Private Insurance Research Articles (Page 1)

Projecting financial sustainability for clinical pharmacy services: An implementation science brief report.

Navigation-assisted spine surgery has become widely used in adult patients with studies demonstrating improved outcomes. This remains poorly studied in pediatric patients. This study examines the impact of navigation on complication rates in pediatric idiopathic scoliosis surgery. A national insurance database, Pearldiver, a national insurance database with claims from Medicare, private insurance, cash pay, and Medicaid Advantage, identified pediatric patients (<21y old) with idiopathic scoliosis who underwent posterior spine fusion with ≥2 years of follow-up. Patients were divided into navigated and non-navigated cohorts. A multivariable logistic regression identified risk factors for instrumentation revision, and cohorts were matched 1:2 based on significant variables. The primary outcome was instrumentation revision at 6 months, 2 years, and 10 years postoperatively. Secondary outcomes were postoperative neurological deficit and surgical site infection. Of 15,917 patients, 1599 had navigated and 14,318 had non-navigated surgery. Decreased age and male sex were associated with a revision risk. After cohort matching (4747 total: 1585 navigated, 3162 non-navigated), navigated cases had significantly lower revision rates: 1.1%, 2.7%, and 3.8% vs. 2.1%, 4.4%, and 6.3% (P<0.05). Surgical site infection was significantly lower in navigated cases at 2 years (6.4% vs. 4.2%) and 10 years (8.3% vs. 4.7%) (P<0.001). The overall rate of postoperative neurological deficit was 2.1% and 2.6% for navigated and non-navigated cases (P>0.05). This largest study to date on navigation in pediatric scoliosis surgery demonstrates significantly lower instrumentation revision and infection rates in navigated procedures compared with non-navigated cases. Level III.

Introduction: Insurance payor is an important social determinant of health that may serve as a proxy for socioeconomic status and mediate outcomes in healthcare. In 2010, 14 percent of stroke patients aged 19-64 lacked health insurance while stroke incidence in the United States continues to increase. Previous research has demonstrated that stroke patients with private insurance experience better clinical outcomes than those with public insurance and that Medicare is associated with longer hospital length of stay (LOS) than private insurance. However, no study has investigated the relationship between intensive care unit (ICU) LOS in stroke patients and insurance payor while controlling for stroke severity. Research Question: Among ICU stroke patients, will those with private insurance have significantly longer ICU length of stay compared to patients with Medicare or Medicaid, after adjusting for demographics and stroke severity? Method: We conducted a retrospective cohort study using the MIMIC-IV (v3.1) database to examine ICU LOS in days among adult stroke patients (≥18 years), identified by ICD-9 and ICD-10 codes for ischemic and hemorrhagic stroke. The primary independent variable was insurance payor (Medicare, Medicaid, Private, No Charge, Other). We adjusted for age, gender, race, comorbidity burden (Elixhauser score and ICD-based comorbidity count), and receipt of intravenous tPA as a proxy for stroke severity. Multivariable linear regression was used to assess the association between insurance status and ICU LOS. Results: A total of 9367 stroke ICU patients were included in the analysis. No Charge patients had the longest while Medicare patients had the shortest mean ICU LOS. Medicaid patients also had a longer mean ICU LOS than those privately insured. After controlling for stroke severity however, only private insurance was significantly associated with a longer ICU LOS compared to other insurance types. Other insurance payors did not show a significant association with ICU LOS. Conclusion: Although privately insured stroke patients did not have the highest mean ICU LOS, private insurance was the only payor type significantly associated with increased ICU LOS after adjusting for demographics and stroke severity. These results suggest potential disparities in ICU resource allocation, post-acute care planning, discharge authorization, and reimbursement among insurance payors that warrant further investigation.

Background: Postoperative atrial fibrillation (AF) significantly increases cardiac arrest risk and mortality following coronary artery bypass grafting (CABG). While clinical predictors are established, the independent impact of socioeconomic factors on outcomes remains poorly characterized. This study aims to evaluate associations between key socioeconomic determinants and adverse outcomes across a 5 year span in CABG patients with postoperative AF. Methods: We analyzed National Inpatient Sample(NIS) data (2018-2022) from adults developing AF post-CABG. Van Walraven Weighted Elixhauser Comorbidity index was used to survey logistic and linear regression models (accounting for 38 standardized covariates) assessed associations between specific demographic/socioeconomic factors (sex; race; payer [Medicare, Medicaid, private insurance]) and outcomes: inpatient mortality, length of stay (LOS), and total charges. Results: Among 943,570 CABG patients, 32% had Afib and significant disparities emerged. Mortality odds were significantly higher for females (OR 1.70, 95% CI 1.58-1.81, p&lt;0.001), but decreased with private insurance (vs Medicaid: OR 0.75, 95% CI 0.86-0.82, p&lt;0.001) and hispanic patients (vs White: OR 0.86, 95% CI 0.76-0.97, p=0.008). LOS increased for females (β 1.11 days, 95% CI 1.02-1.20, p&lt;0.001), Black (vs White: β 1.22, 95% CI 1.05-1.39, p&lt;0.001), Hispanic (vs White: β 0.65, 95% CI 0.49-0.80, p&lt;0.001), and Asian patients (vs White: β 0.28, 95% CI 0.06-0.50, p=0.014), and Medicare recipients (vs Medicaid: β 1.30, 95% CI 1.11-1.49, p&lt;0.001). Private insurance reduced LOS (vs Medicaid: β -0.27, 95% CI -0.37 to -0.17, p&lt;0.001). Total charges were higher for racial minorities (vs White: Black β $20,635, Hispanic β $52,702, Asian β $34,962; all p&lt;0.001) and Medicare patients (vs Medicaid: β $10,310, 95% CI $4,560-$16,060, p&lt;0.001), but lower with private insurance (vs Medicaid: β -$9,636, 95% CI -$12,868 to -$6,403, p&lt;0.001). Conclusion: Significant socioeconomic disparities exist in post-CABG AF outcomes, with females, racial minorities, and Medicaid/Medicare patients experiencing worse outcomes across mortality, LOS, and cost metrics. These findings highlight the urgent need for equity-focused interventions in cardiac surgical care.

Background: Left Atrial Appendage Occlusion (LAAO) is a critical intervention for stroke prevention in patients with atrial fibrillation who are unsuitable for long-term anticoagulation. Despite its efficacy, disparities in referral rates for LAAO based on race and insurance type remain underexplored. This study evaluates the rates of LAAO referrals among atrial fibrillation patients across different racial groups and insurance types using data from the National Inpatient Sample (NIS). Objective: To evaluate disparities in referral rates for left atrial appendage occlusion among patients with atrial fibrillation, specifically examining differences across racial groups and insurance types using data from the National Inpatient Sample. Methods: We conducted a retrospective cohort study using the NIS from 2018 to 2023. Adult patients (≥18 years) with a diagnosis of atrial fibrillation were identified using validated ICD-10 codes. Patients were stratified by race (White, Black, Hispanic, Asian) and primary payer type (Private Insurance vs. Medicaid/Medicare). Referrals for LAAO were identified using procedure-related billing and referral codes. Patients with missing race or insurance data were excluded. Chi-square tests were used to compare referral rates across groups, with statistical significance set at p &lt; 0.05. Results: Among 4,500 atrial fibrillation patients analyzed, 62% were White, 18% Black, 12% Hispanic, and 8% Asian. Overall, referral rates for LAAO were significantly higher among patients with private insurance (68%) compared to those with Medicaid/Medicare (47%) (p &lt; 0.01). Referral disparities were evident across all racial groups. Among White patients, referral rates were 72% (private) vs. 50% (Medicaid/Medicare); for Black patients, 58% vs. 35%; for Hispanic patients, 60% vs. 38%; and for Asian patients, 65% vs. 42%, respectively. Black patients with Medicaid/Medicare had the lowest referral rate of any subgroup. Conclusion: Disparities in LAAO referral rates are evident across racial and insurance groups, with Medicaid/Medicare recipients, particularly Black patients, being significantly less likely to receive referrals for LAAO. Addressing these disparities is crucial to ensure equitable access to stroke prevention strategies in atrial fibrillation care.

Introduction: There have been increasing numbers of heart transplants performed yearly in the United States, but significant waitlist times and patient disparities remain. Multiple new transplant centers have started in all OPTN regions, facilitating new transplant listings and leading to broader population access to this life-saving therapy. Research Question: Are there demographic differences in patient populations undergoing transplant at a newly established transplant center compared to existing centers? Methods/Approach: This retrospective study utilized data from the Scientific Registry of Transplant Recipients (SRTR), which include data of all transplant candidates and recipients in the United States. Demographics were compared between the heart transplant centers opened from 2010 to 2023 (referred as “new centers”) at one year after opening and existing centers (continuously open since before 2010) in the same OPTN region in the same year, and cumulatively between all new and existing centers in the country since 2010. Demographic variables included age, gender, race, insurance status, and pre-transplant clinical condition were compared using t-tests and Chi-squared tests. Results: Patients undergoing transplants at new centers were significantly older than those at existing centers, both by mean age (55.5 ± 12.3 vs. 53.3 ± 12.8; p &lt; 0.001) and proportion ≥ 65 years old (26.3% vs. 20.5%; p &lt; 0.001). Cumulatively, there was a higher proportion of Black patients at new centers (28.6% vs. 23.6%; p &lt; 0.001). Patients at new centers were less likely to have private insurance (39.7% vs. 47.6%; p &lt; 0.001) and more likely to be hospitalized in the ICU at time of transplant (59.4% vs. 42.0%; p &lt; 0.001). Other than race, these differences were present both at one year after new center initiation and cumulatively in the entire study time period. Conclusions: Patients undergoing heart transplant at new centers were found to be older, more likely to be Black, less likely to have private insurance, and more likely to be in the ICU at time of transplant compared to existing centers. These differences were present both in the first year after center initiation and cumulatively in the entire study time period, highlighting a persisting variation in population served by new centers. Transplant center initiation may expand access to cardiac transplant to patients who may otherwise have not been considered for this life saving therapy.

Background: Catheter ablation is a guideline-directed therapy for symptomatic supraventricular tachycardia (SVT), yet disparities in its utilization across patient populations remain inadequately characterized. Objective: To evaluate demographic and hospital-level factors associated with catheter ablation among hospitalized patients with SVT in the United States. Methods: We analyzed adult hospitalizations with a diagnosis of SVT (ICD-10-CM I47.1) from the National Inpatient Sample (NIS) for the years 2016 through 2020. Catheter ablation was identified using ICD-10-PCS procedure codes. Survey-weighted logistic regression was used to assess associations between demographic characteristics and the odds of receiving ablation. Age was evaluated both as a continuous and categorical variable. Analyses accounted for the complex survey design of the NIS. Results: Among approximately 1.87 million weighted hospitalizations for SVT, only 4.1% underwent catheter ablation. Female patients comprised 52.5% of the SVT cohort but had 16.0% lower odds of receiving ablation compared to males (adjusted OR [aOR] 0.84; p &lt;0.001). Black patients had 9.1% lower odds of ablation compared to White patients (aOR 0.91; p =0.002), while Hispanic and Other race groups had 18.1% (aOR 1.18; p &lt;0.001) and 24.6% (aOR 1.25; p =0.003) higher odds, respectively. Insurance status also impacted access: patients with private insurance had 34.2% higher odds of ablation compared to Medicare recipients (aOR 1.34; p &lt;0.001), whereas those with Medicaid had 9.7% lower odds (aOR 0.90; p =0.010). Increasing age was inversely associated with ablation use, with a 1.2% decrease in odds per year of age (aOR 0.99; 95% CI 0.987–0.989; p &lt;0.001). Compared to patients aged 20–29, those aged 40–49 had 15.4% higher odds (aOR 1.15; p =0.018), while patients aged 60–69, 70–79, and ≥80 had 12.8%, 17.5%, and 49.1% lower odds, respectively (all p &lt;0.05; Figure 1). Patients treated at urban teaching hospitals had 316% higher odds of ablation compared to those at rural hospitals (aOR 4.16; p &lt;0.001). Conclusion: Significant disparities exist in the use of catheter ablation for SVT. Female sex, older age, Black race, and Medicaid coverage were associated with lower odds of ablation, while private insurance and care in urban teaching hospitals were associated with higher odds. These findings underscore the need for targeted efforts to address inequities in access to evidence-based electrophysiologic care.

Background: Cardiovascular-kidney-metabolic (CKM) syndrome comprises interconnected conditions such as heart disease, kidney disease, diabetes, and obesity. These conditions often begin early in life and now affect a significant portion of young adults. As CKM becomes more common in this age group, its long-term health and economic consequences are increasingly concerning. This study aimed to estimate trends in U.S. healthcare expenditures related to CKM among young adults from 2010 to 2019. Methods: National healthcare spending on CKM from 2010 through 2019 was estimated using data from the Institute for Health Metrics and Evaluation (IHME). The Disease Expenditure Project (DEX) at IHME provides spending estimates across 3,110 U.S. counties, categorized by condition, payer, age group, and type of care. This analysis utilized over 40 billion administrative insurance claims and nearly 1 billion facility records, capturing expenditures from Medicare, Medicaid, private insurance, and out-of-pocket payments. Results: Between 2010 and 2019, total healthcare spending for CKM in young adults increased by 23%, from approximately $14 billion to $18 billion. Heart failure expenditures showed the largest relative increase (122%), followed by atrial fibrillation (48%), stroke (30%), and type 2 diabetes (23%). Spending for ischemic heart disease declined by 5%, while expenditures for peripheral vascular disease remained stable. Across all years, type 2 diabetes accounted for the greatest share of total spending among CKM components. Spending increased across all types of care, with the largest growth seen in emergency department services (49%), inpatient care (34%), and ambulatory care (24%). In 2019, $4.6 billion in expenditures were attributed to Medicaid and $10.4 billion to private insurance. Over the study period, Medicaid spending increased by 63%, private insurance by 20%, and Medicare spending declined by 10%. Expenditure growth varied by age group, with the highest relative increases observed in adults aged 30 to 34 years (39%) and 25 to 29 years (37%). Conclusion: CKM syndrome imposes a growing health and economic burden on young adults in the United States. This study demonstrates a steady rise in healthcare spending across all CKM conditions, particularly for heart failure and emergency care. The findings underscore the need for early prevention efforts and targeted strategies to mitigate disparities and reduce long-term costs.

Introduction: Previous studies using national administrative data show that among patients who undergo congenital heart surgery, those with public insurance have longer length of stay (LOS) than those with private insurance. This reveals a knowledge gap that requires granular data to investigate: do discharge barriers explain this insurance-based difference in LOS? Objective: To determine whether discharge barriers mediate, or explain, the association between insurance type and postoperative LOS. Methods: Retrospective cohort study of all infants who received interventional catheterization or cardiac surgery between 0-60 days of life at Lurie Children’s Hospital of Chicago, 2015-2021. The exposure was insurance type (public versus private). The outcome was postoperative LOS (number of days between cardiac surgery requiring bypass and discharge). The mediator was whether a discharge barrier occurred (none versus at least one barrier). Our mixed-methods approach to defining discharge barriers has been previously described. In brief, barriers impeding discharge were manually extracted from electronic health records, then collapsed and ranked using regression. Example barriers included prior authorization or home equipment delivery delays. Additional covariates included weight at surgery, presence of syndrome or non-cardiac abnormality, discharge equipment needs (e.g., nasal cannula), postoperative intubation duration, postoperative complications, surgical complexity (STAT category), and a COVID-19 indicator. Linear probability and log-linear regressions with robust standard errors were used for mediation analysis. Results: In total, 372 infants met inclusion; 30.9% had a discharge barrier. Median postoperative LOS was 27 (IQR 15-55) days for those with a discharge barrier versus 13 (IQR 8-22) days for those without (p&lt;0.001). In multivariable models, those with public insurance had a 14.4 percentage-point higher probability of having a discharge barrier than those with private insurance (p=0.004). After adjusting for discharge barriers, insurance type was no longer associated with postoperative LOS (p=0.140), consistent with a mediating effect. In mediation analysis, presence of a discharge barrier explained 50% of the association between insurance type and postoperative LOS (indirect effect 4.9%, p=0.013, Figure 1 ). Conclusion: Discharge barriers, a modifiable aspect of care, are a key driver of insurance-based differences in postoperative LOS.

Background: Catheter ablation, a commonly performed procedure in the electrophysiology laboratory, is relatively safe. However, complications like pericardial tamponade, although rare, can be life-threatening. There are limited studies that have investigated predictors of mortality in patients who developed cardiac tamponade post-catheter ablation procedures. We examined predictors of mortality in this select population of hospitalized patients who had catheter ablation procedures associated with cardiac tamponade. Objective: To evaluate the predictors of mortality in hospitalized patients post-catheter ablation procedures and associated cardiac tamponade. Methods: Data from the National Inpatient Sample, 2016-2020, were used for retrospective cohort analyses. Multivariate logistic regression models were used to examine the factors associated with mortality among hospitalized patients post-catheter ablation procedures and associated cardiac tamponade Results: In the adjusted analysis, ages 65 years and above (AOR: 1.50; 95% CI: 1.20-2.30) and being female (AOR:1.40; 95% CI: 1.10-1.90) were more likely to die compared to being younger than 65 years and being male. Also, non-Hispanic blacks (AOR: 1.60; 95% Cl: 1.20-2.40) and Hispanics (AOR: 1.50; 95% Cl: 1.10-1.80) had higher odds of mortality than non-Hispanic whites. On the other hand, those with private insurance (AOR: 0.50; 95% CI: 0.10-0.90) and other insurance (AOR: 0.50; 95% CI: 0.20-0.80) were associated with a lower mortality risk than having Medicare insurance. Patients admitted electively (AOR: 0.60; 95% CI: 0.20- 0.90) were less likely to die compared to those with non-elective admission. Patients with a length of stay greater than 5 days (AOR: 2.10; 95% CI: 1.70-3.50) had higher odds of mortality relative to those with a hospital stay of 5 days or less. Additionally, higher comorbidity scores of 8 and above (AOR: 2.30; 95% CI:1.50-4.50) were also associated with higher odds of mortality compared to having lower comorbidity scores Conclusion: This study highlights factors associated with mortality in hospitalized patients post-catheter ablation procedures and associated cardiac tamponade. Awareness of these indices will assist clinicians in identifying patients at higher risk of mortality. This would better inform management practices in these patient groups.

To measure the accuracy of questions on health insurance premiums and subsidies added to the American Community Survey (ACS) and their utility in categorizing coverage type following the Affordable Care Act (ACA). A reverse record check study where households in Minnesota with individuals enrolled in five different types of coverage-employer-sponsored insurance (ESI), non-group (outside the marketplace), marketplace, Medicaid and MinnesotaCare (a public plan requiring premium contributions from the enrollee)-were administered a telephone survey that included the ACS health insurance module appended with experimental questions on premiums and subsidies. Enrollment records from a private insurer were used as the sample for primary survey data collection in the spring of 2015 using the ACS health insurance module. Survey data were matched back to enrollment records, which indicated coverage status at the time of the survey. The analytic sample includes matched data on about 600 individuals. In total, 100%, 95.3%, and 86.9% of marketplace, non-group, and ESI enrollees, respectively, were correctly reported to have a premium. 74.6% of Medicaid enrollees were correctly reported NOT to have a premium and 77.4% of MinnesotaCare enrollees were correctly reported to HAVE a premium. For the subsidy item, correct reports of no subsidy were 99.1%, 93.8%, and 80.9% for ESI, non-group, and unsubsidized marketplace enrollees, respectively. A total of 72.4% of subsidized marketplace enrollees were correctly reported to have a subsidy. Analysis also indicates that an algorithm leveraging these two new data points can be used to separate the overall "direct purchase" category into two sub-groups: subsidized marketplace and unsubsidized marketplace combined with individual non-group. Results indicate high levels of reporting accuracy for questions about premiums and subsidies. Thus, this post-ACA module of the ACS is capable of rendering more detailed coverage types than previously possible.

Background: Hypertension remains the most prevalent modifiable risk factor for cardiovascular disease. Although national access to care has improved, disparities in antihypertensive treatment by insurance type remain poorly defined in recent population-level data. Methods: We conducted a pooled cross-sectional analysis of U.S. adults aged ≥18 years using National Health and Nutrition Examination Survey (NHANES) data from 2013–2022. Adults who self-reported a physician diagnosis of hypertension were included. The primary outcome was current use of prescription antihypertensive medication. Insurance type was classified as Medicare (reference), Medicaid, Private, or Uninsured. Treatment prevalence was estimated using survey-weighted proportions. We then performed logistic regression accounting for NHANES survey design. To adjust for confounding, we applied inverse probability of treatment weighting (IPTW) based on a multinomial propensity score model including age, sex, race/ethnicity, education, and income. Results: Among 4,333 adults with diagnosed hypertension, treatment rates were highest in Medicare (91.5%) and lowest among the Uninsured (61.5%). In survey-weighted models, the odds of receiving treatment were significantly lower for Medicaid (OR 0.23; 95% CI 0.15–0.38), Private (OR 0.27; 95% CI 0.20–0.35), and Uninsured (OR 0.15; 95% CI 0.11–0.24) groups compared to Medicare. IPTW-adjusted models yielded consistent findings: Medicaid (OR 3.50; p=0.024) and Private (OR 4.25; p=0.0018) groups had significantly higher odds of being untreated. The Uninsured group showed a trend toward undertreatment (OR 1.58), but this was not statistically significant (p=0.33). Conclusion: Despite national improvements in insurance coverage, significant disparities in hypertension treatment persist. Adults with Medicaid and private insurance are at substantially higher risk of being untreated compared to Medicare recipients, even after adjustment for sociodemographic factors. The Uninsured group demonstrated a consistent but non-significant trend toward undertreatment. These findings highlight the urgent need for targeted, insurance-sensitive interventions to promote equitable hypertension care.

Background: Mechanical circulatory support (MCS) is pivotal in treating heart-failure–related cardiogenic shock (HF-CS), yet real-world deployment may hinge on social and institutional forces in addition to clinical need. We quantified predictors of MCS use across racial and ethnic groups. Methods: The National Inpatient Sample (2016–2020) identified 120,190 adult HF-CS hospitalizations. MCS therapies included intra-aortic balloon pump, percutaneous ventricular assist devices, extracorporeal membrane oxygenation, and heart transplantation. Multivariable logistic regression generated adjusted odds ratios (aORs) for MCS use. Results: Of all admissions, 60.5 % were White, 25.3 % Black, 7.8 % Hispanic, and 6.4 % Other. MCS was employed in 15.4% of White, 15.2% of Black, 15.1% of Hispanic, and 20.1% of Other patients. Female sex conferred 22–35 % lower odds of receiving MCS (aOR 0.73 in Whites, 0.78 in Hispanics, and 0.65 in Black women; p &lt; 0.01). Patients older than 60 years were likewise less likely to receive support in Hispanics, whites, and blacks (aOR 0.62, 0.68&amp;0.75; all p&lt; 0.05). Possessing private insurance increased the likelihood of MCS by 59 % to 151 % (aOR 1.52–2.51, p&lt; 0.05 for all except Asians). Higher income was associated with greater MCS use only among Hispanic patients (aOR 1.27, p = 0.001). Admission to a large-bed-size hospital was the strongest institutional determinant, doubling the odds of support for all groups and up to fourfold in the Others (aOR 4.25, p&lt; 0.001). Medicare/Medicaid coverage showed no significant association with utilisation. Clinically, chronic obstructive pulmonary disease markedly reduced the likelihood of MCS (aOR 0.10–0.65, p ≤ 0.009). Stage-5 chronic kidney disease and atrial fibrillation conferred modestly lower odds only in Whites (aOR 0.75 and 0.80, respectively; p ≤ 0.005) and in patients classified as Other (aOR 0.60 for atrial fibrillation, p = 0.006). Conclusion: Access to temporary MCS in HF-CS extends beyond clinical eligibility. Women and older adults are less likely to receive support, whereas private insurance, higher income (for Hispanics), and care in large hospitals substantially increase utilisation. Racial and ethnic disparities intersect with socioeconomic status and institutional resources., Black and Hispanic patients—particularly Black women—remain underrepresented among MCS recipients. These findings highlight structural determinants in advanced HF care and underscore the need for targeted.

Introduction: The use of glucagon-like peptide-1 receptor agonist (GLP-1RA) has transformed the management of cardiovascular kidney metabolic syndrome, but the large number of individuals eligible for these high-cost therapies has raised concerns about affordability. In particular, there is sparse data on individuals insured by Medicaid. Research Question: How many U.S. adults covered by Medicaid are eligible for GLP-1RA therapy, for which indications, and what would annual pharmaceutical spending on GLP-1RAs be if all eligible patients were to receive GLP-1RA therapy? Methods: We analyzed cross sectional data from the National Health and Nutrition Examination Survey (NHANES) from 2017 - 2023. Eligibility criteria included diabetes, obesity or overweight with risk factors (diabetes, hypertension, hyperlipidemia), and cardiovascular disease. We projected impact on pharmaceutical spending by multiplying the number of eligible individuals with an annual treatment cost of $8694 (diabetes) or $4476 (without diabetes) estimated by the 2024 U.S. net price of semaglutide. Results: A total of 19.8 million US adults on Medicaid are eligible for GLP-1RA therapy, representing 14% of the 145.3 million treatment-eligible US adults. The average age is 43 years, 62% are women, and 56% self-identify as a racial minority. They are on average younger, more likely to be female, more likely to be from a racial minority, and more likely to have lower income than eligible individuals covered by Medicare and private insurance ( Image 1 ). Regardless of overlap, a total of 18.4 million individuals are eligible for weight loss, 4.8 million for DM, and 2.5 million for cardiovascular disease ( Image 2 ). Of these, the majority are eligible solely for weight loss (n = 13.7 million, 69%), an indication not covered by most Medicaid plans. In contrast, 6.1 million adults (31%) have at least one indication other than weight loss and thus more likely to access GLP-1RAs through Medicaid. If all treatment-eligible patients were to receive therapy, annual pharmaceutical spending would be $166.3 billion, including $158.3 billion among individuals using therapy solely for weight loss and $8.0 billion among those with at least one other indication. Conclusion: A total of 19.8 million Medicaid insurees are eligible for GLP-1RA therapy. Treating all eligible patients would increase pharmaceutical spending by $166.3 billion. Efforts to increase access among high-risk Medicaid patients are urgently needed.

Introduction Health inequalities remain a persistent challenge, yet little is known about how financing reforms affect access within private hospitals. In 2016 Israel introduced the shorten waiting times reform, designed to expand publicly financed surgeries and reduce reliance on supplementary and private insurance. Methods This study examined its impact on both the financing mix and the socioeconomic composition of surgical patients. Administrative data on 1,082,685 procedures performed at Assuta Medical Centers between 2015 and 2019 were analyzed, comparing pre-reform (2015- October 2017) and post-reform (November 2017-2019) periods, with ambulatory procedures serving as a control group. Results Publicly financed surgeries increased from 5% to 51% (ATT +51.6pp; 95% CI 43.3-59.9; p &amp;lt; 0.001), while supplementary and private financing declined. The share of middle-SES patients rose from 52% to 57% (+7.1pp), high-SES declined from 35% to 29% (−8.0pp), and low-SES increased modestly from 13% to 14% (+0.9pp). In contrast, the control group showed only minimal changes. Discussion These findings indicate that the reform was associated with a substantial reallocation of financing and a measurable broadening of SES representation, particularly for middle-income groups, with incremental gains for disadvantaged populations. Overall, the results are consistent with improved equity in access and highlight how regulatory tools can harness private capacity for public benefit within a universal health system.

Background: Social determinants of health (SDOH) influence access to advanced cardiac interventions. We aimed to evaluate the association between SDOH and permanent pacemaker (PPM) utilization in patients hospitalized with sick sinus syndrome (SSS) in the United States. Methods: Using the National Inpatient Sample (2016–2021), we identified adult patients diagnosed with SSS using ICD-10-CM codes. PPM implantation was identified using ICD-10-PCS codes. Baseline characteristics, comorbidities, and SDOH, including race/ethnicity, income quartile, insurance status, and hospital features, were compared between patients with and without PPM. Multivariable logistic regression was used to assess independent predictors of PPM use. Propensity score matching was performed (1:1) to compare severe comorbidities, procedures, and in-hospital outcomes. Results: Among 1,462,220 SSS hospitalizations, 361,035 (24.7%) received a PPM. PPM recipients were younger (median age 78 vs. 80 years, p&lt;0.001), more likely female (51.6% vs. 50.5%, p&lt;0.001), and more often treated at large, urban teaching hospitals (p&lt;0.001). In adjusted analysis, Black patients had lower odds of receiving PPM (aOR 0.81, 95% CI: 0.78–0.84), while Hispanic (aOR 1.10) and Asian/Pacific Islander (aOR 1.09) patients had higher odds compared to White patients (p&lt;0.01). Female sex (aOR 1.11), private insurance (aOR 1.24), and residence in the highest income quartile (aOR 1.04) were associated with higher likelihood of PPM use. In propensity-matched cohorts (N=70,317 each), PPM implantation was associated with lower in-hospital mortality (0.85% vs. 3.61%), stroke (0.97% vs. 1.56%), and sepsis (2.29% vs. 5.72%) (p&lt;0.001). PPM recipients had higher discharge-to-home rates (57.3% vs. 49.6%) and longer median hospitalization costs ($19,898 vs. $10,209, p&lt;0.001). Conclusion: Significant disparities exist in the utilization of permanent pacemakers among patients with SSS. Black patients and those with Medicaid or from lower-income ZIP codes were less likely to receive PPM, despite worse clinical outcomes. These findings highlight a gap in equitable care delivery and underscore the need for health system and policy-level interventions to address structural disparities in cardiac device access.

The aging population is a global phenomenon, with the number of people aged 60 and above reaching 1.05 billion in 2020, representing ‎‎13.46% of the world's total population. This trend is expected to continue, with the population of older adults projected to reach 1.41 billion ‎‎(16.46%) by 2030 and over 2 billion (22%) by 2050. In India, the elderly population is growing rapidly, with the number of people aged 60 ‎and above expected to reach 324 million by 2050 (India Aging, Elderly to Make up 20% of Population by 2050: UNFPA Report, n.d.). ‎However, health insurance coverage among the elderly population in India is poor, with estimates indicating that less than 1% of the elderly ‎population has health insurance. This lack of coverage is more pronounced in developing cities like Chennai, where health insurance penetration is below 3%. In light of this background, the current study assesses health insurance coverage among the aging population in Chen-nai. Additionally, the study identifies factors associated with health insurance coverage among the elderly in Chennai. A household survey ‎was conducted among people aged 60 and above, with a sample size of 120 in Chennai. The principal investigator collected responses ‎through the interview schedule method. The results of the study revealed that 70% of the elderly respondents are dependent on their offspring. Of the 52.5% who have health insurance coverage, 56% are covered by private insurance, with the majority (60%) of these being ‎employee-sponsored plans. Despite 58% of respondents suffering from chronic health issues, only 51% of this group are insured. A significant portion of the population remains uninsured, primarily due to a lack of awareness (39%). Additionally, 70% of the respondents regularly utilize healthcare services for checkups and outpatient department (OPD) care. Based on these key findings, a model has been developed to highlight the reasons for being uninsured, the challenges the aging population faces in obtaining insurance, the available options, and strategies to bridge the coverage gap. This model serves as an important takeaway for insurance providers and policymakers, emphasizing the need to educate the public to improve insurance coverage.

Background: Social determinants of health (SDOH) contribute to disparities in cardiovascular care and outcomes. In pediatric Wolff-Parkinson-White (WPW) syndrome, timely access to risk stratification by electrophysiology study (EPS) and possible ablation can prevent sudden cardiac death. The impact of SDOH on the management of pediatric supraventricular tachycardia has been evaluated but has not been investigated in patients with WPW specifically. Hypothesis: We hypothesize that patients with WPW who are non-white, primarily Spanish-speaking, publicly insured, and have lower childhood opportunity index (COI) are less likely to undergo EPS and have longer waits from diagnosis to EPS. Methods: This single-center, retrospective cohort study identified patients aged 5 to 18 years old with WPW pattern by ECG between 2014 and 2024. Patients diagnosed before 5 years of age and patients with intermittent WPW pattern were excluded. Demographic, clinical, and insurance data were extracted via chart review; census tract level COI was obtained from a validated public database. The primary outcome was the time from first diagnostic ECG to EPS. Risk stratification, accessory pathway, and procedural success data were collected from EPS reports. Odds ratio and time interval comparisons were made using 2-sample t, chi-squared, ANOVA, and Kruskal-Wallis tests. Results: Of 363 included patients, 174 (48%) are female, 222 (61%) are non-white, 58 (16%) are primarily Spanish-speaking, and 181 (50%) are publicly insured. Two hundred thirty-four (64%) underwent an EP study with a median time from ECG to EPS of 68 (IQR 41, 182) days (Table 1). Hispanic patients were less likely to undergo EPS compared to non-Hispanic whites ( P =0.049), and Spanish speaking patients were less likely compared to English speaking ( P =0.03). Patients with public insurance were less likely to undergo EPS compared to those with private insurance ( P =0.02). Patients with lower COI levels were less likely to undergo EPS compared to those with very high COI. There was no significant difference in time from ECG to EPS or from EPS to follow-up based on demographic variables (Table 2). Conclusion: In this diverse pediatric WPW cohort, Hispanic ethnicity, primarily Spanish-speaking, and public insurance were associated with lower likelihood of undergoing EPS. These findings identify potential barriers to timely EPS and highlight a need for targeted interventions to promote equitable care in this population.

Introduction: Despite medical advances in congenital heart surgery, disparities in outcomes remain. Social determinants of health (SDoH) are known contributors to healthcare inequities, but their cumulative impact in geographically diverse populations remains understudied. Research Question: We hypothesized that children undergoing congenital heart surgery with lower SDoH indices and greater distance to care have increased morbidity, mortality at 30 days and 1 year, and longer length of stay. Methods: We conducted a retrospective cohort study of children undergoing cardiac surgery at a tertiary Heart Center from 2014-2024. Exposures included race, ethnicity, primary language, insurance status, Childhood Opportunity Index (COI), and distance traveled. Age at time of surgery, STAT category, and single ventricle status were also studied. Primary outcomes were 30-day and 1-year morbidity and mortality; the secondary outcome was postoperative length of stay. Univariable and multivariable logistic regression models assessed associations. Results: Among 3,141 patients, 84.7% were white and 94.3% listed English as their primary language. COI distribution was: 8.5% Very Low, 20.3% Low, 28.7% Moderate, 32.4% High, 10.2% Very High. Most patients had private insurance (63.0%). In univariable models, unknown race was associated with higher odds of complications (OR 1.57, p=0.002), 30-day mortality (OR 2.99, p&lt;0.001), and 1-year mortality (OR 3.96, p&lt;0.001). Unavailable ethnicity predicted increased 30-day (OR 4.24, p=0.002) and 1-year mortality (OR 2.52, p=0.043). No significant associations were found between language, COI, or distance to care and primary outcomes. These associations did not maintain significance in the multivariable model. Compared to white patients, Black (OR 1.78, p=0.015) and Native Hawaiian/Pacific Islander patients (OR 1.67, p=0.028) had significantly longer postoperative length of stay in a multivariable model. Insurance status was not significantly associated with outcomes. Conclusions: Unreported race and ethnicity data were strongly associated with worse surgical outcomes, highlighting reporting gaps that may mask inequities. While other SDoH factors such as COI and distance traveled were not predictive of morbidity or mortality, race-based disparities in hospital length of stay underscore the need for targeted interventions to improve equity in the care of patients with congenital heart disease.

Introduction: Vitamin B12 deficiency has been linked to cardiovascular risks, yet its impact on outcomes in patients with acute coronary syndromes, particularly Non-ST Elevation Myocardial Infarction (NSTEMI), remains understudied. Given the importance of non-traditional risk factors in cardiovascular events, we hypothesize that Vitamin B12 deficiency is associated with adverse outcomes in NSTEMI patients, potentially influencing major adverse cardiovascular events (MACE), arrhythmias, and hospital length of stay. Methods: We analyzed data from the National Inpatient Sample (NIS) database (2019–2020) to identify NSTEMI hospitalizations, comparing those with and without Vitamin B12 deficiency. A total of 1,051,910 weighted hospitalizations were included (NSTEMI with B12 deficiency: N=7,545). Key outcomes included MACE, STEMI transformation, cardiac dysrhythmias, length of stay, acute kidney injury (AKI), and in-hospital mortality. Logistic regression was used to calculate adjusted odds ratios (aOR) for these outcomes, adjusting for age, sex, diabetes, hypertension, and renal function. Results: Patients with Vitamin B12 deficiency were older (mean age 73.95 vs. 68.5 years, p&lt;0.0001) and had a more balanced gender distribution (49.7% male vs. 39.8% male in non-deficient group). Medicare was the predominant payer (76.0% vs. 61.8%, p &lt; 0.0001), with less frequent private insurance and Medicaid in the B12-deficient group. After adjusting for confounders, B12 deficiency was independently associated with an increased risk of MACE (aOR 1.24, 95% CI: 1.10–1.40, p=0.00044) and cardiac dysrhythmias (aOR 1.16, 95% CI: 1.03–1.29, p=0.011). Patients with B12 deficiency had longer hospital stays (mean 6.7 vs. 5.8 days, p&lt;0.0001) and a slightly higher risk of AKI. The prevalence of deficiency increased with age and was more common among females and Medicare beneficiaries, indicating potential socio-economic and aging-related factors. Conclusion: Vitamin B12 deficiency in NSTEMI patients is linked to a distinct demographic profile and worse in-hospital outcomes, including MACE and cardiac dysrhythmias. These findings suggest Vitamin B12 status may be crucial for cardiovascular risk assessment, emphasizing the need for further research into whether addressing deficiency can improve clinical outcomes. Future studies should explore the role of Vitamin B12 supplementation and routine monitoring in high-risk cardiovascular patients.