Payer Type Research Articles

Sunday, June 19, 202211:30 AM - 12:30 PMGSOR13 Presentation Time: 11:30 AM: Factors Associated with Hospital-Negotiated Prices of Tandem & Ovoids in the U.S. in 2021

<h3>Purpose</h3> HDR brachytherapy, such as tandem & ovoids (T&O), is a crucial component of definitive care for locally advanced cervical cancer in the U.S. Its cost and those of other healthcare services are often unknown or unclear at the time of care. Upfront, accessible price transparency may help address patients' financial concern. Effective 1/1/2021, the Hospital Price Transparency Rule (45 CFR Part 180) requires all U.S. hospitals to annually release hospital-related prices. Our project seeks to evaluate the availability, variation, and factors associated with hospital-negotiated prices of T&O in the U.S. <h3>Materials and Methods</h3> We conducted a cross-sectional study of U.S. hospitals in CMS's Care Compare, linking to Turquoise Health (hospital-negotiated prices), Healthcare Cost Report Information System (hospital characteristics), and Social Vulnerability Indices. We identified six T&O-related CPT codes (77280, 77470, 77370, 77318, 77771, and 57155), with their negotiated-prices estimated by payer type. We used regression models to estimate the association of hospital characteristics with commercial prices. <h3>Results</h3> A majority of the hospitals are non-profit (61%), acute care hospitals (69%), and/or non Graduate Medical Education (GME)-participating (72%), with a median operating margin of 0.03 (IQR:-0.03, 0.09), asset-to-liability ratio of 1.79 (1.06, 2.96), and social vulnerability index of 0.53 (0.29, 0.74). 17-28% of hospitals reported T&O-related prices depending on the CPT code. Prices were typically greater for commercial insurance compared to Medicare/Medicaid (+$335-362 simulation, +$550-798 MD plan, +$224-747 physics plan, +$1160-1707 treatment; P<0.001, all tests), except for CPT code 57155 (treatment) where the Medicare price was greater than commercial insurance's price (+403; P<0.001). Table 1 shows the adjusted analysis of commercial prices. <h3>Conclusion</h3> Our analysis shows that negotiated T&O prices in the U.S. is typically higher for commercial insurances, hospitals with higher operating margins, and non GME participating hospitals; it is typically lower for critical access hospitals. Socially vulnerable areas do not consistently enjoy lower prices. Further price transparency research and advocacy could better elucidate this area, thereby promoting economic competition and lower the price for curative cervical cancer treatment.

Geographic disparities in peripartum cardiomyopathy outcomes

BACKGROUNDCardiomyopathy causes more than a third of late postpartum pregnancy–related deaths in the United States, and racial disparities in outcomes among pregnant individuals with cardiomyopathy exist. Underlying community factors may contribute to disparities in peripartum cardiomyopathy outcomes. OBJECTIVEThis study aimed to identify the geographic distribution of and disparities in peripartum cardiomyopathy outcomes, hypothesizing that patients living in communities with higher social vulnerability may have worse outcomes. STUDY DESIGNThis was a retrospective cohort study of patients with peripartum cardiomyopathy per the National Heart, Lung, and Blood Institute definition from January 2000 to November 2017 at a single center, excluding those with a post office box address as a post office box address may not reflect the census tract in which a patient resides. Severe peripartum cardiomyopathy (vs less severe peripartum cardiomyopathy) was defined as ejection fraction <30%, death, intensive care unit admission, left ventricular assist device or implantable cardioverter defibrillator placement, or transplant. The US census tract for the patient's address was linked to the Centers for Disease Control and Prevention Social Vulnerability Index, a 0 to 1 scale of a community's vulnerability to external stresses on health, with higher values indicating greater vulnerability. The Social Vulnerability Index includes social factors divided into socioeconomic, household composition, minority status, and housing type and transportation themes. The Social Vulnerability Index and Social Vulnerability Index components were compared among patients by peripartum cardiomyopathy severity. RESULTSOf 95 patients in the original cohort, 5 were excluded because of the use of a post office box address. Of the remaining 90 patients, 56 met severe peripartum cardiomyopathy criteria. At baseline, individuals with and without severe peripartum cardiomyopathy had similar ages, marital status, payor type, tobacco use, gestational age at delivery, and mode of delivery; however, individuals with severe peripartum cardiomyopathy were more likely to be Black (vs White) (59% vs 29%; P<.007) and less likely to recover ejection fraction (EF) to ≥55% by 12 months (36% vs 62%; P=.02) than individuals with less severe peripartum cardiomyopathy. Patients with severe peripartum cardiomyopathy were more likely to live in areas with a higher Social Vulnerability Index (0.51 vs 0.31; P=.002) and with more residents who were unemployed, impoverished, without a high school diploma, in single-parent households, of minority status, without a vehicle, and in institutionalized group quarters than patients with less severe peripartum cardiomyopathy. The median income was lower in communities of individuals with severe peripartum cardiomyopathy than in communities of individuals with less severe peripartum cardiomyopathy. CONCLUSIONPatients with severe peripartum cardiomyopathy outcomes were more likely to live in communities with greater social vulnerability than patients with less severe peripartum cardiomyopathy outcomes. To reduce disparities and maternal mortality rates, resources may need to be directed to socially vulnerable communities.

ЕКОСИСТЕМНІ ПЛАТЕЖІ ЯК ІНСТРУМЕНТ РЕАЛІЗАЦІЇ ЕКОСИСТЕМНОГО ПІДХОДУ В УПРАВЛІННІ ПРИРОДОКОРИСТУВАННЯМ

Зростання екологічних загроз і виснаження природних ресурсів мотивують до перегляду наукових концепцій взаємодії суспільства з природою. Одночасно в економіку природокористування поступово впроваджується екосистемний підхід, теоретико-методологічні засади якого в Україні ще належним чином не сформовано. З огляду на це, обґрунтовано особливості трансформації сучасного механізму природокористування шляхом упровадження екосистемного підходу з використанням основного його економічного інструменту – екосистемних платежів. Екосистемний підхід до природокористування – напрям в управлінні, який забезпечує врахування при плануванні й здійсненні будь-яких заходів природокористування складних біологічних відносин усередині екосистеми, природні ресурси якої експлуатуються; усвідомлення цінності цих відносин завдяки їх спроможності позитивно впливати на стан, продуктивність екосистеми і виконання нею важливих екологічних функцій. Ієрархічну структуру процесу впровадження екосистемного підходу в практику управління природокористуванням відображають керівні принципи Конвенції про біологічне різноманіття, які з науково-практичної точки зору доцільно розділяти на організаційно-економічні та еколого-економічні. Екосистемні платежі – це платежі за використання, невикористання ресурсів або послуг екосистеми, відшкодування її забруднення чи деградації; усі платежі, що здійснюються в межах екосистемного підходу і мають на меті захист, збереження екосистем, раціональне використання їх ресурсів та підвищення ефективності функцій. Вони включають обов’язкові платежі за використання ресурсів екосистем, їх забруднення, виснаження або деградацію; компенсаційні платежі, які держава сплачує громадянам за використання їх екосистем або фермерам за невикористання ними екосистем чи використання на умовах упровадження нових технологій; платежі за екосистемні послуги; еквівалентні платежі. Критеріями визначення типу платежів є їх добровільність; належність бюджету, за рахунок якого вони сплачуються; переважання екосистемної цінності над ринковими інтересами; сутність платежу; можливість регулювання за допомогою цивільних договорів, відтермінування платежу і зміни його розміру; залежність платежу від результатів господарської діяльності; обопільність вигоди.

Retrospective Identification of Barriers to On-Time Discharge in Common General Surgery Operations

Introduction: Increased durations of hospital stays are associated with increased nosocomial infections, higher mortality rates, lower patient satisfaction, and increased cost. This study aimed to identify barriers to safe and on-time discharge. Methods: Data was collected from electronic health records for all elective surgeries performed at an academic medical center over the last 5 years. The top 4 operations were selected: coronary artery bypass graft surgery (CABG) (n = 342), video-assisted thoracoscopic surgery (VATS) (n = 216), cholecystectomy (n = 350), and ventral hernia repair (n = 153). The primary outcome is length of stay (LOS), specifically extended LOS. Extended LOS was defined by a longer LOS compared with the average LOS provided by the Medicare Severity Diagnosis Related Groups (MS-DRG). Results: There were 6,473 patients and 10,468 operations analyzed. Extended LOS represented 23% of cases. There was no association between extended LOS and demographics, payor type, or employment status. Disposition to short-term nursing facility was associated with extended LOS in CABG and VATS. Unemployed and retired patients were associated with extended LOS among cholecystectomy patients. Conclusion: We identified predictive factors (disposition to a skilled nursing facility, and employment status) contributing to extended LOS postoperatively. We suspect that referral processes, number of facilities, and selection biases associated with short-term nursing facilities are major contributors to extended LOS and improvements in these processes can improve outcomes while decreasing identified risks associated with longer hospital stays.

Real-world variability in use of bone-modifying drugs for multiple myeloma by payer type.

129 Background: The use of bone-modifying agents (BMAs) in multiple myeloma is gold standard. Benefits include prevention of skeletal-related events, reduction in bone pain, and improved progression-free survival. Guidelines recommend that patients with active multiple myeloma receive a BMA for up to two years. Unfortunately, real-world data has shown undertreatment with delays in initiation, interruptions in dosing, and premature discontinuation. These gaps are more pronounced for Black patients. The objective of this study was to describe real-world BMA treatment patterns across different payer types: Medicaid, Medicare, and Commercial/Exchange. Methods: This was a retrospective observational study using oncology prior authorization data from multiple payers in the New Century Health (NCH) database. NCH is specialty risk management company who supported over 107,000 oncology patients in 2021. All patients with a diagnosis of multiple myeloma, as indicated by the treating provider’s office, were included who had a prior authorization request for anti-cancer therapy between January 1, 2021, and December 31, 2021. Use of BMA was defined as having ≥1 authorization request for zoledronic acid or denosumab any time in the prior 24 months. BMA use was also evaluated by payer: Medicaid, Medicare, or Commercial/Exchange. Results: A total of 4774 patients were identified as having active multiple myeloma from January 1, 2021, to December 31, 2021. Fifty-nine percent (59.6%) of patients had at least one authorization request for a BMA submitted by their treating provider any time in the preceding 24 months. While most of the identified patients had Medicare, when request for BMA was disaggregated by payer, meaningful differences were found. For patients with commercial or exchange coverage, 64.6% (281/435) had a BMA requested; for patients with Medicare coverage, 60.1% (2339/3890) had a BMA requested. However, for patients with Medicaid, only 51% (229/449) had a BMA requested. Conclusions: Like other studies, our findings highlight underuse of BMAs in multiple myeloma. Differences in request for BMA across payer types suggests variability in adherence to guidelines may be based on patient insurance. To achieve equitable outcomes, including for patients of lower socioeconomic status, targeted efforts must be put in place to ensure receipt of guideline-directed therapy. A strength of this study is the large population and diversity of patients from practices in 41 states with multiple payer types. However, our analysis is limited by several unknown factors such as patient contraindication to or declination of BMA in past that are not captured in the NCH database. This retrospective study, using a large real-world oncology database, highlights that many patients with multiple myeloma may not be receiving guideline-based BMA therapy and that there are meaningful differences depending on patient insurance type.

EXPOSURE TO SYSTEMIC CORTICOSTEROIDS AMONG US PATIENTS WITH ASTHMA: RISKS ASSOCIATED WITH SHORT-ACTING BETA2-AGONIST USE

EXPOSURE TO SYSTEMIC CORTICOSTEROIDS AMONG US PATIENTS WITH ASTHMA: RISKS ASSOCIATED WITH SHORT-ACTING BETA2-AGONIST USE

The economic burden of HIV-associated wasting in the era of modern antiretroviral therapy.

BACKGROUND: HIV-associated wasting (HIVAW) is associated with increased morbidity and mortality in people living with HIV (PWH). Evaluating health care resource utilization and cost predictors of HIVAW is important in understanding the overall economic burden of the disease. OBJECTIVE: To evaluate the economic burden and cost predictors associated with HIVAW. METHODS: This analysis of the IBM MarketScan Commercial, Medicare Supplemental, and Medicaid databases included members with a claim for HIV (using International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification codes) between July 2012 and September 2018, with the HIV index date defined as the first HIV diagnosis claim in the dataset. PWH were excluded if they were aged less than 18 years, had any malignancy claim, or had less than 6 months of enrollment data pre-HIV or post-HIV index date. Members were defined as having HIVAW using an algorithm of claims for weight loss-related diagnoses, appetite stimulant or nontestosterone anabolic agents, or enteral/parenteral nutrition at any time post-HIV index. Taking antiretroviral therapy (ART) was defined as having at least 1 pharmacy claim of any ART 12 months post-HIV index. Total all-cause costs were calculated as the sum of payments for hospitalizations, emergency department visits, outpatient visits, and pharmacy use. A multivariate generalized linear model with log-link and γ distribution was used to estimate the impact of HIVAW predictors of total all-cause costs. RESULTS: Among 42,587 members with HIV included in the study (64.6% male; mean age: 44 years; 67.5% insured with Medicaid; and 63.9% taking ART), the overall prevalence of HIVAW was 18.3% during the study period. HIVAW prevalence was 17.9% for those taking ART and 19.1% for those not taking ART. Prevalence by payer type was 7.5% for Commercial ± Medicare Supplemental and 23.5% for Medicaid. Members with HIVAW had more comorbidities and opportunistic infections compared with members without HIVAW. Members with HIVAW were also more than twice as likely to be hospitalized (71.1% vs 32.1%) and had 5 times the number of hospitalizations (1.0 vs 0.2) and twice the number of emergency department visits (3.0 vs 1.3) per year post-index compared with members without HIVAW (P < 0.01). HIVAW was associated with 1.3-times-higher mean annualized total all-cause costs per member (95% CI = 1.26-1.36). CONCLUSIONS: HIVAW remains prevalent despite advances in ART and is associated with additional health care resource utilization and costs. Further research is needed to better understand the relationship between HIVAW and comorbidity burden and ART utilization and payer types. DISCLOSURES: This study was sponsored by EMD Serono, Inc., Rockland, MA, USA (CrossRef Funder ID: 10.13039/100004755). Dr Siddiqui has received consulting and speaking fees from AbbVie, BioFire, Cumberland, EMD Serono, Inc., Rockland, MA, USA, and Merck. Dr Samuel, Ms Hayward, Ms Wirka, Dr Phillips, and Dr Harbour are employees of EMD Serono, Inc., Rockland, MA, USA. Drs Deering and Harshaw are employees of EPI-Q, Inc., which received payment from EMD Serono, Inc., Rockland, MA, USA, for the development and execution of this study.

S1488 Characteristics and Healthcare Patterns of Super-Utilizers Among Patients Hospitalized With a GI Diagnosis

Introduction: In the United States, a small number of patients, labeled as super-utilizers accounts for a disproportionately large fraction of healthcare expenditure. The knowledge about the characteristics of super-utilizers and their impact on healthcare utilization would be helpful to various stakeholders to target interventions aimed at reducing the disproportionate use of the healthcare system. Methods: We extracted data from the Nationwide Readmission Database (NRD) 2019, on patients admitted primarily with a gastrointestinal (GI) pathology. We used Agency for Healthcare Research and Quality’s definition for super-utilizers (2 standard deviations above the average number of hospital stays for patients in each payer category which were ≥4 for Medicaid/Medicare and ≥3 for privately /uninsured in 2019). We collected data on demographics, readmission rates, and hospitalization costs. Results: Of 1,704,913 patients who were discharged alive, 6.3% were categorized as super-utilizers. The highest proportion of super-utilizers was observed among patients with hepatic failure (19.6%), non-infectious hepatitis (13.6%), and inflammatory bowel disease (10.4%) (Figure 1). On multivariate analysis, several characteristics were independently associated with super-utilizers, especially the comorbidity burden and disease severity (Table 1). The mean number of admissions for an average super-utilizer was ∼4 times compared to other patients (mean admissions: 5.5 vs 1.4; P < 0.001). Super-utilizers were mostly admitted for medical diagnosis (83.4% vs 67.3%) as compared to surgical (16.5% vs 31.4%) and for non-elective reasons (92.1% vs 88.9%). The 30-day readmission rate was ∼6 times higher among super-utilizers compared to other patients (36.6% vs 6.4% P < 0.001). Compared to other patients, super-utilizers had longer hospital stays (mean days: 5.8 vs 4.4; P < 0.001) and higher average hospitalization costs (mean US$: 15060 vs 13023; P < 0.001). Super-utilizers although only 6.3%, accounted for 31.5% of hospitalization days, 28.2% of costs, 19.6% of hospital stays, and 27.3% of all-cause 30-day readmissions. These findings were consistent across the different payer types on subgroup analysis. Conclusion: 6.3% of patients admitted with a GI diagnosis were classified as super-utilizers. Comorbidity burden and disease severity were strongly associated with super-utilizers. Super-utilizers accounted for a disproportionate share of hospital days, costs, stays, and 30-day readmissions compared to other patients.Figure 1.: Percentage of super-utilizers among various GI pathologies resulting in hospitalization in 2019. Table 1. - Multivariate analysis showing association between super-utilizer status and various patient- and hospital-level characteristics Characteristics Odds Ratio [95% CI] ‘P’ value Charlson Comorbidity index 1.70 (1.68-1.73) < 0.001 Severity 1.37 (1.35-1.38) < 0.001 Teaching hospital 1.21 (1.15-1.28) < 0.001 Hospital Bed size 1.05 (1.03-1.07) < 0.001 Hospital control 1.04 (1.01-1.07) 0.006 Age 0.98 (0.98-0.98) < 0.001 Income 0.98 (0.97-0.99) < 0.001 Female gender 0.97 (0.95-0.98) < 0.001 Urban location 0.88 (0.83-0.92) < 0.001

P.209 Prevalence of healthcare conditions and services used by patients with myotonic dystrophy (DM) pre- and post-diagnosis: A real-world data analysis

DM types 1 and 2 are dominantly inherited multisystem disorders that cause progressive weakness and myotonia along with variable cardiopulmonary, gastrointestinal, endocrine, and neurological manifestations that adversely affect quality of life. Literature describing the DM patient journey is limited. To describe the changes in outcomes (healthcare conditions, services, costs, and care days) we analyzed PharMetrics deidentified-US-claims (Jan-2010—Mar-2021) for patients with DM compared with matched controls (MCs) two years post-pre diagnosis. DM-patients had ≥2 DM claims ≥30 days apart (index date=first diagnosis date). Cohorts were matched (5-MC:1-DM) on index date, age, region, gender, plan, and payer types. Outcomes were compared two-years post-diagnosis minus two-years pre-diagnosis (Post-PreDx) using US agency for healthcare research & quality (AHRQ) categories. Data reported is per-member-per-year. All reported findings were significant (p<0.05). We identified 519 DM-patients and 2595 MCs. Most outcomes demonstrated higher care utilization in DM-patients than MCs. Post-PreDx care days increased at all service settings except lab for both cohorts (↑9.9 DM vs ↑1.5 MCs). Post-preDx DM-patients' AHRQ-prevalence changed in 58 (↑57↓1) categories led by "other nervous system disorders" (37.6% DM vs 3.2% MCs), "cardiac dysrhythmias" (17.3% DM vs 2.3% MCs) and "other lower respiratory disease" (16.0% DM vs 2.7% MCs). DM-patients' mean number of services increased post-preDx (21.3 vs 2.9 MCs). Post-preDx DM-patients' utilization increased in 21 AHRQ-service and 7 AHRQ-cost categories. Total medical and drug costs increased for DM-patients' (↑$6,889 to $25,594) vs MCs (↑$1,044 to $6,684). Health care utilization increased significantly in DM patients following diagnosis and was overall both higher and in different categories than MCs. This likely reflects the need to evaluate and manage previously unsuspected manifestations of DM following formal diagnosis.

S1605 Comparable Outcomes of Endoscopic, Surgical, and Hybrid Resection of Gastric GIST

Introduction: Gastrointestinal stromal tumors (GIST) are rare, comprising < 1% of all gastrointestinal tumors, and most commonly arise in the stomach (60%). Surgical resection (SR) has been the mainstay of therapy, however endoscopic resection (ER) is being performed for small lesions, while hybrid resection (HR) can be used for bigger lesions, both becoming a viable alternative to surgery. We aimed to analyze Gastric GIST (G-GIST) management trends, compare outcomes, and hospital resource utilization between ER, SR, and HR techniques in the USA. Methods: Using ICD-10 diagnosis code for G-GIST (C49.A2), we extracted adult ( >20y) patients’ data from Nationwide Inpatient Sample (2017-2019yy). We used the procedure codes for ER (0D568ZZ, 0DB68ZZ, 0DT78ZZ), open and laparoscopic SR(0D564ZZ, 0DB64ZZ, 0DB60ZZ, 0DT74ZZ,0DT70ZZ), and HR (endoscopic and laparoscopic codes combined), and defined technical procedural and systemic complications. Mortality, complications, length of stay (LOS), and hospitalization charges were used as outcomes. Statistical analysis was performed with SAS. Results: A total of 145 ER, 7875 SR, and 70 HR procedures for G-GIST management was identified. According to different approaches, there was no difference in primary payer types or median household income. There was slight male to female predominance in ER and HR but not in the SR group. Racial disparities were noted in the ER >SR but not in HR (Figure). Most procedures were performed in teaching institutions: ER (93%), SR (86%), and HR (86%). Mortality for SR was 0.8%, and no inpatient deaths were recorded for ER or HR. Mean charges were highest for HR ($163,794) and lowest for ER ($86,811), with LOS highest for HR (10.7d), followed by ER (∼7d) and SR (5.5d). More complications were noted in HR (43%, vs 28% in ER and 18% in SR) (Table). Most SR and HR patients were discharged home (94% and 93%, respectively); A lesser percentage of ER (72%) were discharged home with a relatively higher percentage of 28% sent to long-term care facilities compared to SR (5%) and HR (7%). Conclusion: Minimally invasive management of G-GIST is evolving, with surgery still being most common. Both endoscopic and hybrid techniques are promising alternatives to surgery and show a lower mortality rate, however, with a higher percentage of non-fatal complications (both), increased cost (HR only), and increased LOS (both) compared to SR. Larger studies can help guide providers in choosing the optimal individual approach in G-GIST management.Figure 1.: Sociodemographic Analysis of Endoscopic, Surgical and Hybrid Gastric GIST Resection Table 1. - Hospital Resource Utilization and Complications for Endoscopic, Surgical and Hybrid Gastric GIST Resection Endoscopic Resection 95% CI Surgical Resection 95% CI Hybrid Resection 95% CI Mean Charges $86,811 $54,981-$118,641 $93,112 $87,943-$98,280 $163,794 $114,128-$213,461 Mean Length of Stay (days) 6.9 4.6-9.2 5.5 5.2-5.8 10.7 7.1-14.4 Complications 27.6% 11.2-44% 17.8% 15.9-19.7% 42.9% 16.8-68.9%

Differences in the utilization of palliative care support services among patients with metastatic solid tumor cancer in a community oncology setting: A retrospective review.

82 Background: Palliative care has been underutilized in the setting of advanced cancer despite its established benefit in improving the quality of life in cancer patients. Few studies have evaluated socioeconomic disparities in receiving palliative care in the outpatient oncology setting. We aimed to evaluate for disparities in utilization of palliative care among patients with metastatic solid tumor malignancies at Tennessee Oncology, a large outpatient community oncology practice with an established palliative care program. Methods: We completed a retrospective review of medical records of 1513 patients that were seen in Tennessee Oncology clinics from 12/2020 to 12/2021. We compared the baseline characteristics of patients with metastatic solid tumor malignancies who did and did not receive palliative care. Chi-square and two-sample t-tests were used for data analysis with the 5% significance level using R statistical software. Results: Male patients utilized palliative care less often than female patients (17% versus 24% for females, p =.0002; 95% CI,.05-1.0). Of payer types, Medicare had the least palliative care utilization (14%) compared to commercial (25%) and other payers (23%). Utilization also varied by cancer type, with melanoma (9%), lung cancer (15%) and renal cancer (21%) being least likely to receive palliative care (p &lt;.00005; 95% CI,.19-1.0). We did examine racial differences in palliative care utilization, but those did not reach statistical significance. Conclusions: There are multiple disparities in the utilization of on-site palliative care support services among patients with metastatic solid tumor cancer in this outpatient community oncology setting. Further research is needed to gain insight into why this is, including an in-depth analysis of both patient and provider utilization/referral practices.[Table: see text]

Examining racial and ethnic disparities in adult emergency department patient visits for concussion in the United States.

BackgroundRacial and ethnic differences in emergency department (ED) visits have been reported among adolescent patients but are unsubstantiated among adults. Therefore, our purpose in this study was to examine the relationship between race/ethnicity and adult ED visits for concussions, their injury mechanisms, and computed tomography (CT) scan use among a nationally representative sample.MethodsWe used the National Hospital Ambulatory Medical Care Survey database from 2010–2015 to examine 63,725 adult (20–45 years old) patient visits, representing an estimated 310.6 million visits presented to EDs. Of these visits, 884 (4.5 million national estimate) were diagnosed with a concussion. Visit records detailed patient information (age, sex, race/ethnicity, geographic region, primary payment type), ED visit diagnoses, injury mechanism (sport, motor vehicle, fall, struck by or against, “other”), and head CT scan use. The primary independent variable was race/ethnicity (non-Hispanic Asian, non-Hispanic Black or African American, Hispanic/Latinx, non-Hispanic multiracial or another, and non-Hispanic White). We used multivariable logistic and multinomial regression models with complex survey sampling design weighting to examine the relationship between concussion ED visits, injury mechanisms, and CT scan use separately by race/ethnicity while accounting for covariates.ResultsThere were no associations between race/ethnicity and concussion diagnosis among adult ED visits after accounting for covariates. Relative to sports-related injuries, non-Hispanic Black or African American patient visits were associated with a motor vehicle (OR = 2.69, 95% CI: 1.06–6.86) and “other” injury mechanism (OR = 4.58, 95% CI: 1.34–15.69) compared to non-Hispanic White patients. Relative to sports-related injuries, non-Hispanic Asian, multiracial, or patients of another race had decreased odds of falls (OR = 0.20, 95% CI: 0.04–0.91) and “other” injuries (OR = 0.09, 95% CI: 0.01–0.55) compared to non-Hispanic White patients. The odds of a CT scan being performed were significantly lower among Hispanic/Latinx patient visits relative to non-Hispanic White patients (OR = 0.52, 95% CI: 0.30–0.91), while no other race/ethnicity comparisons differed.ConclusionOur findings indicate that the overarching concussion ED visit likelihood may not differ by race/ethnicity in adults, but the underlying mechanism causing the concussion and receiving a CT scan demonstrates considerable differences. Prospective future research is warranted to comprehensively understand and intervene in the complex, multi-level race/ethnicity relationships related to concussion health care to ensure equitable patient treatment.

What are the reasons for abandonment of low vision devices prescribed in a large tertiary eye care centre?

To investigate abandonment rates of near-vision low vision devices (LVDs) and factors that influence abandonment among patients attending a tertiary low vision rehabilitation centre in South India. Two hundred and eighty-six adults with low vision completed the modified device abandonment survey 1 year following device prescription. The survey included six questions: possession of device, timing of last use, reasons for abandonment, tasks for which the device was used, payment type and change in quality of life (QoL) from device use. The primary outcome measure was abandonment. Multivariate logistic regression analysis was used to investigate factors for abandonment. Three hundred and twelve near-vision devices were prescribed (mean, 1.09 device per patient.) Stand magnifiers (35%) followed by hand-held magnifiers (24%) were most frequently prescribed. Mean logMAR visual acuity (Snellen) in the better-seeing eye was 0.80 (6/38). Of the prescribed near-vision devices, 22% (95% CI, 17 to 27) were abandoned. Patients who abandoned the device were significantly older than those who did not (49.3 ± 17.2 vs. 43.5 ± 18.1 years; p=0.03). In multivariable analysis, patients reporting no change in their QoL from device use had higher odds of abandoning the device (OR: 63.97; 95% CI, 23.77 to 172.12). Device-related (31%) and psychological (30%) factors were the most frequent reasons for abandonment. Among device-related issues, the most frequent reason was that patients felt the device was too complex to use (50%) followed by being too cumbersome to use (25%). The abandonment rate for near-vision LVDs in South India was comparable with that reported in high-income countries. Patients reporting no change in their QoL had a higher likelihood of abandoning the device compared with those who reported some change. Device-related and psychological factors were the most frequent reasons for abandonment. These results can be used to develop strategies to improve compliance with use of devices.

Differences in elective epilepsy monitoring unit admission rates by race/ethnicity and primary payer in New Jersey

Elective admission to the epilepsy monitoring unit (EMU) is an essential service provided by epilepsy centers, particularly for those with drug-resistant epilepsy. Given previously characterized racial and socioeconomic healthcare disparities in the management of epilepsy, we sought to understand access and utilization of this service in New Jersey (NJ). We examined epilepsy hospitalizations in NJ between 2014 and 2016 using state inpatient and emergency department (ED) databases. We stratified admissions by race/ethnicity and primary payer and used these to estimate and compare (1) admission rates per capita in NJ, as well as (2) admission rates per number of ED visits for each group. Patients without insurance underwent elective EMU admission at the lowest rates across all racial/ethnic groups and payer types studied. Black patients with Medicaid and private insurance were admitted at disproportionately low rates relative to their number of ED visits. Hispanic/Latino and Asian/Pacific Islanders with private insurance, Hispanic/Latinos with Medicaid, and Asian/Pacific Islanders with Medicare were also admitted at low rates per capita within each respective payer category. Future studies should focus on addressing causal factors driving healthcare disparities in epilepsy, particularly for patients without adequate health insurance coverage and those who have been historically underserved by the healthcare system.

An observational study of health insured visits for children following Medicaid eligibility expansion for adults among a linked cohort of parents and children.

Despite its focus on adults, the Affordable Care Act (ACA) Medicaid expansion led to increased health insurance enrollment for children in the United States. Previous studies looked at parent and child insurance changes separately, or used a single survey response item to understand changes in health insurance for parents and children. It is, however, important to understand the connection between parent and child insurance changes together (not individually) using data sources that account for insurance over time. Therefore, to understand the association of parental health insurance on their children’s coverage, leveraging a cohort of linked families seen in community health centers (CHCs), we used electronic health records to link a cohort of parents and children with ≥1 visit to a CHC in a Medicaid expansion state pre- (1/1/2012–12/31/2013) and ≥1 visit post-ACA (1/1/2014–12/31/2018) and determined primary payer type for all visits. This observational, cohort study assessed the rate of insured visits for children pre- to post-ACA across four parental insurance groups (always insured, gained Medicaid, discontinuously insured, never insured) using Poisson mixed effects models. We included 335 CHCs across 7 United States. Insurance rates were highest (~95 insured visits/100 visits) for children of parents who were always insured; rates were lowest for children of parents who were never insured (~83 insured visits/100 visits). Children with a parent who gained Medicaid had 4.4% more insured visits post- compared to pre-ACA (adjusted relative rates = 1.044, 95% confidence interval: 1.014, 1.074). When comparing changes from pre- to post-ACA between parent insurance groups, children’s insured visit rates were significantly higher for children of parents who gained Medicaid (reference) compared to children of parents who were always insured (adjusted ratio of rate ratio: 0.963, confidence interval: 0.935–0.992). Despite differences in Medicaid eligibility for children and adults, health insurance patterns were similar for linked families seen in CHCs. Findings suggest consideration should be paid to parent health insurance options when trying to increase children’s coverage.

Investigating the Security Threats on Using M-Payment Applications in Saudi Arabia: Exploratory Study

Online banking, debit cards, credit cards and mobile payments are the most common payment types in Saudi Arabia. This study explored security threats that affect m-payment applications in Saudi Arabia by interviewing 16 IT professionals to explore their insights and opinions about those security threats. Cybersecurity threats present the biggest challenge for most mobile systems, as mobile payments can be affected by cyber-attacks and require sophisticated approaches to achieve the desired security. In our study we report on the impact of security threats on the utilization of mobile payment applications and provide evidence related to those threats and their impact on the use of mobile payment applications. Evidence was provided regarding the security threats and their impact on using mobile payment applications. Information was also provided related to security threats such as Distributed Denial-of-Service, phishing attacks and malware. Although the participants in this study demonstrated a positive attitude regarding the safety and security of mobile payments, they also highlighted the security threats that impact m-payments. The results showed that the three main threats in Saudi Arabia were Distributed Denial-of-Service (DDoS), phishing attacks and Malware (Malicious software). This study makes two contributions. The first is to theory, by filling the gap in the literature because it is the first study to explore the threats to using m-payment in Saudi Arabia. Secondly, this study contributes to practice by providing a clear picture for service providers and users about threats they may face when using m-payment.

Farm technical and environmental efficiency and subsidy redistribution in Ireland: A simulation approach of possible performance and equity effects

AbstractWe investigate the relationship between EU Common Agricultural Policy environmental payments, and dairy and beef farm level competitiveness and environmental performance. We use an Irish panel of farm level financial data for the years 2000–2017 and apply stochastic frontier analysis. Our estimates identify a positive relationship between technical efficiency and the Green, Low‐Carbon, Agri‐Environment Scheme for dairy farms, in contrast with the negative relation identified for previous payments of this kind such as the Rural Environment Protection Scheme for both beef and dairy. We then simulate increases in the first type of environmental payments financed through reductions in decoupled payments. We use alternative scenarios for payment redistribution such as flat allocation, allocation to farms with low stocking rates or proportional reallocation of payments. We find that under the second scenario, marginal environmental gains can potentially be achieved for dairy farms. For beef farms, the proportional allocation performs best regarding environmental gains. We also find that under this scenario, the impacts on income inequality can be smoothed for both farm types.

Changes in industry marketing payments to physicians during the covid-19 pandemic: quasi experimental, difference-in-difference study

ObjectiveTo determine changes in industry marketing payments to physicians due to the covid-19 pandemic.DesignQuasi experimental, difference-in-difference study.Data sourceUS nationwide database of licensed physicians, the National Plan and Provider Enumeration System,...

Prevalence and Outcomes of the Use of Telemedicine for Psychiatry Patients in the Outpatient Setting

OBJECTIVE: With the recent surge in telepsychiatry utilization, it is important to study the effectiveness of this virtual modality. METHOD: To determine if telemedicine visits were effective in keeping psychiatric patients stable, a retrospective study was performed in an outpatient behavioral health setting using the OQ®45.2/Y-OQ® 30.2 assessment tool, which assesses patient reported outcomes across areas of functioning. To qualify for this study, patients needed at least two OQ scores with one being prior to the onset of telepsychiatry care and one being after returning to in-person care. RESULTS: 51.1% of adults (n=176) improved or remained the same, whereas 48.8% deteriorated. Results indicated that 50.0% of youth (n=22) improved or remained the same, whereas 50% deteriorated. There were no significant differences in OQ scores between gender, ethnicity, adult age groups, nor number of visits. There were significant differences in adult OQ scores between payer types, and youth OQ scores between different races. CONCLUSION: It is important to note that this study was conducted during the COVID-19 Pandemic, where, naturally, many individuals were facing hardships; therefore, to improve or remain the same during the pandemic is still an accomplishment. By assessing total OQ scores among telemedicine patients, this study is showing that telepsychiatry is a very valuable resource for psychiatric patient care. Further research with a larger sample size of qualifying patients is warranted especially post pandemic.

Legislations Mandating Insurance Coverage Are Highly Effective in Delivering Surgical Care of Transgender Patients.

Background:Although gender-affirming surgery is increasingly performed, few studies have examined any temporal correlation between legislations mandating transgender care and the actuation of such surgical care.Methods:We assembled a retrospective cohort utilizing the National Inpatient Sample database from 2000 to 2018. We stratified utility trends of gender-affirming surgery based on insurance payer types and regions in a crisscrossing effort to detect any temporal or cause-effect relationship between legislations and outcomes. All regions according to the latest National Inpatient Sample categorization were examined based on the nature of their member state’s legislations relating to gender-affirming care coverage. Diametrically, opposite regions were selected for further comparisons. Interrupted time series analyses were used to demonstrate any significant uptrend since implementation of relevant legislations.Results:In states with explicit inclusion of gender-affirming care, our interrupted time series analyses showed a significant increase in the number of patients on state-dependent insurance (Medicaid and private insurance) receiving gender-affirming surgery around the time during which state legislations began mandating care (P < 0.01) and thereafter (P < 0.01). This significance was not seen in the same regions among patients under nonstate-dependent payers (Medicare and self-pay), nor was it seen in either payer group in states without explicit inclusion of gender-affirming care. At the federal level, statistical significance was noted among Medicare recipients across all states around the time federal legislations took effect and thereafter.Conclusion:Legislations mandating coverage seem highly effective in actuating surgical care of transgender patients in corresponding jurisdictions, which may provide a roadmap for further care expansion.