2004-13.SettingPublicly insured pregnancies in the United...

Co-payment policies and breast and cervical cancer screening in Medicaid.

This study investigated the relationship between state Medicaid co-payment policies and cancer screening for Medicaid-enrolled women. Cross-sectional analysis of administrative claims and enrollment data. Our data included Medicaid Analytic eXtract (MAX) outpatient claims files across 43 states in 2003, 2008, and 2010, the years for which both MAX data and state cost-sharing data were available. Data on enrollee demographics and screening services from enrollment and claims files were merged with state-year data on co-payment policies and county-level controls from the Area Health Resources File. Participants were nonelderly, nondisabled, nonpregnant women in the recommended age range for each screening service (50-64 years for mammograms; 21-64 years for Pap tests) enrolled in fee-for-service Medicaid. The main independent variable is whether an enrollee faced cost sharing for preventive services. We examined 3 categories of cost sharing: co-payments for all visits, including for preventive services; co-payments for outpatient visits but waived for preventive services; and no co-payments. The main outcome measure was receipt of mammogram or Pap test within a 12-month period. Medicaid enrollees with co-payments for preventive services were less likely to receive both screening mammograms and Pap tests than enrollees in states not requiring cost sharing for preventive services. Co-payments for preventive services discourage breast and cervical cancer screening among Medicaid enrollees. The effect is larger for breast cancer screening, which is costlier and requires an additional visit. Considering this evidence, cost sharing for preventive services may lead to adverse health consequences and greater long-term costs.