Comparative Effectiveness and Safety of Seizure Prophylaxis Among Adults After Acute Ischemic Stroke.

BACKGROUND: Older adults occasionally receive seizure prophylaxis in an acute ischemic stroke (AIS) setting, despite safety concerns. There are no trial data available about the net impact of early seizure prophylaxis on post-AIS survival. METHODS: Using a stroke registry (American Heart Association's Get With The Guidelines) individually linked to electronic health records, we examined the effect of initiating seizure prophylaxis (ie, epilepsy-specific antiseizure drugs) within 7 days of an AIS admission versus not initiating in patients ≥65 years admitted for a new, nonsevere AIS (National Institutes of Health Stroke Severity score ≤20) between 2014 and 2021 with no recorded use of epilepsy-specific antiseizure drugs in the previous 3 months. We addressed confounding by using inverse-probability weights. We performed standardization accounting for pertinent clinical and health care factors (eg, National Institutes of Health Stroke Severity scale, prescription counts, seizure-like events). RESULTS: The study sample included 151 patients who received antiseizure drugs and 3020 who did not. The crude 30-day mortality risks were 219 deaths per 1000 patients among epilepsy-specific antiseizure drugs initiators and 120 deaths per 1000 among noninitiators. After standardization, the estimated mortality was 251 (95% CI, 190-307) deaths per 1000 among initiators and 120 (95% CI, 86-144) deaths per 1000 among noninitiators, corresponding to a risk difference of 131 (95% CI, 65-200) excess deaths per 1000 patients. In the prespecified subgroup analyses, the risk difference was 52 (95% CI, 11-72) among patients with minor AIS and 138 (95% CI, 52-222) among moderate-to-severe AIS patients. Similarly, the risk differences were 86 (95% CI, 18-118) and 157 (95% CI, 57-219) among patients aged 65 to 74 years and ≥75 years, respectively. CONCLUSIONS: There was a higher risk of 30-day mortality associated with initiating versus not initiating seizure prophylaxis within 7 days post-AIS. This study does not support the role of seizure prophylaxis in reducing 30-day poststroke mortality.

Identifying Medicare Beneficiaries With Delirium.

BACKGROUND: Each year, thousands of older adults develop delirium, a serious, preventable condition. At present, there is no well-validated method to identify patients with delirium when using Medicare claims data or other large datasets. We developed and assessed the performance of classification algorithms based on longitudinal Medicare administrative data that included International Classification of Diseases, 10th Edition diagnostic codes. METHODS: Using a linked electronic health record (EHR)-Medicare claims dataset, 2 neurologists and 2 psychiatrists performed a standardized review of EHR records between 2016 and 2018 for a stratified random sample of 1002 patients among 40,690 eligible subjects. Reviewers adjudicated delirium status (reference standard) during this 3-year window using a structured protocol. We calculated the probability that each patient had delirium as a function of classification algorithms based on longitudinal Medicare claims data. We compared the performance of various algorithms against the reference standard, computing calibration-in-the-large, calibration slope, and the area-under-receiver-operating-curve using 10-fold cross-validation (CV). RESULTS: Beneficiaries had a mean age of 75 years, were predominately female (59%), and non-Hispanic Whites (93%); a review of the EHR indicated that 6% of patients had delirium during the 3 years. Although several classification algorithms performed well, a relatively simple model containing counts of delirium-related diagnoses combined with patient age, dementia status, and receipt of antipsychotic medications had the best overall performance [CV- calibration-in-the-large <0.001, CV-slope 0.94, and CV-area under the receiver operating characteristic curve (0.88 95% confidence interval: 0.84-0.91)]. CONCLUSIONS: A delirium classification model using Medicare administrative data and International Classification of Diseases, 10th Edition diagnosis codes can identify beneficiaries with delirium in large datasets.

Geographic access to federally qualified health centers before and after the affordable care act.

BACKGROUND: The Affordable Care Act (ACA) increased funding for Federally Qualified Health Centers (FQHCs). We defined FQHC service areas based on patient use and examined the characteristics of areas that gained FQHC access post-ACA. METHODS: We defined FQHC service areas using total patient counts by ZIP code from the Uniform Data System (UDS) and compared this approach with existing methods. We then compared the characteristics of ZIP codes included in Medically Underserved Areas/Populations (MUA/Ps) that gained access vs. MUA/P ZIP codes that did not gain access to FQHCs between 2011-15. RESULTS: FQHC service areas based on UDS data vs. Primary Care Service Areas or counties included a higher percentage of each FQHC's patients (86% vs. 49% and 71%) and ZIP codes with greater use of FQHCs among low-income residents (29% vs. 22% and 22%), on average. MUA/Ps that gained FQHC access 2011-2015 included more poor, uninsured, publicly insured, and foreign-born residents than underserved areas that did not gain access, but were less likely to be rural (p < .05). CONCLUSIONS: Measures of actual patient use provide a promising method of assessing FQHC service areas and access. Post-ACA funding, the FQHC program expanded access into areas that were more likely to have higher rates of poverty and uninsurance, which could help address disparities in access to care. Rural areas were less likely to gain access to FQHCs, underscoring the persistent challenges of providing care in these areas.

Payment Discrepancies and Access to Primary Care Physicians for Dual-eligible Medicare-Medicaid Beneficiaries.

BACKGROUND: Physicians often receive lower payments for dual-eligible Medicare-Medicaid beneficiaries versus nondual Medicare beneficiaries because of state reimbursement caps. The Affordable Care Act (ACA) primary care fee bump temporarily eliminated this differential in 2013-2014. OBJECTIVE: To examine how dual payment policy impacts primary care physicians' (PCP) acceptance of duals. RESEARCH DESIGN: We assessed differences in the likelihood that PCPs had dual caseloads of ≥10% or 20% in states with lower versus full dual reimbursement using linear probability models adjusted for physician and area-level traits. Using a triple-difference approach, we examined changes in dual caseloads for PCPs versus a control group of specialists in states with fee bumps versus no change during years postbump versus prebump. SUBJECTS: PCPs and specialists (cardiologists, orthopedic surgeons, general surgeons) that billed fee-for-service Medicare. MEASURES: State dual payment policies and physicians' dual caseloads as a percentage of their Medicare patients. RESULTS: In 2012, 81% of PCPs had dual caseloads of ≥10% and this was less likely among PCPs in states with lower versus full dual reimbursement (eg, difference=-4.52 percentage points; 95% confidence interval, -6.80 to -2.25). The proportion of PCPs with dual caseloads of ≥10% or 20% decreased significantly between 2012 and 2017 and the fee bump was not consistently associated with increases in dual caseloads. CONCLUSIONS: Pre-ACA, PCPs' participation in the dual program appeared to be lower in states with lower reimbursement for duals. Despite the ACA fee bump, dual caseloads declined over time, raising concerns of worsening access to care.

Patterns of anticonvulsant use and adverse drug events in older adults.

PURPOSE: To examine indications for, duration of use, and rate of adverse drug events (ADE) attributable to anticonvulsant initiation, as adjudicated by expert review of electronic health records (EHR) of older adults. METHODS: We identified a cohort of community dwelling Medicare beneficiaries with linked EHR (aged 65+, continuously enrolled with a large health system/until death between 2012 and 2014, n = 20 945) and drew a stratified EHR review sample (n = 1534). An expert reviewed all records to adjudicate anticonvulsant use, years of use, indication for use, and evidence of ADEs attributable to anticonvulsant initiation. After excluding patients with insufficient EHR data (n = 37; 2%), we reconstructed the cohort using inverse probability weights to resemble the original cohort of eligible beneficiaries (n = 20 380). Among incident users of a single anticonvulsant, we estimated the rate of ADEs and described the type and severity of ADEs. RESULTS: Overall, 12% (n = 2469) of eligible beneficiaries used at least one anticonvulsant in the 2012 to 2014 period (4% [n = 757] incident users, 8% [n = 1712] prevalent users). Incident users were most frequently prescribed gabapentin (n = 461/757, 61%), benzodiazepines (n = 122/757, 16%), and levetiracetam (n = 74/757, 10%); the most common indication was pain relief (n = 214; 28%) followed by epilepsy (n = 53; 7%). Among incident users, the overall ADE rate was 10/100 person-years (95% CI 4-20/100 person-years), of which 29% (n = 28/97) were life threatening (eg, somnolence). Most ADEs among incident monotherapy users were nervous system related (68%, n = 66/97). CONCLUSION: Many older adult community dwelling traditional Medicare beneficiaries had clinically significant ADEs likely attributable to the initiation of anticonvulsant therapy, which was begun for a range of indications.

Access to care among Medicaid and uninsured patients in community health centers after the Affordable Care Act.

BACKGROUND: The Affordable Care Act expanded Medicaid and increased federal funding for Community Health Centers (CHCs). To examine the role of Medicaid coverage on care patterns for those with available safety net care, we assessed differences in access to care for CHC patients with continuous Medicaid coverage vs. gaps in insurance coverage in the last year. METHODS: We used data on adult respondents from the 2014 Health Center Patient Survey (N = 1720) with continuous Medicaid coverage vs. those with some period without insurance coverage in the last 12 months. We examined reported need for any medical care, mental health care, prescription drugs, dental care, and referrals for care outside of the CHC in the last 12 months, and reports of being delayed or unable to get needed care by insurance status. We used logistic regression to assess the association between insurance status and care access, adjusting for patient characteristics. RESULTS: Patients with insurance gaps and continuous Medicaid coverage reported similar levels of need for most types of care in the last 12 months, but those with insurance gaps were significantly more likely to report having difficulty obtaining medical care, prescription drugs, dental care, and completing outside referrals. Of those with incomplete referrals for care outside of the CHC, patients with insurance gaps were more likely than those with continuous Medicaid to cite cost or insurance-related reasons for not following up (70% vs. 19%, p < 0.01). CONCLUSIONS: Having continuous Medicaid coverage appeared to mitigate barriers to care for CHC patients compared to having intermittent or no insurance coverage over the last year. Policies that increase disruptions in Medicaid coverage could adversely impact access to care, even among those with available safety net care.

High-Deductible Insurance and Delay in Care for the Macrovascular Complications of Diabetes.

Background: Little is known about the long-term effects of high-deductible insurance on care for chronic medical conditions. Objective: To determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes. Design: Observational longitudinal comparison of matched groups. Setting: A large national health insurer during 2003 to 2012. Participants: The intervention group comprised 33 957 persons with diabetes who were continuously enrolled in low-deductible (≤$500) insurance plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans. The control group included 294 942 persons with diabetes who were enrolled in low-deductible plans contemporaneously with matched intervention group members. Intervention: Employer-mandated transition to a high-deductible plan. Measurements: The number of months it took for persons in each study group to seek care for their first major macrovascular symptom, have their first major diagnostic test for macrovascular disease, and have their first major procedure-based treatment was determined. Between-group differences in time to reach a midpoint event rate were then calculated. Results: No baseline differences were found between groups. During follow-up, the delay for the high-deductible group was 1.5 months (95% CI, 0.8 to 2.3 months) for seeking care for the first major symptom, 1.9 months (CI, 1.4 to 2.3 months) for the first diagnostic test, and 3.1 months (CI, 0.5 to 5.8 months) for the first procedure-based treatment. Limitation: Health outcomes were not examined. Conclusion: Among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test, and the first procedure-based treatment. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.

Racial and ethnic disparities among enrollees in Medicare Advantage plans.

BACKGROUND: Differences in the control of blood pressure, cholesterol, and glucose among the various racial and ethnic groups of Medicare enrollees may contribute to persistent disparities in health outcomes. METHODS: Among elderly enrollees in Medicare Advantage health plans in 2011 who had hypertension (94,171 persons), cardiovascular disease (112,039), or diabetes (105,848), we compared the respective age-and-sex-adjusted proportions with blood pressure lower than 140/90 mm Hg, low-density lipoprotein cholesterol levels below 100 mg per deciliter (2.6 mmol per liter), and a glycated hemoglobin value of 9.0% or lower, according to race or ethnic group. Comparisons were made nationally and within regions and health plans, and changes since 2006 were assessed. RESULTS: Black enrollees in 2006 and 2011 were substantially less likely than white enrollees to have adequate control of blood pressure (adjusted absolute differences in proportions of enrollees in the 2 years, 7.9 percentage points and 10.3 percentage points, respectively), cholesterol (11.4 percentage points and 10.2 percentage points, respectively), and glycated hemoglobin (10.1 percentage points and 9.4 percentage points, respectively) (P<0.001 for all comparisons). Differing distributions of enrollees among health plans accounted for 39 to 59% of observed disparities in 2011. These differences persisted in 2011 in the Northeast, Midwest, and South (6.9 to 14.1 percentage points, P<0.001 for all comparisons) but were eliminated in the West for all three measures (<1.5 percentage points, P≥0.15). Hispanic enrollees were less likely than whites in 2011 to have adequate control of blood pressure (adjusted difference, 1.6 percentage points), cholesterol (adjusted difference, 1.0 percentage points), and glycated hemoglobin (adjusted difference, 3.4 percentage points) (P≤0.02 for all comparisons). Asians and Pacific Islanders were more likely than whites to have adequate control of blood pressure (difference, 4.4 percentage points; P<0.001) and cholesterol (5.5 percentage points, P<0.001) and had similar control of glycated hemoglobin (0.3 percentage points, P=0.63). CONCLUSIONS: Disparities in control of blood pressure, cholesterol, and glucose have not improved nationally for blacks in Medicare Advantage plans, but these disparities were eliminated in the West in 2011. (Funded by the National Institute on Aging.).

Physician Agency and Patient Survival.

We investigate the role of physician agency in determining health care supply and patient outcomes. We show that an increase in health care supply due to a change in private physician incentives has a theoretically ambiguous impact on patient welfare. The increase can reflect either induced demand for ineffective care or a reduction in prior rationing of effective care. Furthermore, physician market structure matters in determining the welfare effects of changes in private physician incentives. We then analyze a change to Medicare fees that caused physicians to increase their provision of chemotherapy. We find that this increase in treatment improved patient survival, extending median life expectancy for lung cancer patients by about 18%. Consistent with the model, we find that while the treatment response was larger in less concentrated markets, survival improvements were larger in more concentrated markets.

The Oregon experiment--effects of Medicaid on clinical outcomes.

BACKGROUND: Despite the imminent expansion of Medicaid coverage for low-income adults, the effects of expanding coverage are unclear. The 2008 Medicaid expansion in Oregon based on lottery drawings from a waiting list provided an opportunity to evaluate these effects. METHODS: Approximately 2 years after the lottery, we obtained data from 6387 adults who were randomly selected to be able to apply for Medicaid coverage and 5842 adults who were not selected. Measures included blood-pressure, cholesterol, and glycated hemoglobin levels; screening for depression; medication inventories; and self-reported diagnoses, health status, health care utilization, and out-of-pocket spending for such services. We used the random assignment in the lottery to calculate the effect of Medicaid coverage. RESULTS: We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (-9.15 percentage points; 95% confidence interval, -16.70 to -1.60; P=0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures. CONCLUSIONS: This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.

Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies.

BACKGROUND: Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients. OBJECTIVE: To compare outcomes after ALS and BLS in out-of-hospital medical emergencies. DESIGN: Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use. SETTING: Traditional Medicare. PATIENTS: 20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure. MEASUREMENTS: Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years. RESULTS: Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30 days but had better survival at 90 days with ALS (1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored BLS for all diagnoses. Results from instrumental variable analyses were broadly consistent with propensity score analyses for trauma and stroke, showed no survival differences between BLS and ALS for respiratory failure, and showed better survival at all time points with BLS than ALS for patients with AMI. LIMITATION: Only Medicare beneficiaries from nonrural counties were studied. CONCLUSION: Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS. PRIMARY FUNDING SOURCE: National Science Foundation, Agency for Healthcare Research and Quality, and National Institutes of Health.

High-risk medication use by nursing home residents before and after hospitalization.

BACKGROUND: Two prominent challenges in nursing home care are ensuring appropriate medication use and achieving high-quality care as residents transition from the hospital to the nursing home. Research about prescribing practices at this important clinical juncture is limited. OBJECTIVE: To analyze the use of high-risk medications by nursing home residents before and after being hospitalized. We define high-risk medications using the Beers criteria for potentially inappropriate medication use. RESEARCH DESIGN, SUBJECTS, MEASURES: Using a dataset with Medicare claims for inpatient and skilled nursing facility stays and pharmacy claims for all medications dispensed in the nursing home setting, we examine high-risk medication use for hospitalized nursing home residents before and after being hospitalized. Our study population includes 52,559 dual-eligible nursing home residents aged 65 and older who are hospitalized and then readmitted to the same nursing home in 2008. Our primary outcome of interest is the use of high-risk medications in the 30 days before hospitalization and the 30 days following readmission to the same nursing home. RESULTS: Around 1 in 5 (21%) hospitalized nursing home residents used at least 1 high-risk medication the day before hospitalization. Among individuals with high-risk medication use at hospitalization, the proportion using these medications dropped to 45% after nursing home readmission but increased thereafter, to 59% by the end of the 30-day period. CONCLUSION: We found moderate levels of high-risk medication use by hospitalized nursing home residents before and after their hospital stays, constituting an important clinical and policy challenge.

How successful is Medicare Advantage?

CONTEXT: Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. METHODS: This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. FINDINGS: Beneficiaries make "mistakes" in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of "zero-premium" plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. CONCLUSIONS: Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan membership are warranted to move more beneficiaries into MA.

Effect of electronic health records on health care costs: longitudinal comparative evidence from community practices.

BACKGROUND: The United States is aiming to achieve nationwide adoption of electronic health records (EHRs) but lacks robust empirical evidence to anticipate the effect on health care costs. OBJECTIVE: To assess short-term cost savings from community-wide adoption of ambulatory EHRs. DESIGN: Longitudinal trial with parallel control group. SETTING: Natural experiment in which 806 ambulatory clinicians across 3 Massachusetts communities adopted subsidized EHRs. Six matched control communities applied but were not selected to participate. PATIENTS: 47,979 intervention patients and 130,603 control patients. MEASUREMENTS: Monthly standardized health care costs from commercial claims data from January 2005 to June 2009, including total cost, inpatient cost, and ambulatory cost and its subtypes (pharmacy, laboratory, and radiology). Projected savings per member per month (PMPM), excluding EHR adoption costs. RESULTS: Ambulatory EHR adoption did not impact total cost (pre- to postimplementation difference in monthly trend change, -0.30 percentage point; P = 0.135), but the results favored savings (95% CI, $21.95 PMPM in savings to $1.53 PMPM in higher costs). It slowed ambulatory cost growth (difference in monthly trend change, -0.35 percentage point; P = 0.012); projected ambulatory savings were $4.69 PMPM (CI, $8.45 to $1.09 PMPM) (3.10% of total PMPM cost). Ambulatory radiology costs decreased (difference in monthly trend change, -1.61 percentage points; P < 0.001), with projected savings of $1.61 PMPM (1.07% of total PMPM cost). LIMITATIONS: Intervention communities were not randomly selected and received implementation support, suggesting that results may represent a best-case scenario. Confounding is possible. CONCLUSION: Using commercially available EHRs in community practices seems to modestly slow ambulatory cost growth. Broader changes in the organization and payment of care may prompt clinicians to use EHRs in ways that result in more substantial savings.

Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage.

OBJECTIVE: To measure and compare the scope of US insurers' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories. DESIGN: Cross sectional analysis. SETTING: PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B. PARTICIPANTS: 30 540 086 beneficiaries in traditional Medicare Part B. MAIN OUTCOME MEASURES: Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules. RESULTS: The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties. CONCLUSION: PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.

The Impact of the Medicaid Reimbursement Bump on Influenza Vaccination Rates Among US Teens: Evidence from the National Immunization Survey-Teen 2011-2020.

BACKGROUND: Many adolescents do not receive basic preventive care such as influenza vaccinations. The Affordable Care Act (ACA) temporarily increased Medicaid reimbursements for primary care services, including vaccine administration, in 2013 to 2014. The objective of this study is to assess the impact of reimbursement increases on influenza vaccination rates among adolescents with Medicaid. METHODS: This repeated cross-sectional study used a difference-in-difference approach to compare changes in annual influenza vaccination rates for 20,884 adolescents 13 to 17 years old covered by Medicaid with adequate provider-reported data in 18 states with larger extended (>$5, 2013 to 2019) versus larger temporary (2013 to 2014 only) versus smaller reimbursement changes. We used linear probability models with individual-level random effects, adjusting for state and individual characteristics and annual time trends to assess the impact of a Medicaid vaccine administration reimbursement increase on annual influenza vaccination. RESULTS: Mean Medicaid reimbursements for vaccine administration doubled from 2011 to 2013 to 2014 (eg, from $11 to $22 for CPT 90460). States with smaller reimbursement changes had higher mean reimbursements and higher adjusted vaccination rates at baseline (2011) compared with states with larger temporary and extended reimbursement changes. The reimbursement change was not associated with increases in influenza vaccination rates. DISCUSSION: Influenza vaccination rates were low among adolescents with Medicaid throughout the study period, particularly in states with lower Medicaid reimbursement levels before the ACA. CONCLUSION: That reimbursement increases were not associated with higher vaccination rates suggests additional efforts are needed to improve influenza vaccination rates in this population.

Benzodiazepine Initiation and the Risk of Falls or Fall-Related Injuries in Older Adults Following Acute Ischemic Stroke.

Background: Benzodiazepine use in older adults following acute ischemic stroke (AIS) is common, yet short-term safety concerning falls or fall-related injuries remains unexplored. Methods: We emulated a hypothetical randomized trial of benzodiazepine use during the acute post stroke recovery period to assess incidence of falls or fall related injuries in older adults. Using linked data from the Get With the Guidelines Registry and Mass General Brigham's electronic health records, we selected patients aged 65 and older admitted for Acute Ischemic Stroke (AIS) between 2014 and 2021 with no documented prior stroke and no benzodiazepine prescriptions in the previous 3 months. Potential for immortal-time and confounding biases was addressed via separate inverse-probability weighting strategies. Results: The study included 495 patients who initiated inpatient benzodiazepines within three days of admission and 2,564 who did not. After standardization, the estimated 10-day risk of falls or fall-related injuries was 694 events per 1000 (95% confidence interval CI: 676-709) for the benzodiazepine initiation strategy and 584 events per 1000 (95% CI: 575-595) for the non-initiation strategy. Subgroup analyses showed risk differences of 142 events per 1000 (95% CI: 111-165) and 85 events per 1000 (95% CI: 64-107) for patients aged 65 to 74 years and for those aged 75 years or older, respectively. Risk differences were 187 events per 1000 (95% CI: 159-206) for patients with minor (NIHSS≤ 4) AIS and 32 events per 1000 (95% CI: 10-58) for those with moderate-to-severe AIS. Conclusions: Initiating inpatient benzodiazepines within three days of AIS is associated with an elevated 10-day risk of falls or fall-related injuries, particularly for patients aged 65 to 74 years and for those with minor strokes. This underscores the need for caution with benzodiazepines, especially among individuals likely to be ambulatory during the acute and sub-acute post-stroke period.