Medicaid Insurance Research Articles

Relationships of race and area deprivation indices to outcomes in pediatric patients with inflammatory bowel disease.

Social determinants of health (SDOH) are nonmedical factors that influence health outcomes. Children with chronic illnesses living with socioeconomic risk factors have higher rates of unfavorable health outcomes. Our study aimed to assess the association between area deprivation indices (ADI), as a proxy for SDOH, and outcomes in pediatric patients with inflammatory bowel disease (IBD). A retrospective chart review was conducted on 134 pediatric patients with IBD, ages 0-21 years. Explanatory variables were the patient's ADI and demographics. Outcomes were assessed from time of diagnosis over a 1-year follow-up period. The primary outcome was the ratio of missed to completed appointments; secondary outcomes were the numbers of IBD-related emergency department (ED) visits and IBD-related hospitalizations. Race/ethnicity was significantly associated with ADI (p < 0.001). In a multivariable regression model, no variables were associated with ratio of missed to completed appointments. Notably, ADI was not significantly associated with the ratio of missed to completed appointments. In a Poisson regression, Black (non-Hispanic) and Hispanic race/ethnicity, Medicaid insurance, female gender, and lower age were significantly associated with more IBD-related ED visits; ADI was not. In a similar model, Black (non-Hispanic) race, Medicaid insurance status, and lower age were significantly associated with more IBD-related hospitalizations; ADI was not. In our cohort, ADI was not significantly associated with the ratio of missed to completed appointments, IBD-related ED visits, and IBD-related hospitalizations; however, race/ethnicity, age at diagnosis, insurance, and gender were associated with these outcomes.

Insurance Type and Withdrawal of Life-Sustaining Therapy in Critically Injured Trauma Patients

Withdrawal of life-sustaining therapy (WLST) decisions for critically injured trauma patients are complicated and multifactorial, with potential for patients' insurance status to affect decision-making. To determine if patient insurance type (private insurance, Medicaid, and uninsured) is associated with time to WLST in critically injured adults cared for at US trauma centers. This retrospective registry-based cohort study included reported data from level I and level II trauma centers in the US that participated in the American College of Surgeons Trauma Quality Improvement Program (TQIP) registry. Participants included adult trauma patients who were injured between January 1, 2017, and December 31, 2020, and required an intensive care unit stay. Patients were excluded if they died on arrival or in the emergency department or had a preexisting do not resuscitate directive. Analyses were performed on December 12, 2023. Insurance type (private insurance, Medicaid, uninsured). An adjusted time-to-event analysis for association between insurance status and time to WLST was performed, with analyses accounting for clustering by hospital. This study included 307 731 patients, of whom 160 809 (52.3%) had private insurance, 88 233 (28.6%) had Medicaid, and 58 689 (19.1%) were uninsured. The mean (SD) age was 40.2 (14.1) years, 232 994 (75.7%) were male, 59 551 (19.4%) were African American or Black patients, and 201 012 (65.3%) were White patients. In total, 12 962 patients (4.2%) underwent WLST during their admission. Patients who are uninsured were significantly more likely to undergo earlier WLST compared with those with private insurance (HR, 1.54; 95% CI, 1.46-1.62) and Medicaid (HR, 1.47; 95% CI, 1.39-1.55). This finding was robust to sensitivity analysis excluding patients who died within 48 hours of presentation and after accounting for nonwithdrawal death as a competing risk. In this cohort study of US adult trauma patients who were critically injured, patients who were uninsured underwent earlier WLST compared with those with private or Medicaid insurance. Based on our findings, patient's ability to pay was may be associated with a shift in decision-making for WLST, suggesting the influence of socioeconomics on patient outcomes.

Disparity in Risk of Readmission in Adult Burn Patients: Analysis of a Nationwide Readmission Database

IntroductionBurn injuries remain a significant cause of disability, impacting long term quality-of-life and imposing large costs on our health systems. Readmission is a metric of quality and an important contributor to this economic burden. The association of socioeconomic and insurance status with burn readmission is not well established. The aim of our study is to develop a predictive risk model of factors associated with readmission after burns. MethodsUsing the Healthcare Cost and Utilization Project's 2018 Nationwide Readmission Database, we identified patients ≥18 y of age with burns admitted between January and October 2018. We excluded patients who died during index admission. Our primary outcome was readmission within 60 d postdischarge. We performed a Lasso regression analysis with adaptive selection to generate a predictive model with least deviance using patients' demographics and socioeconomic status, burn location and severity, past medical history, and hospital characteristics. Weighted multiple logistic regression was performed to obtain population estimates of adjusted odds ratios (ORs) of each element in the model. ResultsOur cohort included 11,380 burn patients. Of those, 1625 (14.3%) were readmitted and 67% were males. Readmitted patients were older (55 ± 17 versus 49 ± 18, P = 0.0001). Weighted logistic regression for the selected model showed higher odds of readmission for patients with lowest income quartile (OR: 1.19, 95% confidence interval [CI]: 1.04-1.36), Medicare or Medicaid insurance (OR: 1.35, 95% CI: 1.17-1.55), history of psychiatric illness (OR:1.19, 95% CI: 1.02-1.39), diabetes (OR: 1.46, 95% CI: 1.25-1.69), chronic kidney disease (OR: 1.66, 95% CI: 1.30-2.11), chronic obstructive pulmonary disease (OR: 1.55, 95% CI:1.26-1.89), and alcohol use disorder (OR: 1.33, 95% CI: 1.13-1.58). Third degree burns and foot burns had higher OR of readmission (OR: 1.21, 95% CI: 1.38-1.98 and 1.66, 95% CI: 1.02-1.45, respectively), while face and hand burns had lower OR of readmission (OR: 0.77, 95% CI: 0.66-0.90 and 0.84, 95% CI: 0.72-0.98, respectively). ConclusionsBurn readmissions are multifactorial and directly related to the patient's comorbidities, including markers that reflect barriers to care such as socioeconomic characteristics, as well as the anatomical location of burn injuries. Early identification of these high-risk patients may aid in early intervention, resource allocation, and outreach program development in an attempt to reduce readmission rates and improve outcomes. Future prospective validation of these risk factors is warranted.

Attitudes toward and preparedness for lung transplantation among individuals with cystic fibrosis in the era of highly effective modulators

BackgroundOutcomes for individuals with cystic fibrosis (CF) have improved due to highly effective modulator therapy (HEMT). However, lung transplant (LTx) remains an important treatment for people with advanced lung disease. This study assessed attitudes and knowledge about LTx in the HEMT era.MethodsAll patients from the University of Washington CF clinic were surveyed March 25-May 30, 2020. Questions addressed self-rated LTx preparedness and knowledge, as well as barriers and facilitators to discussing LTx. Demographic and clinical data were extracted from the electronic health record.ResultsThere were 159/224 (71%) responses. Respondents had a median forced expiratory volume in one second (FEV1) of 70%, and 142 (89%) were on modulatory therapy. One hundred thirteen (71%) respondents felt that it was moderately or very important to be prepared to make decisions about LTx, though only 56 (35%) felt moderately or very prepared. Only 83 (30%) and 47 (52%) participants correctly answered questions about life expectancy and improved quality of life after LTx, respectively. Respondents with Medicaid insurance less frequently answered questions correctly. The most common barriers to discussing LTx were fear of being a burden on loved ones for 58 respondents (36%) and cost of LTx for 46 (29%). Most participants (94%) trusted their CF doctor, and 75% of participants selected trust as a facilitator for LTx discussions.ConclusionsMany individuals with CF, especially those with lower socioeconomic status, lacked knowledge and did not feel very prepared for decisions about LTx. Earlier education and discussions about LTx represent an area for improvement in CF care.

T42 - Treatment Setting Among Individuals With Opioid Use and Criminal Legal Involvement, Housing Instability, or Medicaid Insurance, 2015-2020

T42 - Treatment Setting Among Individuals With Opioid Use and Criminal Legal Involvement, Housing Instability, or Medicaid Insurance, 2015-2020

Association between Insurance Status and Outcomes of Hospitalizations for Necrotizing Soft Tissue Infections.

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

Screening rates for hepatitis B and C among low-income US veterans: Data from the National Veteran Homeless and Other Poverty Experiences Study.

Screening for viral hepatitis is considered a high-priority area in the Veterans Health Administration (VHA). Yet, few studies have examined viral hepatitis screening test use among low-income veterans who are considered high-risk with limited healthcare access. Using cross-sectional data from 933 participants in the 2021-2022 National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study, we examined rates and correlates of lifetime screening for hepatitis B (HBV) and hepatitis C (HCV) infections. Multivariable logistic regression models evaluated characteristics associated with HBV/HCV screening. Nearly 16% and 21% reported lifetime HBV and HCV screening, respectively. These rates are considerably lower than HBV (47.3%) and HCV (92.9%) screening rates documented among contemporaneous veterans in VHA electronic health records. In the NV-HOPE data, veterans 50-79 years were more likely than those ≥80 years of age to ever-screen for HBV/HCV. Whereas, household income was inversely related to lifetime screening behaviours, veterans reporting 'other' employment types (vs. full-time/part-time employment) were more likely to ever-screen for HBV/HCV. Ever-screening for HBV was more likely among veterans reporting non-Hispanic 'other' (vs. non-Hispanic 'white') race, housing instability, Medicaid insurance, as well as drug use and cognitive disorder histories. Living with ≥5 members (vs. alone), histories of alcohol use, cancer, and liver disorders were also correlated with ever-screening for HCV. HIV/AIDS history correlated with ever-screening for HBV/HCV. In conclusion, fewer than one-third of low-income US veterans ever-screened for HBV/HCV, with lower screening rates among those less likely to be exposed to viral hepatitis, thereby informing interventions aimed at promoting available screening, treatment and vaccinations for HBV/HCV.

Impact of Patient Race/Ethnicity on Premium Intraocular Lens Utilization.

To evaluate the relationship between social determinants of health and the likelihood of receiving a premium intraocular lens (IOL) at the time of cataract surgery. Retrospective chart review of a single-center, academic ophthalmology practice over a one-year period, with a primary outcome measure of placement of either a premium or standard IOL. We used logistic regression to calculate the odds of receiving a premium IOL, stratifying patients based on self-identified race/ethnicity, age, sex, insurance type (private insurance vs. Medicare or Medicaid), estimated household income (based on median household income for zip code), and presence of ocular pathology. Compared with self-identified White patients, Black patients were least likely to receive premium IOLs (OR=0.220, 95% CI 0.137-0.340, P <0.001), followed by Hispanic patients (OR=0.308, 95% CI 0.104-0.730) and Asian patients (OR=0.479, 95% CI 0.302-0.734). Patients with Medicare or Medicaid insurance were also less likely to receive premium IOLs (OR 0.522, 95% CI 0.336-0.784). White patients in our practice were more likely to receive premium IOLs than non-White patients, even when controlling for age, sex, insurance type, estimated median household income, and presence of ocular comorbidities. The underlying reason for this disparity should be explored further.

Patient-Portal Compared with Supplemental In-Office Tablet Screening for Health-Related Social Needs in Primary Care

BackgroundScreening for health-related social needs (HRSN) has become more widespread but the best method of delivering the screening tool is not yet known.ObjectiveDescribe HRSN screening completion rate, specifically portal-based and in-person tablet-based screening.DesignCross-sectional retrospective observational study.ParticipantsAdults age 18 or older who had a non-acute primary care visit at one of three internal medicine primary care clinics at a large, urban, academic medical center between July 2022 and July 2023.Main MeasuresWe identified the proportion of individuals who were screened using the HRSN questionnaire, whether screening was completed by patient-portal or tablet, as well as the degree of burden of HRSN. Using the electronic health record, we explored associations between sociodemographic characteristics and HRSN attributes.Key ResultsOur study included 24,597 patients, of whom 37% completed the HRSN questionnaire. A smaller proportion of Black/African American patients and those with Medicaid insurance completed the questionnaire, yet they comprised a greater percentage of those who screened positive for unmet HRSN (p ≤ 0.001). Most patients completed the questionnaire by patient-portal (86.1%) compared with in-office tablets (14.0%). A larger proportion of those who completed screening by tablet screened positive for HRSN. Of all patients screened, 21.8% were positive for an unmet HRSN and 11.5% had more than one unmet HRSN.ConclusionsA majority of patients are not being screened for HRSN and results illustrate disparities when screening patients for HRSN through portal-based compared with supplemental in-office tablet-based screening. Prevalence of unmet HRSN varied by demographics such as race and insurance status.

Pricing of medication abortion in the United States, 2021-2023.

Financial costs remain one of the greatest barriers to abortion, leading to delays in care and preventing some from getting a desired abortion. Medication abortion is available through in-person facilities and telehealth services. However, whether telehealth offers a more affordable option has not been well-documented. We used Advancing New Standards in Reproductive Health (ANSIRH)'s Abortion Facility Database, which includes data on all publicly advertising abortion facilities and is updated annually. We describe facility out-of-pocket prices for medication abortion in 2021, 2022, and 2023, comparing in-person and telehealth provided by brick-and-mortar and virtual clinics, and by whether states allowed Medicaid coverage for abortion. The national median price for medication abortion remained consistent at $568 in 2021 and $563 in 2023. However, medications provided by virtual clinics were notably lower in price than in-person care and this difference widened over time. The median cost of a medication abortion offered in-person increased from $580 in 2021 to $600 by 2023, while the median price of a medication abortion offered by virtual clinics decreased from $239 in 2021 to $150 in 2023. Among virtual clinics, few (7%) accepted Medicaid. Median prices in states that accept Medicaid were generally higher than in states that did not. Medication abortion is offered at substantially lower prices by virtual clinics. However, not being able to use Medicaid or other insurance may make telehealth cost-prohibitive for some people, even if prices are lower. Additionally, many states do not allow telehealth for abortion, deepening inequities in healthcare.

The Effect of Insurance Type on Length of Stay Following Total Knee Arthroplasty

BackgroundWith the expansion of the Affordable Care Act in 2014, there has been a growing interest in how the Medicaid population will affect postoperative outcomes following total knee arthroplasty (TKA). Studies have shown that lower socioeconomic status, non-Caucasian race, women, cardiac and renal disorders, and younger age have been associated with increased lengths of stay (LOS) after TKA. The primary purpose of our study was to compare the total complications and LOS among patients undergoing TKA who have cash, commercial, government, Medicaid, and Medicare insurances. MethodsWe queried a national, all-payer administrative claims database from 2016 to 2022 among patients undergoing TKA who had cash (n = 3,923), commercial (n = 966,169), government (n = 25,644), Medicaid (n = 56,184), and Medicare (n = 524,034) insurances. We compared and analyzed various baseline demographics, total complications, and LOS (<1 day, 1 to 2 days, 3 to 4 days, and >4 days), between the insurance types. ResultsMedicaid and Medicaid insurance types had patients who had the most comorbidities at baseline, including a comorbidity index >3 (P < 0.0001), women, alcohol abuse, diabetes, obesity, tobacco use, chronic kidney disease, and congestive heart disease (all P < 0.0001). In accounting for comorbidities, Medicaid was the biggest risk factor for total complications (P < 0.001) as well as increased LOS after TKA at 4 to 6 days, 7 to 9 days, and >9 days (P < 0.0001). ConclusionsMedicaid insurance is a risk factor for increased total complications and LOS following TKA. Appropriate preoperative and perioperative management of these patients is essential in order to mitigate the risk and burden on the health care system in this population.

Cons of dermatology practices opting out of Medicare and Medicaid insurances

Cons of dermatology practices opting out of Medicare and Medicaid insurances

The Impacts of Physician Payments on Patient Access, Use, and Health

We examine how supply-side health insurance generosity affects patient access, use, and health. Exploiting large, exogenous changes in Medicaid reimbursement rates for physicians, we find that increasing payments for new patient office visits reduces reports of providers turning away beneficiaries: closing the gap in payments between Medicaid and private insurers would reduce more than half of disparities in access among adults and would eliminate such disparities among children. We further find that higher physician reimbursement leads to more office visits, better self-reported health, and reduced school absenteeism among the program’s beneficiaries. (JEL G22, H51, I11, I13, I18, I38, J44)

Chronic Myelomonocytic Leukemia and Atypical Chronic Myeloid Leukemia: A National Analysis

BackgroundMyelodysplastic/myeloproliferative overlap syndromes (MDS/MPN) are rare blood cancers characterized by concomitant myeloid hyperplasia and dysplasia. These heterogenous disorders include chronic myelomonocytic leukemia (CMML) and atypical chronic myeloid leukemia (aCML). MethodsUsing two large national cancer databases to examine a total of 15,704 CMML and 702 aCML patients, we report the largest study to date on the incidence, survival and demographic characteristics of CMML and aCML in the United States. ResultsOverall age-adjusted incidence of CMML and aCML was 0.63 per 100,000 Americans per year and 0.03 per 100,000 per year, respectively. CMML incidence in the U.S. was noted to rise steadily in the years between 2001 and 2019. Median patient age was 75 and 72 years for CMML and aCML, and the majority of CMML and aCML patients were male (62.9% and 62.0%) and White (90.1% and 86.3%). Median OS was 17.4 months for CMML, and 15.2 months for aCML. Multivariate Cox regression demonstrated features associated with reduced survival, including increasing age, comorbidities, Medicaid insurance status, and low-income residential zip code, highlighting survival disparities in underinsured and socioeconomically disadvantaged patients. In CMML, Black race was associated with inferior survival, while female sex, management at an academic center, and later calendar-year of diagnosis were associated with improved OS. ConclusionThese findings underscore the need to better understand the biological basis for such differences in survival and reflect the importance of access to specialized care for patients with these rare disorders.

Analyzing Racial Disparities in Pediatric Atopic Comorbidity Emergency Department Visitation Using Electronic Health Records

BackgroundAlthough atopic diseases and associated co-morbidities are prevalent in children, little is known about racial differences in emergency department (ED) visitation. ObjectiveWe sought to examine racial differences in ED visitation among children with allergic comorbidities. MethodsWe conducted a retrospective study of patients (<21 years) who visited the ED at a large pediatric hospital for atopic dermatitis (AD), food allergy (FA), asthma, allergic rhinitis (AR), and eosinophilic esophagitis (EoE) from 2015 to 2019. We determined the probability of ED encounter-free using hazard ratios (HR) and time to recurrence (TTR) of ED encounter for patients identified as Black/African American (AA) and White/European American (EA). We assessed potentially underlying allergic, demographic, and place-based factors, and potential interactions between factors. ResultsA total of 30,894 patients (38% AA, 62% EA) had 83,078 ED encounters (38,378 first ED encounters, and 44,700 recurrent ED encounters) during the study period. Asthma and AR showed the highest rate of comorbidity in ED encounters in both AA and EA children. AA children exhibited higher HR for encounter following index AD and asthma encounters. We found an interaction between the type of insurance and race in ED encounters for AD, FA, AR, and EoE. In AA children, those insured by Medicaid demonstrated a higher HR for any encounter compared to those with commercial insurance. Conversely, in EA children, those with Medicaid insurance showed a lower HR compared to their commercially insured peers. Regardless of race, allergic comorbidity increased the HR of ED encounter (1.12-1.62) for all allergic diseases. At 5-years follow up, mean differences in TTR were shorter in AA children compared to EA children in AD, FA, and asthma. ConclusionIdentification of disease-specific racial disparities in ED visitation related to atopic diseases is a necessary first step toward the design and implementation of interventions capable of equitably reducing emergency care in atopic comorbid children.

Patient Practices, Perceptions, and Barriers to Self-measurement of Blood Pressure in a Rural Health System.

Self-measurement of blood pressure (SMBP) is endorsed by current guidelines for diagnosing and managing hypertension (HTN). We surveyed individuals in a rural healthcare system on practices and attitudes related to SMBP that could guide future practice. Survey questions were sent via an online patient portal to a random sample of 56,275 patients with either BP > 140/90 mm Hg or cardiovascular care in the system. Questions addressed home blood pressure (BP) monitor ownership, use, willingness to purchase, desire to share data with providers, perceptions of patient education, and patient-centeredness of care. Multivariable logistic regression was used to examine patient characteristics associated with SMBP behaviors. The overall response rate was 12%, and 8.4% completed all questions. Most respondents, 60.9%, owned a BP monitor, while 51.5% reported checking their BP at home the month prior. Among device owners, 45.1% reported receiving instructions on SMBP technique, frequency, and reading interpretation. Only 29.2% reported sharing readings with providers in the last 6 months, whereas 57.9% said they would be willing to do so regularly. Older age, female sex, and higher income were associated with a higher likelihood of device ownership. Younger age, lower income, and Medicaid insurance were associated with a greater willingness to share SMBP results with providers regularly. While a significant proportion of respondents performed SMBP regularly, many reported insufficient education on SMBP, and few shared their home BP readings with providers. Patient-centered interventions and telemedicine-based care are opportunities that emerged in our survey that could enhance future HTN care.

Early Kidney Transplantation or Conversion to Peritoneal Dialysis after First-Time Arteriovenous Access Creation

After autogenous arteriovenous (AV) access creation for end-stage renal disease, a majority of patients will continue on hemodialysis (HD), a minority will receive definitive treatment with kidney transplantation, and a subset of patients will convert to peritoneal dialysis (PD). Our goal was to identify patient factors associated with early transition from HD to either kidney transplantation or PD. This is a case-control study of all patients with first-time AV access creation in the Vascular Quality Initiative (2011-2022) who had long-term follow-up. Patients who remained on HD after AV access creation were the control group while patients who received early kidney transplant or who converted to PD were the 2 case groups. Relationship among demographics, comorbidities, neighborhood social disadvantage, and functional status as they relate to renal replacement therapy modality was assessed. There were 19,782 patients included; the average age was 62±15years and 57% were male. During the follow-up period of a median 306 (71-403) days, 1.3% underwent a kidney transplantation and 2.3% underwent conversion to PD. On univariable analysis, rates of kidney transplantation or conversion to PD varied with race (P<0.001), insurance status (P<0.001), area deprivation index (ADI) quintile (P<0.001), and several medical comorbidities. On multivariable analysis, impaired ambulation, current smoking, Medicaid or Medicare insurance, Black race, heart failure, body mass index, and older age were associated with decreased transplantation rates. Conversion to PD was associated with ADI Q5, Q4, and Q3. Decreased conversion to PD was associated with impaired ambulation, Hispanic ethnicity, Black race, former smoking, medication-controlled diabetes, and older age. Decreased kidney transplantation was associated with Black race and noncommercial health insurance but not ADI quintile, suggesting disparities exist beyond community-level access to care. Early kidney transplantation conveyed a 3-year survival benefit compared with HD and PD, which had similar survival. Furthermore work is required to increase access to kidney transplantation and PD.

Tele-Mental Health Service: Unveiling the Disparity and Impact on Healthcare Access and Expenditures during the COVID-19 Pandemic in Mississippi.

During the COVID-19 pandemic, tele-mental health (TMH) was a viable approach for providing accessible mental and behavioral health (MBH) services. This study examines the sociodemographic disparities in TMH utilization and its effects on healthcare resource utilization (HCRU) and medical expenditures in Mississippi. Utilizing a cohort of 6787 insured adult patients at the University of Mississippi Medical Center and its affiliated sites between January 2020 and June 2023, including 3065 who accessed TMH services, we observed sociodemographic disparities between TMH and non-TMH cohorts. The TMH cohort was more likely to be younger, female, White/Caucasian, using payment methods other than Medicare, Medicaid, or commercial insurers, residing in rural areas, and with higher household income compared to the non-TMH cohort. Adjusting for sociodemographic factors, TMH utilization was associated with a 190% increase in MBH-related outpatient visits, a 17% increase in MBH-related medical expenditures, and a 12% decrease in all-cause medical expenditures (all p < 0.001). Among rural residents, TMH utilization was associated with a 205% increase in MBH-related outpatient visits and a 19% decrease in all-cause medical expenditures (both p < 0.001). This study underscores the importance of addressing sociodemographic disparities in TMH services to promote equitable healthcare access while reducing overall medical expenditures.

Disparities in neoadjuvant chemotherapy for pancreatic adenocarcinoma with vascular involvement

BackgroundMultiagent neoadjuvant chemotherapy (NAT) has been linked with improved survival for locally advanced (LA) or borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC). However, the existence of disparities in its utilization remains to be elucidated. MethodsAll adults with PDAC were tabulated from the 2011–2017 Nationwide Cancer Database. Tumor vascular involvement was determined using the clinical T stage and CS_EXTENSION variables. The significance of temporal trends was calculated using Cuzick's non-parametric test. A Cox proportional hazard model was used to assess the impact of NAT utilization on hazard of two-year mortality. A logistic regression model was developed to determine factors associated with receipt of NAT. ResultsOf 3811 patients meeting inclusion criteria, 50.8 % received NAT. NAT utilization significantly increased over the study period, from 31.7 % in 2011 to 81.1 % in 2017 (p < 0.001). NAT was associated with significantly reduced two-year mortality (Hazards Ratio 0.34, 95 % Confidence Interval [CI] 0.18–0.67).After adjustment, younger (Adjusted Odds Ratio [AOR] 0.97/year, CI 0.96–0.98) and Black (AOR 0.65, CI 0.48–0.89; ref: White) patients demonstrated reduced odds of NAT. Furthermore, patients with Medicare (AOR 0.73, CI 0.59–0.90; ref: Private) or Medicaid insurance (AOR 0.67, CI 0.46–0.97; ref: Private) had lower odds of NAT, as did those treated at non-academic institutions (Community: AOR 0.42, CI 0.35–0.52, Integrated: 0.68, CI 0.54–0.85) or in the lowest education quartile (AOR 0.52, CI 0.29–0.95; ref: Highest). ConclusionsWe identified increasing utilization of NAT for BR/LA pancreatic adenocarcinoma. Despite being linked with significantly reduced two-year mortality, socioeconomic disparities affect odds of NAT.

Health Insurance Type and Outpatient Specialist Care Among Children With Asthma

Although children with asthma are often successfully treated by primary care clinicians, outpatient specialist care is recommended for those with poorly controlled disease. Little is known about differences in specialist use for asthma among children with Medicaid vs private insurance. To examine differences among children with asthma regarding receipt of asthma specialist care by insurance type. In this cross-sectional study using data from the Massachusetts All Payer Claims Database (APCD) between 2014 to 2020, children with asthma were identified and differences in receipt of outpatient specialist care by whether their insurance was public (Medicaid and the Children's Health Insurance Program) or private were examined. Eligible participants included children with asthma in 2015 to 2020 aged 2 to 17 years. Data analysis was conducted from January 2023 to April 2024. Medicaid vs private insurance. The primary outcome was receipt of specialist care (any outpatient visit with a pulmonology, allergy and immunology, or otolaryngology physician). Multivariable logistic regression models estimated differences in receipt of specialist care by insurance type accounting for child and area characteristics including demographics, health status, persistent asthma, calendar year, and zip code characteristics. Additional analyses examined if the associations of specialist care with insurance type varied by asthma persistence and severity, and whether associations varied over time. Among 198 101 unique children, there were 432 455 child-year observations (186 296 female [43.1%] and 246 159 male [56.9%]; 211 269 aged 5 to 11 years [48.9%]; 82 108 [19.0%] with persistent asthma) including 286 408 (66.2%) that were Medicaid insured and 146 047 (33.8%) that were privately insured. Although persistent asthma was more common among child-year observations with Medicaid vs private insurance (57 381 [20.0%] vs 24 727 [16.9%]), children with Medicaid were less likely to receive specialist care. Overall, 64 239 child-year observations (14.9%) received specialist care, with substantially lower rates for children with Medicaid vs private insurance (34 093 child-year observations [11.9%] vs 30 146 child-year observations [20.6%]). Regression-based estimates confirmed these disparities; children with Medicaid had 55% lower odds of receiving specialist care (adjusted odds ratio, 0.45; 95% CI, 0.43 to 0.47) and a regression-adjusted 9.7 percentage point (95% CI, -10.4 percentage points to -9.1 percentage points) lower rate of receipt of specialist care. Compared with children with private insurance, there was an additional 3.2 percentage point (95% CI, 2.0 percentage points to 4.4 percentage points) deficit for children with Medicaid with persistent asthma. In this cross-sectional study, children with Medicaid were less likely to receive specialist care, with the largest gaps among those with persistent asthma. These findings suggest that closing this care gap may be one approach to addressing ongoing disparities in asthma outcomes.