Years Of Continuous Coverage Research Articles

What explains racial/ethnic inequities in the uptake of differentiated influenza vaccines?

We investigated the role of individual, community and vaccinator characteristics in mediating racial/ethnic disparities in the uptake of differentiated influenza vaccines (DIVs; including high-dose, adjuvanted, recombinant and cell-based vaccines).We included privately-insured (commercial and Medicare Advantage) ≥65 years-old community-dwelling health plan beneficiaries in the US with >1 year of continuous coverage and who received ≥1 influenza vaccine during the study period (July 2014–June 2018).Of 2.8 million distinct vaccination claims, 60% were for DIVs; lower if received in physician offices (49%) compared to pharmacies/facilities (74%). Among those vaccinated in physician offices, non-whites had lower odds of receiving a DIV if they lived in a non-minority county (0.77;95%CI 0.75–0.80) and even lower odds if they lived in a minority county (0.62;0.60–0.63). Differences in education, household income, medical history, community and vaccinator characteristics did not fully explain the disparities. Similar patterns emerged for vaccinations in pharmacies/facilities, although disparities disappeared altogether after controlling for socio-economic and vaccinator characteristics. When vaccinated in physician offices, minority county residents were less likely to receive a DIV, especially for non-whites (0.72;0.67–0.78). These disparities disappeared for whites, but not for non-whites, after controlling for community and vaccinator characteristics.We found an alarming level of inequity in DIV vaccine uptake among fully insured older adults that could not be fully explained by differences in sociodemographic, medical, community, and vaccinator characteristics. New strategies are urgently needed to address these inequities.

Clinical Practice Variation of Statin Use in Pediatric Heart Transplantation

<h3>Purpose</h3> Universal initiation of statin therapy within 2 weeks of heart transplantation (HT) is a Class 1A recommendation in adults due to improved morbidity and mortality via reduction of coronary graft vasculopathy. Data regarding the benefit of statins in pediatric transplant patients is equivocal, although the safety and efficacy of statins in children with conditions including familial hyperlipidemias has now been well established. Previous work reported only 1/3 of pediatric transplant patients were prescribed a statin in the period before 2012. We sought to establish statin prescribing practices in a sample of U.S. pediatric HT recipients in the current era, hypothesizing that use of statins in pediatrics increases with age and has increased over time. <h3>Methods</h3> We performed a retrospective study of a geographically representative sample of U.S. children using the MarketScan® Commercial and Medicaid claims databases. The study population was children who underwent HT between the ages of 2 and 19 and had ≥3 years of continuous coverage from 1/1/2013-6/30/2018. We assessed the average age for initiation of statins and the probability of statin prescription by age. <h3>Results</h3> Of the 8.4 million children with available Marketscan data, 876 children (age: 9.8 ± 5.0 years, 54% male) underwent a HT prior to or during the study period. A higher proportion of HT recipients received Medicaid than commercial insurance coverage (56% vs. 44%, p<0.001). 35% (95% CI 32-38%) of HT recipients were on a statin, at an average age of 11.47 ± 4.6 years at the time of the first statin prescription. The earliest age of statin initiation was at 2 years. Likelihood of statin prescription increased with age (18% of those between 2-5 years, 25% between 6-10 years, and 47% in those over 13 years). <h3>Conclusion</h3> Only 1/3 of pediatric HT patients filled a prescription for a statin in this recent cohort, similar to historical rates. Younger children were less likely to receive statins, which may be related to lack of liquid formulation or lack of historical safety data in young children. However, only half of teenagers receive statins by age 19 which is contrary to current adult HT guidelines. This suggests that statin prescribing practices in children after HT should be a focus for improving adherence to national guidelines. Future work will look at effects of socioeconomic factors in statin prescribing patterns.

Adherence With Lipid Screening Guidelines in Children With Acquired and Congenital Heart Disease: An Observational Study Using Data From The MarketScan Commercial and Medicaid Databases.

BackgroundUniversal lipid screening in children provides an opportunity to mitigate the lifetime risk of atherosclerosis, particularly in children with chronic conditions that are predisposed to early atherosclerosis. In response, national guidelines recommend additional early screening in a subset of cardiac conditions. The penetration of such guidelines has not been evaluated.Methods and ResultsWe performed a retrospective study of a geographically representative sample of US children using the MarketScan Commercial and Medicaid claims databases. The study population was children with cardiac disease between ages 2 and 18 years and ≥3 years of continuous coverage from January 1, 2013, to June 30, 2018, divided into 4 major strata of heart disease. We assessed the likelihood of screening between these classifications and compared with healthy children and calculated multivariate models to identify patient factors associated with screening likelihood. Of the eligible 8.4 million children, 155 000 children had heart disease, of which 1.8% (31 216) had high‐risk conditions. Only 17.5% of healthy children underwent lipid screening. High‐risk children were more likely to be screened (odds ratio [OR], 2.1; 95% CI, 2.09–2.19; P<0.001) than standard‐risk children, but that likelihood varied depending on strata of cardiac disease (22%–77%). Timing of screening also varied, with most occurring between ages 9 and 11 years. Among cardiac conditions, heart transplantation (OR, 16.8; 95% CI, 14.4–19.7) and cardiomyopathy (OR, 2.9; 95% CI, 2.8–3.1) were associated with the highest likelihood of screening.ConclusionsChildren with cardiac disease are more likely to undergo recommended lipid screening than healthy children, but at lower rates and later ages than recommended, highlighting the importance of quality improvement and advocacy for this vulnerable population.

Infant Allergy Testing and Food Allergy Diagnoses Before and After Guidelines for Early Peanut Introduction

A landmark 2015 trial on early exposure to peanuts led to expert recommendations for screening and early peanut introduction in high-risk (severe eczema and/or egg allergy) infants, but the impact of this paradigm shift on allergy testing and diagnosis is unknown. We assessed the effects of the Learning Early About Peanut Allergy (LEAP) trial and guideline publications on allergy testing and food allergy diagnoses in infants. In this retrospective cohort study, deidentified administrative health claims from a commercial and Medicare advantage claims database were used. Infants with at least 1 year of continuous coverage were selected using newborn codes for birth hospitalizations from January 2010 to June 2018. Interrupted time series models were used to compare the prevalence of allergy testing before and after LEAP publication in February 2015 and formal guideline publication in January2017. For 487,533 included infants, allergy testing increased after LEAP (risk ratio [RR]: 1.11 [95% confidence interval (CI), 1.07-1.15]) and guidelines (1.21 [1.18-1.23]). This increase of testing was also seen in infants not considered high risk, both after LEAP (1.12 [1.08-1.17]) and guidelines (1.20 [1.16, 1.23]). For first-time allergy tests, post-guideline median number of allergens tested was 9 for serum tests and 10 for skin tests. Post-guidelines, there was a significant increase in diagnosis of peanut (RR: 1.08 [1.00, 1.16]), egg (1.12 [1.05, 1.20]), and other food allergies (excluding milk) (1.22 [1.14, 1.31]). Allergy testing has increased, including in non-high-risk infants. Multiallergen testing may be contributing to an increase in the diagnosis of other food allergies.

Preoperative opioid use is associated with increased readmission, revision surgery and cost after total shoulder arthroplasty

BackgroundPreoperative opioid use has been associated with higher pain scores and lower functional outcomes after total shoulder arthroplasty (TSA), but the association between preoperative opioid use and readmission, revision surgery and cost following TSA is less well-known. The purpose of this study is to determine the association between preoperative opioid use and readmission, revision surgery and cost after total shoulder arthroplasty. MethodsUsing the Marketscan© administrative claims database, we identified patients from 2010–2015 who underwent primary TSA using Current Procedural Terminology codes. 5,621 patients aged 18–64 were identified who had 6-months of continuous coverage preoperatively and one year of continuous coverage postoperatively. Patients who were using opioids up until the 30-day period prior to surgery were classified as preoperative opioid users. Our primary outcomes were rates of 90-day all-cause hospital readmission, 1-year rates of revision surgery, and 1-year healthcare payments. Logistic regression and a generalized linear model were used to analyze binomial and payment data, respectively. All models were controlled for age, gender and Charlson comorbidity index. ResultsMean age of patients was 57 ± 5.6 years, 42% were females. Average length of stay was 1.7 ± 1.2 days. 28% of patients were using opioids preoperatively. Preoperative opioid use was associated with significantly increased odds of 90-day readmission (OR 2.6, p<0.001), having a revision TSA within 1-year (OR 2.35, p<0.001), and higher total postoperative 1-year healthcare payments (+$10,034, p<0.001). Preoperative opioid use was also associated with a small, but significant increased length of stay (+0.13 days, p = 0.001). ConclusionsPreoperative opioid use is associated with increased rates of readmission and revision surgery following TSA. Patients undergoing TSA have significantly higher total healthcare costs and a modest increase in length of hospital stay. Level of evidenceLevel II

Medical utilization surrounding initial opioid-related diagnoses by coding method.

To identify methods for coding initial opioid-related disorder (ORD) diagnoses in administrative claims and determine whether coding methods correspond to acute medical utilization patterns. Retrospective analysis of Blue Health Intelligence commercial data. We included members with 2 years of continuous coverage around the first appearance of an ORD diagnosis code (initial ORD) in medical or pharmacy claims with dates of service between October 2015 and March 2016. Initial ORD was identified by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) F11 codes or buprenorphine for medication-assisted treatment (BUP-MAT) with a duration of 3 or more days. Descriptive analyses were evaluated prediagnosis, in the month of diagnosis, and post diagnosis and included mean cost per member per month (PMPM); mean monthly percentage of members with at least 1 opioid agonist prescription (OAP), inpatient visit, or emergency department (ED) visit; and percentage of members with at least 1 ICD-10-CM Z79.891 code (long-term [current] use of opiate analgesic). A total of 6426 initial ORD diagnoses were identified by F11.20 (65.2%), F11.x (28.7%), and BUP-MAT (6.1%). PMPM costs for BUP-MAT ($2054) were lower than for F11.20 ($5053) and F11.x ($6597) in the diagnosis month. Mean monthly percentage of members with at least 1 OAP declined from pre- to post initial ORD diagnosis (F11.20, 52.5% to 50.0%; F11.x, 44.1% to 37.9%; BUP-MAT, 34.0% to 12.7%). Members with initial ORD coded as F11.x had the highest mean percentage with at least 1 inpatient or ED visit in the diagnosis month (30.9% and 26.8%, respectively) versus F11.20 (19.3% and 10.8%) and BUP-MAT (5.1% and 3.5%). Percentage of members with at least 1 Z79.891 code was higher post diagnosis than in the month of diagnosis (F11.20, 34.6% vs 25.7%; F11.x, 16.5% vs 8.1%; BUP-MAT, 19.5% vs 8.1%). Medical utilization patterns of members with ORD differ by the coding method used to document their initial diagnosis in administrative claims.

Updated imaging does not affect revision rates in adults undergoing spine surgery for lumbar degenerative disease.

OBJECTIVEDiagnostic workup for lumbar degenerative disc disease (DDD) includes imaging such as radiography, MRI, and/or CT myelography. If a patient has unsuccessful nonoperative treatment, the surgeon must then decide if obtaining updated images prior to surgery is warranted. The purpose of this study was to investigate whether the timing of preoperative neuroimaging altered clinical outcome, as reflected by the subsequent rate of revision surgery, in patients with degenerative lumbar spinal pathology.METHODSFrom the Health Care Service Corporation administrative claims database, adult patients (minimum age 55 years old) with lumbar DDD who underwent surgery including posterior lumbar decompression with and without fusion (1-2 levels) and at least 5 years of continuous coverage after the index surgery were identified. The chi-square test was used to determine differences in revision rates stratified by timing of each imaging procedure relative to the index procedure (< 6 months, 6-12 months, 12-24 months, or > 24 months).RESULTSOf 28,676 cases identified, 5128 (18%) had revision surgery within 5 years. The timing of preoperative MRI or plain radiography was not associated with revision surgery. Among the entire cohort, there was a lower incidence of revision surgery in patients who had a CT myelogram within 1 year prior to the index surgery (p = 0.017). This observation was strongest in patients undergoing decompression only (p = 0.002), but not significant in patients undergoing fusion (p = 0.845).CONCLUSIONSRoutine reimaging prior to surgery, simply because the existing MRI is 6-12 months old, may not be beneficial, at least as reflected in subsequent revision rates. The study also suggests that there may be a subset of patients for whom preoperative CT myelography reduces revision rates. This topic has important financial implications and deserves further study in a more granular data set.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P25. Updated imaging does not affect revision rates in adults undergoing spine surgery for lumbar degenerative disease

BACKGROUND CONTEXT Diagnostic workup for lumbar degenerative diseases (LDD) includes imaging such as radiographs, MRIs and/or CT-myelograms. If a patient fails conservative treatment, the surgeon must then decide if obtaining updated images prior to surgery is warranted. PURPOSE The purpose of this study is to determine if the timing of imaging impacts surgical decision-making as reflected by a difference in the rate of revision surgery in patients with lumbar degenerative disease. STUDY DESIGN/SETTING Analysis of private payor administrative claims database. PATIENT SAMPLE From the Health Care Service Corporation administrative claims database, adult patients (mean age 55) with LDD who had surgery including posterior lumbar decompression with and without fusion (1–2 levels) and at least five years of continuous coverage after the index surgery. OUTCOME MEASURES Revision surgery. METHODS From the Health Care Service Corporation administrative claims database, adult patients (mean age 55) with LDD who had surgery including posterior lumbar decompression with and without fusion (1–2 levels) and at least five years of continuous coverage after the index surgery were identified. Chi-square was used to determine differences in revision rates stratified by timing of each imaging procedure relative to the index procedure (≤6 months, 6–12 months, >12–24 months or >24 months). RESULTS Of 28,676 cases identified, 5,128 (18%) had revision surgery within 5years. The timing of preoperative MRI or plain radiographs was not associated with revision surgery. Among the entire cohort, there was a lower incidence of revision surgery in patients who had a CT-myelogram within 1 year prior to the index surgery (p=.017). This observation was strongest in patients undergoing decompression only (p=.002), but not significant in patients undergoing fusion (p=.845). CONCLUSIONS Routine re-imaging prior to surgery, simply because the existing MRI is 6-12 months old is probably unnecessary, at least as reflected in subsequent revision rates. The study also suggests that there may be a subset of patients for whom preoperative CT myelography reduces revision rates. This topic has important financial implications and deserves further study in a more granular dataset.

Preoperative full-length standing radiographs and revision rates in lumbar degenerative scoliosis.

OBJECTIVE Full-length (36-inch) standing spine radiographs are commonly used by spine surgeons to evaluate patients with lumbar degenerative scoliosis (LDS). Despite this practice, the impact of these images on preoperative decision making and the rate of revision surgery has not been analyzed. The purpose of this study is to determine if preoperative full-length standing spine radiographs improve surgical decision making by decreasing the rate of revision surgery in patients with LDS. METHODS From the Health Care Service Corporation administrative claims database, the authors identified patients 50-80 years of age with LDS who had undergone surgery including posterior lumbar decompression and fusion over 2-6 levels and with at least 5 years of continuous coverage after the index surgery. Patients were stratified into the following groups, according to the preoperative imaging studies performed within 6 months before their index surgery: lumbar spine MRI studies only, lumbar spine MRI studies and standard lumbar spine radiographs, CT myelograms, and full-length standing spine radiographs. Survival analysis was performed with the occurrence of a revision within 5 years of the index surgery as the outcome of interest. RESULTS A total of 411 patients were included in the study after applying the inclusion and exclusion criteria. Revision surgery within 5 years after the index procedure was most frequent in the patients with preoperative MRI only (41.8%), followed by the patients with a CT myelogram (30.4%) and those with MRI and standard radiographs (24.8%). The lowest revision rate was seen among those with long-cassette standing radiographs (11.1%). Patients whose preoperative evaluation included full-length standing radiographs (OR 0.353, p = 0.034) and MRI studies plus radiographs (OR 0.650, p = 0.022) were less likely to require revision surgery at 5 years after the index procedure. CONCLUSIONS An assessment of standing alignment using full-length (36-inch) standing radiographs may be beneficial in reducing the risk of revision surgery in patients with lumbar scoliosis. This observation was not limited to patients with large curves or substantial deformity.

Odense Pharmacoepidemiological Database: A Review of Use and Content.

The Odense University Pharmacoepidemiological Database (OPED) is a prescription database established in 1990 by the University of Southern Denmark, covering reimbursed prescriptions from the county of Funen in Denmark and the region of Southern Denmark (1.2 million inhabitants). It is still active and thereby has more than 25 years of continuous coverage. In this MiniReview, we review its history, content, quality, coverage, governance and some of its uses. OPED's data include the Danish Civil Registration Number (CPR), which enables unambiguous linkage with virtually all other health-related registers in Denmark. Among its research uses, we review record linkage studies of drug effects, advanced drug utilization studies, some examples of method development and use of OPED as sampling frame to recruit patients for field studies or clinical trials. With the advent of other, more comprehensive sources of prescription data in Denmark, OPED may still play a role as in certain data-intensive regional studies.

Changes in health for the uninsured after reaching age-eligibility for medicare

Uninsured adults in late middle age are more likely to have a health decline than individuals with private insurance. To determine how health and the risk of future adverse health outcomes changes after the uninsured gain Medicare. Prospective cohort study. Participants (N=3,419) in the Health and Retirement Study who transitioned from private insurance or being uninsured to having Medicare coverage at the 1996, 1998, 2000, or 2002 interview. We analyzed risk-adjusted changes in self-reported overall health and physical functioning during the transition period to Medicare (t(-2) to t(0)) and the following 2 years (t(0) to t(2)). Between the interview before age 65 (t(-2)) and the first interview after reaching age 65 (t(0)), previously uninsured individuals were more likely than those who had private insurance to have a major decline in overall health (adjusted relative risk [ARR] 1.46; 95% confidence interval [CI] 1.03 to 2.04) and to develop a new physical difficulty affecting mobility (ARR 1.24; 95% CI 0.96 to 1.56) or agility (ARR 1.33; 95% CI 1.12 to 1.54). Rates of improvement were similar between the 2 groups. During the next 2 years (t(0) to t(2)), adjusted rates of declines in overall health and physical functioning were similar for individuals who were uninsured and those who had private insurance before gaining Medicare. Gaining Medicare does not lead to immediate health benefits for individuals who were uninsured before age 65. However, after 2 or more years of continuous coverage, the uninsured no longer have a higher risk of adverse health outcomes.