Primary Insurer Research Articles

Association of enrollment in Medicare Advantage plans versus fee-for-service in patients with a late-stage diagnosis of gynecologic cancer.

11140 Background: In the United States, uterine cancer is the most common gynecologic (GYN) cancer; and ovarian cancer causes more deaths each year than any other GYN cancer. There are currently no recommended population-wide screening tests for ovarian or uterine cancer, which are heavily concentrated in older women. Medicare is the primary health insurer for 97% of Americans aged 65 years and older. This study is the first to examine the association between Medicare enrollment plan – Medicare Advantage (MA) versus fee-for-service (FFS) – and stage at diagnosis among older women newly diagnosed with ovarian or uterine cancer. Methods: Using the linked Surveillance, Epidemiology, and End Results (SEER) registries and Medicare enrollment data, we identified 101,193 women aged 65 years and older with newly diagnosed ovarian or uterine cancer between 2007-2019. We categorized patients into two groups: 1) those continuously enrolled in Medicare MA for six months prior to their diagnosis, through the diagnosis month, and the month following diagnosis; 2) those continuously enrolled in Medicare FFS within the same eight-month window. Late-stage was defined as “Distant” stage (with “Local” and “Regional” stages representing an earlier-stage diagnosis) using the SEER Summary Stage variable. The association between Medicare enrollment plan and stage was examined through multivariable logistic regression modeling that adjusted for sociodemographic characteristics. The influence of each predictor on the difference in the probability of late stage was summarized as an adjusted marginal effect (ME). Results: Among uterine cancer patients, 37% had MA insurance. Compared with Medicare FFS enrollees, the adjusted percentage of late-stage diagnosis was 0.6 percentage points (ppt) lower for MA enrollees (95% CI = -1.1-(-0.1); P<0.05). Notably, patients were more likely to have a late-stage uterine diagnosis if they were: non-Hispanic Black or Hispanic (vs. non-Hispanic White); age 75 and older (vs. between 65 -74); and residing in a lower SES neighborhood. Among ovarian cancer patients, 34% had MA insurance. We found no significant difference between Medicare MA and FFS enrollees in ovarian cancer stage at diagnosis. Of note, Non-Hispanic Black patients were significantly more likely to be diagnosed with late-stage disease compared to Non-Hispanic White, and likewise for patients aged 75 and older (vs. between 65-74). Conclusions: Among Medicare beneficiaries (age 65+) diagnosed with uterine cancer, those enrolled in an MA plan were significantly less likely to be diagnosed at a later stage. In similar analyses for ovarian cancer, there was no such MA - FFS difference in the probability of late-stage. As enrollment in Medicare Advantage plans continues to grow, it becomes increasingly important to identify whether there are significant outcome differences between MA and FFS plans.

Stackelberg reinsurance chain under model ambiguity

In this paper, we consider a continuous-time version of a reinsurance chain, which is sequentially formed by n+1 companies, with the first company being the primary insurer and the rest being reinsurers. Because of possible model misspecification, all companies are ambiguous about the original risk of the primary insurer. We model each reinsurance contracting problem as a Stackelberg game, in which the assuming reinsurer acts as the leader while the ceding company is the follower. Reinsurance is priced using the mean-variance premium principle and all companies are risk neutral under their own beliefs. We obtain equilibrium indemnities, premium loadings, and distortions in closed form, all of which are proportional to the original risk, with the corresponding proportions decreasing along the chain. We also show that the reinsurance chain with ambiguity aversions in increasing order is optimal from the perspectives of both selfish individual companies and an unselfish central planner.

Reinsurance games with variance-premium reinsurers: from tree to chain

AbstractThis paper studies dynamic reinsurance contracting and competition problems under model ambiguity in a reinsurance market with one primary insurer and n reinsurers, who apply the variance premium principle and who are distinguished by their levels of ambiguity aversion. The insurer negotiates reinsurance policies with all reinsurers simultaneously, which leads to a reinsurance tree structure with full competition among the reinsurers. We model the reinsurance contracting problems between the insurer and reinsurers by Stackelberg differential games and the competition among the reinsurers by a non-cooperative Nash game. We derive equilibrium strategies in semi-closed form for all the companies, whose objective is to maximize their expected surpluses penalized by a squared-error divergence term that measures their ambiguity. We find that, in equilibrium, the insurer purchases a positive amount of proportional reinsurance from each reinsurer. We further show that the insurer always prefers the tree structure to the chain structure, in which the risk of the insurer is shared sequentially among all reinsurers.

Diabetes Interacts with Latinx/Hispanic Ethnicity to Increase Major Amputations After Peripheral Vascular Intervention for Chronic Limb-threatening Ischemia

Latinx/Hispanic patients treated for chronic limb-threatening ischemia (CLTI) have higher amputation rates after controlling for presenting Wound, Ischemia, and foot Infection (WIfI) status. We hypothesize that a higher incidence of diabetes mellitus (DM) in Latinx/Hispanic patients may contribute to this disparity. The Vascular Quality Initiative peripheral vascular intervention dataset (2016-2022) was queried for CLTI. Inclusion criteria were reported WIfI stage and White race or Latinx/Hispanic ethnicity. The primary endpoint was 1-year major amputation (through tibia/fibula or more proximally). A multivariate hierarchical Fine Gray analysis was performed controlling for hospital-level variation and competing risk of death. The analysis was stratified by WIfI stage, and DM was treated as an interaction term with race and ethnicity. Overall, 38,079 (45%) cases met inclusion criteria and 3247 (12%) were Latinx/Hispanic with a higher incidence of DM in Latinx/Hispanic patients (77% vs 61%; P < .01). Proportions of WIfI stages were similar between White race and Latinx/Hispanic ethnicity, respectively: stage 1 (29% vs 30%), stage 2 (38% vs 32%), stage 3 (19% vs 21%), and stage 4 (14% vs 18%). The cumulative incidence of major amputation was highest for Latinx/Hispanic patients with DM (Figure). On multivariate analysis, the 1-year subdistribution hazard ratio (SHR) for amputation was highest for Latinx/Hispanic patients with DM at 1.8 (95% confidence interval [CI], 1.3-2.4; P < .01); and 1.4; 95% CI, 0.7-2.6; P = .29) for Latinx/Hispanic without DM, and 1.4 (95% CI, 1.1-1.6; P < .01) for White race with DM compared to White race without DM. When stratified by WIfI stage, the interaction of Latinx/Hispanic ethnicity with DM conferred the greatest increase in 1-year SHR for WIfI stages 2 (SHR, 1.9; 95% CI, 1.1-3.2; P = .03) and 3 (SHR, 2.1; 95% CI, 1.2-3.7; P < .01), compared to White race without DM. Latinx/Hispanic ethnicity requiring insulin treatment for DM had the highest hazard of amputation (SHR, 2.0; 95% CI, 1.4-2.7; P < .01) (Table). The increase in major amputations for Latinx/Hispanic patients after peripheral vascular intervention for CLTI is modified by the interaction with DM with a stepwise increase for those requiring insulin treatment. This study suggests that DM prevention and treatment is a cornerstone in addressing disparities for Latinx/Hispanic patients with limb threat and reducing their amputation risk.TableSubdistribution hazard ratios (SHR) by diabetes mellitus (DM) TreatmentSHR95% CIP valueWhite racea Diet controlled0.80.5-1.2.29 Noninsulin treatment1.20.9-1.6.07 Insulin treatment1.51.2-1.8<.01Latinx/Hispanic ethnicitya No DM diagnosis1.40.8-2.6.29 Diet controlled1.50.6-3.8.26 Noninsulin treatment1.50.9-2.5.09 Insulin treatment2.01.4-2.7<.01CI, Confidence interval.Model adjusted for age, primary insurer, WIfI stage, end-stage renal disease, prior amputation, and intervention level. Boldface entries indicate statistical significance.aReference group for all: White race with no DM diagnosis. Open table in a new tab

Sociodemographic Trends in Telemedicine Visit Completion in Spine Patients During the COVID-19 Pandemic.

Retrospective cohort study. This study identifies potential disparities in telemedicine utilization in the wake of the COVID-19 pandemic and its aftermath in patients receiving spine surgery. COVID-19 led to the rapid uptake of telemedicine in the spine surgery patient population. While previous studies in other medical subspecialties have identified sociodemographic disparities in telemedicine uptake, this is the first study to identify disparities in patients undergoing spine surgery. This study included patients who underwent spine surgery between June 12, 2018 and July 19, 2021. Patients were required to have at least one scheduled patient visit, either virtual (video or telephone visit) or in-person. Binary socioeconomic variables used for modeling included: urbanicity, age at the time of the procedure, sex, race, ethnicity, language, primary insurer, and patient portal utilization. Analyses were conducted for the entire cohort and separately for cohorts of patients who had visits scheduled within specific timeframes: Pre-COVID-19 surge, initial COVID-19 surge, and post-COVID-19 surge. After adjusting for all variables in our multivariable analysis, patients who utilized the patient portal had higher odds of completing a video visit compared with those who did not (OR: 5.21; 95% CI: 1.28, 21.23). Hispanic patients (OR: 0.44; 95% CI: 0.2, 0.98) or those living in rural areas (OR: 0.58; 95% CI: 0.36, 0.93) had lower odds of completing a telephone visit. Patients with no insurance or on public insurance had higher odds of completing a virtual visit of either type (OR: 1.88; 95% CI: 1.10, 3.23). This study demonstrates the disparity in telemedicine utilization across different populations within the surgical spine patient population. Surgeons may use this information to guide interventions aimed at reducing existing disparities and work with certain patient populations to find a solution.

The Association Between Sociodemographic Factors, Social Determinants of Health, and Spine Surgical Patient Portal Utilization.

Retrospective cohort study. To examine patient portal use among the surgical spine patient population across different sociodemographic groups and assess the impact of patient portal use on clinical outcomes. Patient portals (PP) have been shown to improve outcomes and quality of care. Engaging them requires internet access, technological literacy, and dexterity, which may serve as access barriers. After exclusion criteria were applied, the study included data for 9211 encounters from 7955 patients. PP utilization was defined as having activated and used the Duke University Medical Center patient portal system, MyChart, at least once. Sociodemographic characteristics included urbanicity, age, race, ethnicity, language, employment, and primary insurer. Clinical outcomes included the length of hospital stay during the procedure, 30-day return to the emergency department, 30-day readmission, and being discharged somewhere other than home. Being older than 65, non-White, unemployed, non-English-speaking, male, not-partnered, uninsured or publicly insured (Medicaid, Medicare and under 65 years of age, or other government insurance), and living in a rural environment were all risk factors for decreased PP utilization among surgical spine patients. A one-risk factor decrease in the number of social risk factors was associated with a 78% increase in the odds of PP utilization [odds ratio (OR): 1.78; 95% Confidence interval (CI): 1.69-1.87; P <0.001]. Patients not utilizing the portal at the time of their procedure had higher odds of 30-day readmission (OR: 1.59; 95% CI: 1.26-2.00), discharge somewhere other than home (OR: 2.41, 95% CI: 1.95-2.99), and an increased length of hospital stay (geometric mean ratio: 1.21; 95% CI: 1.12-1.30) compared with those who utilized it. In patients undergoing spine procedures, PPs are not equally utilized among different sociodemographic groups. PP utilization is also associated with better outcomes. Interventions aimed at increasing PP uptake may improve care for certain patients.

Access and Treatment Equity across the Comprehensive Cancer Center Catchment Area: Targets for Disparities Remediation in Acute Leukemia Research Participation

Introduction Race-ethnic disparities in acute leukemia research participation limit generalizability and equitable access to novel therapies. We recently found substantial clinical trial enrollment disparities between National Cancer Institute-designated Comprehensive Cancer Center (CCC) hospitals and the catchment areas for which they assume cancer control and treatment responsibility (Hantel JCO 2022). A first step in remediating such participatory disparities is understanding how underserved populations access care at these hospitals. Methods We analyzed hospital access and initial treatment data for a large CCC hospital, the Dana-Farber Cancer Institute (DFCI), relative to its catchment area, Massachusetts (MA), for all patients diagnosed with acute myeloid or lymphoblastic leukemia between 2014-2018. DFCI data were from an institutional cancer registry (OncDRS) that includes rich demographic, treatment, and outcome data; state data were from the MA Cancer Registry. We assessed access proportions (2+ visits for leukemia care) between mutually exclusive race-ethnic groups, using X2 testing, as patients moved from the incident populations within and outside the catchment area to the hospital, and based on their place of initial treatment. Non-Hispanic Whites (NHW) were the comparator with odds ratios (OR) and 95% confidence intervals (CI) reported. For some comparisons, race-ethnicity of was dichotomized as NHW and Diverse (Hispanic White and Hispanic- or non-Hispanic-Black, -Asian/Pacific Islander, -Native American, -another race, and -two or more races). We performed logistic regression modeling of demographics, social determinants of health, and disease characteristics (Table 1) to assess their association with DFCI as the site of initial treatment using complete cases. Results From 2014-18 there were 2077 incident cases of acute leukemia in MA, of which 858 (41.3%) were seen at DFCI. During the same period, 1622 patients with acute leukemia accessed care at DFCI, of which 764 (47.1%) were from outside MA; DFCI patient characteristics are shown in Table 1. Hospital access and location of initial treatment proportions by leukemia subtype, race-ethnicity, and place of residence are shown in Figure 1: bar charts show differences for race-ethnic groups relative to MA incidence proportions, which are displayed in the pie charts. Relative to MA incidence, there was no significant difference in DFCI access by dichotomized race-ethnicity (Diverse vs NWH OR 0.87; 95% CI 0.73,1.05). Among MA residents, NHWs were not more likely to access DFCI than those from Diverse race-ethnicities (OR 0.82; 95% CI 0.65,1.04). NHW were more likely to have received initial treatment at DFCI (OR 1.59; 95% CI 1.12,2.28). Conversely, patients accessing DFCI from outside MA were more likely to be NHW (OR 1.94; 95% CI 1.42,2.65) but were equally likely to have received initial treatment at DFCI (OR 1.04; 95% CI 0.62,1.74). In a multivariable model assessing site of initial treatment receipt for those having accessed DFCI, including only variables from Table 1 that univariably predicted initial treatment site (with predicted defined as p<0.05: age, race-ethnicity, leukemia subtype, alcohol and tobacco use, marital status, primary language, and primary insurer), NHW race-ethnicity was not independently associated with initial treatment receipt (OR 0.69; 95%CI 0.47,1.02) but older age (OR 1.02; 95%CI 1.01,1.03), AML subtype (OR 2.62; 95%CI 1.91,3.95), and primary Medicare insurance (OR 1.70 vs private; 95%CI 1.24,2.31) were. Conclusions For this large and high-enrolling CCC hospital, overall access to leukemia care did not significantly differ by race-ethnicity. This welcome finding suggests that participatory equity for acute leukemia clinical research is achievable at such sites. Known participatory disparities, however, are significant and prevalent. The disparities in access from outside the catchment area and initial treatment within it define targetable issues that impact the ability of under-enrolled populations to participate in clinical research equitably. Next steps include correlating access and enrollment data and developing real-time participatory diversity monitoring tools. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Differences in medication adherence between preemptive and post-dialysis young kidney transplant recipients.

The mechanisms underlying the superior graft survival associated with preemptive kidney transplantation, compared with transplantation following a period of dialysis, are unknown. We aimed to compare medication adherence between preemptively transplanted young kidney transplant recipients and those who received a transplant after an interval of dialysis. This was a secondary analysis of the Teen Adherence in Kidney transplant Effectiveness of Intervention Trial (TAKE-IT), in which adherence was assessed with electronic monitoring over 15months among 11-24-year-old transplant recipients. Adherence scores were calculated for each day as 0%, 50%, or 100% (intake of none, half, or all prescribed doses). We used ordinal logistic regression, with generalized estimating equations to account for repeated measures within each participant, to estimate the association between preemptive transplantation and adherence. The model was adjusted for sex, age at transplant, time since transplant, primary kidney disease, race, donor source, medication insurer, household income, and adherence intervention. There were 43 preemptive transplant recipients and 103 who had been treated with dialysis. The median adherence score was 85.1% (IQR 81.3-88.9) for those preemptively transplanted, and 80.0% (IQR 76.7-83.4) for those transplanted after dialysis. Preemptively transplanted recipients had significantly higher odds of adherence than those dialyzed before transplantation (adjusted OR 1.76 95% CI 1.21-2.55; p = 0.003). Preemptively transplanted patients showed significantly better adherence than those treated with dialysis before transplantation. This suggests that the superior outcomes observed among preemptive kidney transplant recipients may reflect selection of patients more likely to adhere to therapy. A higher resolution version of the Graphical abstract is available as Supplementary information.

Abstract 15121: Specialty Care Visits and Likelihood of Mortality for Children With Congenital Heart Disease

Introduction: Congenital heart disease (CHD) is the most common birth defect and is estimated to affect nearly 37,500 infants born each year in the United States. Children with CHD have complex, nuanced, healthcare needs and frequently require multi-specialty care. The relationship between specialty care utilization and survival for children with CHD is not well known. Methods: We analyzed all payer claims data (APCD) from Colorado from 2012-2019. Children with CHD were identified by applying harmonized ICD-9-CM and ICD-10-CM diagnoses codes. We included children with CHD &lt; 18 years of age who resided in Colorado, had a documented zip code, and had at least one healthcare claim. Specialty care providers were uniquely identified by their National Provider ID. Mortality was defined by discharge status. We evaluated the relationship between specialty care provider visits and mortality using logistic multivariable modeling. Results: There were 24,784 children diagnosed with CHD in Colorado from 2012 - 2019. Of those, 22,413 (90.4%) children had at least one specialty care visit and 465 (2.1%) died during the study period. Children that died had an average of 60 visits per year, while children that survived had an average of 29 visits (p=&lt;0.001). Children primarily commercially insured by are 25% less likely to experience death (OR: 0.75, 95% CI (0.58 - 0.97), p value: &lt;0.001). Children with greater CHD disease severity or presence of a genetic disorder are nearly 2 times more likely to die, and children in the highest community level quartile are less likely to die. Conclusions: In our cohort of children diagnosed with CHD from 2012 - 2019, there was a significant association with the frequency of specialty care visits and likelihood of death. We found that the primary insurer, level of disease severity, presence of any genetic disorder and community level household income were significantly associated with higher likelihood of death.

213.9: Differences in Medication Adherence Between Preemptive and Post-dialysis Young Kidney Transplant Recipients

Introduction: The mechanisms underlying the superior graft survival associated with pre-emptive kidney transplantation, compared with transplantation following a period of dialysis, are unknown. Selection for pre-emptive transplantation of a group biased to better treatment adherence is possible. We aimed to compare medication adherence between pre-emptively transplanted young kidney transplant recipients and those who received a transplant after an interval of dialysis. Methods: This was a secondary analysis of the Teen Adherence in Kidney transplant Effectiveness of Intervention Trial (TAKE-IT), in which adherence was assessed with electronic monitors over a 15-month period among 11–24 year-old kidney transplant recipients. Adherence scores of 0%, 50%, or 100% were calculated for each day, depending on whether the patient took none, half, or all prescribed doses. We used ordinal logistic regression to estimate the association between pre-emptive transplantation and adherence, with generalized estimating equations to account for repeated measures within each participant. The model was adjusted for sex, age at transplant, time since transplant, primary kidney disease, race, donor source, medication insurer, household income, and adherence intervention (time-varying). Results: There were 43 pre-emptive transplant recipients (median age 15.8 [IQR 13.7-17.6]; 60.5% male) and 103 who has been treated with dialysis (median age 15.7 [IQR 13.3-17.4]; 60.2% male). The mean adherence score was 85.1% (IQR 81.3-88.9) for those pre-emptively transplanted, and 80.0% (IQR 76.7-83.4) for those transplanted after dialysis. Table 1 shows the results adjusted logistic regression model. Preemptively transplanted recipients had significantly higher odds of adherence than those dialyzed before transplantation (OR 1.76 95%CI 1.21-2.55; p=0.003). Conclusions: Pre-emptively transplanted patients showed significantly better adherence than those treated with dialysis before transplantation. This suggests that the superior outcomes observed among preemptive kidney transplant recipients likely reflect selection of patients more likely to adhere to therapy.

On the optimal management of counterparty risk in reinsurance contracts

We use a normative analysis and consider the optimal reinsurance coverage structure in the presence of counterparty risk. From the perspective of a risk-averse primary insurer, we derive a cost criterion that indicates the optimality of under-, over- and full hedging of the reinsurers’ counterparty risk and show how the hedging preference can define a vertical layering of the reinsurance coverage. We also determine the optimal diversification strategies between two reinsurers that differ in their counterparty risk. Our results provide evidence that the coverage is allocated either to a single reinsurer or to both in the form of a vertical (quota share) and horizontal (excess-of-loss) allocation. Finally, we demonstrate how to optimally combine hedging and diversification.

Emergency Department Visits by Pediatric Patients for Snakebites.

Few studies have examined pediatric emergency department (ED) visits for snakebites. This study sought to examine characteristics of pediatric patients presenting to EDs nationally in the United States for snakebites. This retrospective cohort study obtained data from the Nationwide Emergency Department Sample for 2006 to 2014. Pediatric patients sustaining a snakebite were identified with International Classification of Diseases, Ninth Revision, E-codes E905.0 or E906.2. Data extracted included age, sex, insurance, disposition, hospital trauma designation, ED charges, and geographic region. Comparative analyses were performed for patients younger than 10 years and aged 10 to 17 years. There were 24,388 ED visits from 2006 to 2014 by pediatric patients for snakebites: 10,554 were younger than 10 years, and 13,834 were aged 10 to 17 years. Males comprised 62% and 67% of the respective age cohorts. Most patients (younger than 10 years, 68%; aged 10-17 years, 63%) experienced snakebites in the South. Only 14% of those younger than 10 years and 10% of those aged 10 to 17 years were treated at a level 1 trauma center, whereas 50% and 54%, respectively, were treated at hospitals with no trauma designation. The majority of patients were discharged from the ED (younger than 10 years, 72%; aged 10-17 years, 80%). The mean ED charges for snakebite victims younger than 10 years were $5363 and for those aged 10 to 17 years were $4618. Medicaid was the primary insurer of younger patients, whereas private insurance was more common in older patients. Most pediatric snakebites are seen in nontrauma centers and in the South region and are more commonly male. Most patients were discharged from the ED, with a small percentage being admitted or transferred to another facility.

The U.S. Preventive Services Task Force Abdominal Aortic Aneurysm Screening Guidelines Negligibly Impacted Repair Rates in Male Never-Smokers and Female Smokers

In 2014, in addition to male smokers aged 65-75 years, the U.S. Preventive Services Task Force (USPSTF) recommended abdominal aortic aneurysm (AAA) screening for male never-smokers aged 65-75 years with cardiovascular risk factors (Grade C). The USPSTF evolved from a negative to neutral position on screening for female smokers aged 65-75 years (Grade I). We sought to determine whether 2014 guidelines resulted in more AAA repairs in these populations. We queried the Vascular Quality Initiative national database (2013-2018) for elective endovascular aortic repairs and open aortic repairs. We implemented difference-in-differences (DID) analysis, a causal inference technique that adjusts for secular time trends, to isolate changes in repair numbers due to the 2014 USPSTF guidelines. Our DID models compared changes in repair numbers in patient groups targeted by the USPSTF updates (intervention group) to those in unaffected, older patient groups (control), before and after 2014. The first model compared changes in repair numbers between male never-smokers aged 65-75 years (intervention group) and 76-85 years (control). The second model compared repair numbers between female smokers aged 65-75 years (intervention group) and 76-85 years (control). There was no significant change in male never-smokers (n=1,295) aged 65-75 (42%) vs. 76-85 (58%) undergoing AAA repairs after guideline updates, averaged over 4.5 years (+2.4 percentage points; 95% Confidence Interval [CI] -.56-5.26). However, when their primary insurer was Medicare, male never-smokers aged 65-75 years compared with 76-85 years underwent significantly more repairs over 4.5 years (+3.69 percentage points; 95% CI.16-7.22; representing a 10.4% relative increase from baseline in the proportion of male never-smokers on Medicare undergoing AAA repair). Comparing female smokers (n=2,312) aged 65-75 (54%) vs. 76-85 (46%), there was no significant change in repairs over 4.5 years (-.66 percentage points; 95% CI -4.57-3.26). The USPSTF 2014 AAA guidelines were associated with modestly increased repairs in male never-smokers aged 65-75 years only on Medicare. There was no impact among female smokers. Higher-grade recommendations and improved guideline adherence may be requisites for change.

A cross-sectional analysis of Medicaid acceptance among US dermatology residency training programs

To the Editor: As few as 15.5% of nonacademic adult medical dermatology practices accept patients covered by Medicaid, the primary insurer for low-income and disabled Americans.1 However, Medicaid acceptance among academic dermatology training sites is unknown. To assess trainee exposure to this patient population, we cross-sectionally investigated Medicaid acceptance rates across dermatology training sites.

With Liberty and Reinsurance for All: Demanding a Government Backstop in Health Care

This article calls attention to our differential neglect of state-sponsored reinsurance for health care when viewed in light of the robust backstopping of risk that the U.S. government undertakes in other domains. For all our vaunted aversion to entitlements, whenever we as a nation we have deemed a material interest to be vital--from housing, food crops, higher education, or even banking--we have provided state guarantees. These guarantees, however, have not necessarily backed the individual beneficiary, but rather the primary private insurer or financier who bridges beneficiary access to that good or service. These commitments suggest an American conception of the government’s role as reinsurer of last resort. In these arenas and more, correlated or high-magnitude catastrophic losses are shed onto the state in order to smooth-out and shore-up the underlying private risk market. Health care risks should be given at least equal consideration.

Medication adherence among prostate cancer patients using advanced oral therapies.

44 Background: Prostate cancer (PC) is associated with a high clinical and economic burden. Advanced oral (AO) therapies have become the standard of care for patients with advanced PC, but real-world data on treatment patterns and their impact on healthcare resource utilization (HRU) are lacking. This study aims to describe treatment adherence, factors associated with adherence, and its impact on HRU in patients with PC initiated on AOs. Methods: Adults with a PC diagnosis initiated on apalutamide, enzalutamide, or abiraterone acetate were identified using Symphony Health Solutions Patient Transactional Databases (10/01/2014-09/30/2019). Patients were included if they had ≥6 months of continuous clinical activity before and after AO initiation (index date) and no other cancer diagnoses. Adherence was defined using the proportion of days covered (PDC) by AOs during the 6-month period following the index date. Patients with a PDC≥80% were considered adherent. Multivariable logistic regression was used to evaluate baseline characteristics associated with AO adherence. All-cause and PC-related HRU was assessed from 6 to 18 months post-index and compared between adherent and non-adherent patients using multivariable Poisson regression. Results: A total of 27,322 patients initiated on an AO were identified. Most patients were aged ≥65 years (81%), were white (60%), had Medicare coverage (48%), and had metastatic PC (56%). At 6 months, 57% of patients were adherent to AOs. Patients aged 55-64 and 65-74 years had greater odds of being adherent versus those aged ≥75 years (24% and 22%, respectively), while Black patients had 17% lower odds of being adherent relative to white patients (all p&lt;0.01). Medicare coverage was associated with 23% greater odds of being adherent relative to commercial insurance (p&lt;0.01). Patients with a below median primary insurer paid amount for their first AO claim had 13% greater odds of being adherent relative to the above median amount (p&lt;0.05). Adherent patients generally had fewer HRU compared to non-adherent patients. More specifically, adherent patients had 25% fewer all-cause inpatient days, 16% fewer all-cause emergency room (ER) visits, 18% fewer all-cause other non-outpatient services use, as well as 30% fewer PC-related inpatient days and 24% fewer PC-related ER visits (all p&lt;0.01) relative to non-adherent patients. Conclusions: In this study, non-adherence over a 6-month period following AO initiation was associated with substantially higher HRU, including inpatient and ER visits. Moreover, non-adherence was widely observed, impacting over 40% of advanced PC patients in the first 6 months after AO initiation. Identifying factors linked to lower adherence and defining strategies to improve adherence may improve patient outcomes and associated medical resource utilization. (1)Abiraterone acetate plus prednisone is the approved therapy although the combination was not imposed.

Early Emergency Department Visits Following Primary Hip and Knee Arthroplasty

BackgroundPostoperative emergency department (ED) utilization remains an understudied aspect of total joint arthroplasty (TJA). The purpose of this study is to characterize 30-day ED visits following TJA. MethodsWe reviewed 4061 primary unilateral total hip and knee arthroplasty cases performed at our hospital from 2013 to 2017. The primary outcome was presentation to our institution’s ED within 30 days of surgery. Chief complaints and their association to the TJA encounter, as well as readmissions and reoperations, were recorded. One-to-three propensity score matched analysis was used to identify index admission variables associated with early ED visits. ResultsThere were 253 recorded ED visits within 30 days of TJA (218 cases, 5.4%). Nearly 60% of ED visits were directly related to the TJA encounter. The remainder were medically related, most commonly for gastrointestinal complaints. The most common TJA-related complaints were surgical limb pain (28%), wound concerns (20%), and swelling (20%). These complaints comprised two-thirds of TJA-related ED visits, though accounted for only 19.4% and 9.5% of readmissions and reoperations observed in this cohort, respectively. Perioperative transfusion, length of stay, primary insurer, and discharge disposition were not associated with an ED visit. ConclusionED visits within 30 days of TJA were common (5.4%). Most visits related to the index procedure were due to surgical limb pain, wound concerns, and swelling. These complaints accounted for a minority of readmissions and reoperations. This study suggests that perioperative strategies addressing common postoperative concerns are warranted to mitigate acute care use after TJA.

52: Major adverse cardiovascular and cerebrovascular events associated with female pelvic reconstructive surgery

To evaluate national trends in major adverse cardiovascular and cerebrovascular events (MACCE) in women undergoing pelvic reconstructive surgery (PRS). Data from the Healthcare Cost and Utilization Project National Inpatient Sample was used to identify women undergoing PRS between 2012 to 2016. Patient- and hospital-level demographic, procedural, and comorbidity data were collected. Patients were stratified into those with and those without MACCE. MACCE was defined as all-cause mortality (ACM), cardiac arrest (CA), acute myocardial infarction (AMI) and acute ischemic stroke (AIS). Descriptive statistics are expressed as medians and interquartile ranges (IQR). Pairwise analysis was performed between groups using Wilcoxon rank-sum or Fisher’s exact test as appropriate. Multivariable logistic regression was used to identify independent risk factors for MACCE. During the study period 53,540 patients underwent PRS. The rate of MACCE was 4.8 per 1,000 surgeries. The most common form of MACCE was AMI (3.7 per 1,000), followed by AIS (0.6 per 1,000), CA (0.4 per 1,000), and ACM (0.3 per 1,000). Patients experiencing MACCE were older (median 69 years, IQR: 58-76 vs 58, 46-68, p<0.001), more likely to have a household income in the 1st quartile (28.5% vs 22.9%, p=0.03), and more likely to have Medicare as their primary insurer (60.9% vs 33.6%, p<0.001). Patients experiencing MACCE were a more likely to have major pre-existing cardiovascular comorbidities, coagulopathy, neurologic disease (ND), and diabetes (Table 1). Additionally, patients experiencing MACCE were more likely to undergo robotic colpopexy (20.7% vs 9.6%, p<0.001), vaginal colpopexy (32.0% vs 28.5%, p=0.04), bilateral salpingo-oophorectomy (25.8% vs 19.6%, p=0.03) and to receive a blood transfusion (8.2% vs 2.5%, p<0.001); and less likely to undergo hysterectomy (39.5% vs 48.8%, p=0.01) and bilateral salpingectomy (3.5% vs 6.8%, p=0.03). On logistic regression, pre-existing coagulopathy was the strongest predictor of MACCE, (aOR=5.53, 95% CI: 2.39-12.78), followed by blood transfusion (aOR=4.84, 95% CI: 1.89-12.45), congestive heart failure (CHF) (aOR=3.61, 95% CI: 1.56-8.37), ND (aOR=3.14, 95% CI: 1.23-8.06), and electrolyte abnormalities (aOR=1.99, 95% CI: 1.05-3.99). MACCE after PRS is a rare event with AMI being the most common manifestation. Pre-existing ND, CHF, coagulopathy, electrolyte disturbances, and perioperative transfusions are strongly associated with MACCE.

Late Week Surgery Is Associated With Longer Length of Stay in Patients Undergoing Laminectomy for Degenerative Lumbar Stenosis

Abstract INTRODUCTION As episode-based payment initiatives are becoming more prevalent, it becomes critical for providers to reduce unnecessary costs. Prolonged length of stay (LOS) can be a major driver of cost following elective spine surgery. While prolonged LOS may be medically indicated, the present study sought to assess how an overlooked variable, the day of the week that the surgery was performed, may influence LOS. METHODS A retrospective review was performed for all patients undergoing level 1 to 2 laminectomy surgery for degenerative lumbar spinal stenosis within a single large healthcare system from March 1, 2016 to February 1, 2019. The weekday of surgery was classified as a binary variable: early (Monday/Tuesday) vs late week (Thursday/Friday). Multiple regression models were fit to assess the association of hospital LOS and weekday of surgery. Additional covariates such as primary insurer, surgery location, Elixhauser comorbidity score, postoperative complications, and discharge disposition were also included in candidate models. RESULTS A total of 1087 subjects fit the inclusion criteria and had a median LOS of 2 d (IQR: 1-3). The final model accounted for 53% of variation in LOS. Late week surgery was a significant predictor of longer LOS (12%, 95% CI: 5.5–20%) after controlling for other covariates. Additionally, late week surgery and discharge disposition demonstrated a significant interaction, where patients requiring a Skilled Nursing Facility/Inpatient Rehabilitation (SNF/Rehab) placement were predicted to have 32% longer LOS (95% CI: 9.1–60.2). Medicaid insurance, greater comorbidities, surgery at main campus, and postoperative complications were also significantly associated with longer LOS. CONCLUSION These results suggest that late-week surgery is associated with a significantly longer LOS compared to early-week surgery while holding other predictors constant. Since the increased LOS of late-week surgery is most pronounced for SNF/Rehab discharges, optimization of scheduling algorithms or presurgical authorization of SNF/Rehab based on SNF/Rehab risk may mitigate longer LOS and their associated expenditures.

Predictors of Antenatal Seasonal Influenza Vaccination in an Underserved Population [15C

INTRODUCTION: Uptake of seasonal influenza vaccination among pregnant women remains low despite recommendations supporting routine vaccination in this population at high risk for severe morbidity. We evaluated predictors of antenatal influenza vaccination in an underserved patient population. METHODS: We conducted a retrospective cohort study of all women with deliveries to Emory healthcare providers at Grady Memorial Hospital, a large safety-net hospital, between July 1, 2016 and June 30, 2018. Demographic and clinical characteristics were abstracted from electronic medical records. The Kotelchuk Index was used to assess prenatal care adequacy. Adjusted relative risks (aRRs) and 95% confidence intervals (CIs) for associations between demographic and clinical characteristics and receipt of influenza vaccine were calculated using multivariable log-binomial models. IRB approval was obtained for this study. RESULTS: Among 3,727 women with deliveries, most were non-Hispanic black (68.60%) and had Medicaid as their primary insurer for delivery (87.93%). The overall vaccination rate was 49.80% (1,856/3,727). Characteristics significantly associated with influenza vaccination in multivariable models were Hispanic ethnicity (aRR 1.44, 95% CI 1.11-1.88), transferring care between institutions (aRR 0.34, 95% CI, 0.29-0.41), and inadequate prenatal care (aRR 0.70, 95% CI, 0.64-0.75). CONCLUSION: Women with inadequate or discontinuous prenatal care were less likely than women with adequate prenatal care to receive a seasonal influenza vaccine. Hispanic ethnicity was associated with increased rates of influenza vaccination, even after controlling for interpretive language services. These findings highlight the importance of continuous, regular prenatal care in recommending and offering antenatal vaccinations to pregnant patients while supporting possible cultural differences in vaccine acceptance.