Medicaid Status Research Articles

Neighborhood Deprivation and Preterm Birth in a North Carolina Birth Cohort

Background: Residing in deprived areas can have health impacts beyond individual level deprivation and may increase vulnerabilities to other exposures. Adverse pregnancy outcomes, including preterm birth, have previously been associated with various indicators of area-level deprivation. Methods: We examined associations between neighborhood deprivation and preterm birth in the North Carolina birth registry cohort from 2006 - 2011 (n=653,887). The neighborhood deprivation index (NDI) was developed at the census tract level using principle components analysis with American Community Survey 5-year estimates representing 5 socio-demographic domains: income/poverty, education, employment, housing, and occupation. Risk ratios (RR) (95% confidence intervals) were estimated using multilevel (random-intercept) binomial regression models adjusted for individual-level gestational parent race/ethnicity, marital status, Medicaid status, and age; race-stratified models were also examined. Results: The adjusted RR for preterm birth for each standard deviation increase in NDI in the unstratified analysis was 1.07 (1.06, 1.08). RRs in race-stratified analyses were highest for white parents (1.11 (1.09, 1.13)), followed by black (1.05 (1.04, 1.07) and Hispanic parents (1.03 (1.00, 1.05)). Conclusions: Increases in neighborhood deprivation were associated with increased risk of preterm birth, while the magnitude of association differed by race/ethnicity. In the future, we will explore interactions between neighborhood deprivation and environmental exposures, such as air pollution. The views expressed in this abstract are those of the authors and do not necessarily represent views or policies of the U.S. Environmental Protection Agency.

Disparities in the use of telehealth at the onset of the COVID-19 public health emergency

Introduction The coronavirus disease 2019 (COVID-19) pandemic resulted in an unprecedented expansion in telehealth, but little is known about differential use of telehealth according to demographics, rurality, or insurance status. Methods We performed a cross-sectional analysis of 7742 family medicine encounters at a single USA institution in the initial month of the COVID-19 public health emergency (PHE). We compared the demographics of those using telehealth during the PHE to those with face-to-face visits during the same time period; we also compared the demographics of those using full audio-video to those using audio-only. Results The likelihood of any telehealth visit in the first 30 days of telehealth expansion was higher for women, those age 65 years and older, self-pay patients, and those with Medicaid and Medicare as primary payers. The likelihood of a telehealth visit was reduced for rural residence and Black or other races. Among all telehealth visits, the likelihood of a full audio-video telehealth visit was reduced for patients who were older, Black, from urban areas, or who were self-pay, Medicaid, or Medicare payer status. Discussion Significant disparities exist in telehealth use during the COVID-19 PHE by age, race, residence and payer.

Association of dementia diagnosis with urinary tract infection in the emergency department.

ObjectivesOverdiagnosis of urinary tract infections (UTI) among people living with dementia is a nationally recognized problem associated with morbidity from antibiotics as well as multidrug‐resistant bacteria. However, whether this problem also exists in the emergency department (ED) is currently unknown.MethodsTo examine the association between dementia and UTI diagnosis in the ED we performed a retrospective analysis of Medicare beneficiaries older than 65 years old who presented to an ED in 2016. A diagnosis of UTI was present in 58,580 beneficiaries, and 321,479 beneficiaries without a diagnosis of UTI served as the comparison group. Our logistic regression model controlled for dementia, older age, female sex, Medicaid status, skilled nursing facility residence, history of prostate cancer, recent urinary catheter use, recurrent UTI, and multiple comorbidities.ResultsIn our model, people living with dementia had over twice the odds (odds ratio = 2.27, 95% confidence interval = 2.21, 2.33) of being diagnosed with a UTI in the ED compared to those without dementia despite their lower prevalence of symptoms and signs localizing to the genitourinary tract (3.8% vs 8.9%, respectively).ConclusionThis is the first study from a national database that examines the association of dementia with UTI diagnosis among older adults who visit the ED. Our study could not establish whether the UTI diagnoses in the ED were accurate but does imply a disproportionate burden of UTI diagnoses in people living with dementia despite their lower prevalence of clinical criterion. Antimicrobial stewardship in the ED should address the complexity of UTI diagnosis in dementia.

Home-Based Primary and Palliative Care in the Medicaid Program: Systematic Review of the Literature.

To describe the use of home-based medical care (HBMC) among Medicaid beneficiaries. A systematic review of the peer-reviewed and gray literature of home-based primary care and palliative care programs among Medicaid beneficiaries including dual eligibles. HBMC including home-based primary care and palliative care programs. Studies describing Medicaid beneficiaries receiving HBMC. Three groups of studies were included: those focused on HBMC specifically for Medicaid beneficiaries, studies that described the proportion of Medicaid patients receiving HBMC, and those that used Medicaid status as a dependent variable in studying HBMC. The peer-reviewed and gray literature searches revealed 574 unique studies of which only 16 met inclusion criteria. Few publications described HBMC as an integral care delivery model for Medicaid programs. Data from the programs described suggest the use of HBMC for Medicaid beneficiaries can reduce healthcare costs. The addition of social supports to HBMC appears to convey additional savings and benefits. This systematic literature review highlights the relative dearth of literature regarding the use and impact of HBMC in the Medicaid population. HBMC has great potential to reduce Medicaid costs, and innovative programs combining HBMC with social support systems need to be tested.

Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications

Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1day. The secondary outcomes included perioperative/in-hospital complications and mortality. There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4±1.5, 2.1±2.5, and 2.2±2.8days (P=0.0001), respectively, and after CAS were 1.7±2.6, 1.8±2.1, and 2±2.6days (P<0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS>1day (P=0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1day (OR 1.42, 95% CI 1.06-1.91) (P=0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P=0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P=0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P=0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P=0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts. Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.

Relationship status and other demographic influences on survival in patients with ovarian cancer

ObjectiveTo evaluate the influence of marital status and other demographic factors on survival of patients with ovarian cancer.Study designData were obtained from the Surveillance, Epidemiology, and End Results database from...

Using a Semi-Markov Model to Estimate Medicaid Cost Savings due to Minnesota's Return to Community Initiative

ObjectivesTo provide an estimate and level of uncertainty for Medicaid cost savings due to Minnesota's Return to Community Initiative (RTCI). DesignMedicaid cost savings are estimated using a semi-Markov model and simulation approach. Setting and ParticipantsRTCI is a statewide program that assists private paying nursing home residents with discharge to the community. When originally proposed, it was expected that the program would reduce state Medicaid expenditures, primarily through the shifting of residents from nursing homes to a less costly community setting. In prior analysis, we estimated that approximately 1 in 9 residents targeted for transition by the program would not have returned to the community without the RTCI. Accurate cost savings estimates require consideration of complex resident care trajectories, that is, nursing home readmissions, use of assisted living and community-based services, and mortality. MeasuresData were from 30,234 private pay nursing home residents admitted during 2011, primarily for post-acute stays, to 378 facilities in Minnesota, and followed for 4 years postadmission for outcomes and time to event. Resident characteristics were taken from the Minimum Data Set (MDS) admission assessment. We modeled variability in care trajectories with a semi-Markov formulation. Transition probabilities were estimated using Multinomial regression. Time to event was modeled using the best-fitting, positive, right-skewed distribution for each path. The simulation was run (1000 times) with and without the RTCI impact to estimate change in Medicaid days in various settings. ResultsProgram savings was estimated at $4.1 million per year of effort over a 4-year accumulation period. Conclusions and ImplicationsThe RTCI produced a modest Medicaid cost savings in excess of the annual program budget of $3.5 million. Findings from the semi-Markov model and simulation increase our understanding of care transitions between nursing home, community, Medicaid status, and mortality.

Impact of Safety-Net Burden on In-Hospital Mortality and Hospitalization Costs Among Patients with Alcoholic Hepatitis and Alcoholic Cirrhosis.

Alcoholic hepatitis (AH) and alcoholic cirrhosis disproportionately affect ethnic minority and safety-net populations. We evaluate the impact of a hospital's safety net burden (SNB) on in-hospital mortality and costs among patients with AH and alcoholic cirrhosis. We performed a cross-sectional analysis of 2012-2016 National Inpatient Sample. SNB was calculated as percentage of hospitalizations with Medicaid or uninsured payer status. Associations between hospital SNB and in-hospital mortality and costs were evaluated with adjusted multivariable logistic regression and linear regression models. Among 21,898 AH-related hospitalizations, compared to low SNB hospitals (LBH), patients hospitalized in high SNB hospitals (HBH) were younger (44.4 y vs. 47.4 y, P<0.001) and more likely to be African American (11.3% vs. 7.7%, P<0.001) or Hispanic (15.4% vs. 8.4%, P<0.001). AH-related hospitalizations in HBH had a non-significant trend towards higher odds of mortality (OR 1.27, 95% CI 0.98-1.65, P=0.07) and higher mean hospitalizations costs. Among 108,669 alcoholic cirrhosis-related hospitalizations, patients in HBH were younger (53.3 y vs. 55.8 y, P<0.001) and more likely to be African American (8.2% vs. 7.3%, P<0.001) or Hispanic (24.4% vs. 12.0%, P<0.001) compared to LBH. Compared to alcoholic cirrhosis-related hospitalizations in LBH, mortality was higher among medium SNB (OR 1.10, 95% CI 1.03-1.17, P=0.007) and HBH (OR 1.07, 95% CI 1.00-1.15, P=0.05). Mean hospitalization costs were not different by SNB status. HBH hospitals predominantly serve ethnic minorities and underinsured/uninsured populations. The higher in-hospital mortality associated HBH particularly for alcoholic cirrhosis patients is alarming given its increasing burden in the USA.

Risk adjusting for Medicaid participation in Medicare Advantage.

Determining appropriate capitated payments has important access implications for dual-eligible Medicare Advantage (MA) members. In 2017, MA plans began receiving higher capitated payments for beneficiaries with full vs partial Medicaid when payments started being risk adjusted for level of Medicaid benefits instead of any Medicaid participation. This approach could favor MA plans in states with more generous Medicaid programs where more beneficiaries qualify for full Medicaid and thus a higher capitated payment. To understand this issue, we examined adjusted Medicare spending for dual-eligible beneficiaries across states with differing Medicaid eligibility criteria. Retrospective analysis of 2007-2015 traditional Medicare data for dual-eligible beneficiaries 65years and older. We compared predicted per-beneficiary spending levels after adjusting for any Medicaid participation and for level of Medicaid benefits across states with varying Medicaid eligibility requirements. States with the most generous Medicaid requirements had more dual-eligible beneficiaries with full Medicaid compared with the most restrictive states (median, 82% vs 55%). Nationally, Medicare spending levels were 1.3times greater for full vs partial Medicaid participants (range across states, 0.8-1.7). When per-beneficiary spending was adjusted for level of Medicaid benefits, rather than any Medicaid participation, states with more generous Medicaid eligibility had larger gains in predicted spending per dual-eligible beneficiary than states with less generous Medicaid coverage (1.7% vs 1.3% increase). Distinguishing between partial and full Medicaid in MA payments may disproportionately increase MA payments in states that have more full Medicaid beneficiaries due to more generous Medicaid eligibility.

Social Determinants of Hallway Bed Use.

IntroductionHallway beds in the emergency department (ED) produce lower patient satisfaction and inferior care. We sought to determine whether socioeconomic factors influence which visits are assigned to hallway beds, independent of clinical characteristics at triage.MethodsWe studied 332,919 visits, across 189,326 patients, to two academic EDs from 2013–2016. We estimated a logistic model of hallway bed assignment, conditioning on payor, demographics, triage acuity, chief complaint, patient visit frequency, and ED volume. Because payor is not generally known at the time of triage, we interpreted it as a proxy for other observable characteristics that may influence bed assignment. We estimated a Cox proportional hazards model of hallway bed assignment on length of stay.ResultsMedian patient age was 53. 54.0% of visits were by women. 42.1% of visits were paid primarily by private payors, 37.1% by Medicare, and 20.7% by Medicaid. A total of 16.2% of visits were assigned to hallway beds. Hallway bed assignment was more likely for frequent ED visitors, for lower acuity presentations, and for psychiatric, substance use, and musculoskeletal chief complaints, which were more common among visits paid primarily by Medicaid. In a logistic model controlling for these factors, as well as for other patient demographics and for the volume of recent ED arrivals, Medicaid status was nevertheless associated with 22% greater odds of assignment to a hallway bed (odds ratio 1.22, [95% confidence interval, CI, 1.18–1.26]), compared to private insurance. Visits assigned to hallway beds had longer lengths of stay than roomed visits of comparable acuity (hazard ratio for departure 0.91 [95% CI, 0.90–0.92]).ConclusionWe find evidence of social determinants of hallway bed use, likely involving epidemiologic, clinical, and operational factors. Even after accounting for different distributions of chief complaints and for more frequent ED use by the Medicaid population, as well as for other visit characteristics known at the time of triage, visits paid primarily by Medicaid retain a disproportionate association with hallway bed assignment. Further research is needed to eliminate potential bias in the use of hallway beds. [West J Emerg Med. 2020;21(4)949–958.]

Patient Risk Factors Associated With 30- and 90-Day Readmission After Cervical Discectomy

This is a retrospective cohort study. The aim of this study was to assess the patient-level risk factors associated with 30- and 90-day unplanned readmissions following elective anterior cervical decompression and fusion (ACDF) or cervical disk arthroplasty (CDA). For cervical disk pathology, both ACDF and CDA are increasingly performed nationwide. However, relatively little is known about the adverse complications and rates of readmission for ACDF and CDA. A retrospective cohort study was performed using the Nationwide Readmission Database from the years 2013 to 2015. All patients undergoing either CDA or ACDF were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and to identify 30- and 31-90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R). There were a total of 13,093 index admissions with 856 (6.5%) readmissions [30-R: n=532 (4.0%); 90-R: n=324 (2.5%)]. Both overall length of stay and total cost were greater in the 30-R cohort compared with 90-R and Non-R cohorts. The most prevalent 30- and 90-day complications seen among the readmitted cohorts were infection, genitourinary complication, and device complication. On multivariate regression analysis, age, Medicaid status, medium and large hospital bed size, deficiency anemia, and any complication during index admission were independently associated with increased 30-day readmission. Whereas age, large hospital bed size, coagulopathy, and any complication during the initial hospitalization were independently associated with increased 90-day readmission. Our nationwide study identifies the 30- and 90-day readmission rates and several patient-related risk factors associated with unplanned readmission after common anterior cervical spine procedures. Level III.

Understanding Risk Factors for Amputation in Patients With Diabetes and/or Peripheral Arterial Disease in a Highly Rural State

Amputation is a devastating but prevenTable complication of diabetes and peripheral arterial disease (PAD). It is a marker of severe disease and of disparities in quality of care. Rural populations have multiple risk factors for amputation; however, there is a significant gap in amputation research in rural communities. This study sought to identify risk factors for amputation in the highly rural state of West Virginia using a large, longitudinal institutional database. The West Virginia Clinical and Translational Science Institute Integrated Data Repository, a longitudinal database of more than 2 million patients, containing electronic health record data for all inpatient and outpatient encounters at West Virginia University and West Virginia University-affiliated hospitals and clinics comprised the sample for analyses. Adults (≥18 years) with recorded diagnoses of diabetes and/or PAD between 2011 and 2016 were included based on International Classification of Diseases, 9th clinical modification, and 10th edition clinical modification codes. Major and minor amputations were identified using Current Procedural Terminology codes. Trauma patients were excluded. Descriptive analyses and multivariable logistic regression models examining factors associated with major, minor and any amputation were performed. During the study period, 50,276 patients were treated for diabetes and/or PAD, 369 (7.3/1000) had any amputation over the study period; 210 had major (4.2/1000) amputations, 128 had minor (2.5/1000) amputations and 31 patients had both (0.6/1000). On multivariable analyses (Table I), male sex, self-pay, Medicaid, and Medicare insurance status all had significantly higher risk for major amputation. Minor amputation, which is often considered protective for major amputation, was found to increase the odds of major amputation 11.7 times. PAD patients had 12.3 times higher odds of any amputation compared to patients with diabetes, while patients with both diabetes and PAD had a 51.8 times higher odds of any amputation compared to patients with diabetes alone. C-statistics for all models were over 0.8, indicating a strong model. This unique longitudinal dataset has allowed us to identify several important features of diabetes and PAD-related amputation in our patient population: the first is that West Virginians undergo amputation for diabetes and/or PAD at rates more than double (7.3/1000 compared to the national prevalence of 2.4/1000) the rest of the country. In addition, patients with PAD alone or PAD plus diabetes had strikingly higher odds for amputation compared to diabetes alone. This suggests that population-based interventions for amputation prevention may be more successful if focused on PAD risk factor modification, such as tobacco cessation and medical optimization, rather than just simple diabetic foot care measures.TableMultivariable analysis of odds of major, minor and any amputation in patients with diabetes and/or peripheral artery disease (PAD) in West VirginiaVariableMajor (adjusting for minor)Minor (excluding majors)Any amputationMinora11.79 (7.19-19.33)––Rural (defined using Rural-urban community area code)1.09 (0.8-1.48)0.82 (0.52-1.29)0.98 (0.77-1.27)Tobacco user0.91 (0.57-1.44)0.9 (0.48-1.71)0.9 (0.62-1.31)Male vs female2.15 (1.61-2.85)2.63 (1.77-3.9)2.43 (1.93-3.07)Medicaid vs private1.79 (1.18-2.71)0.88 (0.51-1.51)1.35 (0.98-1.87)Medicare vs private1.54 (1.04-2.26)0.7 (0.43-1.15)1.12 (0.83-1.52)Self-pay vs private1.83 (1.09-3.07)1.42 (0.76-2.66)1.69 (1.13-2.52)Age0.99 (0.98-1)0.99 (0.97-1.01)0.99 (0.98-1)CAD0.36 (0.27-0.49)0.18 (0.12-0.28)0.26 (0.2-0.33)PAD vs diabetes13.78 (7.75-24.49)8.4 (4.18-16.85)12.29 (7.93-19.07)PAD and diabetes vs diabetes41.07 (23.27-72.46)52.52 (27.43-100.53)51.81 (33.85-79.3)CHF1.11 (0.79-1.54)1.5 (0.94-2.38)1.24 (0.95-1.62)CKD1.83 (1.32-2.54)1.5 (0.95-2.36)1.75 (1.34-2.27)COPD0.99 (0.73-1.34)1.07 (0.7-1.64)1 (0.78-1.29)Hypercholesterolemia0.97 (0.73-1.3)0.76 (0.52-1.13)0.89 (0.71-1.13)Obesity0.92 (0.68-1.25)0.92 (0.61-1.4)0.93 (0.73-1.19)Renal failure1.47 (0.97-2.24)0.85 (0.43-1.7)1.24 (0.87-1.77)C-statistic0.8500.8160.841Text in bold indicates statistically significant findings.aFor those with both major and minor amputations, we only counted minors occurring before major to see if that led to higher odds of major amputations. Open table in a new tab

Hospital-Level Medicaid Prevalence Is Associated With Increased Length of Stay After Asymptomatic Carotid Endarterectomy and Stenting Despite No Increase in Complications

Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure by payers and affects hospital operating margins. Patient-level Medicaid status has been shown to be associated with longer LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. The National Inpatient Sample was queried from 2006 to 2014 for CEA and CAS performed for asymptomatic carotid stenosis. Hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM; lowest quartile), medium Medicaid prevalence (MM; second and third quartiles), and high Medicaid prevalence (HM; fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. Secondary outcomes included perioperative complications. There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Among patients who underwent CEA, 1.9%, 34.7%, and 63.4% received care at hospitals with LM, MM, and HM prevalence, respectively. Among patients who underwent CAS, 1.9%, 26.4%, and 71.8% received care at hospitals with LM, MM, and HM prevalence, respectively. Hospital-level Medicaid prevalence cohorts for CEA differed by age, sex, race, insurance, hospital size, region, neighborhood income, diabetes, and anemia (P < .05). Cohorts for CAS differed by age, race, insurance, hospital size, region, neighborhood income, illegal drug use, diabetes, and chronic renal disease (P < .05). Neurologic (0.8% vs 0.9% vs 0.9%; P = .83) and cardiac complications (0.9% vs 1.2% vs 1.2%; P = .24) after CEA were similar between hospitals with LM, MM, and HM prevalence, respectively. Neurologic (1.1% vs 1% vs 1.2%; P = .42) and cardiac complications (2% vs 1.3% vs 1.5%; P = .46) after CAS were also similar. Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5 days, 2.1 ± 2.5 days, and 2.2 ± 2.8 days (P = .0001), respectively. Mean postoperative LOS after CAS at hospitals with LM, MM, and HM prevalence was 1.7 ± 2.6 days, 1.8 ± 2.1 days, and 2 ± 2.6 days (P < .0001), respectively. On multivariable analysis for CEA, relative to LM prevalence, MM prevalence (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.17-2.24) and HM prevalence (OR, 1.66; 95% CI, 1.2-2.28; P = .009) were associated with LOS >1 day. On multivariable analysis for CAS, HM prevalence was associated with LOS >1 day (OR, 1.42; 95% CI, 1.06-1.91; P = .003). Increased hospital-level Medicaid prevalence is associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Medicaid prevalence is important in creating appropriate risk-adjusted quality metrics and developing care pathways that optimize hospital reimbursement.

National Survey of US HIV Clinicians: Knowledge and Attitudes About the Affordable Care Act and Opinions of its Impact on Quality of Care and Barriers to Care.

BackgroundThe Affordable Care Act’s (ACA’s) major reforms started in 2014. In addition to assessing HIV clinicians’ ACA knowledge and attitudes, this study aims to evaluate HIV clinicians’ perspectives on whether the ACA has impacted the quality of HIV care and whether it addresses the main barriers to HIV care.MethodsHIV clinicians were emailed a survey weblink in 2018. Descriptive statistics, Mann-Whitney U tests, and binary logistic regression were performed.ResultsOf the 211 survey participants, the majority (70%) answered all 4 knowledge questions correctly. About 80% knew correctly whether their state had expanded Medicaid. Participants from Medicaid expansion states were more likely to report an improved ability to provide high-quality care compared with participants from Medicaid nonexpansion states (50% vs 34%; P = .01). The average response to whether the ACA addresses the main barriers to HIV care was neutral and did not differ based on Medicaid status. The top 3 main barriers to HIV care cited were mental health, substance use, and transportation.ConclusionsHIV clinicians in Medicaid expansion states were more likely to report an improved ability to provide high-quality care since ACA implementation compared with those in Medicaid nonexpansion states. However, HIV clinicians across the United States are concerned that the ACA does not address the main barriers to HIV care. To be successful, the “Ending the HIV Epidemic” initiative should address these identified barriers.

Behavioral Risk Factors for Acute and Chronic Disease-Related Malnutrition

Abstract Objectives To determine the association between mental health and substance use and the risk of developing malnutrition. Methods Mental health, substance abuse, and malnutrition were defined by ICD-10 codes. Diseases were classified as either acute or chronic based on the Beta Chronic Condition Indicator for ICD-10 codes. Age, sex, race, primary language, marital status, Medicaid status, cigarette use, and median household were taken from the EMR. No patients were identified with pure SRM. Cases were matched by disease status. Conditional logistic regression was used to determine odds ratio and 95% confidence intervals. Pearson chi-square test was used to assess the demographic differences between malnutrition categories. Results We analyzed 2356 matched pairs for CDRM and 1935 for ADRM. ADRM was associated with age, race, and primary language (all P &amp;lt; 0.004), while CDRM was associated with race, primary language, Medicaid, and median household income (all P-value &amp;lt; 0.037). For both ADRM and CDRM, a mental health diagnoses was associated with increased odds of malnutrition (OR: 1.370, CI: 1.169, 1.605) and (OR: 1.484, CI: 1.296, 1.700) respectively, while substance use was not associated with either sub-category of malnutrition. Among ADRM, a mental health diagnosis was associated with being 80 years and older (OR: 1.313, CI: 1.031, 1.672), Asian and Pacific Islander (OR: 1.472, CI: 1.030, 2.105) and Hispanic (OR: 2.404, CI: 1.707, 3.385) compared to White, female (OR: 0.863, CI: 0.755, 0.985), widowed (OR: 0.768, CI: 0.615, 0.959) compared to single, and being on Medicaid (0.860, CI: 0.756, 0.978). Among CDRM, a mental health diagnosis was associated with being Hispanic (OR: 2.911, CI: 2.098, 4.040), primary language being Spanish (OR: 2.771, CI: 1.112, 1.644), married and/or life partner (OR: 0.851, CI: 0.752, 0.964) and widowed (OR: 0.780, CI: 0.635, 0.958) compared to single, and on Medicaid (OR: 0.817, 0.733, 0.910). Conclusions This study provides the first known assessment of the relationship between mental health, substance abuse, and malnutrition diagnosed based on the AND/ASPEN guidelines. Only a mental health diagnosis, but not substance use, was associated with the development of both ADRM and CDRM. Future research with a larger sample size is needed to better understand these effects. Funding Sources None.

What Are the Effects of Patient Point of Entry and Medicaid Status on Postoperative Opioid Consumption and Pain Following Primary Total Knee Arthroplasty?

BackgroundTotal knee arthroplasty (TKA) provides excellent results across a variety of pathologies. As greater focus is placed on the opioid epidemic, we sought to determine if patients presenting for TKA via the Medicaid clinic (Medicaid) differed in terms of their opioid requirements compared to patients presenting via private office clinics (non-Medicaid). MethodsA single-institution total joint arthroplasty database was utilized to identify patients who underwent elective TKA between January 2016 and May 2019. Medicaid clinic patients were insured by some form of Medicaid, whereas private office patients had commercial or Medicare insurance. Morphine milligram equivalents (MMEs) and Activity Measure for Post-Acute Care scores were calculated. ResultsA total of 6509 patients were identified: 413 (6.35%) Medicaid and 6096 (93.65%) non-Medicaid. Medicaid patients were younger (63.32 vs 66.21 years, P < .0001), less likely to be of Caucasian race (21.31% vs 56.82%, P < .0001), and more likely to be active smokers (11.14% vs 7.73%, P < .0001). Although surgical time and home discharge rates were similar, Medicaid patients had longer length of stay (2.80 vs 2.46 days, P < .0001). Opioid requirements were higher for Medicaid patients (200.1 vs 132.2 MMEs, P < .0001), paralleling higher pain scores (3.03 vs 2.55, P < .0001). No differences were found in Activity Measure for Post-Acute Care scores (18.47 vs 18.77, P = .1824). ConclusionMedicaid patients tended to be younger, of minority race, and active smokers compared to non-Medicaid patients. Medicaid patients demonstrated worse postoperative pain scores and required 51% greater MMEs immediately following TKA, highlighting the need for preoperative counseling in traditionally at-risk socioeconomic groups. Level of EvidenceIII, Retrospective Observational Analysis.

Disparities in Preterm Infant Emergency Room Utilization and Rehospitalization by Maternal Immigrant Status

To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90days after discharge. This was a retrospective cohort study of 732 mothers of 866 preterm infants (<37weeks of gestational age) cared for in a neonatal intensive care unit (NICU) for >5days. Medical and demographic data and number of ER visits and rehospitalizations were collected. The primary outcomes were the numbers of ER visits and rehospitalizations. Analysis included bivariate comparisons of immigrant and native mother-infant dyads. Regression models were run to estimate the effects of immigrant mother status and risk factors. Compared with native mothers, immigrant mothers (176 of 732; 24%) were more likely to be older, to be gravida >1, to be nonwhite, to have a non-English primary language, to have less than a high school education, and to have Medicaid insurance but less likely to have child protective services, substance abuse, and a mental health disorder. Infants of immigrant mothers (203 of 866; 23%) had higher rates of ER visits and more days of hospitalization compared with infants of native mothers. Among immigrant mothers only, >5years living in the US, non-English primary language, and bronchopulmonary dysplasia (BPD) were predictive of ER visits, whereas Medicaid and BPD were predictive of rehospitalization. For the total cohort, after an interaction between Medicaid and immigrant status was added to the model, immigrant status became nonsignificant and immigrant mothers with Medicaid emerged as a strong predictor of hospitalization and a borderline predictor for ER visits. Among immigrant mothers, non-English primary language, >5years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use.

Do Patient Point of Entry and Medicaid Status Affect Quality Outcomes Following Total Knee Arthroplasty?

BackgroundThe effect of surgeon practice and patient care setting have not been studied in the Medicaid population undergoing total knee arthroplasty (TKA). This study aims to evaluate whether point of entry and Medicaid status affect outcomes following TKA. MethodsThe electronic medical record at our urban, academic, tertiary care hospital system was retrospectively reviewed for all primary, unilateral TKA during January 2016 and January 2018. Outpatient visits within the 6-month preoperative period categorized TKA recipients as either Hospital Ambulatory Clinic Centers patients with Medicaid insurance or private office patients with non-Medicaid insurers. ResultsThere were 174 Medicaid patients and 317 non-Medicaid patients for 491 total patients. Medicaid patients were significantly younger (62.6 ± 1.6 vs 65.4 ± 1.1 years, P < .01), of “other’ ethnicity (43.1% vs 25.6%, P < .01), and to be a current smoker (9.3% vs 6.6%, P = .02). There was no difference in gender, body mass index, and American Society of Anesthesiologists score. After controlling for patient factors, the Medicaid effect was insignificant for surgical time (exponentiated β 0.93, 95% confidence interval [CI] 0.86-1.01, P = .076) and facility discharge (odds ratio 1.58, 95% CI 0.71-3.51, P = .262). Medicaid status had a significant effect on length of stay (LOS) (rate ratio 1.21, 95% CI 1.02-1.43, P = .026). ConclusionMultivariable analysis controlling for patient factors demonstrated that Medicaid coverage had minimal effect on surgical time and facility discharge. Medicaid patients had significantly longer LOS by one-half day. These results indicate that comparable outcomes can be achieved for Medicaid patients following TKA provided that the surgeon and care setting are similar. However, increased care coordination and preoperative education may be necessary to normalize disparities in hospital LOS. Level of EvidenceIII, retrospective observational analysis;

Abstract 185: Trends in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks Among Rural and Urban Medicare Beneficiaries, 2008-2017

Introduction: Over the last decade substantial investments have been made in implementing stroke systems of care to improve access and quality of care. We sought to determine if these interventions have narrowed the rural-urban disparities in care over time for patients with acute stroke or transient ischemic attack (TIA). Methods: Descriptive observational study using data from all traditional Medicare beneficiaries in the United States from 2008-17 who presented to a hospital emergency department and were admitted either under observation stay or inpatient admission. Patients were classified as rural or urban based on home zip code. The main outcomes were rates of presentation to a certified stroke center, neurology consultation during admission, IV altepase, 90-day mortality, days living independently in the first 90 days post stroke, and 90-day spending. Results: We identified 3.31 million hospital stays for TIA and stroke in the study period. Rural and urban patients had similar age, race, gender, Medicaid status and presence of chronic conditions. In 2008, 24.4% and 60.4% of rural and urban patients respectively were cared for at a certified stroke center (disparity -36.1%). By 2017 this disparity had narrowed by 8.6% points (95% CI 6.6%,10.7%) (Fig). Between 2008 and 2017, the disparity in neurologist evaluation during admission narrowed by 7.4% (5.2%, 9.6%). However, there was no substantive change in disparity in alteplase use -0.1% (95% CI -0.5%,0.3%), mortality at 90 days 0.4% (95% CI 0.1%, 0.7%), or days living independently within 90 days -0.7 days (95% CI -1.1, 0.2). Spending in the first 90 days differentially increased among rural patients by $867 (95% CI 85, 1649). Conclusions: In the last decade, rural residents are more likely to receive care at a certified stroke center and receive neurologist consultation. However, disparities in outcomes are persistent, highlighting more work is needed to equitably extend stroke expertise to all Americans.

Medicaid and Medicare Payer Status Are Associated With Worse Surgical Outcomes in Gynecologic Oncology

(Abstracted from Gynecol Oncol 2019;155:93–97) Medicaid provides health insurance for Americans earning less than 133% of the federal poverty limit, amounting to approximately $35,000 for a family of 4, and covering approximately 1 in 5 Americans. Medicaid participants may have decreased access to care despite having insurance, as providers are less likely to accept Medicaid compared with private insurance.