York State Medicaid Research Articles

Integration of Data and Management Tools Into the New York State Medicaid Managed Care Encounter Data System

The New York State Department of Health has created a data warehouse to analyze and evaluate the Medicaid managed care program. Online query tools and reports, grouping tools such as Diagnostic Related Groups, and measurement tools such as Health Plan Data and Information Set (HEDIS) measures have been incorporated into the data warehouse. Other public health data sets including birth certificate data have also been integrated. The result is a powerful data set that can analyze information quickly and efficiently, with built-in data intelligence. Developed over time, this system can provide states, health insurance companies, and health data consortiums a roadmap on how to implement an integrated data warehouse solution.

Fragmentation of Care for Frequently Hospitalized Urban Residents

Fragmentation across sites of care may impede efficient healthcare delivery. The objectives of this study were to evaluate fragmentation of hospital care for chronically ill New York City (NYC) residents and its association with enrollment in the New York State (NYS) Medicaid program. We conducted a cross-sectional study using the NYS Department of Health's Statewide Planning and Research Cooperative System discharge database. We identified 53,031 NYC residents admitted 3 or more times to acute care hospitals between 2000 and 2002 with the same principal diagnosis of a specific chronic illness (diabetes, sickle cell anemia, psychosis, substance abuse, cancer, gastrointestinal disease, chronic obstructive pulmonary disease/asthma, coronary artery disease, or congestive heart failure). We also evaluated a larger cohort of 225,421 patients with >or=3 admissions for a specific chronic illness coded as either the principal or a secondary diagnosis. A generalized logit model was used to examine the relationship between fragmentation and each patient's primary insurance adjusted for diagnosis and demographic characteristics. Fragmentation was characterized as high, moderate, or low based on the number of distinct hospitals a patient visited relative to the patient's total number of hospitalizations over the 3-year interval. Among frequently hospitalized NYC residents with select chronic conditions, 17.1% experienced highly fragmented care. This rate was 9.9% for patients with commercial insurance, 24.4% for those with Medicaid, and 9.7% for those with Medicare. The unadjusted odds ratio describing high fragmentation of Medicaid enrollees compared with commercially insured patients was 3.82 (95% confidence interval [CI], 3.50-4.18) and, although attenuated, remained significant after adjustment for demographic characteristics (odds ratio, 1.33; 95% CI, 1.20-1.47). The strongest predictor of fragmentation was a diagnosis of psychosis (OR, 2.81; 95% CI, 2.43-3.25) or substance abuse (OR, 7.58; 95% CI, 6.55-8.77). In NYC, Medicaid enrollment is associated with greater fragmentation of hospital care, but this is largely attributable to the preponderance of Medicaid enrollees with diagnoses of psychosis and substance abuse. Strategies to improve the efficiency of healthcare delivery should focus on patients with mental illness who are frequently admitted to general hospitals.

Relationship of gender, depression, and health care delivery with antiretroviral adherence in HIV-infected drug users.

Antiretroviral adherence is worse in women than in men, and depression can influence medication adherence. To evaluate the relationship of gender, depression, medical care, and mental health care to adherence in HIV-infected drug users. Retrospective cohort study. New York State Medicaid program. One thousand eight hundred twenty-seven female and 3,246 male drug users on combination antiretroviral therapy for more than 2 months in 1997. A pharmacy-based measure of adherence was defined as > or =95% days covered by at least 2 prescribed antiretroviral drugs. Independent variables were: depression, regular drug treatment (> or =6 months), regular medical care (2+ and >35% of visits), HIV-focused care (2+ visits), psychiatric care (2+ visits), and antidepressant therapy. Women were less adherent than men (18% vs 25%, respectively,P <.001) and more likely to be diagnosed with depression (34% vs 29%). In persons with depression, the adjusted odds ratio (AOR) for adherence was greater for those with psychiatric care alone (AOR 1.52; 95% confidence interval [95% CI], 1.03 to 2.26) or combined with antidepressants (AOR 1.49; 95% CI, 1.04 to 2.15). In separate models by gender in persons with depression, psychiatric care plus antidepressants had a slightly stronger association with adherence in women (AOR 1.92; 95% CI, 1.00 to 3.68) than men (AOR, 1.26; 95% CI, 0.81 to 1.98). In drug users without depression, antidepressants alone were associated with greater adherence (AOR, 1.23; 95% CI, 1.02 to 1.49) with no difference by gender. Regular drug treatment was positively associated with adherence only in men. In this drug-using cohort, women had worse pharmacy-measured antiretroviral adherence than men. Mental health care was significantly associated with adherence in women, while regular drug treatment was positively associated with adherence in men.

Medicaid prescriber compliance with Joint National Committee VI Hypertension Treatment Guidelines.

Since the early 1970s, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) has been tasked with the formulation of national guidelines for the management of hypertension. These were significantly changed in 1993 with publication of JNC-5. JNC-6 kept many basic treatment recommendations (i.e., initiation of therapy with a thiazide diuretic or beta-blocker), partly in response to the low adoption rate of the treatment recommendations of JNC-5. To describe single-drug outpatient therapy of hypertension and temporally correlate these therapies with the publication of JNC-5 and JNC-6. The electronic records of randomly selected New York State Medicaid recipients without hospitalization who had a diagnosis of hypertension and who were receiving only 1 antihypertensive medication were analyzed for 1994, 1997, and 1999. This analysis identified the medications selected for monotherapy of hypertension and compared these therapies with JNC recommendations. The analysis was correlated to patient comorbidities to further account for provider selection of a non-first-line agent. In 1994, angiotensin-converting enzyme (ACE) inhibitors and calcium-channel blockers accounted for 69% of therapies, with 67.5% of these patients having no JNC-recognized individualizing consideration for their use. In 1999, the combined use of ACE inhibitors and calcium-channel blockers accounted for over 65% of all single-drug therapy; 60% of these patients had no individualizing considerations. Also, in 1999, 47.7% of all patients appeared to be receiving antihypertensive therapies that are not compliant with JNC recommendations. Single-drug therapy of hypertension in a nonhospitalized New York state Medicaid population from 1994 through 1999 did not closely follow JNC recommendations for the single-agent treatment of hypertension.

Effect of medical, drug abuse, and mental health care on receipt of dental care by drug users

We examined the association of patterns of health care in 1996 with subsequent dental care in 1997 or 1998 for 47,260 drug users enrolled in New York State Medicaid. From Medicaid files, we identified psychiatric care, prescribed antidepressants, a regular source of medical care, regular drug treatment (6+ contiguous months), and clinical conditions. Of this cohort, 58% received dental care. The adjusted odds ratios (AOR) of dental care were increased for drug users receiving psychiatric care and antidepressants (1.66 [1.55, 1.77]), psychiatric care alone (1.48 [1.41, 1.56]), or only antidepressants (1.18 [1.10, 1.27]), vs. neither. AORs of dental care were also higher for those with a regular source of medical care alone (1.27 [1.23, 1.35]) or with regular drug treatment (1.33 [CI 1.25, 1.41]) vs. neither. Mental health care and, to a lesser extent, a regular source of medical care and regular drug treatment may promote dental care in this vulnerable population.

Outpatient patterns of care and longitudinal intensity of antiretroviral therapy for HIV-infected drug users.

To examine the association of drug users' outpatient patterns of care with subsequent intensity of antiretroviral therapy (ART). Annual types of ART in 8897 New York State Medicaid drug users who were prescribed ART for > or =6 months in 1996 or 1997 were determined. From pharmacy claims, intensity was classified from changes in annual type of ART in 1996 to 97 and 1997 to 98 as: optimal (ie, on or starting highly active ART [HAART]), acceptable (ie, on or starting 2+ non-HAART drugs), or suboptimal (ie, none, <6 months, one drug, or change from HAART to non-HAART). In both 1996 and 1997, outpatient pattern of care was defined including regular medical care, regular drug treatment, both, and neither and categories of visits for HIV-focused care. Predictors of adequate ART intensity were examined among the group with suboptimal or adequate intensity (model 1) and predictors of optimal ART intensity among the group with adequate or optimal intensity (model 2). The adjusted odds ratios (AOR) of acceptable ART intensity in model 1 were increased for those with HIV-focused care (AOR, 2.9; 95% CI, 2.6, 3.3 for 4+ visits 1.7; 95% CI, 1.5, 1.9 for 1-3 visits) or regular medical care (AOR, 1.2 [1.1, 1.4]. Adjusted odds ratios (AOR) of optimal intensity in model 2 were increased for those with regular substance abuse care with (AOR, 1.4 [1.2, 1.7]) or without (AOR, 1.2 [1.1, 1.4]) regular medical care whereas HIV-focused visits had no effect. Care from an HIV-focused provider was predictive of a drug user receiving at least adequate intensity of ART for more than 2 years whereas regular drug abuse treatment, especially with regular medical care, was associated with optimal intensity of ART.

HIV-1 RNA viral load monitoring in HIV-infected drug users on antiretroviral therapy: relationship with outpatient care patterns.

HIV-1 viral load (VL) testing is a standard component of HIV care. We examined the use and predictors of VL testing in drug users, a group at risk for problematic care. Using 1996 to 1998 New York State (NYS) Medicaid files, we studied drug users who had been enrolled >10 months, had been prescribed antiretroviral agents in 1997 and 1998, and who had undergone any VL testing in 1997. Our outcome was regular VL testing shown by two or more paid claims for this test in 1998. Patterns of care in 1997 were defined as: regular source of medical care (>35% of visits to one provider), and/or regular drug treatment of >6 months, or neither. We counted visits in 1997 to a provider offering HIV-focused care. Adjusted odds ratios (AORs) of VL testing were assessed. Of 3131 drug users, 73.9% had at least one VL test, whereas 56.2% had two or more VL tests in 1998. The AORs of two or more VL tests were increased for those with regular drug abuse care alone (AOR, 1.50; 95% confidence interval [CI], 1.21-1.84) or with regular medical care (AOR, 1.27; 95% CI, 1.03-1.57) versus those with neither. HIV-focused care was positively associated with two or more VL tests (AOR, 1.38; 95% CI, 1.05-1.81 for 1-3 visits; AOR, 1.94; 95% CI, 1.50-2.51 for four or more visits). We found that nearly half this cohort of drug users did not have regular VL testing. Drug users with HIV-focused care or with regular drug treatment are more likely to have regular VL testing.

Regular outpatient medical and drug abuse care and subsequent hospitalization of persons who use illicit drugs.

Patients and the public could benefit from identification of factors that prevent drug users' heavy reliance on inpatient care; however, optimal health care delivery models for illicit drug users remain ill-defined. To evaluate associations of outpatient medical and drug abuse care with drug users' subsequent hospitalization rates. Retrospective cohort study of data from longitudinally linked claims for all ambulatory physician/clinic services and drug abuse services covered by the New York State Medicaid program. A total of 11 556 human immunodeficiency virus (HIV)-positive and 46 687 HIV-negative drug users. Hospitalization in federal fiscal year (FFY) 1997 compared by 4 patterns of care in FFY 1996: regular drug abuse care (>/=6 months in 1 program), regular medical care (>35% of care from 1 clinic, group practice, or individual physician), both, or neither. Hospitalization occurred in 55.6% of HIV-positive and 37.5% of HIV-negative drug users, with a mean of 27.5 and 24.5 inpatient days, respectively. In HIV-positive drug users, the adjusted odds ratio (AOR) for hospitalization was lowest among those with both regular medical and drug abuse care (AOR, 0.76; 95% confidence interval [CI], 0.67-0.85) followed by those with regular medical care alone (AOR, 0.82; 95% CI, 0.74-0.91) and regular drug abuse care alone (AOR, 0.85; 95% CI, 0.76-0.96) vs those with neither. In HIV-negative drug users, the AOR of hospitalization was lower for those with regular medical and drug abuse care (AOR, 0.73; 95% CI, 0.68-0.79), regular drug abuse care alone (AOR, 0.71; 95% CI, 0.66-0.76), and regular medical care (AOR, 0.91; 95% CI, 0.86-0.95) vs those with neither. Both types of care showed favorable effects for all but drug abuse-related hospitalizations. Our data indicate that regular drug abuse care with regular medical care for drug users is associated with less subsequent hospitalization.

Commercial managed care plans leaving the Medicaid managed care program in New York State: impact on quality and access.

To develop sufficient managed care capacity to accomplish the goal of transitioning Medicaid recipients into managed care, state policymakers have relied on commercial health maintenance organizations to open their panels of providers to the Medicaid population. However, while commercial health maintenance organization involvement in Medicaid managed care was high initially, since 1996 New York State has had 14 commercial plans leave the New York State Medicaid Managed Care Program. It has been speculated that the exodus of these commercial plans would have a negative impact on Medicaid enrollees' access and quality of care. This paper attempts to evaluate the impact of this departure from the perspective of quality and access measures and plan audit performance. Univariate and multivariate analyses were performed to evaluation the effect of commercial managed care plans leaving the Medicaid program. The overall performance of plans that remained in the program was compared to that of the plans that chose to leave for the two time periods 1996-1997 and 1998-2000. Access to care, quality of care, and annual audit performance data were analyzed. The departure of commercial health plans from the New York State Medicaid Managed Care Program has not had a statistically significant negative effect on the quality of care provided to Medicaid recipients as evaluated by standardized performance measures. In addition, there were no instances when there was a negative impact of the exit of the commercial plans on access to care. Managed care plans that chose to remain in Medicaid passed the Quality Assurance Reporting Requirements audit at a significantly (P < .01) higher rate than plans that chose to leave. A program consisting of health plans voluntarily participating and committed to Medicaid managed care can provide Medicaid recipients with appropriate access to high-quality health care. The exodus of commercial health plans from New York's Medicaid Managed Care Program during the time periods studied did not result in a detectable adverse impact on the quality of care for enrollees.

Models of care in New York State Medicaid substance abuse clinics. Range of services and linkages to medical care.

To explore the range of health care services in substance abuse clinics. Survey of directors of a stratified random sample of 125 substance abuse treatment clinics offering methadone, drug-free therapy, or both, representing 344 clinics participating in the New York State (NYS) Medicaid program. Survey asked about clinic services and referral patterns. We defined five categories of linkage of substance abuse to medical care ranging from unlinked (e.g. referral to distant sites) to highly linked (e.g. on site). To estimate the number of patients served, State data on licensed patient capacity for each clinic were used. This sample represented 344 clinics statewide serving an estimated 60,914 patients. For patients with acute, chronic, or HIV-related medical conditions, weighted analyses showed highly linked care in 54 of the 344 (16%) clinics statewide, serving an estimated 13,741 patients. Unlinked care for all these medical conditions was found for 28% of statewide clinics, serving an estimated 8866 patients. Clinics offering both methadone and drug-free therapy were generally more likely to have medically related services on site. The extent of medical care services available at substance abuse clinics varies widely. Over one-quarter of clinics offered only loosely connected medical and substance abuse care.

Effect of enhanced prenatal and HIV-focused services for pregnant women who are infected by human immunodeficiency virus on emergency department use.

This study examines whether the receipt of enhanced prenatal or human immunodeficiency virus (HIV) medical services is associated with in-pregnancy emergency department (ED) utilization by HIV-infected women. Medicaid and vital statistics records were linked for 1,826 women who are infected by HIV and who were delivered from 1993 to 1995 while receiving New York State Medicaid. The authors examined two types of ambulatory care--the Prenatal Care Assistance Program (PCAP) and enhanced care focused on HIV--that offer additional services in exchange for increased Medicaid reimbursement. From logistic regression models, the authors estimated adjusted associations of these types of care with ED use during pregnancy not leading directly to hospitalization. Fifty-three percent of pregnant women visited the ED. Women with ED use averaged 2.0 visits (SD = 1.1). After adjustment for demographic and substance use factors, enhanced care focused on HIV was not associated with any ED use (OR = 1.11, 95% CI 0.94, 1.30) or, among those using the ED at least once, with number of visits (P = 0.84). Interactions of receipt of PCAP care with the Adequacy of Prenatal Care Utilization Index (APNCU) and having a usual source of care in pregnancy improved model fit (P < 0.001 and P = 0.06, respectively). PCAP was associated with increased ED use only among women with inadequate APNCU or no usual source of prenatal care. Pregnant women infected with HIV receiving Medicaid relied heavily on ED care. Use of the ED was not associated with services focused on HIV but was positively associated with enhanced prenatal care. The association of enhanced prenatal care with greater ED use was curbed for women with more timely and adequate prenatal care visits or a usual source of prenatal care.

Frequency and predictors of medically attended injuries in HIV-infected children.

The extent to which medically attended injuries complicate the clinical course of HIV-infected (HIV+) children is unknown. In a cohort of HIV+ children delivered from 1985 to 1990 and aged less than 60 months, we determined medically attended injuries per 100 child-years, Injury Severity Scores (ISS), and predictors of medically attended injuries by using New York State Medicaid claims from 1986 to 1992 linked to birth certificates. Injury rates and ISS were compared to those of a population of black, inner city children aged less than 60 months from emergency room records. HIV+ children had slightly more injuries (19.3 vs. 16.8/100 child-years) but similar ISS (2.4 vs. 2.3). Predictors of injuries in HIV+ children included younger maternal age (24/100 child-years, p = 0.008) and delivery outside of New York City (29/100 child-years, p = 0.02). Illicit drug use and alcohol use were associated with greater ISS while cocaine use was associated with a higher rate of possibly intentional injuries. Medically attended injuries affected one in five HIV+ children in our cohort annually, slightly more than the comparison population. Specific maternal and birth characteristics such as substance abuse and younger age at delivery may help target at-risk children.

Relationship between ambulatory care accessibility and hospitalization for persons with advanced HIV disease.

Specific features of ambulatory care, such as accessibility, may influence hospital use for patients with HIV infection. To identify clinic features associated with a lower risk of hospitalization, 6,280 New York state Medicaid enrollees diagnosed with AIDS in 1987-1992 and managed by one of 157 surveyed clinics were studied. The odds of hospitalization in the year before AIDS diagnosis were associated with five clinic features that facilitate the accessibility of care: (1) evening/weekend hours, (2) case manager, (3) appointments within 48 hours, (4) telephone consultation, and (5) whether the clinic handled urgent care. Hospitalization in the year before AIDS diagnosis occurred for 49 percent of patients. Three of the five accessibility features had unadjusted associations with lower hospitalization rates. The adjusted odds of hospitalization were lower for patients in clinics with extended hours (OR = 0.77, 95% CI = 0.63, 0.93) and for patients in clinics with four or more accessibility features compared with those in clinics with less than two features (OR = 0.67; 95% CI = 0.50, 0.89).

Translating clinical trial results into practice: the effect of an AIDS clinical trial on prescribed antiretroviral therapy for HIV-infected pregnant women.

The success of Pediatric AIDS Clinical Trials Group (PACTG) Protocol 076 in preventing vertical HIV transmission prompted intensive efforts to inform lay-persons and professionals about the trial's results. To explore community responsiveness to these efforts by assessing temporal, maternal, and health care factors associated with prescribed antiretroviral therapy before and after PACTG Protocol 076. Retrospective cohort study. New York State Medicaid program. 2607 HIV-infected women who delivered a living child between January 1993 and September 1996. Adjusted odds of being prescribed antiretroviral treatment in the second or third trimester for women who delivered in period 1 (during the trial [January 1993 to February 1994]), period 2 (after the trial's end and announcement of the results to publication of the results [March 1994 to November 1994]), and period 3 (after publication of the trial results [December 1994 to September 1996]). The adjusted odds of being prescribed antiretroviral therapy increased 21% per month in period 2 and decreased to 3% per month in period 3. In all time periods, the adjusted odds of being prescribed antiretroviral therapy were at least 60% greater (P < 0.05) for women who were treated at an institution that performed HIV clinical trials, received HIV-focused ambulatory care, or had adequate prenatal care visits. After the trial, women receiving methadone treatment had at least twofold (95% CI, 1.5- to 4.3-fold) greater adjusted odds of being prescribed antiretroviral therapy than women who did not take any illicit drugs. Latin-American women, older women, and women born in the United States had greater adjusted odds (P < 0.05) of being prescribed treatment in period 3. Community practice responded rapidly to efforts to disseminate the results of PACTG Protocol 076; however, the absolute increase in prescribed therapy was greatest for women who had adequate prenatal visits or were receiving HIV-focused care, care at a site that performed clinical trials, or methadone therapy.

Improved Birth Outcomes Associated With Enhanced Medicaid Prenatal Care in Drug-Using Women Infected With the Human Immunodeficiency Virus

Objective: To evaluate the effectiveness of an intervention designed to enhance Medicaid prenatal care in improving birth outcomes of drug-using women infected with the human immunodeficiency virus (HIV). Methods: Medicaid and vital statistics records were linked for 353 HIV-infected drug-using women delivering in 1993 and 1994 while enrolled in New York State Medicaid. Of these, 68% were treated by providers participating in the Prenatal Care Assistance Program, designed to provide case management, improved continuity, referral services, and behavioral risk reduction counseling. In a series of logistic models, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of low birth weight (less than 2500 g) and preterm delivery (before 37 weeks), comparing women using and not using the program. Results: Women using the Prenatal Care Assistance Program were significantly less likely, after adjustments were made for maternal characteristics, to have low birth weight infants and preterm deliveries (OR 0.52, 95% CI 0.31, 0.89; and OR 0.57, 95% CI 0.34, 0.97, respectively). Adding measures of greater adequacy and continuity of prenatal care to the models explained just over 20% of the Prenatal Care Assistance Program’s protective effect. The addition of maternal high-risk behavior, HIV-focused care, and drug use treatment variables altered program effect estimates less profoundly (together accounting for 4 and 9% of the program’s protection against low birth weight and preterm delivery, respectively). Conclusion: The Prenatal Care Assistance Program appeared to be successful in reducing the incidence of low birth weight and preterm delivery in this high-risk population. The program’s success can be attributed, in part, to increased adequacy and continuity of prenatal care and, to a lesser extent, to more frequent receipt of special services and reduced maternal high-risk behaviors.

Clinic characteristics associated with reduced hospitalization of drug users with AIDS.

To identify features of ambulatory care associated with reduced hospitalization among drug users with acquired immunodeficiency syndrome (AIDS). A nonconcurrent prospective study of hospital use by 1,369 drug users with AIDS was conducted using data from New York State Medicaid research data files linked to telephone interview data from directors of ambulatory care clinics serving this group. Follow-up averaged 29 months, during which 88% of subjects were hospitalized at least once. On average, those hospitalized spent 14% of follow-up time as inpatients. Hospitalization was less likely for patients in clinics with case managers (adjusted odds ratio = 0.42, 95% confidence interval 0.25, 0.69) or high director's rating of coordination of care (adjusted odds ratio = 0.50, 95% confidence interval 0.29, 0.89). Multivariate analysis showed significantly less time in hospital for patients in clinics with methadone maintenance, case managers, high continuity ratings, and clinic physicians attending for hospitalized clinic patients. Drug users with AIDS rely heavily on inpatient care, but those followed in clinics featuring greater coordination and offering special services, including methadone treatment and case management, appear to have significantly less hospital use.

Repeated emergency department use by HIV-infected persons: effect of clinic accessibility and expertise in HIV care.

Repeated emergency department (ED) visits by HIV-infected persons may signify poor access to care or treatment from inexperienced ambulatory providers. We examined features of 157 clinics following 6820 HIV-infected patients and associations with repeated (> or =2) ED visits by these patients in the year before their first AIDS diagnosis. Patient clinical and health care data came from 1987-1992 New York State (NYS) Medicaid files and clinic data came from interviews of clinic directors. The HIV/AIDS experience of each study patient's clinic was measured as the annual number of Medicaid enrollees newly diagnosed with AIDS who were contemporaneously followed by the patient's clinic. Repeated ED use was observed for 24%. The adjusted odds ratio (AOR) of repeated ED visits was reduced for patients in clinics with a physician on-call (0.77; 95% confidence interval [CI] = 0.65, 0.92), evening or weekend clinic hours (0.77; 95% CI = 0.64, 0.93), or >50 AIDS patients/year in 1987-1988 (0.56; 95% CI = 0.44, 0.71) versus fewer patients in those years. Patients in clinics with more than one feature promoting accessibility or HIV expertise had a greater reduction in their AOR of repeated ED use. HIV-infected patients in clinics with greater accessibility and HIV expertise rely less on the ED for care.

The Risk for Outpatient Antibiotic-Treated Infections Following a Course of Oral Corticosteroids Among Children with Asthma

Short courses of oral corticosteroids are widely used to treat asthma. The objective of this study was to assess if one course of oral corticosteroids increases asthmatic children's risk for infections treated with outpatient antibiotics. Using New York State Medicaid claims data on asthmatic children 2–15 years old, we made cohorts of oral corticosteroid users and nonusers. We determined the percentage of children who filled antibiotic prescriptions in the 30 days after index dates. Index dates were dates oral steroids were started (for steroid users) or matched dates (for nonusers). Odds ratios were adjusted for age, month of index date, and prior antibiotic use. Among children not receiving antibiotics on index dates, antibiotic prescriptions were filled in the next 30 days for 438 (20%) of 2145 steroid nonusers and 130 (19%) of 698 steroid users (p = 0.30); compared to nonusers, steroid users had an adjusted odds ratio of subsequent antibiotic use of 0.92 (95% confidence interval [CI] 0.73–1.15). Among children receiving antibiotics on index dates, antibiotic prescriptions were filled in the next 30 days for 116 (26%) of 451 steroid nonusers and 50 (19%) of 260 steroid users (p = 0.05); compared to nonusers, steroid users had an adjusted odds ratio of subsequent antibiotic use of 0.65 (95% Cl 0.53–0.97). We conclude that one course of oral corticosteroids does not increase asthmatic children's risk for infections treated with outpatient antibiotics.

Prevention of vertical HIV transmission with zidovudine: Projected impact of HIV testing and prenatal care

We sought to estimate the impact of maternal HIV testing and prenatal care on the potential to reduce vertical transmission through zidovudine (AZT) use by HIV-infected mothers. We evaluated the prepartum maternal HIV diagnosis rate, prenatal care, disease stage, and vertical transmission rate (from a two-part mixture model) using New York State Medicaid and vital statistics data for HIV-infected mothers and their singletons in 1985-90. We used published data to estimate the effect of AZT on vertical transmission and expert input to define other parameters for the model. Our HIV-infected (N = 1514) had a vertical transmission rate of 27.0%. HIV was diagnosed prepartum for 39.5% of women in 1990. Transmission would have been 22.2% if AZT had been taken only by the subset of women diagnosed prepartum with HIV and receiving prenatal care by 34 weeks gestation (86.7%). Transmission would have dropped to 11.2% if all women had been diagnosed prepartum with HIV and received adequate prenatal care. The observed deficiencies in prenatal care and maternal HIV diagnosis rates in this Medicaid population-based cohort must be addressed to realize the promise of AZT to reduce vertical transmission.

Cigarette smoking and maternal-child HIV transmission.

We investigated the association of cigarette smoking with maternal-child HIV transmission, adjusting for illicit drug use, maternal clinical status, and delivery factors. Vital statistics birth data were linked to the New York State Medicaid HIV/AIDS Research Database for HIV-infected women delivering a liveborn singleton from 1988 through 1990. Follow-up of these children was accomplished by Medicaid data > or = 2 years after birth, and their HIV status was ascertained by a clinically based classification. The adjusted relative risk or hazard (RH) of transmission for maternal factors was determined from Cox models. The overall transmission was 24.5% for the 901 maternal-child pairs. Smokers comprised 40% of women with data on smoking (n = 768); their transmission rate was 31% versus 22% for nonsmokers (p = 0.02). In the entire cohort, the adjusted RH of transmission for smokers was 1.45 (95% confidence interval [CI] 1.07-1.96); among women with advanced HIV, the adjusted RH was even higher (RH = 1.71; 95% CI 1.14-2.58). Users of cocaine (15% of the cohort) or of mixed or unspecified illicit drugs (28%) had higher transmission rates in unadjusted analysis (33%, p = 0.06 and 31%, p = 0.06 respectively); after adjustment for smoking and other maternal factors, neither cocaine (RH = 1.04 (95% CI 0.66-1.63)) nor mixed nor unspecified drug use (RH = 1.13 (95% CI = 0.75-1.70)) was significantly associated with transmission. Our data document an association of cigarette smoking during pregnancy with an increased risk of maternal-child HIV transmission that can be added to the growing list of complications caused by cigarette smoking.