non-Medicaid Insurance Research Articles

Client and program-level factors associated with planned use of medications for opioid use disorder in specialty substance use treatment programs: Evidence from linked administrative data and survey data

BackgroundMost patients in specialty drug treatment programs that are not federally licensed Opioid Treatment Programs (OTPs) programs do not receive medications for opioid use disorder (MOUD). MethodsWe linked results from a survey of non-OTP treatment program directors in New Jersey (n = 81) to statewide administrative records of admissions for opioid use to those programs between July 2021–June 2022. Using multi-level regression, we examined the association of three types of factors with planned MOUD use: program survey responses, client-level factors, and program-level client characteristic mix. ResultsOf 9583 opioid treatment admissions in non-OTP settings, 41 % included treatment plans involving MOUD. Programs where directors reported staff concerns about buprenorphine's efficacy or diversion had a lower proportion of clients with planned MOUD, as did programs reporting too little physical space to prescribe. Being self-referred to treatment, unemployed and not looking for work, aged 30–49, heroin use (vs. prescription opioid use), and stimulant use in addition to opioids, were positively associated with planned MOUD; while non-Medicaid insurance, and Black and Hispanic race/ethnicity, were negatively associated with planned MOUD. Clients were more likely to have planned MOUD if their programs had a higher proportion of clients aged 30 or older, heroin as primary “drug of abuse,” stimulant use, and not working but actively looking for work. ConclusionFindings suggest addressing program staff attitudes toward buprenorphine could help increase planned MOUD. There is also a need to improve access for clients with non-Medicaid insurance, address within-program race and ethnic disparities, and address employment-related barriers to medication.

A Retrospective Cohort Study of Disparities in Urine Drug Testing During the Perinatal Period in an Urban, Academic Medical Center

The purpose of this study was to evaluate disparities in urine drug testing (UDT) during perinatal care at a single academic medical center. This retrospective cohort study included patients who had a live birth and received prenatal care at our institution between 10/1/2015 and 9/30/2020. The primary outcomes were maternal UDT during pregnancy (UDTPN) and UDT only at delivery (UDTDEL). Secondary outcomes included the number of UDTs (UDTNUM) and the association between a positive UDT test result and race/ethnicity. Mixed model logistic regression and negative binomial regression with clustering based on prenatal care locations were used to control for confounders. Of 6,240 live births, 2,265 (36.3%) and 167 (2.7%) received UDTPN and UDTDEL, respectively. Black (OR 2.09, 95% CI 1.54–2.84) and individuals of Other races (OR 1.64, 95% CI 1.03–2.64) had greater odds of UDTPN compared to non-Hispanic White individuals. Black (beta = 1.12, p < 0.001) and Hispanic individuals (beta = 0.78, p < 0.001) also had a positive relationship with UDTNUM. Compared to individuals with non-Medicaid insurance, those insured by Medicaid had greater odds of UDTPN (OR 1.66, 95% CI 1.11–2.49) and had a positive relationship with UDTNUM (beta = 0.89, p < 0.001). No significant associations were found for UDTDEL and race/ethnicity. Despite receiving more UDT, Black individuals were not more likely to have a positive test result compared to non-Hispanic White individuals (OR 0.95, 95% CI 0.72–1.25). Our findings demonstrate persistent disparities in substance use testing during the perinatal period.

Risk Factors for Pediatric Intracranial Neoplasms in the Kids’ Inpatient Database

Introduction: In children and adolescents, brain and central nervous system (CNS) tumors are the leading types of cancers. Past studies have found differing rates of intracranial cancers among races and identified additional cancer risk factors. This study aimed to see if these differences can be substantiated with further investigation of the latest version (2019) of the Kids’ Inpatient Database (KID). Methods: A total of 7,818 pediatric patients <21 years old in KID with ICD-10 codes consisting of malignant neoplasms of the brain, brainstem, and cerebral meninges (C700, C709–C719) were queried. Modifiable risk factors evaluated include: hospital region, insurance type, hospital city size, the average income of patient zip code, and location/teaching status of a hospital. Non-modifiable risk factors were race and sex at birth. Dependent variables were tested in Excel and GraphPad Prism 9 using a χ2 test with Yates’ continuity correction and Tukey’s one-way and two-way ANOVAs. Results: Mortality rates of females (2.88%) compared to males (1.99%) were significant (p < 0.05). Mortality was (4.17%) in black patients compared to (1.68%) for white (p < 0.0001), Hispanic mortality (2.95%) compared to white (p < 0.01), and mortality of Asian/Pacific Islander (3.86%) compared to white (p < 0.01). Black patients had significantly higher mortality than white, Hispanic, Asian/Pacific Islander, Native American, and other races overall (p < 0.01). There was no significant difference in the mortality rates between children’s hospitals and large hospitals for any race. After accounting for patient race, mortality was still not significantly different for patients with Medicaid insurance compared to non-Medicaid insurance types. Of the children treated at children’s hospitals, the most transferred in from outside hospitals were Native American (20.00%) followed by Asian/Pacific Islander (15.09%) then Hispanic patients (13.67%). A significant difference between races was also seen regarding length of stay (p < 0.001) and number of charges (p < 0.001). Conclusion: These findings confirm prior studies suggesting gender and race are significant factors in mortality rates for children with intracranial neoplasms. However, the findings do not identify the root causes of these discrepancies but may serve as an impetus for clinicians, healthcare administrators, and governmental leaders to improve national resource allocation to better care for pediatric patients with intracranial neoplasms.

High deductible health plans and survival among cancer survivors.

11005 Background: High deductible health plans (HDHP) enable lower premiums at the expense of potentially high out-of-pocket costs. They are associated with more advanced cancer stage diagnoses and delayed or forgone care among cancer survivors. However, it is unknown how HDHPs are associated with survival among cancer survivors. Methods: Individuals ages 18-84 years with non-Medicaid insurance were identified from the 2011-2018 National Health Interview Survey (NHIS) with linked mortality files from the National Death Index. HDHP status was defined by the NHIS as a yearly deductible ≥$1200-1350 for an individual or ≥2400-$2700 for a family (values depend on survey year with increases over time). Cox proportional hazards models using age as the time scale were utilized to determine: 1) association of HDHP status with overall survival (OS) and cancer survival (CS; i.e., freedom from cancer death) among cancer survivors, and 2) how associations differed for survivors compared to those without a cancer history. Models accounted for the NHIS survey design and survey weights and were adjusted for insurance status, marital status, sex, comorbidities, education, income, national region, and cancer site and time since cancer diagnosis (if applicable). Sensitivity analyses adjusting for age at cancer diagnosis were performed using time since diagnosis as the time scale. Results: A total of 147,254 respondents were identified, 5.9% of whom were cancer survivors. 25.6% of survivors and 28.5% of individuals without a cancer history reported being insured by a HDHP at the time of NHIS participation. HDHP status was associated with worse OS (HR: 1.46, 95% CI = 1.19 - 1.79) and CS (HR: 1.34, 95% CI = 1.01 - 1.77) among cancer survivors overall in the adjusted model. HDHP status was additionally associated with worse OS among the following subgroups of cancer survivors: non-Hispanic White (HR: 1.45, 95% CI = 1.16 - 1.82), income &gt; 400% federal poverty level (HR: 1.65, 95% CI = 1.16 - 2.36), college (HR: 1.47, 95% CI = 1.07 – 2.00) or high school (HR: 1.59, 95% CI = 1.19 - 2.12) education, and multiple cancers (HR: 1.58, 95% CI = 1.06 - 2.36), without clear patterns by sex, comorbidities, insurance, and cancer site. Sensitivity analyses provided similar results. In contrast, among adults without a history of cancer at the time of NHIS participation, HDHP status was not significantly associated with OS (HR: 1.08, 0.96 - 1.21; Pinteraction &lt; .01) or CS (HR: 0.90, 95% CI = 0.70 - 1.14; Pinteraction &lt; .01). Conclusions: This nationwide population-based analysis suggests that HDHPs are associated with both worse overall survival and cancer survival among cancer survivors but are not associated with survival in adults without a history of cancer. HDHPs may financially disincentivize cancer survivors from utilizing necessary medical care to optimize survivorship thereby compromising mortality and cure. Policy changes to limit the proliferation of these plans may improve cancer outcomes.

Abstract PO3-03-10: Race and neoadjuvant treatment of triple negative breast cancer (TNBC) in the US community oncology setting

Abstract Background: TNBC is an aggressive subtype of breast cancer with limited targeted therapies. Black women have twice the incidence of TNBC compared to White women and within TNBC, Black women have worse outcomes than White women. Differences in both tumor biology of TNBC and social determinants of health (SDOH) play a role in observed disparities. The focus of this study is to evaluate SDOH factors associated to differences in the use of neoadjuvant chemotherapy (NC) in Black and White women in the US community oncology setting. Methods: This study was a retrospective, observational, cross-sectional design and used iKnowMed SM EHR data from the The US Oncology Network. Patients diagnosed with TNBC between 03/31/2017 and 09/30/2021 with stages II-III disease of tumor size ≥ 2cm (T2 or higher) were included. The index date was date of TNBC diagnosis and records were assessed from 6 months pre- to 6 months post-diagnosis for NC initiation. Univariable and multivariable logistic regression was conducted to evaluate impact of self-reported race on NC. Age, stage, BMI, insurance, area deprivation index (ADI), size of practice represented by physician count and geographical region, were studied in their mediating and moderating effects1 on the relationship between race and NC treatment. Results: Of the 3321 patients with TNBC identified in this study, 1969 self-reported white and 494 self-reported black (80% and 20% respectively). In multivariable regression accounting for all variables, Black race (OR = 1.57, 95% CI [ 1.02, 2.44], p=0.04), younger age, more advanced stage, obesity, non-Medicaid insurance, and West region, were all found to be positively associated with use of NC. Higher physician count was nominally associated, (p = 0.07). ADI was not found to be associated to NC. Mediator and moderator analysis for the relationship between race and NC showed that only stage and ADI variable inclusion in the model are required for the positive association between black race and NC. This is driven by a significant interaction between ADI and stage (p = 0.027) which differed for Black and White women. Mainly, for Black women ADI is positively associated to NC treatment in stage IIA, but negatively associated in all other stages (interaction term, p = 0.033). For White women, ADI is negatively associated to NC treatment in all stages. Only Black women with stage IIA tend to be treated more instead of less with NC in areas of greater deprivation (greater ADI). BMI presents nominal interactions with both race and stage, where obesity was more strongly associated with NC treatment in Black women (p = 0.088) and in stage IIA (p = 0.086). All other variables presented association to NC treatment without mediation or moderation of the race effect and without detectable differences across stages. Conclusions: Black women with stage IIA appear to be a special subgroup of TNBC patients for whom treatment with NC increases with ADI. Increased ADI generally results in less standard of care treatment; this is observed in this study for White women overall and for Black women in stages &amp;gt; IIA. Black women in areas of greater deprivation with stage IIA disease, may be perceived to be presenting with more aggressive disease and thus offered NC preferentially. This result lends support to the hypothesis that young black women present with a distinct, more aggressive subtype of TNBC in the early stages. Mediator and moderator analyses are important tools in elucidating the relationships between factors underlying racial disparities in both care and outcomes. 1. Hayes AF, Rockwood NJ. Regression-based statistical mediation and moderation analysis in clinical research: Observations, recommendations, and implementation. Behav Res Ther. 2017 Nov;98:39-57. Odds ratios for multivariable analysis –insert figure image– Race, stage and ADI –insert figure image– Race and BMI in stage IIA –insert figure image– Citation Format: Paola Raska, Joseph Dye, Nicholas J Robert, Angel Kidd, Michael Danso. Race and neoadjuvant treatment of triple negative breast cancer (TNBC) in the US community oncology setting [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-03-10.

High Hydroxyurea Usage in Sickle Cell Anemia Regardless of Patient Demographic

Introduction/Background: Hydroxyurea is highly effective in sickle cell disease, yet it is still underutilized. The Pediatric Sickle Cell Program of Northern Virginia recently published a 10-year analysis of uniform hydroxyurea (HU) implementation starting in infancy for all patients with sickle cell disease of severe genotype (SCA), demonstrating rise in HU usage from 32.5% baseline rate to 79.6% after two years, and to &amp;gt; 90% after 8 years. 1 Other HU utilization studies reporting lower rates largely use Medicaid data, and lower socioeconomics is often cited as a barrier to HU utilization. The Northern Virginia study reported on all patients with SCA regardless of insurance coverage, thus raising the question whether the high HU usage rate achieved in this program was influenced by a high proportion of non-Medicaid patients or other unusual demographic features. Therefore, we analyzed 10 years of HU usage data by insurance, ethnicity, and age. Methods: HUdata extracted from a longitudinal REDCap database and electronic medical records (EMR) with IRB approval (Children's National Medical Center IRB, Pro00002745, Pro00013374) previously reported 1 for five 2-year intervals are additionally analyzed for insurance, ethnicity, and age, with new data for 2019-2021. HU-eligibility includes SCA patients age ≥ 9 months and not chronically transfused. HU users (on HU) are patients demonstrating Hgb F rise and expected hemogram changes in response to HU, monitored every 2-3 months; HU non-users (not on HU) are patients who refuse HU or are grossly non-adherent as evidenced by lack of changes in Hgb F and hemogram. Pharmacy dispense records available in Epic EMR are used as corroborative information. Results: 1. Medicaid patients comprised 39 - 46% and non-Medicaid patients comprised 54 - 61% of all patients over the five 2-year periods. African-American (AA) and African patients comprised 85% of all patients. Medicaid coverage ranged from 24 - 39% for AA patients and 38 - 48% for African patients. (African is defined as born in Africa or having parents born in Africa who immigrated to the US.) 2. Comparing HU usage by insurance over the five 2-year periods, HU users increased from 72% to 91% for Medicaid patients and from 83% to 95% for non-Medicaid patients. Conversely, HU non-users decreased from 28% to 9% for Medicaid patients and from 17% to 5% for non-Medicaid patients. No statistical difference was detected in HU usage by Medicaid versus non-Medicaid insurance in any interval (p = 0.13 to 0.91) (Table 1). 3. HU usage rates in AA and African patients were not statistically different (p = 0.07 to 0.32), except in one interval (2013-15) (p = 0.006) (Table 1). 4. Comparison of HU usage in two age groups, 9 months-12 years and ≥ 13 years, showed that while HU non-acceptance/non-adherence tended to be higher in the age ≥ 13 group, no statistical significance was reached in any interval (p = 0.13 to 0.97) (Table 1). 5. The uniform HU implementation program targeted for fetal hemoglobin (Hgb F) 30% or higher by frequent HU dose optimization and close adherence monitoring. Hgb F &amp;gt; 20% was considered good adherence, and Hgb F 10-20% reflected partial adherence. Partially adherent patients did not distribute differently between Medicaid and non-Medicaid insurance (p = 0.07 to 0.86) but were predominantly age &amp;gt; 13 (p = 0.0005 to 0.001) (Table 2). Conclusion: 1. HU users and HU non-users did not disproportionately distribute to any demographic group. 2. Uniform HU implementation was effective in both Medicaid and non-Medicaid populations. 3. Ethnicity and age were not significant factors in HU uptake or acceptance, but decreased HU adherence is more frequent in teenagers. 4. HU can be effectively implemented for all SCA patients across demographic groups. Medicaid insurance, as a proxy for socioeconomic level, is not a barrier to high HU usage. Reference: 1. Phan V, Park JA, Dulman R, Lewis A, Briere N, Notarangelo B, Yang E. Ten-year longitudinal analysis of hydroxyurea implementation in a pediatric sickle cell program. Eur J Haematol. 2022 Nov;109(5):465-473. doi: 10.1111/ejh.13827. Epub 2022 Sep 2. PMID: 35811388.

After Anterior Cruciate Ligament Injury, Patients With Medicaid Insurance Experience Delayed Care and Worse Clinical Outcomes Than Patients With Non-Medicaid Insurance

To evaluate the effects of socioeconomic factors on the operative treatment of anterior cruciate ligament injuries and outcomes following surgical reconstruction. A retrospective cohort study of primary anterior cruciate ligament reconstruction surgeries at a single institution performed from 2011 to 2015 with minimum 2-year follow-up was conducted. Patient demographics, insurance type, workers' compensation status, surgical variables, International Knee Documentation Committee score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups. In total, 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group, overall mean follow-up of 3.1 ± 0.8 years). The Medicaid group demonstrated lower annual income (P < .001) and a lower level of completed education compared with the non-Medicaid group (P<.001). Patients who received Medicaid had a greater duration between time of initial knee injury and surgery compared with the those in non-Medicaid group (11.8 ± 16.3 months vs 6.1 ± 16.5 months, P < .001). At the time of follow-up, patients in the non-Medicaid group had a significantly greater International Knee Documentation Committee score compared with patients who received Medicaid (82.5 ± 13.8 vs 75.3 ± 20.8, P= .036). Patients with Medicaid insurance were seen in the clinic significantly later after initial injury and had worse outcomes compared with patients with other insurance types. Also, patients in higher annual income brackets had significantly better clinical outcomes scores at a minimum of 2 years postoperatively. Level III, retrospective cohort study.

Assessing and Improving WIC Enrollment in the Primary Care Setting: A Quality Initiative.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides food and other resources to mitigate the harmful effects of food insecurity on child and maternal health. From a 2009 peak, nationwide WIC participation declined through 2020. Our objectives were to understand factors influencing WIC engagement and improve WIC enrollment through novel, primary care-based quality improvement interventions. Plan-do-study-act cycles were implemented at a majority Medicaid-insured pediatric primary care clinic. Universal WIC screening at <5-year-old well-child visits was initiated, with counseling and referrals offered to nonparticipants. Clinic providers received WIC education. WIC screening, counseling reminders, and referrals were streamlined via the electronic health record. Families were surveyed on WIC participation barriers. Patient demographic data were analyzed for predictors of WIC participation. Mean new WIC enrollments increased significantly (42%) compared with baseline, with sustained special cause variation after study interventions. Provider WIC knowledge improved significantly at study end (P <.001). Rates of WIC screening, counseling, and referrals remained stable for >1 year after study interventions. The most common family-reported barriers to WIC participation were "Access problems" and "WIC knowledge gap." Factors associated with decreased WIC participation in multivariable analysis were increasing age (P <.001), and non-Medicaid insurance status (P = .03). We demonstrate feasible primary care-based screening, education, and referral interventions that appear to improve WIC enrollment. We identify knowledge gap and access problems as major potentially modifiable barriers to WIC participation. The expansion of similar low-cost interventions into other settings has the potential to benefit under-resourced children and families.

RACIAL DIFFERENCES IN FOOD ALLERGY DIAGNOSIS AMONG CHILDREN WITH ATOPIC DERMATITIS INDEPENDENT OF SOCIOECONOMIC CONDITION

<h3>Introduction</h3> It is well-known that children with atopic dermatitis are at increased risk of developing food allergy. To deepen this understanding, we explored the possible association of race and socioeconomic condition with diagnosis of food allergy in children with atopic dermatitis. <h3>Methods</h3> We conducted a large single-center retrospective cohort study of children aged 0-18 years with atopic dermatitis to determine whether each child had a food allergy diagnosis. We performed logistic regression, adjusting for age, race, sex, BMI, and indicators of socioeconomic condition [insurance status and Area Deprivation Index (ADI)]. <h3>Results</h3> Among the 4,322 children analyzed for this study, 16% were Non-Hispanic White, 39% Black, 33% Hispanic, and 6% Asian. Compared with non-Hispanic White children with atopic dermatitis, Hispanic children with atopic dermatitis were significantly less likely to have a food allergy diagnosis (OR=0.774, 95% CI [0.689-0.983], p=0.036). Conversely, both Black children and Asian children with atopic dermatitis were more likely to have been diagnosed with food allergy (OR=1.293, 95% CI [1.109-1.642], p=0.035 and OR=1.493, 95% CI [1.075-2.073], p=0.017 respectively). Age, male gender, non-Medicaid insurance, and lower area deprivation (higher socioeconomic condition) were all statistically significantly associated with increased risk of food allergy diagnosis. <h3>Conclusion</h3> The association between race/ethnicity and risk of food allergy diagnosis among children with atopic dermatitis persisted after thoroughly adjusting for socioeconomic condition using two different markers (insurance status and ADI). Clearly defining which children with atopic dermatitis are at highest risk of developing food allergies can help inform future efforts in early food allergy diagnosis and prevention.

Changes in Type 2 Diabetes Trends in Children and Adolescents During the COVID-19 Pandemic.

PURPOSETo examine whether trends in new-onset pediatric type 2 diabetes (T2D) -- inclusive of patients requiring hospitalization and patients managed outpatient -- were impacted during the COVID-19 pandemic, and to compare patient characteristics prior to and during COVID-19.METHODSA retrospective single-center medical-record review was conducted in a hospital which cares for 90% of Alabama’s pediatric T2D patients. Patients with new-onset T2D referred from March 2017-March 2021 were included. Counts of patients presenting per month (“monthly rates”) were computed. Linear regression models were estimated for the full sample and stratified by Medicaid and non-Medicaid insurance status. Patient characteristics prior to versus during COVID-19 were compared.RESULTS642 patients presented with new-onset T2D over this period. Monthly rates were 11.1 ± 3.8 prior to COVID-19,19.3 ± 7.8 during COVID-19 (p=0.004). Monthly rates for Medicaid patients differed prior to and during COVID-19 (7.9 ± 3.4 vs 15.3 ± 6.6, p = 0.003) but not for non-Medicaid patients (3.3 ± 1.7 vs 4.0 ± 2.4, p=0.33). Regression results showed significant increases in monthly rates during COVID-19 for the full sample (β=, p<0.05) and for Medicaid enrollees (β=, p<0.05) Hospitalization-rate, severity of obesity, and hemoglobin A1c remained similar prior to and during COVID-19, though the proportion of male patients increased from 36.8% to 46.1% (p=0.021).CONCLUSIONSA rise in new-onset T2D was observed among Alabama’s youth during the COVID-19 pandemic, a burden that disproportionately affected Medicaid enrollees and males. Future research should explore the pathways through which the pandemic impacted pediatric T2D.

Continued Increase in Cost of Care Despite Decrease in Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

Introduction:Previous studies have demonstrated decreased hospital length of stay (LOS) for children undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).Methods:Hospitalization event data from the Kids Inpatient Database were queried for all PSF events for AIS performed in 2009, 2012, and 2016 using diagnosis and surgical codes. Data were subdivided into two groups: pre–enhanced recovery after surgery (ERAS) (2009 and 2012) and post-ERAS (2016). The primary outcome variables were LOS and total treatment charge (adjusted for 2020 inflation). Univariate and multivariate analysis were performed to identify differences in outcome variables.Results:A total of 12,010 unique hospitalization events were identified, 74% female, mean 14.3 years. There was a decrease in LOS (pre-ERAS: 5.4 ± 4.0 versus 4.3 ± 3.2 days, P < 0.0001) with an increase in adjusted total treatment charge (pre-ERAS $193,544.4 ± $108,116.1 versus $200,469.1 ± $110,112.6; P = 0.0013). Pre-ERAS, male sex, smaller hospital, and non-Medicaid insurance were predictive of longer LOS, whereas pre-ERAS, older age, non-White race, male sex, hospital outside the Northeast, and non-Medicaid insurance were predictive of higher treatment costs.Discussion:There continues to be a significant decrease in LOS for PSF hospitalization events for AIS; however, total treatment charges continue to rise. Future research should investigate potential factors influencing total treatment charges after PSF for AIS.

Screening for co-infections in patients with substance use disorders and severe bacterial infections.

Background:Patients with substance use disorders admitted for severe bacterial infection are in a prime position to be screened for important co-infections. However, data suggest that standard screening for co-infections in this population during hospital admission can vary in frequency and type of testing.Methods:We performed a retrospective review of patients to evaluate screening for co-infections during admission, followed by a case–control analysis to determine factors associated with lack of any screening.Results:We identified 280 patients with 320 eligible admissions. Most were male and Caucasian with unstable housing. Only 67 (23.9%) patients had a primary-care provider. About 89% (n = 250) of our cohort were screened for one or more co-infection during their first admission with one patient never screened despite subsequent admissions. Of those screened, the greatest proportion was HIV (219, 81.4% of those without history of HIV), HCV (94, 79.7% of those without a prior positive HCV antibody), syphilis (206, 73.6%), gonorrhea, and chlamydia (47, 16.8%) with new positive tests identified in 60 (21.4%) people. Screening for all five co-infections was only completed in 15 (14.0%) of the 107 patients who had screening indications. Overall, a high proportion of those screened had a new positive test, including three cases of neurosyphilis, highlighting the importance of screening and treatment initiation. One patient was prescribed HIV pre-exposure prophylaxis at discharge and only 37 (34.6%) of those eligible were referred for HCV treatment or follow-up. In multivariable case–control analysis, non-Medicaid insurance (OR 2.8, 95% CI: 1.2–6.6, p = 0.02), use of only 1 substance (OR 2.9, 95% CI: 1.3–6.5, p < 0.01), and no documented screening recommendations by the infectious disease team (OR 3.7, 95% CI: 1.5–8.8, p < 0.01), were statistically significantly associated with lack of screening for any co-infection during hospital admission.Conclusion:Our data suggest additional interventions are needed to improve inpatient screening for co-infections in this population.

Insurance Status Effect on Laryngeal Cancer Survival: A Population Based Study.

To analyze insurance status effect on overall survival (OS) and disease-specific survival (DSS) in laryngeal cancer. Cross-sectional population analysis. Surveillance, Epidemiology, and End Results (SEER) database. Laryngeal cancer patients from 2007 to 2016. Kaplan-Meier method with log-rank statistic analyzed OS and DSS by insurance status. Multivariable cox proportional hazard modeling generated survival prognostic factors. Of 19 667 laryngeal cancer cases, initial disease presentation was stage I: 7770 patients (39.5%), stage II: 3337 patients (17.0%), stage III: 3289 patients (16.7%), and stage IV: 5226 patients (26.6%). Patients had non-Medicaid insurance (15 523, 78.9%), had Medicaid (3306, 16.8%), or were uninsured (891, 4.5%). Mean and median OS for insured, Medicaid, and uninsured patients were 60.5, 49.6, and 56.6 and 74.0, 40.0, and 65.0 months, respectively. Following multivariable analysis, OS for insured, Medicaid, and uninsured patients was stage I: 87.9, 82.8, and 88.4 (P < .001), stage II: 79.1, 75.1, and 78.3 (P = .12), stage III: 68.7, 66.1, and 72.1 (P = .11), and stage IV: 57.1, 51.7, and 50.3 (P < .001) months. DSS mean survival times were 77.0, 65.8, and 67.7 months (P < .001) for insured, Medicaid, and uninsured patients. Age (HR: 1.02/year, P < .001) and black (HR: 1.15, P = .001) compared to white race predicted worse survival. Compared to insured status, Medicaid insurance carried a death hazard ratio of 1.40 (P < .001) and uninsured status had a death hazard ratio of 1.40 (P < .001). Insured laryngeal cancer patients had prolonged OS and DSS compared to Medicaid and uninsured patients. Medicaid patients had equivalent survival outcomes to uninsured patients. 2c.

Adherence to Car Seat Tolerance Screening Differs by Indication and Patient Characteristics.

ObjectivesTo assess whether adherence to institutional car seat tolerance screening (CSTS) guidelines differed for infants born preterm (PTM), term low birth weight (T-LBW), or both preterm and low birth weight (P-LBW), and to examine the association between CSTS adherence and patient characteristics.Study DesignWithin two large academic and community hospitals, we retrospectively reviewed all infants meeting institutional criteria (< 37 weeks’ gestation and/or < 2.27 kg) for CSTS from 2014 to 2018. Multivariable logistic regression evaluated the association of patient characteristics with institutional CSTS guideline adherence.Results4374 eligible infants were born PTM (50.9%), T-LBW (6.5%), or P-LBW (42.6%). Adherence rates were 92.7% in the neonatal intensive care unit (NICU) and 95.2% in the well-baby nursery with initial CSTS failure rates of 6.1% and 9.9%, respectively. Adherence was lowest among T-LBW (80.7%) compared to PTM (95.1%) or P-LBW (92.2%) infants in the NICU (p < 0.001) and well-baby nursery (81.6%, 96.7% and 97.1%, respectively, p < 0.001). In bivariate analyses, gestational age, birth weight, insurance, race, hospital type, discharge year, and preferred language were associated with adherence. In fully-adjusted models, adherence was positively associated with lower gestational age, higher birth weight, non-Medicaid insurance, and later discharge year (NICU) and lower gestational age and later discharge year (well-baby nursery).ConclusionsAdherence was lower for T-LBW than PTM or P-LBW infants, despite similar CSTS failure rates. Disparities in adherence among Medicaid-insured patients in the NICU warrant further study. Future studies are needed to clarify the benefit of CSTS and increase adherence in high-risk populations.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10995-021-03220-5.

CORR Insights®: Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location.

CORR Insights®: Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location.

Population Level Survival for Patients with Multiple Myeloma By Insurance Type and Early Indications of Changes with Adoption of the Medicaid Expansion of the Affordable Care Act

Introduction: Five year survival rates for patients with multiple myeloma have improved during the first part of the 21st century and the approval of new drugs for myeloma makes it likely that further increases in survival will be observed in the next several years. However, barriers to care, including lack of insurance, may keep some patients from benefiting as much as they could from newer treatments. The Affordable Care Act (ACA), intended to reduce the number of uninsured people in the United States (US), was fully implemented in 2014, although five states took the option of expanding access early. In 2017, survival data from 2014 became available, providing the first chance to evaluate the effect of the ACA on cancer survival. Here, we examine survival for patients with myeloma by insurance type and examine the first survival results comparing survival outcomes in states that accepted the Medicaid expansion versus those that did not.Methods: Data were drawn from the Surveillance, Epidemiology, and End Results (SEER18) database. Patients with a diagnosis of myeloma (ICD-10 code C90.0) were included. Because the vast majority of patients age 65 and older are covered by Medicare, the analysis was limited to those aged 15 to 64 years. Kaplan-Meier analysis was used to determine 1-year absolute survival. In order to determine if an effect from the Medicaid expansion could be observed, survival by insurance type was calculated for patients who lived in states that accepted early expansion of Medicaid (California, New Jersey, Connecticut, and Washington) versus those that had not accepted the Medicaid expansion as of the end of 2014 (Louisiana, Georgia, Alaska, and Utah.)Results: One year absolute survival increased overall between the periods studied, going from 85.3% (95% confidence interval 84.2-86.4) in 2008-09 to 87.6% (95% confidence interval 86.4-88.8) in 2013-14 for patients age 15-64. Survival was lower for patients with no insurance or with Medicaid only than for patients with other insurance in all time periods (see table). When states which were early adopters of the Medicaid expansion were compared to those that were not, more patients were insured in the Medicaid expansion states in 2013-14 (3.5% compared to 8.5%), although the rate of non-Medicaid insurance was the same in each group at 77.4% in 2013-14. Survival increased slightly for patients with Medicaid in the Medicaid expansion states, with an increase of 4.0% units compared to a decrease of 1.6% units in the non-expansion states. However, the confidence intervals were large in both populations.Discussion: One year survival has increased between 2008-09 and 2013-14 for patients with multiple myeloma. Patients with no insurance or with Medicaid have lower survival expectations than patients with other insurance. Fewer patients are uninsured in the states where the ACA Medicaid expansion was adopted. There is a preliminary indication that results for patients using Medicaid may be improving in states that adopted the Medicaid expansion, although the significance of this observation remains in doubt due to the small case numbers. Furthermore, the reasons for these changes are unclear at this time. Further research as more data become available may help clarify this issue. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Increased Risk of Sub-Clinical Blood Lead Levels in the 20-County Metro Atlanta, Georgia Area-A Laboratory Surveillance-Based Study.

Lead (Pb) is a naturally occurring, highly toxic metal that has adverse effects on children across a range of exposure levels. Limited screening programs leave many children at risk for chronic low-level lead exposure and there is little understanding of what factors may be used to identify children at risk. We characterize the distribution of blood lead levels (BLLs) in children aged 0–72 months and their associations with sociodemographic and area-level variables. Data from the Georgia Department of Public Health’s Healthy Homes for Lead Prevention Program surveillance database was used to describe the distribution of BLLs in children living in the metro Atlanta area from 2010 to 2018. Residential addresses were geocoded, and “Hotspot” analyses were performed to determine if BLLs were spatially clustered. Multilevel regression models were used to identify factors associated with clinical BBLs (≥5 µg/dL) and sub-clinical BLLs (2 to <5 µg/dL). From 2010 to 2018, geographically defined hotspots for both clinical and sub-clinical BLLs diffused from the city-central area of Atlanta into suburban areas. Multilevel regression analysis revealed non-Medicaid insurance, the proportion of renters in a given geographical area, and proportion of individuals with a GED/high school diploma as predictors that distinguish children with BLLs 2 to <5 µg/dL from those with lower (<2 µg/dL) or higher (≥5 µg/dL) BLLs. Over half of the study children had BLLs between 2 and 5 µg/dL, a range that does not currently trigger public health measures but that could result in adverse developmental outcomes if ignored.

Medicaid-Insured Client Characteristics and Quit Outcomes at the Arizona Smokers’ Helpline

Medicaid-insured individuals who smoke experience disparities in quitting and are a priority population for assistance. This retrospective cohort study of Arizona Smokers' Helpline clients (Jan 2014-Mar 2019) examined the association between insurance status, treatment, and smoking cessation. When compared to clients with non-Medicaid insurance or no insurance, clients with Medicaid (26%) were more likely to be female, referred directly to the ASHLine by a healthcare or community partner, smoke in the home, and report having a mental health condition. They also were less likely to utilize cessation medication and reported receiving less social support to quit. Controlling for these and other theoretically relevant variables, insurance status was stratified (Medicaid, non-Medicaid, and uninsured), and quit outcomes were compared by level of treatment (4 treatment groups: more and less than 3 coaching sessions and cessation medication use yes/no). Compared to clients who received 3+ coaching sessions, those who had less than 3 coaching sessions had significantly lower adjusted odds of quitting. Results were similar regardless of cessation medication use or insurance status. There is no indication that treatment effects differ by insurance status. While insurance status appears to proxy for other important factors like low social and economic status and higher comorbidity prevalence, in a quitline setting, quitting is associated with additional, high-quality coaching. Where coaching sessions may offset social and economic barriers to quitting, quitlines may consider focusing on assisting Medicaid-insured clients to connect and engage with treatment.

Insurance disparity in cardiovascular mortality among non-elderly cancer survivors

BackgroundInsurance status plays a vital role in cancer diagnosis, treatments and survival. Cancer patients have higher cardiovascular disease (CVD) mortality than the general population.MethodsThe Surveillance, Epidemiology and End Results (SEER) program 2007–2016 was used to estimate the CVD mortality among cancer patients aged 18 to 64 years at the time of diagnosis of an initial malignancy with the eight most prevalent cancers. Standardized mortality ratios (SMRs) were calculated for each insurance (Non-Medicaid vs Medicaid vs Uninsured) using coded cause of death from CVD with adjustment of age, race, and gender. The Fine-Grey Model was used to estimate adjusted Hazard Ratios (HR) of each insurance in CVD mortality.ResultsA total of 768,055 patients were included in the final analysis. CVD death in patients with Medicaid insurance remained higher than in those with Non-Medicaid insurance (HR = 1.71; 95%CI, 1.61–1.81; p < 0.001). Older age, male gender, and black race were all associated with increased CVD mortality in the multivariable model. Compared to the general population, patients with Medicaid had the highest SMRs of CVD mortality, regardless of year of cancer diagnosis, follow-up time, cancer site, and race. Non-Medicaid insured patients had similar CVD mortality to the general population after 2 years out from their cancer diagnosis.ConclusionCancer patients with Non-Medicaid insurance have significantly lower CVD mortality than those with no insurance or Medicaid. The insurance disparity remained significant regardless of type of CVD, cancer site, year of diagnosis and follow-up time.

Equal care for all? Do surgical outcomes in shoulder arthroplasty depend on insurance type?

BackgroundAlthough it has been shown that Medicare populations have a higher overall rate of complications than those with private insurances for large cohort total joint studies, there is limited information comparing patient-reported outcomes (PROs) among private insurance patients. The purpose of this study was to determine the impact of non-Medicaid insurance type on outcomes after shoulder arthroplasty.MethodsThis retrospective case-controlled study included 203 patients who underwent shoulder arthroplasty from 2012 to 2017 by a single surgeon. Preoperative and postoperative PROs were collected and included the Simple Shoulder Test, the American Shoulder and Elbow Surgeons Shoulder Assessment Form, and the Constant Shoulder Score. Patients were categorized into groups based on insurer—preferred provider organization, health maintenance organization, Medicare, and Veterans Affairs Care program—and outcomes were compared between groupsResultsThe 4 insurance provider groups were matched for body mass index, surgery type, and comorbidities (P = .526). Preoperatively, no significant differences in PROs between groups were present except for the Constant Shoulder Score (P = .029). All payer groups significantly improved from preoperative to postoperative PROs (P ≤ .001). At the final follow-up, no significant difference in PROs between groups were seen (American Shoulder and Elbow Surgeons Shoulder mean 75.3 ± 20.9 [P = .757], Simple Shoulder Test of 9.1 ± 2.9 [P = .312], and Constant Shoulder Score of 65.0 ± 15.2 [P = .526]).ConclusionsOur results suggest variations in insurance type did not significantly impact outcomes for our cohort of patients undergoing shoulder arthroplasty. Although variations in patient cohorts exist, patients regardless of insurance type and coverage variations can expect significant improvements in their function and pain after shoulder arthroplasty.