Use of Immunization Information Systems in Ascertainment of COVID-19 Vaccinations for Claims-Based Vaccine Safety and Effectiveness Studies.

Importance: Safety and effectiveness studies of COVID-19 vaccines are being conducted using clinical data, including administrative claims. However, claims data only partially capture administered COVID-19 vaccine doses for numerous reasons, such as vaccination at sites that do not generate claims for reimbursement. Objective: To evaluate the extent to which Immunization Information Systems (IIS) data linked to claims data enhances claims-based COVID-19 vaccine capture for a commercially insured population and to estimate the magnitude of misclassification of vaccinated individuals as having unvaccinated status in the linked IIS and claims data. Design, Setting, and Participants: This cohort study used claims data from a commercial health insurance database and obtained vaccination data from IIS repositories in 11 US states. Participants were individuals younger than 65 years who resided in 1 of 11 states of interest and who were insured in health plans from December 1, 2020, through December 31, 2021. Main Outcomes and Measures: Estimated proportion of individuals with at least 1 dose of any COVID-19 vaccine and proportion of individuals with a completed vaccine series based on general population guidelines. Vaccination status estimates were calculated and compared using claims data alone and linked IIS and claims data. Remaining misclassification of vaccination status was assessed by comparing linked IIS and claims data estimates with estimates from external surveillance data sources (Centers for Disease Control and Prevention [CDC] and state Department of Health [DOH]) and capture-recapture analysis. Results: This cohort study included 5 112 722 individuals (mean [SD] age, 33.5 [17.6] years; 2 618 098 females [51.2%]) from 11 states. Characteristics of those who received at least 1 vaccine dose and those who completed a vaccine series were similar to the overall study population. The proportion with at least 1 vaccine dose increased from 32.8% using claims data alone to 48.1% when the data were supplemented with IIS vaccination records. Vaccination estimates using linked IIS and claims data varied widely by state. The percentage of individuals who completed a vaccine series increased from 24.4% to 41.9% after the addition of IIS vaccine records and varied across states. The percentages of underrecording using linked IIS and claims data were 12.1% to 47.1% lower than those using CDC data, 9.1% to 46.9% lower than the state DOH, and 9.2% to 50.9% lower than capture-recapture analysis. Conclusion and Relevance: Results of this study suggested that supplementing COVID-19 claims records with IIS vaccination records substantially increased the number of individuals who were identified as vaccinated, yet potential underrecording remained. Improvements in reporting vaccination data to IIS infrastructures could allow frequent updates of vaccination status for all individuals and all vaccines.

Impact of the Comprehensive Care for Joint Replacement model on patient-reported outcomes.

OBJECTIVE: To determine whether the Comprehensive Care for Joint Replacement (CJR) model, a mandatory episode-based payment program for knee and hip replacement surgery, affected patient-reported measures of quality. DATA SOURCES: Surveys of Medicare fee-for-service beneficiaries who had hip or knee replacement surgery, collected between July 2018 and March 2019, secondary Medicare administrative data, the Provider of Services file, CJR and Bundled Payments for Care Improvement participant lists from the Centers for Medicare & Medicaid Services, and the Area Health Resource Files. STUDY DESIGN: In 2018, participation in the CJR model was mandatory for nearly all hospitals in 34 randomly selected, metropolitan statistical areas (MSAs) that had high historical Medicare payments for lower-extremity joint replacements surgery. The control group included 47 high-payment MSAs randomly assigned as controls. We estimated risk-adjusted differences in self-reported measures of functional status and pain, satisfaction with care, and caregiver help between respondents in CJR hospitals and respondents in hospitals located in the control group. DATA COLLECTION: We selected a census of CJR patients and an equal number of control patients to survey. We fielded two waves of surveys using a mail and phone protocol, yielding 8433 CJR and 9014 control respondents. PRINCIPAL FINDINGS: CJR respondents were slightly more likely to depend on caregivers for certain activities of daily living when they got home (either directly from the hospital or after an institutional post-acute care stay). On a 100-point scale, differences ranged from -2.6 points (p < 0.01) for help needed bathing to -1.7 points (p < 0.05) for help needed using the toilet. However, differences in eight measures of self-reported functional status approximately 90-120 days after hospital discharge were not statistically significant, ranging from -1.1% (p = 0.087) to 0.7% (p = 0.437). CONCLUSIONS: CJR did not harm patient health or affect patient satisfaction on average but did increase reliance on caregivers during recovery.

From Theory to Practice: Implementation of a Resource Allocation Model in Health Departments.

OBJECTIVE: To develop a resource allocation model to optimize health departments' Centers for Disease Control and Prevention (CDC)-funded HIV prevention budgets to prevent the most new cases of HIV infection and to evaluate the model's implementation in 4 health departments. DESIGN, SETTINGS, AND PARTICIPANTS: We developed a linear programming model combined with a Bernoulli process model that allocated a fixed budget among HIV prevention interventions and risk subpopulations to maximize the number of new infections prevented. The model, which required epidemiologic, behavioral, budgetary, and programmatic data, was implemented in health departments in Philadelphia, Chicago, Alabama, and Nebraska. MAIN OUTCOME MEASURES: The optimal allocation of funds, the site-specific cost per case of HIV infection prevented rankings by intervention, and the expected number of HIV cases prevented. RESULTS: The model suggested allocating funds to HIV testing and continuum-of-care interventions in all 4 health departments. The most cost-effective intervention for all sites was HIV testing in nonclinical settings for men who have sex with men, and the least cost-effective interventions were behavioral interventions for HIV-negative persons. The pilot sites required 3 to 4 months of technical assistance to develop data inputs and generate and interpret the results. Although the sites found the model easy to use in providing quantitative evidence for allocating HIV prevention resources, they criticized the exclusion of structural interventions and the use of the model to allocate only CDC funds. CONCLUSIONS: Resource allocation models have the potential to improve the allocation of limited HIV prevention resources and can be used as a decision-making guide for state and local health departments. Using such models may require substantial staff time and technical assistance. These model results emphasize the allocation of CDC funds toward testing and continuum-of-care interventions and populations at highest risk of HIV transmission.

All black people are not alike: differences in HIV testing patterns, knowledge, and experience of stigma between U.S.-born and non-U.S.-born blacks in Massachusetts.

Non-U.S.-born black individuals comprise a significant proportion of the new diagnoses of HIV in the United States. Concurrent diagnosis (obtaining an AIDS diagnosis in close proximity to an initial diagnosis of HIV) is common in this subpopulation. Although efforts have been undertaken to increase HIV testing among African Americans, little is known about testing patterns among non-U.S.-born black people. A cross-sectional survey was self-administered by 1060 black individuals in Massachusetts (57% non-U.S.-born) to assess self-reported rates of HIV testing, risk factors, and potential barriers to testing, including stigma, knowledge, immigration status, and access to health care. Bivariate analysis comparing responses by birthplace and multivariate logistic regression assessing correlates of recent testing were completed. Non-U.S.-born individuals were less likely to report recent testing than U.S.-born (41.9% versus 55.6%, p<0.0001). Of those who recently tested, the majority did so for immigration purposes, not because of perceived risk. Stigma was significantly higher and knowledge lower among non-U.S.-born individuals. In multivariate analysis, greater length of time since immigration was a significant predictor of nontesting among non-U.S.-born (adjusted odds ratio [AOR] 0.56, 95% confidence interval [CI] 0.36-0.87). Poor health care access and older age were correlated to nontesting in both U.S.- and non-U.S.-born individuals. Our findings indicate that differences in HIV testing patterns exist by nativity. Efforts addressing unique factors limiting testing in non-U.S.-born black individuals are warranted.

Improved quality of HIV care over time among participants in a national quality improvement initiative.

Ensuring comprehensive quality HIV and primary care is critical for effective HIV management. This study evaluates the impact of long-term engagement in a quality management (QM) initiative on performance measures. HIVQUAL-US is a federally-funded program to build clinic QM capacity to improve care for people living with HIV/AIDS. Forty-five facilities with four or more years of HIVQUAL-US performance measurement between 2002 and 2009 were included. Composite quality scores were constructed for HIV care, primary care and overall quality. Unadjusted analyses showed significant improvements in HIV care (76.2% to 88.8%, p<.0001), primary care (65.7% to 71.4%, p<.05) and overall (70.6% to 79.6%, p<.0001). Improvement was higher among clinics performing in the lowest quartile. Adjusting for clinic factors, the probability of improvement increased with each additional year of data submission for all scores. Engagement in a QM capacity building program was associated with continuing improvement in quality of HIV and primary care.

Evaluation of regional HIV provider quality groups to improve care for people living with HIV served in the United States.

HIVQUAL-US is a capacity-building quality initiative for federally-funded HIV primary care clinics. Since 2004, HIVQUAL-US has supported the formation of regional groups, geographically-clustered clinics that build quality management capacity through collective learning about quality improvement. The purpose of this qualitative study was to examine members' experiences participating in groups and their self-reported quality management and improvement outcomes related to HIV primary care. Interviews were conducted with a sample of three HIVQUAL-US coaches who facilitated 11 regional groups and with nine of the clinic representatives participating in the regional groups. The regional groups were heterogeneous in composition, focus and style, but shared common activities. Benefits included implementation of group quality improvement projects and opportunities for sharing activities and challenges. Improved performance in targeted areas, enhanced understanding/use of improvement methods, and increased quality management capacity were reported outcomes. Regional groups can effectively promote peer-to-peer learning, develop leadership, strengthen quality management capacity, and improve quality of care for the HIV population.

Evaluating the impact of non-response bias in the Behavioral Risk Factor Surveillance System (BRFSS).

BACKGROUND: Response rates of national health surveys are decreasing, which potentially can bias obtained prevalence estimates. The purpose of this study is to evaluate the extent to which non-response impacts the representativeness of the 2000 Behavioral Risk Factor Surveillance System (BRFSS) sample compared to the 2000 Decennial Census. METHODS: The 2000 BRFSS had a median response rate of 48%, while the 2000 Decennial Census had a response rate of 67%. Representativeness of the BRFSS sample was evaluated on gender, race, ethnicity, age, household income and marital status. Prevalence of each factor in the BRFSS was compared to the prevalence found in the US Census on both the state and county levels. Prevalence differences between the BRFSS and Census were calculated and their association with response rates was evaluated using robust OLS regression and polytomous logistic regression. The relationship between prevalence differences and other survey design elements, such as data collection procedure and sampling fraction, was also explored. RESULTS: The BRFSS prevalence estimates diverged from the Census estimates on several sociodemographic factors even after adjustment for non-response/non-coverage. This was found on both the state and county levels; however, smaller absolute differences between the BRFSS and Census prevalence estimates were found for factors included in the non-response/non-coverage adjustment weight. Lower response rates (<40%) were associated with the under-representation of racial/ethnic minorities, women and younger individuals in the BRFSS survey. CONCLUSION: Future research should examine alternative approaches to increase response rate (eg, mixed mode) and to adjust for non-response (eg, multiple imputation).

Investigating partner abuse among HIV-positive men who have sex with men.

High rates of partner abuse (PA) of all types-physical, sexual, and psychological-have been identified in studies of HIV-positive individuals. We examined both the prevalence and correlates of same-sex PA in HIV-positive men who have sex with men (MSM). Participants recruited from public outpatient HIV clinics (N = 168) completed CASI surveys about PA and current physical and mental health. Electronic medical record data were obtained for HIV biomarkers. Results indicate high rates of past year PA (physical, 19%; sexual, 17%; psychological, 51%; any, 54%), with rates comparable to, or higher than, those reported in recent studies of HIV-positive women and older studies of HIV-positive MSM. Overall, participants endorsing past year PA reported poorer mental but not physical health. Participants who endorsed past year physical PA, specifically, reported the largest number of mental health problems. HIV care providers should routinely assess PA, especially physical PA, in all MSM patients.

Massachusetts' health care reform increased access to care for Hispanics, but disparities remain.

Hispanics are more likely than any other racial or ethnic group in the United States to lack health insurance. This paper draws on quantitative and qualitative research to evaluate the extent to which health reforms in Massachusetts, a model for the Affordable Care Act of 2010, have reduced disparities in insurance coverage and access to health care. We found that rates of coverage and the likelihood of having a usual provider increased dramatically for Massachusetts Hispanics after the state's reforms, but disparities remained. The increase in insurance coverage among Hispanics was more than double that experienced by non-Hispanic whites. Even so, in 2009, 78.9 percent of Hispanics had coverage, versus 96 percent of non-Hispanic whites. Language and other cultural factors remained significant barriers: Only 66.6 percent of Hispanics with limited proficiency in English were insured. One-third of Spanish-speaking Hispanics still did not have a personal provider in 2009, and 26.8 percent reported not seeing a doctor because of cost, up from 18.9 percent in 2005. We suggest ways to reduce such disparities through national health care reform, including simplified enrollment and reenrollment processes and assistance in finding a provider and navigating an unfamiliar care system.

E-PRESCRIBING AND PATIENT SAFETY: RESULTS FROM A MIXED METHOD STUDY.

OBJECTIVES: To describe ambulatory care clinicians' perspectives on the effect of e-prescribing systems on patient safety outcomes. STUDY DESIGN: We used a mixed-method study of clinicians and staff in 64 practices using one of six e-prescribing technologies in six U.S. states. METHODS: We used clinician surveys (web-based and paper) and focus groups to obtain clinicians' perspectives on e-prescribing and patient safety. RESULTS: Providers highly valued having medications prescribed by other providers on the medication list and the ability to access patients' medication lists remotely. Providers felt that there will always be prescription or medication errors and that the implementation of e-prescribing software changes rather than eliminates prescription or medication errors. New errors related to the dosing or scheduling of a medication, accidentally prescribing the wrong drug, or duplicate prescriptions. CONCLUSIONS: Lessons from the ambulatory care trenches must be considered as technology moves forward so that the hypothesized patient safety gains will be realized.

Using small-area estimation to describe county-level disparities in mammography.

INTRODUCTION: Breast cancer control efforts could benefit from estimating mammography prevalence at the substate level because studies have primarily analyzed health survey data at the national and state levels. The purpose of this study was to evaluate the extent to which geographic disparities exist in mammography use across counties in the contiguous United States. METHODS: We estimated county-level prevalence of recent mammography (past 2 years) for women aged 40 to 79 years by using synthetic regression, a small-area estimation method. The 2000 Behavioral Risk Factor Surveillance System (BRFSS), 2000 Census, Area Resource File, and Food and Drug Administration mammography facility data were merged by BRFSS respondents' county of residence. We conducted separate analyses to produce county-level prevalence estimates for each race and age group. RESULTS: Mammography use varied geographically, and the magnitude of geographic disparities differed by race and age. Nonwhite women showed the lowest prevalence of mammography and widest range in county-level estimates. Women aged 40 to 49 had generally lower prevalence than other age groups, while women aged 65 to 79 showed the greatest variation in county-level mammography estimates. CONCLUSION: Small-area estimation using BRFSS data is advantageous for surveillance of mammography use at the county level. This method allows documentation of geographic disparities and improves our understanding of the spatial distribution of mammography prevalence. Future interventions should consider this county-level geographic variation, targeting women in the neediest counties.

A mixed method study of the merits of e-prescribing drug alerts in primary care.

OBJECTIVES: The objective of this paper was to describe primary care prescribers' perspectives on electronic prescribing drug alerts at the point of prescribing. DESIGN: We used a mixed-method study which included clinician surveys (web-based and paper) and focus groups with prescribers and staff. PARTICIPANTS: Prescribers (n = 157) working in one of 64 practices using 1 of 6 e-prescribing technologies in 6 US states completed the quantitative survey and 276 prescribers and staff participated in focus groups. MEASUREMENTS: The study measures self-reported frequency of overriding of drug alerts; open-ended responses to: "What do you think of the drug alerts your software generates for you?" RESULTS: More than 40% of prescribers indicated they override drug-drug interactions most of the time or always (range by e-prescribing system, 25% to 50%). Participants indicated that the software and the interaction alerts were beneficial to patient safety and valued seeing drug-drug interactions for medications prescribed by others. However, they noted that alerts are too sensitive and often unnecessary. Participant suggestions included: (1) run drug alerts on an active medication list and (2) allow prescribers to set the threshold for severity of alerts. CONCLUSIONS: Primary care prescribers recognize the patient safety value of drug prescribing alerts embedded within electronic prescribing software. Improvements to increase specificity and reduce alert overload are needed.

Correlates of suicide ideation in a population-based sample of cancer patients.

National studies on suicide ideation in cancer patients are small in size, including only patients from select medical centers. Our purpose was to determine correlates of suicide ideation in a population-based sample of cancer patients. Data from the sixth National Mortality Followback Survey were analyzed using SAS and SUDAAN for 980 individuals with cancer present at time of death. Multiple logistic regression analyses included sociodemographics, health-related factors, and social support variables. Prevalence of suicide ideation was 17.7%. Suicidality was significantly more likely in cancer patients who were previously married, had a history of mental illness, died of lung, respiratory or oral cancer, had one or more chronic diseases and used multiple prescription drugs in the past year. Suicide ideation in cancer patients is not solely a manifestation of depression. Overall poor physical health influences patients' desires for hastened death.

Misperceptions of patients vs providers regarding medication-related communication issues.

OBJECTIVES: To test the hypothesis that there is little concordance in perceptions of medication-related communication between patients and providers, with providers estimating greater frequency of such discussions than patients; and to determine whether discordance is less apparent among patients who received e-prescriptions. STUDY DESIGN: Data are from a convenience sample of 96 providers practicing in 6 states and 1100 of their patients. Twenty-nine practices used e-prescribing, and 3 practices were initiating e-prescribing. METHODS: Patients' and providers' perceptions regarding discussions with their providers or patients regarding medication costs, adherence, and potential adverse effects were collected by survey. RESULTS: Relative to patients, providers estimated more frequent discussions of medication issues with patients. Most patients (83%) reported that they would never tell their physician if they did not plan on picking up a prescription. Patients receiving electronic prescriptions were more likely than patients with paper prescriptions (54% vs 43%) to report that their provider always checks the accuracy of their medication list. CONCLUSION: Although e-prescribing may not change the extent to which patients and physicians discuss medication issues, patients of e-prescribing providers more frequently report provider verification of medication lists.

Patient perceptions regarding electronic prescriptions: is the geriatric patient ready?

OBJECTIVES: To evaluate the extent to which electronic prescribing (e-prescribing) alters communication about medication use between geriatric patients and their clinicians, as well as geriatric patients' perceptions regarding e-prescribing. DESIGN: Cross-sectional. SETTING: Thirty-five physician practices in six states using e-prescribing. PARTICIPANTS: Convenience sample of patients (n=244) aged 65 and older. MEASUREMENTS: Patient perceptions regarding discussions with their doctors regarding medication costs, adherence, and potential side effects, as well as expectations about and satisfaction with e-prescribing collected on a voluntary survey. RESULTS: Of patients at e-prescribing practices, 53% reported ever receiving e-prescriptions. Patients who reported having e-prescriptions were more likely to feel favorably toward the electronic method, whereas most of those who reported never receiving e-prescriptions preferred paper prescriptions. Patients reporting use of e-prescriptions were somewhat more likely to have adherence discussions often or most of the time than patients who had not used e-prescriptions. Regardless of e-prescribing experience, few patients reported that they would tell their physicians if they did not want a drug or did not plan to pick up the drug from the pharmacy. CONCLUSION: E-prescribing technology solutions may provide opportunities for earlier and enhanced communication between geriatric patients and their clinicians; geriatric patients may require more education to appreciate the value of e-prescribing.