Medicaid Claims Research Articles

Extended Medicaid coverage will improve access but insufficient to enhance postpartum care utilization: a secondary analysis of the 2016-2019 Arizona Medicaid claims.

Postpartum Medicaid eligibility extensions may increase access to healthcare for low-income women. However, its implications for healthcare utilization are unknown. We analyzed the linked-infant birth certificate and claims data of women whose childbirths were paid for by Medicaid between 2016 and 2019 in Arizona, United States. We evaluated associations between postpartum care visits and Medicaid insurance type and assessed effect modification by the delivery route and type of residence. Women with pregnancy-related Medicaid insurance were less likely to attend postpartum visits, with an adjusted odds ratio (aOR) of 0.70 and a 95% confidence interval (CI) of 0.66 to 0.74 than those with continuous Medicaid insurance. Younger age, rural residence [aOR 0.83, CI 0.78, 0.88], vaginal delivery route [aOR 0.11, CI 0.10, 0.12], and the absence of complications during/after childbirth [aOR 0.58, CI 0.49, 0.70] were associated with the absence of postpartum care visit. Low-income women who lost their pregnancy-related Medicaid coverage after 60 days in Arizona experienced lower rates of postpartum care utilization. Interventions to improve postpartum utilization should be considered beyond extending postpartum Medicaid coverage for low-income women.

Simulated impact of mobile opioid treatment program units on increasing access to methadone for opioid use disorder.

To model the potential impact of mobile methadone unit implementation in Louisiana on net medication for opioid use disorder (MOUD) treatment rates. We use secondary Louisiana Medicaid claims data between 2020 and 2021. We simulate the impact of mobile methadone units in Louisiana using two approaches: (1) a "Poisson regression approach," which predicts the number of opioid use disorder (OUD) patients that might use methadone at mobile locations based on the underlying association between methadone use and proximity to a brick-and-mortar methadone clinic; (2) a "policy approach," which leverages local treatment uptake rates following the expansion of methadone coverage to Louisiana Medicaid beneficiaries in 2020 to estimate methadone use following mobile unit implementation. Models were run in cases where mobile methadone operators could choose their operation locations freely and in a separate instance where they were restricted to serving rural locations. Our analytic sample includes 43,341 Louisiana Medicaid beneficiaries with one or more primary or secondary diagnoses for opioid dependence. We predict that 10 new mobile methadone units in Louisiana would increase the net MOUD treatment rate in the state by 0.54-2.39 percentage points. If these mobile units delivered Methadone exclusively to rural areas, they could increase rural MOUD treatment by 8.54-13.67 percentage points. Further, roughly 20% of all beneficiaries residing in rural areas being treated with methadone would be an average of 24 miles closer to a methadone treatment provider following mobile unit implementation. Mobile methadone units represent a promising innovation in the delivery of methadone that is likely to increase methadone use, especially in underserved rural locations. However, we find significant variation in their impact conditional on where they choose to operate, and so careful location planning will be required to maximize their benefit.

Healthcare utilization for asthma exacerbation among children of migrant and seasonal farmworkers

Latino children of Migrant and Seasonal Farmworkers (MSFWs) with asthma are at risk for poor health outcomes due to medical access barriers. We compared differences in acute care utilization for asthma exacerbations among migrant and non-migrant Latino and non-Hispanic white (NHW) children at U.S. community health centers.A retrospective observational study utilizing electronic health record data from the ADVANCE Clinical Research Network of United States community health centers included 13,423 children ages 3–17 with a primary care visit between 2005 and 2017 from eight states. Emergency department (ED) and hospitalization data came from Oregon Medicaid claims. Outcomes included acute clinic visits, ED visits, and hospitalizations for asthma exacerbation. Regression analyses adjusted for patient-level covariates.Latino children had higher odds of acute clinic visits for asthma exacerbation compared to NHW children (MSFW odds ratio [OR] = 1.17, 95 % CI = 1.03–1.33; without migrant status OR = 1.13, 95 % CI = 1.03–1.23). MSFW children using Oregon Medicaid had fewer ED visits (rate ratio [RR] = 0.72, 95 % CI = 0.52–0.99) and hospitalizations (RR = 0.47, 95 % CI = 0.26–0.86) compared to NHW children.Increased community health center visits may help mitigate disparities in acute asthma care for MSFW children.

Exchanging Housing Dollars for Health Care Savings: The Impact of Housing First on Health Care Costs

This paper assesses the effects of the Housing First model on the utilization of public health services and claims among chronically homeless individuals and in the process addresses the problem of attribution to natural stabilization on account of regression to the mean. The study uses Medicaid claims data from participants in a Massachusetts “Housing First” program (n = 1,342) and non-participants (n = 44,022) who included chronically homeless individuals. A control group design, propensity score matching techniques, and difference in differences were employed to estimate effects on utilization of and claims for emergency room visits, inpatient hospitalization, mental health encounters, and pharmacy and other claims. We find that both groups registered statistically significant pre–post improvements in utilization of health care services and claims, but these are greater among the Housing First cohort. The findings suggest that Housing First significantly reduces utilization of health care services beyond regression to the mean and that the resultant health care savings offset a significant portion of the cost of housing. Policy proponents and opponents of Housing First must recognize that the model has a significant portion of its costs offset by savings from lower Medicaid claims.

Measuring quality of dental care during pregnancy

BackgroundThe authors aimed to develop and validate 2 Dental Quality Alliance measures of dental care access during pregnancy (Utilization of Services During Pregnancy, Oral Evaluation During Pregnancy) using claims and enrollment data and to report performance on these measures for a sample of Medicaid and Children’s Health Insurance Program beneficiaries. MethodsThe authors used Transformed Medicaid Statistical Information System enrollment and claims data for 7,767,806 people enrolled in 5 state Medicaid programs and Children’s Health Insurance Programs during 2018. The authors used split-half reliability testing to assess measure reliability. The authors calculated 95% CIs to assess statistically significant variation in performance between programs. ResultsThe intraclass correlation coefficient used to assess agreement between the split samples was 0.992 (95% CI, 0.941 to 0.999; P < .0001) for Utilization of Services During Pregnancy and 0.983 (95% CI, 0.879 to 0.998; P < .0001) for Oral Evaluation During Pregnancy. Performance scores ranged from 20% through 34% of beneficiaries receiving any dental service during pregnancy (Utilization of Services During Pregnancy) and from 14% through 23% of beneficiaries receiving a periodic or comprehensive oral evaluation during pregnancy (Oral Evaluation During Pregnancy), with statistically significant differences between programs. ConclusionsThe measures reliably assessed access to dental services and can distinguish performance between programs. Practical ImplicationsThese measures can be used to advance population health by means of supporting national efforts to improve access to dental care during pregnancy.

Medications For Opioid Use Disorder Increased Among Louisiana Medicaid Enrollees During Policy Reforms, 2018-21.

Increasing access to medications for opioid use disorder (MOUD) is a key strategy in addressing the opioid crisis. To increase MOUD access, state governments have pursued a combination of increased funding for MOUD and requirements that providers offer treatment. Louisiana has pursued multiple strategies, including a requirement that residential treatment programs offer MOUD as part of their licensure. Using Louisiana Medicaid claims data for enrollees with diagnosed OUD from the period 2018-21, we analyzed trends in MOUD between enrollees treated in residential and nonresidential settings and across demographic subgroups, and we compared trends by MOUD type. MOUD use more than tripled from 2018 to 2021 among Louisiana Medicaid enrollees diagnosed with OUD. Most of the increase in MOUD was attributable to buprenorphine use. Methadone uptake also contributed to greater MOUD use but was almost exclusively used by enrollees treated in nonresidential settings, whereas naltrexone was consistently more common in residential treatment. By 2021, differences persisted across demographic groups: MOUD use was highest among enrollees who were White, were older, had comorbidities, and lived in a metropolitan area. Policies that promote MOUD in substance use treatment programs, particularly residential programs, are critical tools for policy makers confronting a complex and unprecedented national overdose crisis.

Predictors of flare-related inpatient or emergency department stay in systemic lupus erythematosus: A real-world analysis of Medicaid claims in the United States.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem inflammation. Medical management of SLE is based on reducing inflammation and tissue damage in the affected organs; however, medications used to treat SLE have been found to contribute to additional organ damage. Therefore, finding new ways to predict and prevent flares that require an inpatient (IP) stay or emergency department (ED) visit is critical for reducing the clinical and economic burden in patients with SLE. To identify risk factors of SLE flares requiring an IP/ED visit among a Medicaid-insured population with SLE. This retrospective study included patients from the Merative MarketScan Medicaid database (2013-2019). To capture patients at all stages of their SLE journey, all SLE claims for a patient were captured, and the index date was randomly selected among those claims that were at least 12 months after the first evidence of SLE. Patients were required to be continuously enrolled 1-year pre-index (year 1) and post-index (year 2). Demographics, clinical characteristics, and health care use and costs were measured in year 1, and flares requiring an IP/ED visit were identified in year 2 using the Garris algorithm. Multivariable logistic regression and classification and regression tree (CART) modeling were used to identify year 1 predictors and combination of factors, respectively, associated with flares-related IP/ED visits. Of the 8,083 patients included in the study, 37.6% of patients (n = 3,039) had a flare. Logistic regression identified ED visits in year 1 as one of the strongest predictors of flares-related IP/ED visits in year 2 (odds ratio = 2.19 [95% CI = 1.93-2.49]). SLE treatment progression to biologics (0.54 [0.42-0.70]) was the strongest predictor of decreased odds. Other strong predictors included other neurological disorders (1.63 [1.43-1.87]), Black race (1.49 [1.32-1.68]), chronic kidney disease/renal failure (1.35 [1.10-1.66]), and opioid use (1.30 [1.17-1.45]). CART modeling identified patients with an ED visit, an IP admission, and a diagnosis of Elixhauser Comorbidity Index-defined other neurological disorders in year 1 as having the highest probability of a flare-related IP/ED visit in year 2 (probability = 0.708), whereas patients without an ED visit had the lowest probability (probability = 0.185). Patients with the highest risk of a flare that required an IP/ED visit were those with a prior ED visit, IP admission, and other neurological disorders. Modeling also identified patients with prior opioid use, Black patients, and patients without SLE medications as subgroups with a high risk of a flare requiring an IP/ED visit.

Provider's Individual and Network Attributes in the Selection Process of a Predominant Antenatal Care Provider in South Carolina: A Case-Control Study.

This study aims to examine the association between provider attributes, including network (patient panel size, degree-number of peer connections, and community size- number of a closely connected group of peers) and individual attributes (travel distance, specialties, and rural practice), and a predominant (most visited) provider. This study utilized South Carolina's Medicaid claims data during 2014 to 2018, focusing on live births in hospitals. Samples were limited to pregnant women continuously enrolled in Medicaid throughout pregnancy. Predominant providers (total = 2153) were identified for 29 569 pregnancies. Network analyses involved 5520 providers, comprising 3667 antenatal care (ANC) providers and 1853 non-ANC providers. A Cartesian product (n = 45 929 845) combined five annual provider lists with all included pregnancies. Logistic regressions with repeated measures were applied to this retrospective case-control study. The results demonstrated that a medium or large degree were associated with being a predominant provider if the community size was medium or large. A predominant provider was more likely to be located near, rather than far from, the served woman, and in rural areas rather than urban ones. They were also more likely to be specialists, midwives, and nurse practitioners than primary care physicians. The results suggest that both individual and network attributes were significantly associated with being a predominant provider. Policies aimed at addressing access issues for antenatal care should consider both the individual and network attributes of providers, as providers may not be able to alter their individual attributes but can always optimize their social network.

Association Between Persistence with Oral Atypical Antipsychotic Medications and Hospital and Emergency Department Utilization in Medicaid Patients with Schizophrenia.

To examine 1-year persistence with oral atypical antipsychotics (OAAPs) for Medicaid patients with schizophrenia and assess the association between OAAP persistence and hospital and emergency department (ED) resource utilization. Using 2016-2020 multi-state Medicaid claims data, this retrospective study followed patients diagnosed with schizophrenia for 12 months after initiating OAAP therapy. Patients started on an OAAP with no evidence of antipsychotic use in the previous 6 months were included if they had a diagnosis of schizophrenia, were not dually enrolled in Medicaid and Medicare, did not switch to a long-acting injectable antipsychotic, and were continuously eligible 6 months before and 12 months after the initial OAAP prescription (index date). OAAP persistence was measured allowing for a <60-day gap. All-cause and schizophrenia-related inpatient and emergency department (ED) resource utilization during the follow-up period were compared between OAAP persistent and non-persistent groups. The study sample of 13,007 had an average age of 39.1 years and 57.0% were male. Patients were persistent with their index OAAP for 135 days on average and 73.1% had a ≥60-day gap in antipsychotic therapy post-index. While 32.8% and 28.6% of patients who did not persist with their index OAAP restarted the index OAAP or switched to a different OAAP medication later in the year, respectively, a larger proportion (38.6%) had no further OAAP prescriptions. After adjustment for demographic and clinical variables, compared to non-persistent patients, persisting with OAAPs was significantly associated with fewer all-cause and schizophrenia-related hospitalizations (Incidence Rate Ratio [IRR]=0.742, p<0.001; IRR=0.823, p<0.001; respectively) and ED visits (IRR=0.759, p<0.001; IRR=0.773, p<0.001; respectively). Non-persistence with OAAP medication is common among patients with schizophrenia and associated with negative outcomes including increased utilization of hospital and ED resources. Patient-centered interventions that improve antipsychotic persistence should be implemented to facilitate optimal outcomes in this population.

Differences in Self-Reported and Billed Postpartum Visits Among Medicaid-Insured Individuals

State Medicaid programs have recently implemented several policies to improve access to health care during the postpartum period. Understanding whether these policies are succeeding will require accurate measurement of postpartum visit use over time and across states; however, current estimates of use vary substantially between data sources. To examine disagreement between postpartum visit use reported in the Pregnancy Risk Assessment Monitoring System (PRAMS) and Medicaid claims and assess whether insurance transitions from Medicaid at the time of childbirth to other insurance types after delivery are associated with the degree of disagreement. This cross-sectional study was conducted among individuals in South Carolina after delivery who had completed a PRAMS survey and for whom Medicaid was the payer of their delivery care. PRAMS responses from 2017 to 2020 were linked to inpatient, outpatient, and physician Medicaid claims; survey-weighted logistic regression models were then used to examine the association between postpartum insurance transitions and data source disagreement. Data were analyzed from February through October 2023. Insurance transition type: continuous Medicaid, Medicaid to private insurance, Medicaid to no insurance, and Emergency Medicaid to no insurance. Data source disagreement due to reporting a postpartum visit in PRAMS without a Medicaid claim for a visit or having a Medicaid claim for a visit without reporting a postpartum visit in PRAMS. Among 836 PRAMS respondents enrolled in Medicaid at delivery (663 aged 20-34 years [82.9%]), a mean of 85.7% (95% CI, 82.1%-88.7%) reported a postpartum visit in PRAMS and a mean of 61.6% (95% CI, 56.9%-66.0%) had a Medicaid claim for a postpartum visit. Overall, 253 respondents (30.3%; 95% CI, 26.1%-34.7%) had data source disagreement: 230 individuals (27.2%; 95% CI, 23.2%-31.5%) had a visit in PRAMS without a Medicaid claim, and 23 individuals (3.1%; 95% CI, 1.8%-5.2%) had a Medicaid claim without a visit in PRAMS. Compared with individuals continuously enrolled in Medicaid, those who transitioned to private insurance after delivery and those who were uninsured after delivery and had Emergency Medicaid at delivery had an increase in the probability of data source agreement of 15.8 percentage points (95% CI, 2.6-29.1 percentage points) and 37.2 percentage points (95% CI, 19.6-54.8 percentage points), respectively. This study's findings suggest that Medicaid claims may undercount postpartum visits among people who lose Medicaid or switch to private insurance after childbirth. Accounting for these insurance transitions may be associated with better claims-based estimates of postpartum care.

HARMONIZATION OF CHRONIC CONDITIONS WAREHOUSE DATA FOR OUTCOMES RESEARCH ON GERIATRIC SYNDROMES

Abstract Geriatric syndromes such as cognitive impairment, falls, depression, urinary incontinence, pressure ulcers, and polypharmacy are common conditions and syndromes that affect older adults. Studying geriatric syndromes in Medicare beneficiaries may provide important insights for improving health outcomes and quality of life. As a result of the Improving Medicare Post-Acute Care Transformation Act of 2014, it is now easier to compare standardized geriatric assessment data (including information about geriatric syndromes) collected in post-acute and long-term care settings with corresponding data from claims, encounter, Part D, and durable medical equipment files. However, to our knowledge, methods to link and harmonize post-acute and long-term care assessment data (available for 75% of decedents) are yet to be utilized in the health services research community. The goal of this project is to develop harmonized datasets that can be used to identify geriatric syndromes and study their prevalence, cost, health outcomes, and service delivery factors over time. This work will allow our team and other researchers to fully leverage these data for use in predictive algorithms and artificial intelligence and machine learning (AI/ML) research. The project uses the five most recent years of data available from the Centers for Medicare and Medicaid Services (CMS) Chronic Conditions Data Warehouse. Data sources include Medicare and Medicaid claims, encounter, MedPAR, Hospice claims, Minimum Data Set (MDS), MDS-Swing Bed (SB), Outcome and Assessment Information Set (OASIS), Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), Pharmacy (Part D), and Durable Medical Equipment (DME).

THE ROLE OF MEDICAID HOME- AND COMMUNITY-BASED SERVICES IN USE OF MEDICARE POST–ACUTE CARE

Abstract Medicaid-funded long-term services and supports are increasingly provided through home and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aims to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled. Using national Medicare claims, Medicaid claims (TAF), MDS, and OASIS data from 2014 to 2017, we estimated the relationship between prior Medicaid HCBS use and PAC utilization in a national sample of duals with qualifying index hospitalizations. We used inverse probability weights to create balanced samples on observed characteristics and estimated multivariable regression with hospital fixed effects and extensive controls. We also conducted stratified analyses for key subgroups and tested for interactions between HCBS use and three measures of states’ HCBS generosity. We found HCBS use was associated with a 5.2 percentage-point increase in use of any Medicare-funded PAC, a 7.2 percentage-point increase in home health use, a 2.1 percentage-point decrease in institutional PAC, and a 1.95-day reduction of skilled nursing facility length of stay. In other words, use of Medicaid-funded HCBS was associated with a shift in Medicare-funded PAC use toward home-based settings. These findings were stronger in states with more generous HCBS funding. As we found that use of Medicaid-funded HCBS may alter choices about Medicare-funded PAC use, this synergy with HCBS should be considered by policymakers when contemplating further HCBS expansions.

EMERGENCY DEPARTMENT USE AMONG OLDER ADULTS RECEIVING MEDICAID HOME- AND COMMUNITY-BASED SERVICES

Abstract Medicaid-funded home and community-based services (HCBS) for older adults aim to prolong independent living despite physical and cognitive disabilities. Medicaid-eligible HCBS populations are racially and ethnically heterogeneous, with multiple chronic conditions. Clinical threats to continued independent living among older adult HCBS recipients include acute illnesses, injuries, and exacerbations of chronic conditions, which could trigger a pathway of emergency department (ED) visits, hospitalization, and long-term nursing home admission. Despite its importance in the pathway from independent living, little is known about the rate of, or risk factors for, ED use in this target population. Accordingly, we determined predictors of ED use in a statewide cohort (N=5,651) in Connecticut’s Medicaid HCBS program for adults age &amp;gt;65, who were clinically assessed using a uniform tool between April 2020-March 2021. ED use, (0 vs 1+ visits), was ascertained over 12 months following clinical assessment using Medicare and Medicaid claims data. Predictor variables were racial and ethnic group, primary language, age, sex, educational attainment level, dementia diagnosis or moderate-severe cognitive impairment, depressive symptom severity, and Charlson comorbidity index. Cohort members were 76% female, 30% Hispanic, 15% non-Hispanic Black, 4% non-Hispanic Asian, 33% age &amp;gt;85. Forty-one percent had 1+ ED visits. Multivariate logistic regression analyses revealed that ED use was associated with (adjusted odds ratios p&amp;lt;0.05): high school education, more severe depressive symptoms, and more chronic conditions. Non-Hispanic Asian individuals had lowest ED visit likelihood. ED use among older adults receiving Medicaid HCBS might be reduced if depressive symptoms and multiple chronic conditions are optimally managed.

Psychotropic Medication Use in Children and Youth with Autism Enrolled in Medicaid.

Children with autism frequently present with complex mental health diagnoses and psychotropic medications are often a component of comprehensive biopsychosocial treatment plans for these conditions. The purpose of this study is to provide rates and patterns of psychotropic medication use, and predictors thereof, in childrenand youth with autism enrolled in Medicaid across the US. This study examined national Medicaid claims from 2008 to 2016 of all children and youth with autism ages 0-21 years enrolled in Medicaid. Psychotropic medication use was examined across several child and youth characteristics, including age, co-occurring mental health conditions, sex, and race and ethnicity. About half of children and youth with autism enrolled in Medicaid had at least one psychotropic prescription in a year, a number that decreased slightly across the study period due to decreases in the prescription of antipsychotics. As new medications for autism or co-occurring conditions are developed and deployed, and as the understanding of the characteristics of the population of children with autism evolves, studying rates of medication usage helps to understand utilization patterns and differences in access to quality care.

One-Year Medication Treatment Patterns, Healthcare Resource Utilization, and Expenditures for Medicaid Patients with Schizophrenia Starting Oral Atypical Antipsychotic Medication

Oral atypical antipsychotic (OAAP) medications are the most commonly prescribed treatment for the management of schizophrenia symptoms. This retrospective study, using Medicaid claims data (2016–2020), followed patients for 12 months after initiating OAAP therapy. Study outcomes included OAAP adherence, switching, augmentation, healthcare resource utilization (HRU), and expenditures. All-cause and schizophrenia-related HRU and expenditures were compared between adherent and nonadherent cohorts. Among 13,007 included patients (39.1 ± 12.8 years of age, 57.0% male, 36.1% Black, 31.8% White, 9.7% Hispanic), 25.7% were adherent to OAAPs (proportion of days covered [PDC] ≥ 0.8). During the 1-year follow-up period, Black individuals were in possession of an OAAP for an average of 166 days compared to 198 and 202 days for White and Hispanic patients, respectively. Approximately 16% of patients switched OAAP medications and 3.2% augmented therapy with an OAAP added to their index medication. Nearly 40% of patients were hospitalized during follow-up and 68.4% had emergency department (ED) visits. A greater proportion of nonadherent patients had all-cause inpatient (41.7% vs. 34.1%, p < 0.001) and ED visits (71.7% vs. 58.8%, p < 0.001) compared to adherent patients. Annual total healthcare expenditures were $21,020 per patient; $3481 higher for adherent versus nonadherent patients. Inpatient expenditures comprised 44.6% and 30.6% of total expenditures for nonadherent and adherent patients, respectively. Hospitalized patients’ total expenditures were $23,261 higher compared to those without a hospitalization. Adherence to OAAP medication is suboptimal and associated with increased utilization of costly hospital and ED resources. Efforts to improve therapies and increase medication adherence could improve clinical and economic outcomes among individuals with schizophrenia.

Racial and Ethnic Differences in Hospice Use Among Medicaid-Only and Dual-Eligible Decedents

Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population. To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period. This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020. Race and ethnicity. Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death. Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85). Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.

The impact of the baby friendly hospital initiative on healthcare utilization among newborns insured by Medicaid in Delaware

BackgroundThe Baby Friendly Hospital Initiative was created to enhance breastfeeding, although its impact on infant healthcare utilization is unclear. Breast feeding infants are vulnerable to readmission soon after birth secondary to dehydration and hyperbilirubinemia. Breastfeeding can also protect infants from unnecessary health care utilization later in life by preventing infection. The objective of this study was to examine the impact of the Baby Friendly Hospital Initiative on readmissions and emergency department utilization among Medicaid births in Delaware.MethodsThe study was a quasi-experimental design. Medicaid claims files were used to study births at five hospitals in Delaware born between January 1, 2014, and December 31, 2018, and covered under Medicaid at time of birth. Three hospitals were designated Baby Friendly, two were not and served as controls. Outcomes included Emergency Department (ED) utilization and readmissions within 30 days and one-year of birth hospitalization. Exposure to the Baby Friendly Hospital Initiative was determined by year and hospital of birth. Logistic regression and interrupted time series segmented regression analysis with controls were used to assess the effect of Baby Friendly Hospital Initiative on healthcare utilization.ResultsIn total, 19,695 infants were born at five hospitals with 80% (15,939) born at hospitals that were designated Baby Friendly. ED utilization and readmissions over the 1st year of life for breastfeeding related diagnosis at the Baby Friendly hospitals occurred in 240 (1.5%) and 226 (1.4%) of infants, respectively. Exposure to the Baby Friendly Hospital Initiative was associated with increased odds of all cause 30-day readmission (AOR: 1.15; 95% CI: 1.03–1.28) but not readmissions over the 1st year of life. While 30-day ED visits did not change after BFHI, one-year ED visits were reduced (0.91, 95% CI 0.86–0.97). A significant negative trend was seen over time for ED utilization post BFHI compared to controls (B: -5.90, p < 0.01).ConclusionThere was a small observed increase in the odds of all cause 30-day readmissions with no change in one-year readmissions after BFHI in Delaware. Although there were no observed changes in 30-day ED utilization, there was a reduction in one-year ED utilization following the implementation of the Baby Friendly Hospital Initiative in Delaware birth hospitals. Our data help to inform policy and decision making for statewide systems of care that may be used to support breast feeding.

Preconception care utilization: Self-report versus claims-based measures among women with Medicaid.

The objective of this study is to compare self-reported preconception care utilization (PCU) among Medicaid-covered births to Medicaid claims. We identified all Medicaid-covered births to women ages 15-45 in 26 states in the year 2012 among the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey and Medicaid Analytic eXtract (MAX) claims data, and identified preconception services in the latter using diagnosis codes published by Health and Human Services' Office of Population Affairs. We fit mixed-effects logistic regression models for the probability of PCU on sociodemographic factors (age, race, and ethnicity) and clinical diagnoses (depression, diabetes, or hypertension), separately for each dataset. Among 652,929 women delivering in MAX, 28.1% received at least one claims-based preconception service while an estimated 23.6% (95% CI 22.1-25.3) of PRAMS respondents reported receiving preconception care. Adjusting for age, chronic diseases, and state, PCU rates in both MAX and PRAMS were higher for non-Hispanic Black versus non-Hispanic White women (OR 1.51, 95% CI 1.49-1.54 and OR 2.05, 95% CI 1.60-2.62, respectively). Adjusting for differences in age, race and ethnicity, and state, PCU rates were higher for patients with diabetes (OR 1.34, 95% CI 1.29-1.40 and OR 1.82, 95% CI 1.16-2.85) or hypertension (OR 1.22, 95% CI 1.18-1.27 and OR 1.85, 95% CI 1.41-2.44). While Hispanic and Asian women were also more likely to report PCU than their non-Hispanic White counterparts (OR 2.07, 95% CI 1.53-2.80 and OR 3.37, 95% CI 2.28-4.98), they were less likely to have received it (OR 0.74, 95% CI 0.73-0.75 and OR 0.65, 95% CI 0.63-0.67). In conclusion, comparing self-report to claims measures of PCU, we found similar trends in the differences between non-Hispanic Black and White women, and between those with vs. without diabetes and hypertension. However, the two data sources differed in trends in other racial/ethnic groups (differences between Hispanic vs. non-Hispanic White women, and between Asian vs. non-Hispanic White women), and in those with vs. without depression. This suggests that while Medicaid claims can be a useful tool for studying preconception care, they may miss certain types of care among some sub-groups of the population or be subject to reporting differences that are hard to surmise. Both data sets have potential benefits and drawbacks as research tools.

A Geospatial Analysis of Social and Structural Determinants of Health and High HIV Prevalence in Alabama, USA.

This study utilizes geospatial analytic techniques to examine HIV hotspots in Alabama leveraging Medicaid utilization data. This cross-sectional study leveraged Medicaid utilization data from Alabama's 67 counties, averaging 9,861 Medicaid recipients aged > 18 years old per county. We used Alabama Medicaid administrative claims data from January 1, 2016, to December 31, 2020, to identify individuals with HIV. Using Microsoft SQL Server, we obtained the average annual count of HIV Medicaid claims in each of the 67 Alabama counties (numerator) and the number of adult Medicaid recipients in each county (denominator), and standardized with a multiplier of 100,000. We also examined several other area-level summary variables (e.g., non-high school completion, income greater than four times the federal poverty level, social associations, urbanicity/rurality) as social and structural determinants of health. County-boundary choropleth maps were created representing the geographic distribution of HIV rates per 100,000 adult Medicaid recipients in Alabama. Leveraging ESRI ArcGIS and local indicators of spatial association (LISA), results were examined using local Moran's I to identify geographic hotspots. Eleven counties had HIV rates higher than 100 per 100,000. Three were hotspots. Being an HIV hotspot was significantly associated with relatively low educational attainment and less severe poverty than other areas in the state. Findings suggesting that the HIV clusters in Alabama were categorized by significantly less severe poverty and lower educational attainment can aid ongoing efforts to strategically target resources and end the HIV epidemic in U.S.' Deep South.

Characterization of Sickle Cell Disease Mortality in a National Electronic Health Record (EHR) System

Introduction Sickle cell disease (SCD) is a chronic condition with significant morbidity in children and early adult mortality. Identifying high-risk SCD populations has been challenging due to limited population cohorts of children and adults. Understanding the clinical course of SCD in both children and adults is crucial for informed treatment decisions around disease-modifying therapy vs. curative and transformative therapies. Recent use of Medicaid, Medicare, and private insurer claims datasets has helped define high-risk populations and estimate mortality, but they have limitations in clinical record depth. In contrast, electronic health record (EHR)-based datasets offer a better option for assessing the impact of disease-modifying therapy and allow comprehensive mortality risk prediction analyses, using high-dimensional laboratory data. Objective Previously, using the data warehouse at a single institution (Vanderbilt University School of Medicine) with data collected over 18 years, members of our team developed a contemporaneous cohort of children and adults with SCD. To do this our team developed a dual-approach algorithm that combined patients categorically selected by diagnosis using ICD-10 (International Classification of Diseases -10) codes and by laboratory data including hemoglobin fractionation values. The team estimated the median survival in adults with SCD and predicted mortality risk based on disease-modifying therapy and insurance status. We expanded this work by testing the hypothesis that we can first apply the laboratory portion of the Vanderbilt algorithm to identify children and adults with SCD living in the United States from the national Cerner Learning Health Network (Cerner LHN) EHR dataset. Methods The Cerner LHN is a nationwide dataset comprised of 88 million patients from over 74 hospital systems across 37 states (as of September 17, 2021). We used data from the Cerner LHN collected between 8/26/2002 and 12/13/2022 for our analysis. We extracted laboratory data elements required for the Vanderbilt algorithm including hemoglobin fractionation data with HbS values as well as total hemoglobin timepoints and blood transfusion time frames. The results of the laboratory portion of the Vanderbilt algorithm predict genotype of sickle cell disease in the following categories: SCA (HbSS or HbSB 0 ), SC (Hb SC), HbSBeta + and HbSE. There were 5,827 patients identified with these laboratory components necessary for the algorithm. We applied an updated python script that detailed the logic from the Vanderbilt algorithm on the 5,827 patients and we identified 3,248 children and adults with SCD. Patients were then evaluated for demographics and hospital systems coverage within the Cerner LHN. Results Black/African Americans made up 2947 patients (90.7%) of the SCD cohort. There were 1325 (54%) male and 1150 (46.5%) female patients with SCA within the phenotyped cohort. Patients with SCA were collected from 44.6% of the Cerner LHN health systems. Conclusions The population was 90.7% Black/African American as expected in patients carrying a diagnosis of SCD. This contemporaneous national cohort represents 44.6% of the health systems within the Cerner LHN which denoted wide-reaching patient sampling. These findings show that the laboratory portion of the Vanderbilt SCD algorithm can, in an automated fashion, establish a phenotyped SCD cohort of children and adults in a national EHR system. We plan to power the total number by adding the ICD-10 portion of the algorithm and estimating mortality in the final cohort. Further, we will validate combined algorithm by chart review.