Medicaid-insured Patients Research Articles

Effect of Race and Insurance Status on Treatment and Outcomes in Diabetic Retinopathy: Analysis of 43 274 Eyes Using the IRIS Registry.

Purpose: To examine disparities in visual acuity (VA) outcomes 1 year and 2 years after initiation of diabetic retinopathy (DR) or diabetic macular edema (DME) treatment in patients based on race/ethnicity and insurance status, accounting for disease severity. Methods: This retrospective analysis used the IRIS Registry and included DR patients older than 18 years with documented antivascular endothelial growth factor (anti-VEGF) treatment and VA data for at least 2 years. International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to determine the severity of DR and DME presence. VA outcomes were assessed using multivariable linear regressions and anti-VEGF drug use by multivariable logistic regressions, with race and insurance status as independent variables. Main outcome measures comprised the mean VA change at 1 year and 2 years and percentage of patients treated with bevacizumab. Results: The study included 43 274 eyes. White patients presented with a higher mean VA and lower mean DR severity than Black patients and Hispanic patients. Multivariable logistic regression showed Hispanic patients were significantly more likely to be treated with bevacizumab than White patients across all insurance types, controlling for disease severity and VA. After 1 year, the letter improvement was 1.73, 1.33, and 1.13 in White patients, Black patients, and Hispanic patients, respectively. Multivariable linear regression suggested that across races, Medicaid-insured patients had significantly smaller gains in VA than privately insured patients. Conclusions: Race-based and insurance-based differences in 1-year and 2-year outcomes after anti-VEGF treatment for DR and anti-VEGF treatment patterns suggest a need to ensure earlier and more effective treatment of minority and underserved patients in the United States.

Health Insurance Continuity Is Associated with Stage at Diagnosis Among Children, Adolescents, and Young Adults Newly Diagnosed with Lymphoma

Background: Many uninsured patients do not gain Medicaid coverage until the point of, or after, their cancer diagnosis, which can limit access to early cancer detection and delay diagnosis and treatment, leading to poorer survival outcomes. Our previous research found that gaining Medicaid at, or after, diagnosis (vs. continuous Medicaid coverage) is significantly associated with inferior survival among children and adolescents/young adults (AYAs) with lymphoma, a leading cause of pediatric and AYA cancers. However, whether this relationship is mediated by lymphoma stage at diagnosis is unknown. To fill this knowledge gap, the current study examines the association between Medicaid coverage continuity and disease stage among this vulnerable population. Methods: We identified 13,655 children and AYAs (ages 0-39 years) newly diagnosed with lymphoma between 2007-2012, using the linked Surveillance, Epidemiology, and End Results (SEER) registries and Medicaid enrollment data. To measure coverage continuity, we categorized patients into those with 1) continuous Medicaid (enrolled in Medicaid for ≥12 months prior to and through diagnosis), 2) newly gained Medicaid (enrolled in the month of or within 12 months after diagnosis), 3) other patterns of noncontinuous Medicaid, 4) private insurance at diagnosis, 5) other insurance types at diagnosis (Medicare, TRICARE, Military, VA, or Indian/Public Health Service), and 6) unknown or no insurance at diagnosis. The last 3 groups comprised patients not linked to Medicaid enrollment data; thus their insurance continuity patterns were unknown, and their insurance status at the time of diagnosis was extracted from SEER registries. The association between coverage continuity and late-stage diagnosis was examined with separate multivariable logistic regression models among all patients and by cancer subtypes (Hodgkin lymphoma, non-Hodgkin lymphoma). Late-stage was defined as stage IV (vs. stage I-III) using the Ann-Arbor staging classification. Regressions also adjusted for sex, race/ethnicity, age at diagnosis, diagnosis year, rurality, neighborhood socioeconomic status (SES), and state of residence. Results: Half of our sample had private insurance (50.3%), followed by Medicaid insurance (26.9%), other insurance type (10.3%), and unknown (7.9%) or no insurance (4.7%). Among Medicaid-insured patients, 40.1% had newly gained Medicaid, followed by continuous Medicaid (32.5%) and other patterns of noncontinuous Medicaid (27.3%). Overall, one-fourth (24.8%) of the sample had stage IV lymphoma (Figure 1). Compared with privately insured patients, the adjusted percentage of stage IV diagnoses was 16.8 percentage points (ppt; 95% CI=14.6-19.0, p<0.001), 10.6 ppt (95% CI=8.2-13.0, p<0.001), and 4.9 ppt (95% CI=2.7-7.1, p<0.001) higher in patients with newly gained Medicaid, other patterns of noncontinuous Medicaid, and continuous Medicaid, respectively. Among the subset of Medicaid-insured patients, the adjusted percentage of stage IV diagnoses was 10.7 ppt (95% CI=7.5-13.8, p<0.001) and 5.4 ppt (95% CI=3.1-7.6, p<0.001) higher among patients with newly gained Medicaid and other patterns of noncontinuous Medicaid, respectively, compared to those with continuous Medicaid. These patterns persisted across lymphoma subtypes. Notably, coverage continuity patterns varied by sociodemographic factors, with non-Hispanic Black (vs. non-Hispanic White) patients, AYAs ages 15-39 years (vs. pediatric patients ages ≤14), and residents of non-metropolitan (vs. metropolitan) areas or lower SES neighborhoods significantly more likely to have newly gained Medicaid. Conclusions: Less than one-third of Medicaid-insured children and AYAs with lymphoma had continuous insurance coverage prior to cancer diagnosis. Lacking continuous Medicaid coverage was significantly associated with advanced-stage lymphoma diagnosis.

Measuring substance use disorder (SUD) in commercial and Medicaid insured patients with cancer in Washington state.

177 Background: Studies have shown that SUDs not only impact cancer risk, treatment, and survivorship but also increase ED and hospital use. We sought to characterize SUD within Medicaid enrollees diagnosed with cancer in Washington state, hypothesizing thatMedicaid enrollees were more likely to be diagnosed with SUDs than commercial enrollees, and that patients with an SUD experienced higher rates of emergency department (ED) visits or inpatient (IP) stays during initial cancer treatment. Methods: We linked Washington State cancer registry records with claims data from two large commercial insurers and Medicaid. Eligibility criteria included patients under 65 diagnosed with a solid tumor between 2013-2021 who started systemic therapy within 6 months of diagnosis. SUD diagnoses were identified using codes from CMS’s hierarchical condition category for SUD in the 6 months following diagnosis. Chi-square tests were used to compare demographic characteristics of those with and without a SUD diagnosis. Multivariate logistic regressions were used to evaluate the association between SUD and likelihood of at least one ED visit or IP stay, after controlling for payer, sex, race, ethnicity, age, marital status, stage, cancer group, area deprivation index, and diagnosis year. Results: Among the 10,709 patients (6,680 Commercial, 3,718 Medicaid, 311 Multiple) who received systemic therapy, 7.2% had a SUD diagnosis. SUD patients were less likely to be Asian and more likely to be male, living without a partner, diagnosed at a later cancer stage, and living in more deprived areas. Medicaid patients had significantly higher rates of SUD than commercial-insured patients (14.3% vs 3.3%). Overall, 46.6% of cancer patients had an ED visit or IP stay. Patients with SUD had greater use of ED or IP visits than patients without SUD (70.1% and 44.8%, respectively). In the first 6 months of systemic therapy patients with SUD were significantly more likely to visit the ED or be admitted to IP (OR 2.12, 95% CI 1.79 - 2.50) than cancer patients without SUD. Conclusions: More than 1 in 7 Medicaid cancer patients in WA state has an identified SUD. SUD is associated with significant excess risk for ED/IP admissions during treatment. Accurate identification of SUD in patients is necessary prior to strategies aimed at mitigation of unplanned ED visits and hospitalizations during cancer care. Further research is needed on interventions that effectively reduce the risk during treatment.[Table: see text]

Emergency Department Visits Following Patellofemoral Arthroplasty.

Readmissions are a typical postoperative metric; however, postoperative emergency department (ED) utilization also negatively affects patient care. Few studies have explored this metric after patellofemoral arthroplasty (PFA); thus, we investigated the incidence, timing, predictive factors, and reasons for ED utilization within 90 days after PFA. Using the 2010 to 2021 PearlDiver M151Ortho data set, a national billing claims database containing information of over 151 million US orthopaedic patients across all payer types, the study examined weekly ED visits up to 90 days after PFA and conducted univariate and multivariate analyses to identify predictive factors. Of 7765 PFA patients, 11.2% (922) had ED visits within 90 days, with 46.7% (431) occurring in the first 3 weeks. Independent predictors of ED utilization included younger age (OR 1.40 per decade decrease), higher Elixhauser Comorbidity Index (OR 1.44 per 2-point increase), surgery in the South or Midwest (OR 1.27 and 1.31), and Medicaid insurance (OR 1.74). Postoperative pain accounted for 50.6% of visits. 11.2% of PFA patients visited the ED within 90 days, primarily for postoperative pain. Younger, more comorbid, and Medicaid-insured patients were most likely to use the ED. This study suggests the need for targeted perioperative pain management to reduce ED utilization after PFA.

Malnutrition and Adverse Outcomes After Surgery for Head and Neck Cancer

Patients with head and neck cancer (HNC) have an increased risk of malnutrition, partly due to disease location and treatment sequelae. Although malnutrition is associated with adverse outcomes, there is little data on the extent of outcomes and the sociodemographic factors associated with malnutrition in patients with HNC. To investigate the association of race, ethnicity, and payer type with perioperative malnutrition in patients undergoing HNC surgery and how malnutrition affects clinical outcomes. This retrospective cohort study used data from the Premier Healthcare Database to assess adult patients who had undergone HNC surgery from January 2008 to June 2020 at 482 hospitals across the US. Diagnosis and procedure codes were used to identify a subset of patients with perioperative malnutrition. Patient characteristics, payer types, and hospital outcomes were then compared to find associations among race, ethnicity, payer type, malnutrition, and clinical outcomes using multivariable logistic regression models. Analyses were performed from August 2022 to January 2023. Race, ethnicity, and payer type for primary outcome, and perioperative malnutrition status, race, ethnicity, and payer type for secondary outcomes. Perioperative malnutrition status. Secondary outcomes were discharge to home after surgery, hospital length of stay (LOS), total cost, and postoperative pulmonary complications (PPCs). The study population comprised 13 895 adult patients who had undergone HNC surgery during the study period; they had a mean (SD) age of 63.4 (12.1) years; 9425 male (67.8%) patients; 968 Black (7.0%), 10 698 White (77.0%), and 2229 (16.0%) individuals of other races; and 887 Hispanic (6.4%) and 13 008 non-Hispanic (93.6%) individuals. Among the total sample, there were 3136 patients (22.6%) diagnosed with perioperative malnutrition. Compared with White patients and patients with private health insurance, the odds of malnutrition were higher for non-Hispanic Black patients (adjusted odds ratio [aOR], 1.31; 95% CI, 1.11-1.56), Medicaid-insured patients (aOR, 1.68; 95% CI, 1.46-1.95), and Medicare-insured patients (aOR, 1.24; 95% CI, 1.10-1.73). Black patients and patients insured by Medicaid had increased LOS, costs, and PPCs, and lower rates of discharge to home. Malnutrition was independently associated with increased LOS (β, 5.20 additional days; 95% CI, 4.83-5.64), higher costs (β, $15 722 more cost; 95% CI, $14 301-$17 143), increased odds of PPCs (aOR, 2.04; 95% CI, 1.83-2.23), and lower odds of discharge to home (aOR, 0.34; 95% CI, 0.31-0.38). No independent association between malnutrition and mortality was observed. This retrospective cohort study found that 1 in 5 patients undergoing HNC surgery were malnourished. Malnourishment disproportionately affected Black patients and patients with Medicaid, and contributed to longer hospital stays, higher costs, and more postoperative complications.

S1624 Burden of Liver Cancer Among Medicaid-Insured Patients: A Retrospective Analysis of a National All-Payer Claims Database

S1624 Burden of Liver Cancer Among Medicaid-Insured Patients: A Retrospective Analysis of a National All-Payer Claims Database

A Clinical-Community Partnership to Address Food Insecurity and Reduce Emergency Department Utilization Among Medicaid-Insured Patients in North Carolina.

Socioeconomic risk factors have the greatest impact on overall health trajectory. Patients with Medicaid insurance are more likely to experience food insecurity, in addition to poor health and increased health care utilization. Targeted food and produce prescription programs can reduce food insecurity, but sustainable implementation is challenging and evidence demonstrating the impact on clinical utilization outcomes is lacking. In 2021, a cross-sector collaboration between Mecklenburg County Public Health, Reinvestment Partners, and Atrium Health initiated a food prescription program in urban North Carolina. A low-cost mass text message campaign was used to identify and enroll Medicaid-insured patients with a history of emergency department (ED) utilization. A nonrandomized before/after evaluation design was used with a 12-month data collection window (6 months before/after program enrollment) for 711 patients enrolled between June 2021 and 2022. Changes in the odds of nonadmission ED utilization were modeled using logistic regression, adjusting for race/ethnicity, gender, age, comorbidity, and dose, along with interaction by comorbidity. A majority of the sample was non-Hispanic Black (61%; n = 436), female (90%; n = 643), with "none to mild" chronic disease comorbidity (81%; n = 573). The unadjusted and adjusted odds of nonadmission ED utilization significantly reduced between time periods, along with significant interaction by comorbidity. Among the subsamples, patients with "none to mild" comorbidity showed 34% reduction in odds of nonadmission ED utilization (OR = 0.64; 95% CI, 0.47-0.86). Food prescription programming targeting Medicaid-insured patients may reduce ED utilization, particularly among those without severe comorbidity. Retrospective data collection and sample homogeneity reduced the quality of evidence, but results offer a pragmatic example that can be replicated for further study. Additional research is needed to strengthen the body of evidence and support cross-sector investment in food and produce prescription programming.

A Mixed-Methods Study to Evaluate the Feasibility and Acceptability of Implementing an Electronic Health Record Social Determinants of Health Screening Instrument into Routine Clinical Oncology Practice.

Routine screening for social determinants of health (SDOH) in the outpatient oncology setting is uncommon. The primary goal of this study was to prospectively evaluate the feasibility and acceptability of implementing an electronic health record (EHR) SDOH screening instrument into routine, clinical, oncology practice. Adult patients with newly diagnosed gastrointestinal cancer presenting to a regional cancer center (November 2020 to July 2021) were eligible. Based on the consolidated framework for implementation research, feasibility measures included screening completion, median clinic visit time, and acceptability by the inter-professional care team and patients as measured by semistructured, qualitative interviews and surveys. Secondary outcomes included SDOH needs identified. Of 137 eligible patients, 112 (81.8%) were screened for SDOH. Demographics of the cohort included: 41.1% black (n = 46), 48.2% rural (n = 54), 4.5% uninsured (n = 5), and 6.3% Medicaid-insured (n = 7) patients. Median visit time was 97min (95% CI 70-107min) before and 100min after implementation (95% CI 75-119min; p = 0.95). In total, 95.5% (n = 107) reported at least one SDOH need. Clinicians (7/10) reported that SDOH screening was not disruptive and were supportive of ongoing use. Patients (10/10) found the screening acceptable. Screening staff (5/5) reported workflow barriers. Patients and staff also recommended revision of specific instrument questions. Routine collection of SDOH in an outpatient oncology setting using an EHR instrument is feasible and does not result in increased visit time for patients or clinicians. However, staff perceptions of clinic workflow disruption were reported. Further investigation to determine whether standardized SDOH assessment can improve cancer care delivery and outcomes is ongoing.

Medicaid Expansion of the Patient Protection and Affordable Care Act and Participation of Patients With Medicaid in Cancer Clinical Trials

The Patient Protection and Affordable Care Act (ACA) Medicaid expansion resulted in increased use of Medicaid insurance nationwide. However, the association between Medicaid expansion and access to clinical trials has not been examined to date. To examine whether the implementation of ACA Medicaid expansion was associated with increased participation of patients with Medicaid insurance in cancer clinical trials. Data for this cohort study of 51 751 patients were from the SWOG Cancer Research Network. All patients aged 18 to 64 years and enrolled in treatment trials with Medicaid or private insurance between April 1, 1992, and February 29, 2020, were included. Interrupted time-series analysis with segmented logistic regression was used. The monthly unemployment rate and presidential administration were adjusted to reflect potential differences in Medicaid use associated with economic conditions and national administrative policies, respectively. Data analysis was conducted between June 22, 2021, and August 5, 2022. Implementation of Medicaid expansion on January 1, 2014, was the independent exposure variable. The number and proportion of patients by insurance type enrolled in cancer clinical trials over time were analyzed. Overall, data for 51 751 patients were analyzed. Mean (SD) age was 50.6 (9.8) years, 67.3% of patients were female, 41.1% were younger than 50 years, and 9.1% used Medicaid. A 19% annual increase (odds ratio [OR], 1.19; 95% CI, 1.11-1.28; P < .001) was identified in the odds of patients using Medicaid after the ACA Medicaid expansion, resulting in a 52% increase (OR, 1.52; 95% CI, 1.29-1.78; P < .001) compared with what was expected in the number of Medicaid patients enrolled over time. The association was greater in states that adopted Medicaid expansion in 2014 to 2015 (OR, 1.26; 95% CI, 1.15-1.38; P < .001) compared with other states (OR, 1.08; 95% CI, 0.96-1.21; P = .20; P = .04 for interaction). By February 2020, the proportion of patients with Medicaid insurance was 17.8% (95% CI, 15.0%-20.8%; P < .001), whereas the expected proportion had ACA Medicaid expansion not occurred was 6.9% (95% CI, 4.4%-10.3%; P < .001). Findings suggest that implementation of ACA Medicaid expansion was associated with increased participation of patients using Medicaid in cancer clinical trials. Improved participation in clinical trials for Medicaid-insured patients is critical for socioeconomically vulnerable patients seeking access to the newest treatments available in trials and for improving confidence that trial findings apply to patients of all backgrounds.

MP75-07 Access to Urologic Cancer Care for Medicaid-insured Patients

MP75-07 Access to Urologic Cancer Care for Medicaid-insured Patients

Impact of the Affordable Care Act on Insurance Status of Patients Newly Diagnosed With Kaposi Sarcoma

Background: The Affordable Care Act (ACA) role in changing the insurance composition of patients diagnosed with many dermatological conditions, such as Kaposi Sarcoma (KS), has not been assessed. Methods: The Surveillance, Epidemiology and End Results (SEER) Program, which captures cancer data from nearly 40% of cases in the US was used to extract cases. Cases were subgrouped by Medicaid expansion and non-expansion states. Standard mean differences were used as the statistical measure with P-value &lt;0.05 used for statistical significance. Results: 2,465 patients met the inclusion criteria. In patients newly diagnosed with Kaposi sarcoma nationally before and after ACA implementation, the analysis showed there was no significant difference in the percentage of uninsured patients, Medicaid-insured patients, or privately insured patients. Pre- and post-ACA sub-analysis of patients newly diagnosed with Kaposi sarcoma in states that expanded Medicaid showed: (1) significant decrease in the percentage of uninsured patients (-5.81% difference, 95% CI -9.58% to -2.04%, P &lt;.05); (2) significant increase in the percentage of Medicaid-insured patients (+9.36% difference, 95% CI +0.35% to +18.37%, P &lt;.05) and (3) no significant difference in the percent of privately insured patients (-3.54% difference, 95% CI -13.74% to +6.64%). Sub-analysis in non-expansion states showed no difference between the insurance subtypes. Conclusion: Medicaid expansion played the largest role in reducing the percentage of uninsured patients newly diagnosed with KS. In states without Medicaid expansion, it is important that public health forces ensure adequate access to medications with services like the Ryan White HIV/AIDS Program

Shorter Duration HepatitisC Virus Treatment is Associated with Better Persistence to Prescription Refills in People Who Inject Drugs: A Real-World Study.

Direct-acting antiviral (DAA) therapy is highly effective in curing hepatitisC virus (HCV) infection in people who inject drugs (PWID). Previous studies showed declining persistence to DAA therapy over the course of treatment. This study compares real-world medication persistence to prescription refills for 8- versus 12-week DAA in treatment-naïve PWID with chronic HCV with compensated cirrhosis or without cirrhosis. Symphony Health's claims database was used to collect data from patients with chronic HCV aged ≥ 12years who were prescribed 8- or 12-week DAA therapy between August 2017 and November 2020 and had a diagnosis of addicted drug use within 6months prior to index date. Eligible patients had medical/pharmacy claims in the 6months before and 3months after the first index medication fill date (i.e., index date). Patients completing all refills (8-week = 1 refill, 12-week = 2 refills) were deemed persistent. The percentage of persistent patients in each group, and at each refill step, was determined; outcomes were also assessed in a subgroup of Medicaid-insured patients. This study assessed 7203 PWID with chronic HCV (8-week, 4002; 12-week, 3201). Patients prescribed 8-week DAA treatment were younger (42.9 ± 12.4 vs 47.5 ± 13.2, P < 0.001) and had fewer comorbidities (P < 0.001). Patients receiving 8- versus 12-week DAA had greater refill persistence (87.9% vs 64.4%, P < 0.001). Similar percentages of patients missed their first refill (8-week, 12.1% vs 12-week, 10.8%); nearly 25% of patients receiving 12-week DAA missed their second refill. After baseline characteristics were controlled, patients prescribed 8- versus 12-week DAA were more likely to be persistent (odds ratio [95% confidence interval] 4.3 [3.8, 5.0]). Findings in the Medicaid-insured subgroup were consistent. Patients prescribed 8- vs 12-week DAA therapy had significantly greater prescription refill persistence. Most nonpersistence was due to missed second refills, highlighting the potential benefit of shorter treatment durations in this population.

Health insurance continuity and survival among children, adolescents, and young adults with blood cancer: An analysis based on SEER-Medicaid data.

6504 Background: Many previously uninsured patients do not receive Medicaid coverage until the point of, or after, cancer diagnosis, which may delay access to life-saving therapies. We examined whether continuous Medicaid coverage prior to diagnosis (vs. gaining Medicaid at, or after, diagnosis) provides a survival benefit in children and adolescents/young adults (AYAs) newly diagnosed with blood cancer. Methods: Using the linked SEER cancer registry-Medicaid enrollment data, we assessed coverage during the six months prior to, the month of, and the six months after cancer diagnosis (13-month window) in 29,873 children and AYAs (aged 0-39 years) diagnosed with blood cancer in 2006-2013. To measure insurance continuity, we categorized patients who had: (1) continuous Medicaid (enrolled for ≥6 months prior to through diagnosis), (2) newly gained Medicaid at/after diagnosis (enrollment only at or ≤6 months after diagnosis), (3) other patterns of noncontinuous Medicaid, (4) private insurance, (5) other insurance, or (6) uninsured/unknown insurance. The last three groups contain patients in SEER not linked to Medicaid enrollment data; these patients’ insurance at diagnosis was available in SEER. Kaplan-Meier (KM) survival curve of 5-year overall survival was stratified by insurance continuity category. Associations between insurance continuity and survival were examined using Cox proportional hazard models, for all blood cancers combined and by cancer type (leukemia, lymphoma, myeloma). Models also adjusted for age, sex, race/ethnicity, rurality, neighborhood socioeconomic status, and diagnosis year. Results: Of our sample, 44.1% had private insurance, followed by Medicaid (28.3%), other insurance (9.6%), and no insurance (3.9%) or unknown insurance (14.1%). Of Medicaid-insured patients, 44.9% had continuous Medicaid, 38.9% gained Medicaid at/after diagnosis, and 16.2% experienced other noncontinuous patterns. The KM-estimated 5-year survival probability was 89.3% for privately insured patients, followed by other insurance (88.1%), continuous Medicaid (78.2%), other patterns of noncontinuous Medicaid (74.3%), and newly gained Medicaid at/after diagnosis (70.6%; p&lt;0.001). In multivariable analysis, patients who newly gained Medicaid at/after diagnosis had a hazard ratio (HR) for death of 2.63 (95%CI=2.42-2.87), whereas patients with continuous Medicaid and those with other noncontinuous patterns had HRs of 2.08 (95%CI=1.90-2.28) and 2.31 (95%CI=2.04-2.60), respectively, compared to privately insured patients. This finding persisted across blood cancer types. Conclusions: Less than half of Medicaid-insured children and AYAs with blood cancer had continuous insurance coverage prior to and following cancer diagnosis. Lacking continuous Medicaid coverage was associated with inferior survival.

Patient Utilization of Premium Intraocular Lenses Before and During the COVID-19 Pandemic.

To compare the choice of intraocular lens (IOL) and sociodemographic characteristics between patients who underwent elective cataract surgery before the COVID-19 pandemic and during the pandemic at the Wilmer Eye Institute. A retrospective chart review of patients who underwent cataract surgery before the COVID-19 pandemic (June 1 to November 30, 2019) and during the pandemic (June 1 to November 30, 2020) was conducted. Sociodemographic information, including age, sex, race, and insurance, and choice of IOL (premium or standard) were analyzed. The association between timing of surgery and choice of IOL was analyzed using multivariable logistic regression. The study included 2,877 patients (3,946 eyes) before COVID-19 and 2,564 patients (3,605 eyes) during COVID-19. However, 9.0% (357/3,946) of surgeries before COVID-19 used premium IOLs compared with 11.1% (399/3,605) during COVID-19 ( P =0.004). There was no difference in the racial characteristics of patients between before and during COVID-19. After adjusting for time of surgery and demographics, the odds of choosing premium IOLs for black patients was 0.32 times the odds for white patients ( P <0.001). There was an increase in private-insured patients but a decrease in Medicare-insured patients during COVID-19. After adjusting for time of surgery and demographics, private-insured patients had higher odds of choosing premium IOLs ( P <0.001), whereas Medicaid-insured patients had lower odds ( P =0.007) when compared with Medicare-insured patients. More patients chose premium IOLs during COVID-19 than before COVID-19, concurrent with change in insurance status. White patients were more likely to choose premium IOLs than black patients, as were private-insured patients compared with Medicare-insured patients.

Long-Term Health Care Utilization After Cardiac Surgery in Children Covered Under Medicaid

BackgroundUnderstanding the longitudinal burden of health care expenditures and utilization after pediatric cardiac surgery is needed to counsel families, improve care, and reduce outcome inequities. ObjectivesThe purpose of this study was to describe and identify predictors of health care expenditures and utilization for Medicaid-insured pediatric cardiac surgical patients. MethodsAll Medicaid enrolled children age <18 years undergoing cardiac surgery in the New York State CHS-COLOUR database, from 2006 to 2019, were followed in Medicaid claims data through 2019. A matched cohort of children without cardiac surgical disease was identified as comparators. Expenditures and inpatient, primary care, subspecialist, and emergency department utilization were modeled using log-linear and Poisson regression models to assess associations between patient characteristics and outcomes. ResultsIn 5,241 New York Medicaid-enrolled children, longitudinal health care expenditures and utilization for cardiac surgical patients exceeded noncardiac surgical comparators (cardiac surgical children: $15,500 ± $62,000 per month in year 1 and $1,600 ± $9,100 per month in year 5 vs noncardiac surgical children: $700 ± $6,600 per month in year 1 and $300 ± $2,200 per month in year 5). Children after cardiac surgery spent 52.9 days in hospitals and doctors’ offices in the first postoperative year and 90.5 days over 5 years. Being Hispanic, compared with non-Hispanic White, was associated with having more emergency department visits, inpatient admissions, and subspecialist visits in years 2 to 5, but fewer primary care visits and greater 5-year mortality. ConclusionsChildren after cardiac surgery have significant longitudinal health care needs, even among those with less severe cardiac disease. Health care utilization differed by race/ethnicity, although mechanisms driving disparities should be investigated further.

PD20-07 ASSOCIATIONS BETWEEN PATIENT SOCIODEMOGRAPHIC FACTORS AND RISK-APPROPRIATE PROSTATE CANCER MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023PD20-07 ASSOCIATIONS BETWEEN PATIENT SOCIODEMOGRAPHIC FACTORS AND RISK-APPROPRIATE PROSTATE CANCER MANAGEMENT Madison Novosel, Shayan Smani, Victoria Marks, Farah Jeong, Preston Sprenkle, and Michael Leapman Madison NovoselMadison Novosel More articles by this author , Shayan SmaniShayan Smani More articles by this author , Victoria MarksVictoria Marks More articles by this author , Farah JeongFarah Jeong More articles by this author , Preston SprenklePreston Sprenkle More articles by this author , and Michael LeapmanMichael Leapman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003286.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although definitive treatment is associated with improved survival for aggressive prostate cancer, a significant number of patients do not receive treatment. To identify gaps in practice, we sought to evaluate sociodemographic factors associated with non-treatment by clinical risk strata in the contemporary era. METHODS: We performed a retrospective study of patients with prostate cancer using the National Cancer Database. A total of 954,591 patients diagnosed with localized prostate (cT1-4N0M0) cancer from 2010 to 2020 were included in the analysis. We used descriptive statistics and multivariable logistic regression to evaluate factors associated with non-treatment, stratifying analyses by D’Amico clinical risk criteria. RESULTS: The mean patient age at diagnosis was 65 years. Overall, 26.0% were diagnosed with low, 43.4% with intermediate, and 30.6% with high-risk prostate cancer. There were 131,122 (13.7%) who did not undergo initial treatment, including 82,318 (62.8%) with low, 35,499 (27.1%) with intermediate, and 13,305 (10.2%) with high-risk disease. The proportion of patients not receiving treatment increased over time in all risk groups between 2010 and 2010, including among low (11.7% versus 59.5%), intermediate (4.5% versus 12.5%) and high risk (3.6% versus 5.1%) disease. Compared with White patients, Black patients had lower odds of definitive treatment. This effect was more pronounced for patients with high (OR 0.61, 95% CI 0.58-0.64) rather than intermediate (OR 0.76, 95% CI 0.73-0.78) risk prostate cancer. Asian patients had lower odds of treatment compared with White patients across all disease risk strata (OR 0.84, 95% CI 0.80-0.88) but not high-risk disease (OR 0.90, 95% CI 0.80-1.00). There were lower odds of treatment among American Native/Alaskan Native versus White patients but not for high-risk disease (OR 0.79, 95% CI 0.57-1.10) Uninsured (OR 0.45, 95% CI 0.42-0.47, p<0.001), and Medicaid-insured (OR 0.68, 95% CI 0.66-0.71, p<0.001) patients were less likely to be treated overall. Patients residing in higher income areas had lower odds of over-treatment for low-risk prostate cancer (OR 0.84, 95% CI 0.81-0.87) and higher odds of treatment for high-risk prostate cancer (OR 1.34, 95% CI 1.25-1.44). CONCLUSIONS: Among patients diagnosed with prostate cancer in the contemporary era race and insurance are significantly associated with non-treatment for aggressive prostate cancer. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e586 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Madison Novosel More articles by this author Shayan Smani More articles by this author Victoria Marks More articles by this author Farah Jeong More articles by this author Preston Sprenkle More articles by this author Michael Leapman More articles by this author Expand All Advertisement PDF downloadLoading ...

Access to urologic cancer care for Medicaid-insured patients.

The expansion of state Medicaid programs associated with the Affordable Care Act has led to significant increases in insurance coverage for economically vulnerable patients, however barriers to accessing cancer care still exist. To develop strategies to improve healthcare access, we characterized access to new urologic cancer care for patients with Medicaid insurance in the United States. Using a secret shopper approach, we contacted a representative sample of facilities designated for cancer care in United States. Trained volunteers posed as a family member seeking urologic cancer care using a simulated scenario of a parent with a new diagnosis of a localized kidney tumor. The primary study outcome was acceptance of Medicaid. In addition, we assessed facility characteristics associated with Medicaid acceptance relating to state Medicaid expansion status, Medicare reimbursement rates, and teaching hospital status using data from the Medicare & Medicaid Services Hospital General Information data file, the American Hospital Directory, and the American Medical Association of Colleges Organizational Characteristics Database. We sampled a total of 389 facilities, of which 14.4% did not accept new Medicaid patients. Medicaid acceptance was higher in facilities located in states that elected to expand Medicaid through the ACA vs. non-expansion states (90.1% vs. 77.4% respectively, P < 0.001). Facilities accepting patients with Medicaid were located in states with higher mean Medicaid-to-Medicare fee indexes (0.70 for Medicaid-accepting vs. 0.65 for non-accepting facilities, P < 0.001). In addition, Medicaid acceptance was higher in teaching hospitals vs. non-teaching facilities (93.8% vs. 83.4% P = 0.02), and medical school affiliated facilities (89.2% vs. 79.7% P = 0.01). We identified access disparities for patients with Medicaid insurance seeking urologic cancer care at centers. These findings highlight opportunities to improve the quality and timeliness of cancer care.

The Effect of Community Type on Access to Orthopedic Services for Medicaid-Insured Patients

Purpose Medicaid-insured patients have less access to specialty care compared to those who are privately insured. Limited and delayed access to orthopaedic services can affect patient outcomes, especially for patients living in rural areas. The purpose of this study was to evaluate the effect of community setting in access to orthopaedic care for Medicaid-insured patients. Methods The study population included board-certified orthopaedic specialists obtained from the American Academy of Orthopaedic Surgeons (AAOS) within five Florida counties, representing urban and rural communities. Investigators used the Secret Shopper methodology to schedule an appointment for a rotator cuff repair. Medicaid acceptance rate, wait time, and average distance to clinics accepting Medicaid were calculated and compared between urban and rural counties. Results Of the 108 clinics identified, 76.9% performed arthroscopic rotator cuff repair. The appointment rate across all counties was 100% (n=83) for privately insured patients and 9.6% (n=8) for Medicaid patients. There was no significant difference in access when comparing access to care with Medicaid in urban and rural counties (p=0.984). Medicaid patients had significantly shorter wait times in rural counties compared to urban counties (p=0.021). Rural counties encountered a significantly greater average travel distance to clinics accepting Medicaid compared to urban counties (p=0.042). Conclusion Medicaid-insured patients have limited access to orthopaedic care, regardless of community setting. Medicaid-insured patients in rural counties were more likely to have shorter wait times to the appointment and travel longer distances to clinics.

Racial differences in survival and healthcare resource utilization among Medicaid-insured adults with metastatic castration-sensitive prostate cancer.

26 Background: Racial inequalities in healthcare have long existed in the United States, with Black or African American (BAA) men having higher overall cancer death rates compared to other racial or ethnic groups. One of the greatest disparities is in prostate cancer (PC), which disproportionately affects BAA men, though when matched for stage, whether outcomes differ by race is controversial. This study assessed differences in overall survival (OS) and healthcare resource utilization (HRU) by race in Medicaid-insured patients with metastatic castration-sensitive prostate cancer (mCSPC). Methods: This retrospective longitudinal cohort study evaluated de-identified administrative claims data from the Centers for Medicare and Medicaid Services 100% Medicaid data files, from 01/01/2010 - 12/31/2018. The study included adult patients with a diagnosis for PC, ≥1 claim for androgen deprivation therapy (ADT), diagnosis of metastasis before or within 90 days after ADT, and continuous eligibility for ≥6 months pre-index (defined baseline period) and ≥3 months post-index. The date of first receipt of ADT or first receipt of novel hormonal therapy or docetaxel if initiated within 30 days before ADT defined the index date. OS and HRU were assessed from the index date to the earliest of end of continuous eligibility, data availability, or death. A multivariable Cox proportional hazards model of OS and a multivariable Poisson model of HRU were implemented and controlled for age, plan type, region, median state income, residence in a state with Medicaid expansion, index year, Charlson comorbidity index (CCI), baseline HRU, and clinical characteristics. Results: The study included 1,488 patients with mCSPC (467 [31%] BAA, 446 [30%] White [W], 219 [15%] Hispanic [H], 356 [24%] Other races [O]). H were the oldest (mean age 68 years), followed by O (67 years), W (64 years), and BAA (63 years). BAA and H had the highest CCI (0.6), followed by O (0.5), and W (0.4). Median unadjusted OS was 71.3 months in H, 57.1 months in O, 52.1 months in BAA, and 44.9 months in W. After adjustment, H had significantly lower risk of death compared to W (hazard ratio [95% confidence interval (CI)]: 0.65 [0.43, 0.96]) and BAA patients had comparable survival to W (0.91 [0.69, 1.22]). Adjusted incidence rate ratios (IRR) showed significantly lower incidence of PC-related outpatient (OP) visits for BAA as compared to W (IRR [95% CI]: 0.71 [0.55, 0.99]), per patient per year. The remaining HRU endpoints were not significantly different among racial groups. Conclusions: Among Medicaid-insured adult patients with mCSPC, H were more likely to live longer than W patients. BAA patients had similar survival and lower rates of PC-related OP visits as compared with W, which shows differential use of PC-related healthcare resources between BAA and W.

Racial differences in survival and healthcare resource utilization among Medicaid-insured adults with metastatic castration-resistant prostate cancer.

29 Background: Prostate cancer (PC) disproportionately affects Black or African American (BAA) men in the United States (US), but racial disparities in outcomes are not well understood. This study analyzed racial disparities in OS, healthcare resource utilization (HRU), and PC treatments in Medicaid-insured metastatic castration resistant PC (mCRPC) patients. Methods: This retrospective longitudinal cohort study evaluated de-identified data from the Centers for Medicare and Medicaid Services 100% Medicaid data files from 01/01/2010 – 12/31/2018. The study included adult patients with a diagnosis of PC and metastasis, and a claim for at least one of the following drugs prior to 9/30/2018, which is specific to mCRPC (date defined index): ≥1 claim for cabazitaxel, mitoxantrone, enzalutamide, radium-223, or sipuleucel-T, ≥1 claim for abiraterone acetate before June 2017, ≥1 claim for docetaxel at least 90 days after initiation of hormone therapy, or evidence of castration resistance. Patients were required to be continuously enrolled for ≥6 months pre-index (i.e., baseline period) and ≥3 months post-index. Outcomes were assessed from the index date to the earliest of end of continuous enrollment, data availability, or death. A multivariable Cox proportional hazards model of OS, and a multivariable Poisson model of HRU were implemented and controlled for age, plan type, region, median state income, residence in a state with Medicaid expansion, index year, Charlson comorbidity index, baseline HRU, baseline PC treatments, and clinical characteristics. Results: The study included 1,095 mCRPC patients (320 [29%] White [W], 278 [25%] BAA, 190 [17%] Hispanic [H], 307 [28%] Other races [O]). H had the highest mean age of 69 years, followed by 68 years for O, and 63 years for both W and BAA. Median unadjusted OS was 46.7 months in H, 40.5 months in BAA, 35.3 months in O, and 32.3 months in W. After adjustment, H had significantly lower risk of death vs. W (hazard ratio [95% confidence interval (CI)]: 0.62 [0.42, 0.90]) and BAA had comparable survival to W (0.85 [0.62, 1.16]). BAA had significantly fewer PC-related outpatient (OP) visits vs. W (adjusted incidence rate ratios [IRR] [95% CI]: 0.67 [0.48, 0.93]), but significantly more PC-related emergency room (ER) visits (5.03 [2.03, 12.47]) per patient per year. Race cohorts differed in the proportions of patients treated with novel hormonal therapy (70% W, 63% BAA, 58% H, 67% O) and chemotherapy use (29% BAA, 26% H, 24% W, 19% O). Conclusions: Among Medicaid-insured adult mCRPC patients, H were more likely to live longer than W patients, while BAA and W patients had similar OS. BAA patients had a higher rate of PC-related ER visits but fewer PC-related OP visits as compared to W, showing differential use of PC-related healthcare resources.