States' Abortion Laws Associated With Intimate Partner Violence-Related Homicide Of Women And Girls In The US, 2014-20.

Women who are pregnant or recently gave birth are significantly more likely to be killed by an intimate partner than nonpregnant, nonpostpartum women of reproductive age, implicating the risk of fatal violence conferred by pregnancy itself. The rapidly increasing passage of state legislation has restricted or banned access to abortion care across the US. We used the most recent and only source of population-based data to examine the association between state laws that restrict access to abortion and trends in intimate partner violence-related homicide among women and girls ages 10-44 during the period 2014-20. Using robust difference-in-differences ecologic modeling, we found that enforcement of each additional Targeted Regulation of Abortion Providers (TRAP) law was associated with a 3.4 percent increase in the rate of intimate partner violence-related homicide in this population. We estimated that 24.3 intimate partner violence-related homicides of women and girls ages 10-44 were associated with TRAP laws implemented in the states and years included in this analysis. Assessment of policies that restrict access to abortion should consider their potential harm to reproductive-age women through the risk for violent death.

Guaranteed Cash Incentives Boosted COVID-19 Vaccinations Of Young Adults: Evidence From West Virginia.

Guaranteed small cash incentives were widely employed by policy makers during the COVID-19 vaccination campaign, but the impact of these programs has been largely understudied. We were the first to exploit a statewide natural experiment of one such program implemented in West Virginia in 2021 that provided a $100 incentive to fully vaccinated adults ages 16-35. Using individual-level data from the Census Bureau's Household Pulse Survey, we isolated the policy effect through a difference-in-discontinuities design that exploited the discontinuity in incentive eligibility at age thirty-five. We found that the $100 incentive was associated with a robust increase in the proportion of people ever vaccinated against COVID-19 and the proportion who completed or intended to complete the primary series of COVID-19 vaccines. The policy effects were also likely to be more pronounced among people with low incomes, those who were unemployed, and those with no prior COVID-19 infection. The guaranteed cash incentive program may have created more equitable access to vaccines for disadvantaged populations. Additional outreach may also be needed, especially to unvaccinated people with prior COVID-19 infections.

Effects of Non-Face-to-Face Chronic Care Management on Service Utilization and Outcomes Among US Medicare Beneficiaries with Diabetes.

BACKGROUND: Type 2 diabetes mellitus (T2DM) results in heavy economic and disease burdens in Louisiana. The Centers for Medicare and Medicaid Services has reimbursed non-face-to-face chronic care management (NFFCCM) for patients with two or more chronic conditions since 2015. OBJECTIVE: To assess the impacts of NFFCCM on healthcare utilization and health outcomes. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included Medicare fee-for-service beneficiaries with T2DM and at least one additional chronic disease between 2014 and 2018. EXPOSURES: At least one record of NFFCCM Current Procedural Terminology codes. MAIN MEASURES: The health outcomes in the study included major adverse cardiovascular events (MACE), all-cause mortality, and heart failure. The monthly service utilization and continuity of care index for primary care were also included. The propensity score method was used to balance the baseline differences between the two groups. Weighted multivariate regression models were developed using propensity score weights to assess the impacts of NFFCCM on outcomes. KEY RESULTS: During the 5 years of study period, 8415 patients among the 118,643 Medicare beneficiaries received at least one NFFCCM. Patients receiving any NFFCCM had reduced healthcare utilization compared with patients not receiving NFFCCM, including 0.012 (95% CI - 0.014 to - 0.011; p < 0.001) fewer monthly hospital admissions, 0.017 (95% CI - 0.019 to - 0.016; p < 0.001) fewer monthly ED visits, and 0.399 (95% CI 0.375 to 0.423; p < 0.001) more monthly outpatient encounters. Patients receiving NFFCCM services had lower MACE event rates of 7.4% (95% CI 7.1 to 7.8%; p < 0.001), all-cause mortality rate of 7.8% (95% CI 7.4 to 8.1%; p < 0.001), and heart failure rate of 0.3% (95% CI 0.2 to 0.5%; p < 0.001), respectively. CONCLUSIONS AND RELEVANCE: These findings suggest that reimbursement for NFFCCM was associated with the shifting high-cost utilization to lower-cost primary health care settings among patients with diabetes in Louisiana.

Telehealth Use and Healthcare Utilization Among Individuals with Type 2 Diabetes During the COVID-19 Pandemic: Evidence From Louisiana Medicaid Claims.

INTRODUCTION: The impact of telehealth use on healthcare utilization is limited, especially among Medicaid beneficiaries with type 2 diabetes. Considering the rapid adoption of telehealth during the COVID-19 pandemic, this study examined associations between telehealth use and healthcare utilization among Medicaid beneficiaries with type 2 diabetes. METHODS: Using Louisiana Medicaid claims data from March 2019 to August 2021, the associations were examined using a difference-in-difference model with propensity score weighting. Demographic characteristics, baseline comorbidities and healthcare utilization, and zip code level environmental factors were included in the analysis. The monthly frequency of healthcare services, including in-person outpatient visits, inpatient visits, emergency department (ED) visits and hemoglobin A1C (HbA1C) tests, were measured as outcomes. Several sensitivity analyses were conducted across different subgroups. RESULTS: We included 48,992 beneficiaries with type 2 diabetes in the study of 27,340 beneficiaries in the telehealth group and 21,652 beneficiaries in the non-telehealth group. Of 1000 beneficiaries per month, the telehealth group had significantly more utilization compared to the non-telehealth group, with an increase of 195.049 in-person outpatient visits (95% CI: 166.169 to 223.929, p < 0.001), 3.816 inpatient visits (95% CI: 2.539 to 5.093, p < 0.001), 10.499 ED visits (95% CI: 7.287 to 13.712, p < 0.001) and 14.153 HbA1c tests (95% CI: 11.431 to 16.875, p < 0.001, respectively. Excluding beneficiaries who had ED or inpatient visits in the 30 days prior to receiving telehealth visits, overall ED visits significantly decreased for the telehealth group versus the non-telehealth group over time, by 9.456 visits (95% CI: - 12.356 to - 6.557, p < 0.001) per 1000 beneficiaries per month on average. CONCLUSION: The study found that telehealth was associated with a significant increase in healthcare utilization in general but has the potential to decrease ED and inpatient utilization for some groups among low-income populations with diabetes.

Predictors of Telehealth Utilization and Subsequent Inpatient Stays and Emergency Visits During the COVID-19 Pandemic Among Patients with Type 2 Diabetes: Evidence from Louisiana.

Objective: To understand which types of Medicare patients with diabetes disproportionately used telehealth during the coronavirus disease 2019 pandemic and how their characteristics mediated their inpatient and emergency department (ED) utilization. Methods: Logistic regression analyses were used to measure the associations between patient characteristics and telehealth utilization using electronic health records among Medicare patients with diabetes (n = 31,654). Propensity score matching was used to examine the relative impact of telehealth use in conjunction with race, ethnicity, and age on inpatient and ED outcomes. Results: Telehealth was associated with age (75-84 vs. 65-74; odds ratio [OR] = 0.810, p < 0.01), gender (female: OR = 1.148, p < 0.01), and chronic diseases (e.g., lung disease: OR = 1.142; p < 0.01). Black patients using telehealth were less likely to visit the ED (estimate = -0.018; p = 0.08), whereas younger beneficiaries using telehealth were less likely to experience an inpatient stay (estimate = -0.017; p = 0.06). Conclusions: Telehealth expansion particularly benefited the clinically vulnerable but saw uneven use and uneven benefit along sociodemographic lines. Clinical Trial Registration Number: NCT03136471.

Telehealth use and its impact on clinical outcomes in patients with type 2 diabetes during the COVID-19 pandemic.

AIM: To evaluate the impact of telehealth use during the COVID-19 pandemic on glycaemic control and other clinical outcomes among patients with type 2 diabetes. METHODS: We used electronic health records from the Research Action for Health Network (REACHnet) database for patients with type 2 diabetes who had telehealth visits and those who only received in-person care during the pandemic. A quasi-experimental method of difference-in-difference with propensity-score weighting was implemented to mitigate selection bias and to control for observed factors related to telehealth use. Outcomes included glycated haemoglobin (HbA1c) and other clinical measures (low-density lipoprotein [LDL] cholesterol, blood pressure [BP], and body mass index [BMI]). RESULTS: Patients using telehealth had better HbA1c control compared to those receiving in-person care only during the pandemic. The telehealth group saw a significant average decrease of 0.146% (95% confidence interval [CI] -0.178% to -0.1145%; P < 0.001) in HbA1c levels over time. The proportion of patients with average HbA1c levels >7% decreased by 0.023 (95% CI -0.034, -0.011; P < 0.001) in the treatment group relative to the comparison group. Modest benefits in the control of LDL cholesterol levels, diastolic BP, and BMI were found in association with telehealth use. CONCLUSIONS: Our findings suggest that telehealth services contributed to better glycaemic control and management of other clinical outcomes in patients with type 2 diabetes during the pandemic. Factors unmeasured in this study would need to be further explored to better understand the impact of telehealth.

Non-face-to-face care management and service utilization in patients with diabetes.

OBJECTIVES: In 2015, CMS implemented reimbursement for non-face-to-face chronic care management (NFFCCM) for beneficiaries with multiple chronic conditions, including diabetes. This analysis estimated the association between NFFCCM and utilization of inpatient, outpatient, and emergency services. STUDY DESIGN: We implemented a doubly robust estimator using propensity score matching in a regression context to compare eligible patients who used NFFCCM (n = 282) with eligible patients who did not use NFFCCM (n = 26,759). METHODS: We tested 4 definitions of treatment: having any NFFCCM encounters and having 1 NFFCCM encounter per month, per 2 months, and per 3 months. Two-tailed statistical inference testing was conducted at the 5% level. We examined the utilization differences among patients with diabetes 65 years and older using merged electronic health records for 4 health systems in Louisiana from the Research Action for Health Network database in 2013 through 2018. RESULTS: We found NFFCCM was associated with increased utilization of care in the outpatient setting by 0.056 visits per month (95% CI, 0.027-0.086) and with lower utilization in the inpatient setting (-0.024 visits per month; 95% CI, -0.038 to -0.010) and in the emergency department setting (-0.017 visits per month; 95% CI, -0.031 to -0.003). Alternative specifications of treatment showed similar associations. CONCLUSIONS: CMS implementation of reimbursement codes for NFFCCM, and subsequent utilization of that reimbursement by health systems, was associated with a shift in patient utilization from high-cost settings (inpatient and emergency department) to a lower-cost setting (outpatient office).

Evaluating the outcomes and implementation determinants of interventions co-developed using human-centered design to promote healthy eating in restaurants: an application of the consolidated framework for implementation research.

Background: Restaurants are an emerging yet underutilized setting to facilitate healthier eating, particularly among minoritized communities that disproportionately experience health inequities. The present study aimed to examine outcomes from interventions co-developed using Human-Centered Design (HCD) in two Latin American restaurants, including sales of healthier menu items (HMI) and the consumer nutrition environment. In addition, we aimed to assess implementation outcomes (acceptability, fidelity, and sustainability) and elucidate the determinants for implementation using the Consolidated Framework for Implementation Research. Methods: This study used a mixed-methods, longitudinal design. Data were collected pre-, during, and post-intervention testing. Intervention outcomes were examined through daily sales data and the Nutrition Environment Measures Survey for Restaurants (NEMS-R). Changes in HMI sales were analyzed using interrupted time series. Implementation outcomes and determinants were assessed through site visits [observations, interviews with staff (n = 19) and customers (n = 31)], social media monitoring, and post-implementation key informant interviews with owners and staff. Qualitative data were analyzed iteratively by two independent researchers using codes developed a priori based on CFIR. Results: The HCD-tailored interventions had different outcomes. In restaurant one (R1), where new HMI were introduced, we found an increase in HMI sales and improvements in NEMS-R scores. In restaurant two, where existing HMI were promoted, we found no significant changes in HMI sales and NEMS-R scores. Acceptance was high among customers and staff, but fidelity and sustainability differed by restaurant (high in R1, low in R2). Barriers and facilitators for implementation were found across all CFIR constructs, varying by restaurant and intervention. Most relevant constructs were found in the inner setting (restaurant structure, implementation climate), individual characteristics, and process (HCD application). The influence of outer setting constructs (policy, peer pressure) was limited due to lack of awareness. Conclusion: Our findings provide insights for interventions developed in challenging and constantly changing settings, as in the case of restaurants. This research expands the application of CFIR to complex and dynamic community-based settings and interventions developed using HCD. This is a significant innovation for the field of public health nutrition and informs future interventions in similarly dynamic and understudied settings.

Trends and disparities in telehealth use among Louisiana Medicaid beneficiaries with type 2 diabetes.

AIM: To examine trends in telehealth use among Medicaid beneficiaries with type 2 diabetes (T2D) before and during the coronavirus disease 2019 (COVID-19) pandemic and identify factors related to telehealth use. METHODS: We compared monthly proportions of outpatient visits delivered by telehealth by race/ethnicity, geography and age among Louisiana Medicaid beneficiaries with T2D using claims data from January 2018 to August 2021. We also examined the changes in provider types delivering telehealth. Multivariable logistic regression was conducted to identify individual level and zip code-level factors associated with telehealth use during the COVID-19 pandemic. RESULTS: The monthly proportion of outpatient visits delivered by telehealth was low (< 1%) before the pandemic, spiked in April 2020 (> 15%), then remained at approximately 5%. Telehealth use varied across different racial/ethnic groups, geography and age groups over years. Older beneficiaries were less probable to use telehealth during the pandemic (adjusted odds ratio [AOR] = 0.874, 95% confidence interval [CI]: 0.831-0.919). Females used more telehealth than males (AOR = 1.359, 95% CI: 1.298-1.423). Black beneficiaries used more telehealth than White beneficiaries (AOR = 1.067, 95% CI: 1.000-1.139). More telehealth services were used by Medicaid beneficiaries who were living in urban areas, with more primary care utilization, and with more chronic conditions at baseline. CONCLUSIONS: We found disparities in the uptake of telehealth during the COVID-19 pandemic, but they might have been narrowed for some groups (Hispanic and rural) among Louisiana Medicaid beneficiaries with T2D. Future studies should explore strategies to improve access to telehealth services and reduce related disparities for the low-income population.

Public health impact and cost-effectiveness of 15-valent pneumococcal conjugate vaccine use among the pediatric population of the United States.

BACKGROUND: Although use of the 13-valent pneumococcal conjugate vaccine (PCV13) among children has reduced incidence of pneumococcal disease, a considerable burden of disease remains. PCV15 is a new vaccine that contains pneumococcal serotypes 22F and 33F in addition to serotypes contained in PCV13. To inform deliberations by the Advisory Committee on Immunization Practices on recommendations for PCV15 use among U.S. children, we estimated the health impact and cost-effectiveness of replacing PCV13 with PCV15 within the routine infant immunization program in the United States. We also assessed the impact and cost-effectiveness of a supplementary PCV15 dose among children aged 2-5 years who have already received a full PCV13 series. METHODS: We estimated the incremental number of pneumococcal disease events and deaths averted, costs per quality adjusted life-year (QALY) gained, and costs per life-year gained under different vaccination strategies using a probabilistic model following a single birth cohort of 3.9 million individuals (based on 2020 U.S. birth cohort). We assumed that vaccine effectiveness (VE) of PCV15 against the two additional serotypes was the same as the VE of PCV13. The cost of PCV15 use among children was informed from costs of PCV15 use among adults and from discussions with the manufacturer. RESULTS: Our base case results found that replacing PCV13 with PCV15 prevented 92,290 additional pneumococcal disease events and 22 associated deaths, while also saving $147 million in costs. A supplementary PCV15 dose among children aged 2-5 years who were fully vaccinated with PCV13 prevented further pneumococcal disease events and associated deaths but at a cost of more than $2.5 million per QALY gained. CONCLUSIONS: A further decrease in pneumococcal disease in conjunction with considerable societal cost savings could be expected from replacing PCV13 with PCV15 within the routine infant immunization program in the United States.

Effectiveness of Incentivized Peer Referral to Increase Enrollment in a Community-Based Chlamydia Screening and Treatment Study Among Young Black Men.

OBJECTIVES: Young Black men are under-represented in sexual health services and research, a condition likely magnified during COVID-19 shutdowns due to disruption of STI screening and treatment services. We examined the effect of incentivized peer referral (IPR) increasing peer referral among young Black men in a community-based chlamydia screening program. METHODS: Young Black men in New Orleans, LA, age 15-26 years enrolled in a chlamydia screening program between 3/2018 and 5/2021 were included. Enrollees were provided with recruitment materials to distribute to peers. Starting July 28, 2020, enrollees were also offered a $5 incentive for each peer enrolled. Enrollment was compared before and after the incentivize peer referral program (IPR) was implemented using multiple time series analysis (MTSA). RESULTS: The percentage of men referred by a peer was higher during IPR compared to pre-IPR (45.7% vs. 19.7%, p < 0.001). After the COVID-19 shutdown was lifted, there were 2.007 more recruitments per week (p = 0.044, 95% CI (0.0515, 3.964)) for IPR, compared to pre-IPR. Overall, there was a trending increase in recruitments in the IPR era relative to the pre-IPR era (0.0174 recruitments/week, p = 0.285, 95% CI (- 0.0146, 0.0493)) with less recruitment decay during IPR compared to pre-IPR. CONCLUSIONS: IPR may be an effective means of engaging young Black men in community-based STI research and prevention programs, particularly when clinic access is limited. CLINICAL TRIALS REGISTRY SITE AND NUMBER: Clinicaltrials.gov identifier NCT03098329.

Telehealth and Medicare Type 2 Diabetes Care Outcomes: Evidence From Louisiana.

BACKGROUND: At the onset of the COVID-19 pandemic, the Centers for Medicare and Medicaid Services broadened access to telehealth. This provided an opportunity to test whether diabetes, a risk factor for COVID-19 severity, can be managed with telehealth services. OBJECTIVE: The objective of this study was to examine the impacts of telehealth on diabetes control. RESEARCH DESIGN: A doubly robust estimator combined a propensity score-weighting strategy with regression controls for baseline characteristics using electronic medical records data to compare outcomes in patients with and without telehealth care. Matching on preperiod trajectories in outpatient visits and weighting by odds were used to ensure comparability between comparators. SUBJECTS: Medicare patients with type 2 diabetes in Louisiana between March 2018 and February 2021 (9530 patients with a COVID-19 era telehealth visit and 20,666 patients without one). MEASURES: Primary outcomes were glycemic levels and control [ie, hemoglobin A1c (HbA1c) under 7%]. Secondary outcomes included alternative HbA1c measures, emergency department visits, and inpatient admissions. RESULTS: Telehealth was associated with lower pandemic era mean A1c values [estimate=-0.080%, 95% confidence interval (CI): -0.111% to -0.048%], which translated to an increased likelihood of having HbA1c in control (estimate=0.013; 95% CI: 0.002-0.024; P<0.023). Hispanic telehealth users had relatively higher COVID-19 era HbA1c levels (estimate=0.125; 95% CI: 0.044-0.205; P<0.003). Telehealth was not associated with differences in the likelihood of having an emergency department visits (estimate=-0.003; 95% CI: -0.011 to 0.004; P<0.351) but was associated with more the likelihood of having an inpatient admission (estimate=0.024; 95% CI: 0.018-0.031; P<0.001). CONCLUSION: Telehealth use among Medicare patients with type 2 diabetes in Louisiana stemming from the COVID-19 pandemic was associated with relatively improved glycemic control.

The Impact of Reimbursement for Non-Face-to-Face Chronic Care Management on Comprehensive Metabolic Biomarkers Among Multimorbid Patients With Type 2 Diabetes.

AIMS: We evaluated the impact of reimbursement for non-face-to-face chronic care management (NFFCCM) on comprehensive metabolic risk factors among multimorbid Medicare beneficiaries with type 2 diabetes in Louisiana. MATERIALS AND METHODS: We implemented a propensity score method to obtain comparable treatment (n=1501 with NFFCCM) and control (n=17,524 without NFFCCM) groups. Patients with type 2 diabetes were extracted from the electronic health records stored in REACHnet. The study period was from 2013 to February 2020. The comprehensive metabolic risk factors included the primary outcome of glycated hemoglobin (HbA1c) (as the primary outcome) and the secondary outcomes of body mass index (BMI), systolic blood pressure (BP), and low-density lipoprotein cholesterol. RESULTS: Receiving any NFFCCM was associated with improvement in all outcomes measures: a reduction in HbA1c of 0.063% (95% CI: 0.031%-0.094%; P <0.001), a reduction in BMI of 0.155 kg/m 2 (95% CI: 0.029-0.282 kg/m 2 ; P =0.016), a reduction in systolic BP of 0.816 mm Hg (95% CI: 0.469-1.163 mm Hg; P <0.001), and a reduction in low-density lipoprotein cholesterol of 1.779 mg/dL (95% CI: 0.988 2.570 mg/dL; P <0.001). Compared with the control group, the treatment group had 1.6% more patients with HbA1c <7% (95% CI: 0.3%-2.9%; P =0.013). CONCLUSIONS: Patients with diabetes in Louisiana receiving NFFCCM experienced better control of HbA1c, BMI, BP, and low-density lipoprotein outcomes.

The Impact of Reimbursement for Non-Face-to-Face Chronic Care Management on Health Utilization Among Patients With Type 2 Diabetes in Louisiana.

OBJECTIVES: We evaluated the impact of reimbursement for non-face-to-face chronic care management (NFFCCM) on healthcare utilization among Medicare beneficiaries with type 2 diabetes in Louisiana. METHODS: We implemented group-based trajectory balancing and propensity score matching to obtain comparable treatment (with NFFCCM) and control (without NFFCCM) groups at baseline. Patients with diabetes with Medicare as their primary payer at baseline were extracted using electronic health records of 3 health systems from Research Action for Health Network, a Clinical Research Network. The study period is from 2013 to early 2020. Our outcomes include general healthcare utilization (outpatient, emergency department, and inpatient encounters) and health utilization related to diabetic complications. We tested each of these outcomes according to multiple treatment definitions and different subgroups. RESULTS: Receiving any NFFCCM was associated with an increase in outpatient visits of 657 (95% confidence interval [CI] 626-687; P < .001) per 1000 patients per month, a decrease in inpatient admissions of 5 (95% CI 2-7; P < .001) per 1000 patients per month, and a decrease in emergency department visits of 4 (95% CI 1-7; P = .005) per 1000 patients per month after 24-month follow-up from initial NFFCCM encounter. Both complex and noncomplex NFFCCM significantly increased visits to outpatient services and inpatient admissions per month. Receiving NFFCCM has a dose-response association with increasing outpatient visits per month. CONCLUSIONS: Patients with diabetes in Louisiana who received NFFCCM had more low-cost primary healthcare and less high-cost healthcare utilization in general. The cost savings of NFFCCM in diabetes management could be further explored in the future.

Moving the Needle: Association Between a Vaccination Reward Lottery and COVID-19 Vaccination Uptake in Louisiana.

OBJECTIVE: On June 17, 2021, Louisiana launched a lottery campaign to reward residents who received a COVID-19 vaccination. We investigated the association between the lottery and vaccination uptake by characteristics of parishes. METHODS: We constructed an interrupted time series based on daily parish-level data on COVID-19 vaccinations to analyze the association with the lottery. We used recursive partitioning to separate vaccination uptake due to the Delta variant from vaccination uptake due to the lottery and limited our study period to May 25 through July 20, 2021. We performed subanalyses that grouped parishes by political affiliation, hesitancy toward COVID-19 vaccines, race and ethnicity, and socioeconomic status to detect heterogeneous responses to the lottery by these characteristics. We ran models separately for parishes in the top and bottom tertiles of each sociodemographic indicator and used a z test to check for differences. RESULTS: The lottery was associated with an additional 1.03 (95% CI, 0.61-1.45; P < .001) first doses per parish per day. Comparing lottery impacts between top and bottom tertiles, we found significantly larger associations in parishes with lower vaccine hesitancy rates, higher percentage of Hispanic population, higher median annual household income, and more people with a college degree. CONCLUSIONS: Results suggest that the lottery was associated with increased COVID-19 vaccination uptake in Louisiana. However, larger associations were observed in parishes with an already higher likelihood of accepting vaccines, which raises equity issues about the opportunity created by the lottery and its effectiveness as a long-term behavioral incentive.

Data-Related Challenges in Cost-Effectiveness Analyses of Vaccines.

Cost-effectiveness analyses (CEAs) are often prepared to quantify the expected economic value of potential vaccination strategies. Estimated outcomes and costs of vaccination strategies depend on numerous data inputs or assumptions, including estimates of vaccine efficacy and disease incidence in the absence of vaccination. Limitations in epidemiologic data can meaningfully affect both CEA estimates and the interpretation of those results by groups involved in vaccination policy decisions. Developers of CEAs should be transparent with regard to the ambiguity and uncertainty associated with epidemiologic information that is incorporated into their models. We describe selected data-related challenges to conducting CEAs for vaccination strategies, including generalizability of estimates of vaccine effectiveness, duration and functional form of vaccine protection that can change over time, indirect (herd) protection, and serotype replacement. We illustrate how CEA estimates can be sensitive to variations in specific epidemiologic assumptions, with examples from CEAs conducted for the USA that assessed vaccinations against human papillomavirus and pneumococcal disease. These challenges are certainly not limited to these two case studies and may be relevant to other vaccines.

COVID-19 and Routine Childhood and Adolescent Immunizations: Evidence from Louisiana Medicaid.

The COVID-19 pandemic disrupted routine vaccinations for children and adolescents. However, it remains unclear whether the impact has been different for children and adolescents from low-income families. To address this, we compared monthly routine vaccination use per 1000 vaccine-eligible children and adolescents enrolled in Louisiana Medicaid in the years before (2017-2019) and during the COVID-19 pandemic (2020). Compared to the 2017-2019 average vaccination rates, we found a 28% reduction in measles, mumps, and rubella (MMR), a 35% reduction in human papillomavirus (HPV), and a 30% reduction in tetanus, diphtheria, pertussis (Tdap) vaccinations in 2020. Vaccine uptake was lower in April 2020 after the declaration of a state of emergency and in late summer when back-to-school vaccinations ordinarily occur. We found little evidence of recovery in later months. Our findings suggest that a substantial number of disadvantaged children may experience longer periods of vulnerability to preventable infections because of missed vaccinations.

Louisiana Medicaid Expansion Associated With Reduced Travel For Care Among Minority Groups And Rural Residents.

Distance traveled to a provider has been associated with access to and timely use of health care services. Medicaid expansion has been previously linked to an increase in the number of providers accepting Medicaid patients. We hypothesized that by increasing the density of providers accepting Medicaid in any area, Louisiana's Medicaid expansion in July 2016 may have increased access to health care services for Medicaid patients already eligible for Medicaid in Louisiana by decreasing distances traveled to reach health care providers. We tested our hypothesis using a regression discontinuity model on all continuously enrolled Louisiana Medicaid beneficiaries' transactions from the period 2015-17 across eight different service lines. Distance traveled to appointments declined across all service lines, with declines ranging from -3.46 miles for general practices to -0.70 miles for specialty care. The most robust declines in distance traveled were among Black enrollees living in nonmetropolitan areas, with the largest being a decline of 9.25 fewer miles traveled for general practice care. Medicaid expansion has the potential to address racial and geographic disparities in health care access through decreased travel distances.

Impact of Check It: A Novel Community-Based Chlamydia Screening and Expedited Treatment Program for Young Black Men.

OBJECTIVES: This study aimed to estimate the impact of the Check It program, a novel community-based chlamydia seek, test, and treat program for young Black men who have sex with women, on test positivity rates for chlamydia in young Black women. METHODS: We used a synthetic control model to compare chlamydia test positivity rates in Orleans Parish (intervention site) with other similar parishes (control sites) in Louisiana. We estimated a model that used all other parishes as potential contributors to a synthetic control for Louisiana as well as a sample limited to the 40 parishes in Louisiana with the largest Black populations. RESULTS: The Check It program was associated with a 1.69-percentage-point decline in chlamydia positivity in the first full year of operation and a 2.44-percentage-point decline in chlamydia positivity in the second full year of operation compared with control sites with the largest Black populations (P = 0.05). Results were similar when the treatment site was compared with all other sites in Louisiana. CONCLUSIONS: The Check It program was associated with a significant decline in chlamydia testing positivity rates among women in Orleans Parish compared with control sites. Screening of young Black men who have sex with women can decrease rates in women living in the same community. Future recommendations for chlamydia screening of young men should be considered.

The Effect of Louisiana Medicaid Expansion on Affordability of Health Care.

OBJECTIVES: Louisiana extended Medicaid coverage on July 1, 2016, to previously ineligible populations. We aimed to estimate the effect of Louisiana's Medicaid expansion on self-reported affordability of health care. METHODS: We used 2011-2019 data from the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS measured affordability of health care by asking respondents 2 questions: (1) whether they could not see a doctor due to cost in the previous 12 months and (2) whether they could not get a prescribed medication due to cost in the previous 12 months. We estimated difference-in-differences and difference-in-difference-in-differences analytical models using multivariable linear regression that compared trends in Louisiana with trends in states that did not expand Medicaid during the study period. RESULTS: Compared with adults aged <65 with annual household income >138% of the federal poverty level (FPL) in nonexpansion states, Medicaid expansion in Louisiana decreased the percentage of adults aged <65 with annual household income ≤138% FPL who reported being unable to see a doctor due to cost by 5.1 percentage points (95% CI, -6.5 to -3.6; P < .001) and unable to afford prescribed medication by 7.9 percentage points (95% CI, -9.2 to -6.6; P < .001). We found similar estimates when we limited the comparison group to Southern nonexpansion states. CONCLUSIONS: Louisiana's Medicaid expansion lowered cost barriers to health care. Further research may find improvements in health care affordability in states that have not yet expanded Medicaid.