Inequities in imaging: The association between patient demographics and use of point-of-care ultrasound in the ED.

This research assesses the predictive efficacy of ARIMA models for projecting Gross Premium Collected in India (GPI) by New India Assurance. The study utilizes historical data from 2002 to 2023 and includes stationarity testing, model selection, and residual diagnostics. The study designates ARIMA(1,1,5) as the most efficacious model, shown by its optimal performance measures, which include the minimal Akaike Information Criterion (AIC) value and the maximal R-squared among the assessed alternatives. The projection anticipates consistent rise in GPI from 2024 to 2027, suggesting possible revenue enhancements driven by elements such as market development and heightened insurance penetration. This study enhances the current literature by underscoring the applicability of ARIMA models in projecting public sector insurance, therefore addressing a gap identified in previous studies centered on macroeconomic and efficiency evaluations. The findings corroborate the current research about ARIMA’s forecasting efficacy, endorsing its use in strategic planning and risk management in the insurance sector.

Selective serotonin reuptake inhibitors (SSRIs) are often co-prescribed with oxycodone, yet may potentiate respiratory depression. We aimed to assess the comparative effects of SSRIs on opioid overdose when added to oxycodone. Using US commercial and public health insurance claims data (2004 - 2020), we conducted a cohort study in adults who initiated SSRI while on oxycodone. We assigned patients to one of five exposures (sertraline, citalopram, escitalopram, fluoxetine, and paroxetine) and followed them for opioid overdose (hospitalization or emergency room visit) for 365 days and while they stayed on both oxycodone and index SSRI. We used propensity score matching weights to adjust for potential confounders and weighted Cox proportional hazard models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). Among 753,263 eligible individuals (mean age 46 years [SD 16]; 527,340 females [70%]), 221,792 initiated sertraline, 173,352 citalopram, 153,968 escitalopram, 126,954 fluoxetine, and 77,197 paroxetine. Overall, 1250 opioid overdose events occurred, with incidence rates ranging from 10.8 to 15.2 per 1,000 person-years across individual SSRIs. Weighted HRs, relative to sertraline, were 1.24 (95% CI = 1.04, 1.50) for citalopram, 1.22 (95% CI = 1.01, 1.47) for escitalopram, 1.26 (95% CI = 1.04, 1.53) for fluoxetine, and 1.26 (95% CI = 1.01, 1.57) for paroxetine. No differences were observed across SSRIs other than sertraline. In this study of individuals who added an SSRI to oxycodone, the incidence of opioid overdose was low. Patients who initiated sertraline experienced overdose at a slightly lower rate than patients who initiated other SSRIs.

ABSTRACT Herpes zoster imposes a substantial disease burden in China. Despite vaccination being critical for burden mitigation, willingness-to-pay (WTP) for herpes zoster vaccines among urban residents remains understudied, with a lack of national-level evidence on its determinants. A national-wide survey was conducted among 2,864 urban residents aged ≥25 years across nine provinces and nine cities in China. Using the contingent valuation method (CVM), three elicitation approaches – payment scales, bidding, and open-ended questions – were employed to assess respondents’ willingness-to-pay (WTP) for herpes zoster vaccination. Univariate statistical analyses were then performed to explore the associations between socioeconomic characteristics and WTP. Median WTP varied by methods (payment cards: CNY 300, bidding: CNY 500, open-ended: CNY 300). Across these methods, 36.09%, 29.06%, and 23.64% of participants, respectively, were unwilling to pay (including those rejecting free vaccination). For higher thresholds, 2.36% and 9.96% reported WTP ≥ 2,000 CNY via the payment scale and bidding methods, while 2.09% indicated WTP ≥ 2,000 CNY through the open-ended method. Age was negatively associated with WTP, and respondents from moderately developed regions had the highest WTP. Education and annual household income showed positive associations with WTP. Additionally, unemployment, chronic disease, divorced or widowed residents, and below-average self-reported health correlated with lower WTP. While respondents with public or commercial insurance had highest WTP. In conclusion, individual WTP for herpes zoster vaccine is substantially influenced by socioeconomic characteristics, which are inherently linked to income. This highlights the need for income-sensitive policies, including affordable pricing and targeted health education for vulnerable groups.

Osteoporosis is prevalent in patients undergoing total shoulder arthroplasty (TSA) and affects perioperative management and outcomes, including fragility fractures. Despite guidelines recommending dual-energy radiograph absorptiometry (DXA) screening in women at risk for osteoporosis, screening before TSA remains low. With TSA procedures rising, it is important to identify factors that may contribute to low DXA utilization rates. This study aims to (1) evaluate the influence of demographic and social determinants of health on preoperative DXA screening and (2) identify predictors of postoperative fragility fractures. We retrospectively reviewed female patients who underwent TSA from 2016 to 2024 by a single surgeon. Patients meeting guideline-based indications for DXA were included. Multivariable logistic regression identified predictors of DXA utilization. Among patients without prior fragility fractures, time-to-event analysis using Firth penalized Cox regression assessed predictors of postoperative fractures. A bootstrap sensitivity analysis (1,000 iterations) evaluated the stability of smoking-related risk estimates. Of 432 eligible women, only 39.7% (n = 176) received a preoperative DXA screening. In adjusted analysis, married patients had 52% higher odds of receiving screening (odds ratios 1.52, 95% confidence intervals [1.01 to 2.29], P = 0.044), whereas those with public insurance had 54% lower odds compared with privately insured patients (odds ratios 0.46 [0.29 to 0.74], P = 0.001). Among 358 patients without prior fragility fractures, current tobacco use markedly increased postoperative fracture risk (hazard ratios [HR] 14.87 [1.69 to 130.88], P = 0.015). Higher body mass index was protective: overweight (HR 0.27 [0.08 to 0.87], P = 0.028) and obese (HR 0.03 [0.003 to 0.29], P = 0.002) patients had a lower fracture risk. DXA screening is underused in women undergoing TSA. Marital status and insurance type markedly affect screening rates, whereas low body mass index and tobacco use remain strong predictors of fragility fractures. These findings suggest a need for comprehensive bone health management strategies, including improved screening, risk counseling, and optimized osteoporosis management. III.

Medicare Part D innovatively included a market in public health insurance in the United States. Proponents argued that increased competition would drive better value for beneficiaries, but others feared that beneficiaries would struggle to navigate the complex program. Understanding how Part D beneficiaries choose between plans allows us to evaluate the extent to which Medicare Part D succeeds at increasing value to beneficiaries and where there is scope to support beneficiaries. Many Part D beneficiaries are sensitive to price cues in relation to pharmacy choice and medication adherence, yet frequently overpay for their plans. Empirical literature suggests that behavioral aspects including information overload, low salience, low trust, and practical 'sludge' all partly contribute to failure to switch. We propose solutions to address these barriers based on behavioral insights.

Insurance sector liberalization has been a crucial component of India’s economic reform process, aimed at promoting competition, efficiency, and market development. This study evaluates the impact of insurance sector liberalization on market structure and performance in India, with a specific focus on changes in ownership patterns, competitive intensity, product diversification, and the regulatory environment. The study adopts a descriptive and analytical research design and is qualitative in nature, relying exclusively on secondary data collected from IRDAI reports, Government of India publications, academic research papers, and policy documents covering the post-liberalization period. The analysis reveals that prior to liberalization, the Indian insurance market was characterized by a highly concentrated and monopolistic structure dominated by public sector insurers. The entry of private and foreign insurers after 2000 significantly increased the number of market participants and transformed the market into a competitive oligopolistic structure. However, the extent of competition varies across segments, with life insurance remaining highly concentrated due to the continued dominance of LIC, while general and health insurance exhibit stronger private sector participation and higher competitive intensity. Liberalization has also led to substantial improvements in product variety, innovation, distribution channels, and consumer choice. The study further highlights the pivotal role of the Insurance Regulatory and Development Authority of India in balancing competition with financial stability and consumer protection. Overall, the findings indicate that insurance sector liberalization has positively influenced market structure and qualitative performance outcomes, though its impact has been uneven across different segments of the insurance industry.

Despite documented benefits of doula support for patients and newborns, access remains limited. This evaluation examined patient and neonatal outcomes associated with a hospital-based, shift model of doula care. This retrospective analysis was conducted on eligible births at a single, safety-net teaching hospital between January 1 and December 31, 2022. Patients who received doula care during labor and/or birth were compared with those who did not. Doulas were volunteers who self-scheduled shifts and provided support when available. Primary outcomes included cesarean birth and neonatal intensive care unit (NICU) admission. Adjusted odds ratios were calculated to assess the association between doula presence and outcomes of interest. Among 3055 eligible patients, 375 (12.2%) were offered doula support, and 355 (11.6% of total; 94.7% of those offered) accepted. Most patients were 25 to 34 years old (53.6%), were multiparous (67.2%), identified as Hispanic (65.7%), and had public insurance (82.5%). Patients who received doula support were more likely to identify as Black non-Hispanic or multiracial (P=.005). Labor complications, including chorioamnionitis, shoulder dystocia, and arrest of labor, were more frequent among those with doula support (18.9% vs 14.6%; P=.034), as was oxytocin augmentation (54.9% vs 37.0%; P <.001), and induction of labor (55.2% vs 37.1%, P <.001). NICU admissions were lower among doula-supported births, although not statistically significant (2.8% vs. 5.1%, P=.058). Doula-supported patients had lower odds of cesarean birth (11.8% vs 16.5%; P=.024; adjusted odds ratio, 0.69; 95% CI, 0.48-0.97). Doula care provided through a shift-based hospital model was associated with a decreased cesarean birth rate despite increased labor complications, induction of labor, and oxytocin use. These findings suggest that even intermittent doula support may improve outcomes. Additional studies are warranted to further evaluate the impact of shift-based doula care models on perinatal outcomes.

IntroductionHip arthroscopy has become increasingly popular over the years, making it a leading treatment for hip pain in adolescents and young adults. The influence of various demographic factors, including insurance status, on hip arthroscopy outcomes remains uncertain. This is important, as insurance status is a known predictor of orthopedic surgical outcomes – patients with public insurance often experience worse results compared to those with commercial coverage. This study utilizes Patient-Reported Outcomes Measurement Information System (PROMIS) data to evaluate the role of insurance type on hip arthroscopy outcomes, aiming to identify at-risk populations and improve healthcare equity.MethodsPatients who underwent hip arthroscopy between 1/1/2015–6/30/2024 at our institution were identified (Current Procedural Terminology codes: 29861, 29862, 29863, 29914, 29915, 29916, and 29999). The patients’ insurance information was obtained, and patients were split into two groups for analysis: Commercial and Medicare/Medicaid. PROMIS scores along the pain interference, physical function, and depression domains were obtained and analyzed between the two groups. Furthermore, demographic information such as gender, age at surgery, and smoking status were analyzed. Surgical procedures and intraoperative findings were also examined between groups.ResultsA total of 333 patients were included in this study and all patients had minimum 1-year follow-up. The two groups split by insurance status yielded 272 patients in the Commercial group and 61 patients in the Medicare/Medicaid group. No significant differences were observed in preoperative demographic variables. The Commercial group had a significantly greater number of femoroplasties performed (P = 0.018). There were significant preoperative and postoperative differences in all PROMIS measures examined (P < 0.05). Both groups showed significant improvement in PROMIS measures, however, there were no significant differences in this improvement (P > 0.05).ConclusionThe most important finding in our study is that regardless of insurance status, our cohort of patients improved with surgery. However, patients with Medicare or Medicaid had worse pre-operative and post-operative depression and pain interference scores compared to patients with Commercial insurance. These findings highlight that although patients with Medicare/Medicaid improve overall, this insurance status may be associated with poorer hip arthroscopy outcomes.

Abstract Objectives Youth with type 1 diabetes (T1D) and obesity face challenges in achieving optimal glycemic control and experience higher risk for long-term complications. While glucagon-like peptide-1 receptor agonists (GLP-1RA) have shown weight and glycemic benefits in adults with type 1 diabetes, data in pediatric populations are scarce. We report here changes in glycemia, weight, and insulin doses in youth with T1D and obesity prescribed GLP-1RA. Methods We conducted a single-center retrospective observational study of adolescents and young adults (ages 10–20) with T1D and obesity prescribed GLP-1RA (liraglutide, exenatide, dulaglutide, semaglutide, or tirzepatide) between 2019 and 2024. Data collected included HbA1c, body weight, BMI, total daily insulin dose (TDD), and continuous glucose monitoring (CGM) metrics. Linear mixed effects models assessed changes over time, adjusting for age and gender. Results Among 24 patients (75 % female, 67 % public insurance, 88 % CGM users, 67 % insulin pump users), 12 months of GLP-1RA treatment led to significant reductions in weight (−9.49 kg, p&lt;0.0001), BMI (−3.69 kg/m 2 , p&lt;0.0001), and BMI Z-score (−0.30, p=0.04). CGM time-in-range increased by +7.96 % (p=0.08), and time above range (180–250 mg/dL) decreased by −3.04 % (p=0.06). TDD among pump users declined by −21.42 % (p=0.002). After approximately 16 months, HbA1c decreased by −0.81 % (p=0.04). Side effects were mainly gastrointestinal and transient. Conclusions This first longitudinal report of GLP-1RA use in youth with T1D and obesity shows clinically meaningful improvements in weight, glycemia, and insulin requirements, supporting the potential role of GLP-1RA as adjunct therapy. Larger prospective studies are needed to guide clinical practice.

Oropharyngeal cancer (OPC) involves the base of tongue, palatine tonsils, lingual tonsil, and soft palate. Established risk factors for OPC include tobacco usage, alcohol usage, and human papillomavirus infection. Although white populations tend to have the highest risk of developing OPC, Black patients are more likely to experience distant stage disease. The aim of this study was to elucidate epidemiological factors that are associated with regional and distant stage disease at OPC diagnosis. We performed a retrospective cross-sectional analysis utilizing the Florida Cancer Data System (FCDS) from 2010 to 2017. Sociodemographic factors among Black and white patients were compared using chi-square analysis. Multivariable logistic regression analysis determined risk factors associated with distant stage diagnosis. Geographical mapping of census tract levels was performed to illustrate prevalence of distant stage disease at diagnosis in Florida. Among 8,908 OPC cases, 7,534 (84.6%) patients were white non-Hispanic, 834 (9.4%) were white Hispanic, and 540 (6.1%) were Black. Multivariable logistic regression revealed increased distant stage disease compared to local stage among those who were Black (compared to white non-Hispanic and white Hispanic; OR = 1.55 [95% CI:1.12-2.13], p = 0.007), separated/divorced/widowed (OR = 1.36 [95% CI:1.11-1.68], p = 0.004) (compared to married), and lack insurance (OR = 1.67 [95% CI:1.16-2.41], p = 0.006) or have public insurance (OR = 1.26 [95% CI:1.04-1.53], p = 0.017) (compared to those with private insurance). There was decreased regional stage disease compared to local stage among females (OR = 0.57 [95% CI:0.49-0.66], p < .001) and older patients (OR = 0.975, [95% CI:0.968-0.982], p < 0.001). Mapping revealed higher percent of distant stage diagnoses in census tracts with lower median income. Distant stage at OPC diagnosis is influenced by many risk factors, including race, sex, age, marital, and insurance status. Geographical mapping analysis can help direct screening efforts to high-risk communities.

Routine developmental screening is essential for early identification of autism. Reliable autism screening is even more valuable for individuals from minoritized groups who are often under-detected and receive later diagnoses. Despite this importance, disparities in access to screening and accurate identification persist. Given these disparities, we were interested in examining group differences in autism screening rates at 18 and 24 months of age among children referred to Georgia's Part C Babies Can't Wait (BCW) program between 2018 and 2022. Among a sample of 52,282 infants and toddlers enrolled in BCW, as hypothesized males and children with private insurance had higher screening likelihoods compared to females and children with public insurance. Unexpectedly, Black and Hispanic children were more likely to be screened than their counterparts. To examine this further, an examination of screening timing revealed that White and male children were more likely to be screened before their referral to BCW compared to peers. This reveals continued inequities in screening timing but suggests that BCW providers serve an important role in identifying children who may have been missed in other settings.

BackgroundQuality of life (QOL) data for the Brazilian population with breast cancer are scarce. This study aimed to evaluate QOL in Brazilian women with early-stage breast cancer treated with adjuvant endocrine therapy (ET) and to explore its relationship with patients’ clinical and social characteristics and type of healthcare insurance.MethodsWe performed a cross-sectional study among women with early-stage estrogen receptor-positive (ER +) invasive carcinoma of the breast in Brazil. Eligible patients who had received locoregional care and had undergone adjuvant ET for more than 6 months were contacted in person during clinic visits. The EORTC QLQ-C30-V3 and QLQ-BR23 scales were used as questionnaires to assess the QOL of patients.ResultsFrom June 2021 to March 2024, 774 women with ER + early-stage breast cancer from 14 Brazilian institutions were contacted. A total of 347 women (44.8%) were treated at private institutions. The mean age was 56.5 years (SD 11.9). The median duration of ET use was 3.2 years (SD, 2.1). Multivariate regression analysis revealed that treatment at a public institution was a significant predictor of higher nausea and vomiting scores (p = 0.042), pain (p = 0.0008), financial difficulty (p < 0.0001), arm symptoms (p < 0.0001), and breast symptoms (p < 0.0001).ConclusionIn this cohort, patients treated at public institutions had lower QOL. Younger age (< 60 years), presence of comorbidities, and ovarian suppression associated with ET were key predictors of poor QOL. These findings provide insights for guiding the development of tailored interventions for the Brazilian population.

ABSTRACT The Chinese government issued public long-term care insurance (LTCI) in 2016 in response to its rapidly ageing population and the rising need for long-term care (LTC). Using nationally representative survey data, this paper investigates the intergenerational effect of LTCI on adult children’s location choice. Leveraging a difference-in-differences (DID) approach, we find that parents’ LTCI coverage decreases parents’ perceptions of utilizing future care from children by 9.9% points and lowers adult children’s rate of living in the same city by 3.9% points. The annual average benefit of migration associated with insuring both parents is approximately $29. Additionally, the increased geographical mobility is more pronounced in offspring with heavier caregiving burdens. Our findings provide new evidence on the spillover effect of LTCI on geographical mobility, demonstrating a new perspective when evaluating the benefits of old-age support policies in a developing country.

Despite a small prevalence, children with complex chronic conditions (CCCs) use substantial inpatient resources. To assess national trends in hospital discharges, bed days, and hospital charges for children with and without CCCs in the US from 2000 to 2022. This retrospective, repeated cross-sectional study used hospital discharge data from the Kids' Inpatient Database (KID) from the years 2000, 2003, 2006, 2009, 2012, 2016, 2019, and 2022 for US children aged 0 to 18 years, excluding uncomplicated newborn discharges. Presence of 0, 1, 2, or 3 or more CCCs. Trends in the hospital discharge rate per 100 000 children and percentage of total hospital discharges, bed days, and charges attributable to children with CCCs, identified with International Classification of Diseases, 9th Revision, Clinical Modification and International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification codes using Feudtner's diagnosis code classification system, version 3. Survey weights were applied to estimate hospital discharges, bed days, and charges. Sociodemographic (eg, primary payer) and clinical (eg, technology dependence, mental health comorbidity) characteristics for each hospital discharge were also assessed. Across all years, there were an estimated 26 342 497 hospital discharges, of which 54.1% (95% CI, 54.0%-54.2%) were among males and 55.4% (95% CI, 54.4%-55.8%) were for infants. From 2000 to 2022, the discharge rate per 100 000 US children increased by 24.3% (95% CI, 22.7%-26.3%), from 779 to 968, for children with 1 or more CCCs and decreased by 9.7% (95% CI, 9.4%-10.0%), from 3831 to 3459, for children with no CCCs. From 2000 to 2022, the percentage change in the hospital discharge rate varied by number of CCCs: a 3.8% (95% CI, 0.9%-6.0%) decrease was found for 1 CCC, a 60.9% (95% CI, 57.7%-65.5%) increase for 2 CCCs, and a 340.0% (95% CI, 332.6%-351.1%) increase for 3 or more CCCs. In 2000 and 2022, children with 1 or more CCCs accounted for 16.9% (95% CI, 15.7%-17.9%) and 21.9% (95% CI, 20.7%-22.9%) of hospital discharges, 32.0% (95% CI, 30.8%-33.1%) and 44.1% (95% CI, 42.6%-45.4%) of bed days, and 44.2% (95% CI, 42.6%-45.5%) and 59.5% (95% CI, 57.8%-60.9%) of hospital charges, respectively. From 2000 to 2022, the percentage of hospital discharges in children with 1 or more CCCs increased with gastroenterologic technology dependence (7.0% [95% CI, 6.0%-8.0%] to 14.4% [95% CI, 12.4%-16.4%]), neurodevelopmental or neurocognitive disorders (5.7% [95% CI, 4.8%-6.5%] to 13.5% [95% CI, 11.7%-15.2%]), and public insurance (40.9% [95% CI, 38.8%-42.9%] to 52.1% [95% CI, 50.2%-54.1%]). In this national, repeated cross-sectional study, the hospital discharge rate and the percentage of hospital resource use attributable to children with CCCs increased from 2000 to 2022, and these trends were mainly attributable to children with multiple CCCs. It is critical that health systems are equipped with the resources, staff, and payments to sustainably meet the increasing needs for inpatient care among children with CCCs.

Socioeconomic Factors Associate With Access but not Survival in Neurosurgical Brain Tumor Patients.

Understanding how social determinants of health (SDoH) affect clinical outcomes is important in achieving health equity. The impact of SDoH on pediatric transplant recipients is poorly understood. We investigated the effect of SDoH on pediatric kidney allograft outcomes. In a single-center retrospective pilot cohort study, data were extracted from electronic health records using bioinformatics. patients 0-18years old who received a kidney transplant at our center from 9/25/2012-12/31/2022. Exposures were insurance type, distance to transplant center, language, and area deprivation index (ADI). Primary outcomes were graft survival, time to first biopsy-proven acute rejection (BPAR), and number of BPAR. Secondary outcomes were hospitalization and clinic attendance rates. Kaplan-Meier estimates were used for graft survival. Cox proportional hazards models estimated associations of exposure with outcome. N = 78 participants were 37% female; 37% had living donor; median age at transplant 8.5years [IQR 3, 14]; median follow-up 5.0years [IQR 4.1, 7.0]. Insurance type, distance to transplant center, language, and ADI were not associated with higher risk of graft failure, time to first BPAR, or hospitalization rates. Public insurance was associated with increased BPAR episodes [IRR 3.01, 95% CI (1.04, 9.69)]. In a regression analysis, greater distance from the transplant center was associated with a higher rate of missed (either cancelled or no-show) clinic appointments [IRR = 1.04 cancellations per 10-mile increase, 95% CI (1.02, 1.06)]. Public insurance was associated with greater number of BPAR, which impacts long-term graft function. Greater distance to the transplant center was associated with lower clinic attendance, which delays care and may cause negative health effects. These are important SDoH to investigate in larger multi-center cohorts to develop effective strategies to reduce health inequities.

Evolution in the use of epilepsy surgery in tuberous sclerosis complex. Analysis of the Pediatric Health Information System over two decades.

OBJECTIVES We evaluated the frequency and patterns of comorbidity and multimorbidity in adolescents with congenital heart disease (CHD) using data from a multisite population-based surveillance project. METHODS Adolescents aged 11 to 18 years with at least 1 CHD-related diagnosis code and residing in one of 5 geographic areas in the US were identified using linked clinical and administrative data sources for the years 2011 to 2013. Sites linked data on all inpatient, emergency department, and outpatient visits. Multivariate Poisson regression with robust error estimates was used to assess the association of comorbidity with age, sex, insurance type, race, ethnicity, and CHD severity. RESULTS The study included 9626 adolescents. Of these, 26% had severe CHDs. Overall, 68% had at least one comorbidity during the study period, and 46% had multiple comorbidities. Noncardiac comorbidities (55%) were more frequent than cardiac comorbidities (40%). Major noncardiac comorbidities included mental health conditions, neurodevelopmental disorders, pulmonary obstructive disease, nutrition-related (overweight, obesity) conditions, and endocrine conditions. Cardiac comorbidities included arrhythmias and residual cardiac disease. Variations by age and sex were minimal, but a higher burden of comorbidity and multimorbidity was associated with CHD severity, multiracial background, and public insurance. CONCLUSIONS Comorbidities, both cardiac and noncardiac, are prevalent in adolescents with CHD, underscoring the need for targeted care strategies in this age group and effective transition programs from pediatric to adult CHD care.

Association between sociodemographic and clinical factors and utilization of hematopoietic cell transplant in acute myeloid leukemia from 2004 to 2020.