Changes in Hydroxyurea Use Among Youths Enrolled in Medicaid With Sickle Cell Anemia After 2014 Revision of Clinical Guidelines.

Importance: Youths with sickle cell anemia (SCA) are at risk of pain crises, stroke, and early death. Complications can be reduced by the oral disease-modifying medication hydroxyurea, and in 2014, the National Heart, Lung, and Blood Institute published revised guidelines that hydroxyurea should be offered to youths aged 9 months and older with SCA regardless of disease severity. Objective: To describe changes in hydroxyurea use among youths with SCA before and after release of the National Heart, Lung, and Blood Institute guidelines. Design, Setting, and Participants: This cross-sectional study was conducted using administrative data from 2010 to 2018 from Michigan and New York State (NYS) Medicaid programs. The study population included youths aged 1 to 17 years with SCA enrolled in the Michigan or NYS Medicaid programs for at least 1 year (Michigan: 2010-2018; NYS: 2012-2018). Youths with SCA were identified using validated claims-based definitions. Data were analyzed from June to October 2020. Main Outcomes and Measures: The main outcome was hydroxyurea use characterized as mean annual counts of days' supply of filled hydroxyurea prescriptions. Rates of hydroxyurea use over time were assessed using regression models (Michigan: zero-inflated negative binomial; NYS: negative binomial). Models included indicators for periods before and after guideline release. Results: A total of 4302 youths with SCA (2236 males [52.0%]; 2676 born 2005-2017 [62.2%]; 150 Hispanic [3.5%], 2929 non-Hispanic Black [68.0%], and 389 non-Hispanic White [9.0%]) contributed 12 565 person-years. The mean (SD) annual days' supply of hydroxyurea was 47.2 (93.6) days per youth in Michigan and 97.4 (137.0) days per youth in NYS. In Michigan, there was an increase in the odds of having nonzero days' supply after the guidelines were released (odds ratio, 1.52; 95% CI, 1.07-2.14). In NYS, no change was seen in the mean days' supply of filled hydroxyurea. Conclusions and Relevance: These findings suggest that hydroxyurea was substantially underused among youths with SCA, despite establishment as the primary disease-modifying therapy for SCA, and that there was incomplete clinician or patient uptake of newly released guidelines. Results suggest that expanding use of hydroxyurea may require a multifaceted approach that includes addressing multiple system- and patient-level barriers.

Can prenatal care impact future well-child visits? The experience of a low income population in New York State Medicaid managed care.

To examine the association between maternal characteristics and care patterns and the subsequent utilization of well-child visits in a low income population in New York State (NYS). We analyzed Medicaid managed care birth data from 2004 to 2005 linked to an administrative database to obtain information on preventive well-care visits for the child. The outcome variable was whether the child had five or more well-child visits (WCVs) in their first 15 months of life. Of the 101,461 children in this study 67% had received five or more well-child visits by 15 months of age. This varied by region with a lesser proportion of children receiving well-child visits in New York City (NYC) and a higher proportion in the rest-of-state. Children born to mothers with intensive and adequate prenatal care were significantly more likely to have the necessary well-child visits. Foreign born women were more likely than US born women to bring their children in for well-child visits across all racial and ethnic groups. This study indicated that women who received adequate prenatal care were more likely to bring their children to well-child visits even after adjusting for maternal and infant characteristics. Maternal birthplace modified the association between race and well-child visits. The black-white disparity typically seen in WCVs in the United States was not found in NYC among children of US born women in Medicaid managed care.

The impact of the Medicaid high-risk ob care management program in New York State.

OBJECTIVES: To examine the effect of high-risk obstetrics (HROB) care management on infant health and Medicaid expenditures. DATA SOURCES/STUDY SETTING: Medicaid administrative data and vital statistics from 2011 to 2013. In New York State, all Medicaid managed care plans provide HROB care management to their members. STUDY DESIGN: We conducted a retrospective cohort study with a nonequivalent control group. Selection bias was addressed by using probit and OLS models with the Heckman correction and inverse probability weight with regression adjustment. PRINCIPAL FINDINGS: While program enrollment was associated with poor infant health outcomes (low birthweight, very low birthweight, preterm delivery, and gestational age), correcting for sample selection substantially improved most of these outcomes. All infant health outcomes significantly improved as the number of weeks in the program increased. We found that a 1-week increase in program duration is associated with a 0.01 percentage point decrease in low birthweight and a 0.03 percentage point decrease in very low birthweight. Further, a 1-week increase in program duration decreases the probability of preterm delivery by 0.01 percentage points and increases gestational age by 0.14 days. Medicaid expenditures for maternity care and newborn delivery were not significantly or materially affected by program enrollment or program duration. CONCLUSIONS: High-risk obstetrics care management appears to successfully identify individuals with high-risk pregnancies and improve health without substantially increasing medical expenses.

Performance of ICD-10-CM diagnosis codes for identifying children with Sickle Cell Anemia.

OBJECTIVE: To develop, test, and validate the performance of ICD-10-CM claims-based case definitions for identifying children with sickle cell anemia (SCA). DATA SOURCES: Medicaid administrative claims (2016) for children <18 years with potential SCA (any D57x diagnosis code) and newborn screening records from Michigan and New York State. STUDY DESIGN: This study is a secondary data analysis. DATA COLLECTION/EXTRACTION METHODS: Using specific SCA-related (D5700, D5701, and D5702) and nonspecific (D571) diagnosis codes, 23 SCA case definitions were applied to Michigan Medicaid claims (2016) to identify children with SCA. Measures of performance (sensitivity, specificity, area under the ROC curve) were calculated using newborn screening results as the gold standard. A parallel analysis was conducted using New York State Medicaid claims and newborn screening data. PRINCIPAL FINDINGS: In Michigan Medicaid, 1597 children had ≥1 D57x claim; 280 (18 percent) were diagnosed with SCA. Measures of performance varied, with sensitivities from 0.02 to 0.97 and specificities from 0.88 to 1.0. The case definition of ≥1 outpatient visit with a SCA-related or D571 code had the highest area under the ROC curve, with a sensitivity of 95 percent and specificity of 92 percent. The same definition also had the highest performance in New York Medicaid (n = 2454), with a sensitivity of 94 percent and specificity of 86 percent. CONCLUSIONS: Children with SCA can be accurately identified in administrative claims using this straightforward case definition. This methodology can be used to monitor trends and use of health services after transition to ICD-10-CM.

Identifying Children with Special Health Care Needs Using Medicaid Data in New York State Medicaid Managed Care.

OBJECTIVE: The ability to identify children with special health care needs (CSHCN) is crucial to evaluate disparities in the quality of health care for children in Medicaid Managed Care. We developed and assessed the accuracy of a new method to classify CSHCN. DATA SOURCES: Secondary data analysis was conducted using NYS Medicaid administrative data and the Children with Chronic Conditions Screener (CCC Screener). STUDY DESIGN: This study included 5,907 NYS Medicaid beneficiaries (17 years old or younger) whose parents completed the CCC Screener in 2014. Medicaid administrative data were used to create a risk score to assess the risk of special needs, and a cut point was identified to differentiate between children with versus without special needs. Diagnostic accuracy of the method was assessed using sensitivity and specificity analyses. PRINCIPAL FINDINGS: Applying the CCC Screener as the "gold standard," the risk score correctly classified the majority of CSHCN as positive (sensitivity = 75 percent) and the majority of the children without special needs as negative (specificity = 79 percent). This method demonstrated decent diagnostic ability (AUC = 0.77). CONCLUSIONS: Our method can identify CSHCN in the NYS Medicaid Managed Care population and will help the State monitor the quality of care for this vulnerable population.