American clusters: using machine learning to understand health and health care disparities in the United States.

Health and health care access in the United States are plagued by high inequality. While machine learning (ML) is increasingly used in clinical settings to inform health care delivery decisions and predict health care utilization, using ML as a research tool to understand health care disparities in the United States and how these are connected to health outcomes, access to health care, and health system organization is less common. We utilized over 650 variables from 24 different databases aggregated by the Agency for Healthcare Research and Quality in their Social Determinants of Health (SDOH) database. We used k-means-a non-hierarchical ML clustering method-to cluster county-level data. Principal factor analysis created county-level index values for each SDOH domain and 2 health care domains: health care infrastructure and health care access. Logistic regression classification was used to identify the primary drivers of cluster classification. The most efficient cluster classification consists of 3 distinct clusters in the United States; the cluster having the highest life expectancy comprised only 10% of counties. The most efficient ML clusters do not identify the clusters with the widest health care disparities. ML clustering, using county-level data, shows that health care infrastructure and access are the primary drivers of cluster composition.

Impact of COVID-19 on healthcare utilization, cases, and deaths of citizens and displaced Venezuelans in Colombia: Complementary comprehensive and safety-net systems under Colombia's constitutional commitment.

OBJECTIVE: Colombia hosts 1.8 million displaced Venezuelans, the second highest number of displaced persons globally. Colombia's constitution entitles all residents, including migrants, to life-saving health care, but actual performance data are rare. This study assessed Colombia's COVID-era achievements. METHODS: We compared utilization of comprehensive (primarily consultations) and safety-net (primarily hospitalization) services, COVID-19 case rates, and mortality between Colombian citizens and Venezuelans in Colombia across 60 municipalities (local governments). We employed ratios, log transformations, correlations, and regressions using national databases for population, health services, disease surveillance, and deaths. We analyzed March through November 2020 (during COVID-19) and the corresponding months in 2019 (pre-COVID-19). RESULTS: Compared to Venezuelans, Colombians used vastly more comprehensive services than Venezuelans (608% more consultations), in part due to their 25-fold higher enrollment rates in contributory insurance. For safety-net services, however, the gap in utilization was smaller and narrowed. From 2019 to 2020, Colombians' hospitalization rate per person declined by 37% compared to Venezuelans' 24%. In 2020, Colombians had only moderately (55%) more hospitalizations per person than Venezuelans. In 2020, rates by municipality between Colombians and Venezuelans were positively correlated for consultations (r = 0.28, p = 0.04) but uncorrelated for hospitalizations (r = 0.10, p = 0.46). From 2019 to 2020, Colombians' age-adjusted mortality rate rose by 26% while Venezuelans' rate fell by 11%, strengthening Venezuelans' mortality advantage to 14.5-fold. CONCLUSIONS: The contrasting patterns between comprehensive and safety net services suggest that the complementary systems behaved independently. Venezuelans' lower 2019 mortality rate likely reflects the healthy migrant effect (selective migration) and Colombia's safety net healthcare system providing Venezuelans with reasonable access to life-saving treatment. However, in 2020, Venezuelans still faced large gaps in utilization of comprehensive services. Colombia's 2021 authorization of 10-year residence to most Venezuelans is encouraging, but additional policy changes are recommended to further integrate Venezuelans into the Colombian health care system.

Economic Evaluation Design within the HEAL Prevention Cooperative.

The rapid rise in opioid misuse, disorder, and opioid-involved deaths among older adolescents and young adults is an urgent public health problem. Prevention is a vital part of the nation's response to the opioid crisis, yet preventive interventions for those at risk for opioid misuse and opioid use disorder are scarce. In 2019, the National Institutes of Health (NIH) launched the Preventing Opioid Use Disorder in Older Adolescents and Young Adults cooperative as part of its broader Helping to End Addiction Long-term (HEAL) Initiative ( https://heal.nih.gov/ ). The HEAL Prevention Cooperative (HPC) includes ten research projects funded with the goal of developing effective prevention interventions across various settings (e.g., community, health care, juvenile justice, school) for older adolescent and young adults at risk for opioid misuse and opioid use disorder (OUD). An important component of the HPC is the inclusion of an economic evaluation by nine of these research projects that will provide information on the costs, cost-effectiveness, and sustainability of these interventions. The HPC economic evaluation is integrated into each research project's overall design with start-up costs and ongoing delivery costs collected prospectively using an activity-based costing approach. The primary objectives of the economic evaluation are to estimate the intervention implementation costs to providers, estimate the cost-effectiveness of each intervention for reducing opioid misuse initiation and escalation among youth, and use simulation modeling to estimate the budget impact of broader implementation of the interventions within the various settings over multiple years. The HPC offers an extraordinary opportunity to generate economic evidence for substance use prevention programming, providing policy makers and providers with critical information on the investments needed to start-up prevention interventions, as well as the cost-effectiveness of these interventions relative to alternatives. These data will help demonstrate the valuable role that prevention can play in combating the opioid crisis.

Impact of weekday and weekend mobility and public policies on COVID-19 incidence and deaths across 76 large municipalities in Colombia: statistical analysis and simulation.

BACKGROUND: Despite widespread restrictions on residents' mobility to limit the COVID-19 pandemic, controlled impact evaluations on such restrictions are rare. While Colombia imposed a National Lockdown, exceptions and additions created variations across municipalities and over time.  METHODS: We analyzed how weekend and weekday mobility affected COVID-19 cases and deaths. Using GRANDATA from the United Nations Development Program (UNDP) we examined movement in 76 Colombian municipalities, representing 60% of Colombia's population, from March 2, 2020 through October 31, 2020. We combined the mobility data with Colombia's National Epidemiological Surveillance System (SIVIGILA) and other databases and simulated impacts on COVID-19 burden.  RESULTS: During the study period, Colombians stayed at home more on weekends compared to weekdays. In highly dense municipalities, people moved less than in less dense municipalities. Overall, decreased movement was associated with significant reductions in COVID-19 cases and deaths two weeks later. If mobility had been reduced from the median to the threshold of the best quartile, we estimate that Colombia would have averted 17,145 cases and 1,209 deaths over 34.9 weeks, reductions of 1.63% and 3.91%, respectively. The effects of weekend mobility reductions (with 95% confidence intervals) were 6.40 (1.99-9.97) and 4.94 (1.33-19.72) times those of overall reductions for cases and deaths, respectively. CONCLUSIONS: We believe this is the first evaluation of day-of-the week mobility on COVID-19. Weekend behavior was likely riskier than weekday behavior due to larger gatherings and less social distancing or protective measures. Reducing or shifting such activities outdoors would reduce COVID-19 cases and deaths.

Impact of Respiratory Syncytial Virus on Child, Caregiver, and Family Quality of Life in the United States: Systematic Literature Review and Analysis.

BACKGROUND: Respiratory syncytial virus (RSV), a leading cause of lower respiratory tract infection in US children, reduces quality of life (QOL) of children, their caregivers, and families. METHODS: We conducted a systematic literature review in PubMed, EconLit, and other databases in the United States of articles published since 2000, derived utility lost per RSV episode from cohort studies, and performed a systematic analysis. RESULTS: From 2262 unique citations, 35 received full-text review and 7 met the inclusion criteria (2 cohort studies, 4 modeling studies, and 1 synthesis). Pooled data from the 2 cohort studies (both containing only hospitalized premature infants) gave quality-adjusted life-year (QALY) losses per episode of 0.0173 at day 38. From the cohort study that also assessed caregivers' QOL, we calculated net QALYs lost directly attributable to RSV per nonfatal episode from onset to 60 days after onset for the child, caregiver, child-and-caregiver dyad of 0.0169 (167% over prematurity alone), 0.0031, and 0.0200, respectively. CONCLUSION: Published data on QOL of children in the United States with RSV are scarce and consider only premature hospitalized infants, whereas most RSV episodes occur in children who were born at term and were otherwise healthy. QOL studies are needed beyond hospitalized premature infants.

Cost of Respiratory Syncytial Virus Infections in US Infants: Systematic Literature Review and Analysis.

BACKGROUND: Limited data are available on the economic costs of respiratory syncytial virus (RSV) infections among infants and young children in the United States. METHODS: We performed a systematic literature review of 10 key databases to identify studies published between 1 January 2014 and 2 August 2021 that reported RSV-related costs in US children aged 0-59 months. Costs were extracted and a systematic analysis was performed. RESULTS: Seventeen studies were included. Although an RSV hospitalization (RSVH) of an extremely premature infant costs 5.6 times that of a full-term infant ($10 214), full-term infants accounted for 82% of RSVHs and 70% of RSVH costs. Medicaid-insured infants were 91% more likely than commercially insured infants to be hospitalized for RSV treatment in their first year of life. Medicaid financed 61% of infant RSVHs. Paying 32% less per hospitalization than commercial insurance, Medicaid paid 51% of infant RSVH costs. Infants' RSV treatment costs $709.6 million annually, representing $187 per overall birth and $227 per publicly funded birth. CONCLUSIONS: Public sources pay for more than half of infants' RSV medical costs, constituting the highest rate of RSVHs and the highest expenditure per birth. Full-term infants are the predominant source of infant RSVHs and costs.

Integrating Venezuelan Migrants into the Colombian Health System during COVID-19.

Colombia provides a unique setting to understand the complicated interaction between health systems, health insurance, migrant populations, and COVID-19 due to its system of Universal Health Coverage and its hosting of the second-largest population of displaced persons globally, including approximately 1.8 million Venezuelan migrants. We surveyed 8,130 Venezuelan migrants and Colombian nationals across 60 municipalities using a telephone survey during the first wave of the pandemic (September through November 2020). Using self-reported enrollment in one of the several Colombian health insurance schemes, we analyzed the access to and disparities in the use of health-care services for both Colombians and Venezuelan migrants by insurance status, including access to formal health services, virtual visits, and COVID-19 testing for both groups. We found that compared with 3.6% of Colombians, 73.6% of Venezuelan telephone survey respondents remain uninsured, despite existing policies that allow legally present migrants to enroll in national health insurance schemes. Enrolling migrants in either the subsidized or contributory regime increases their access to health-care services, and equality between Colombians and Venezuelans within the same insurance schemes can be achieved for some services. Colombia's experience integrating Venezuelan migrants into their current health system through various insurance schemes during the first wave of their COVID-19 pandemic shows that access and equality can be achieved, although there continue to be challenges.

Cost analysis in implementation studies of evidence-based practices for mental health and substance use disorders: a systematic review.

BACKGROUND: This study is a systematic literature review of cost analyses conducted within implementation studies on behavioral health services. Cost analysis of implementing evidence-based practices (EBP) has become important within implementation science and is critical for bridging the research to practice gap to improve access to quality healthcare services. Costing studies in this area are rare but necessary since cost can be a barrier to implementation and sustainment of EBP. METHODS: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and applied the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Key search terms included: (1) economics, (2) implementation, (3) EBP, and (4) behavioral health. Terms were searched within article title and abstracts in: EconLit, SocINDEX, Medline, and PsychINFO. A total of 464 abstracts were screened independently by two authors and reduced to 37 articles using inclusion and exclusion criteria. After a full-text review, 18 articles were included. RESULTS: Findings were used to classify costs into direct implementation, direct services, and indirect implementation. While all studies included phases of implementation as part of their design, only five studies examined resources across multiple phases of an implementation framework. Most studies reported direct service costs associated with adopting a new practice, usually summarized as total EBP cost, cost per client, cost per clinician, and/or cost per agency. For studies with detailed analysis, there were eleven direct cost categories represented. For five studies that reported costs per child served, direct implementation costs varied from $886 to $9470 per child, while indirect implementation costs ranged from $897 to $3805 per child. CONCLUSIONS: This is the first systematic literature review to examine costs of implementing EBP in behavioral healthcare settings. Since 2000, 18 studies were identified that included a cost analysis. Given a wide variation in the study designs and economic methods, comparison across studies was challenging, which is a major limitation in the field, as it becomes difficult to replicate studies or to estimate future costs to inform policy decisions related to budgeting. We recommend future economic implementation studies to consider standard economic costing methods capturing costs across implementation framework phases to support comparisons and replicability.

The Challenge of Additionality: The Impact of Central Grants for Primary Healthcare on State-Level Spending on Primary Healthcare in India.

BACKGROUND: In planning for universal health coverage, many countries have been examining their fiscal decentralization policies with the goal of increasing efficiency and equity via "additionalities." The concept of "additionality," when the government of a lower administrative level increases the funding allocated to a particular issue when extra funds are present, is often used in these contexts. Although the definition of "additionality" can be used more broadly, for the purposes of this paper we focus narrowly on the additional allocation of primary healthcare expenditures. This paper explores this idea by examining the impact of central level primary healthcare expenditure, on individual state level contributions to primary healthcare expenditure within 16 Indian states between 2005 and 2013. METHODS: In examining 5 main variables, we compared differences between government expenditures, contributions, and revenues for Empowered Action Group (EAG) states, and non-EAG states. EAG states are normally larger states that have weaker public health infrastructure and hence qualify for additional funding. Finally, using a model that captured the quantity of central level primary healthcare expenditure distributions to these states, we measured its impact on each state's own contributions to primary healthcare spending. RESULTS: Our results show that, at the state level, growth in per capita central level primary healthcare expenditure has increased by 110% from 2005-2013, while state's own contributions to primary healthcare expenditure per capita increased by 32%. Further analyses show that a 1% change disbursement from the central level leads to a -0.132%, although not significant, change by states in their own expenditure. The effect for wealthier states is -0.151% and significant and for poorer states the effect is smaller at -0.096% and not significant. CONCLUSION: This analysis suggests that increases in central level primary healthcare expenditure to states have an inverse relationship with primary healthcare expenditures by the state level. Furthermore, this effect is more pronounced in wealthier Indian states. This finding has policy implications on India's decision to increase block grants to states in place of targeted program expenditures.

Cost Effectiveness of Mobile Health for Antenatal Care and Facility Births in Nigeria.

BACKGROUND: The use of mobile technology in the health sector, often referred to as mHealth, is an innovation that is being used in countries to improve health outcomes and increase and improve both the demand and supply of health care services. This study assesses the actual cost-effectiveness of initiating and implementing the use of the mHealth as a supply side job aid for antenatal care. The study also estimates the cost-effectiveness ratio if mHealth was also used to encourage and track women through facility delivery. METHODS: The methodology utilized a retrospective, micro-costing technique to extract costing data from health facilities and administrative offices to estimate the costs of implementing the mHealth antenatal care program and estimate the cost of facility delivery for those that used the antenatal care services in the year 2014. Five different costing tools were developed to assist in the costing analysis. FINDINGS: The results show that the provision of tetanus toxoid vaccination and malaria prophylaxis during pregnancy and improved labor and delivery during facility delivery contributed the most to mortality reductions for women, neonates and stillbirths in mHealth facilities versus non-mHealth facilities. The cost-effectiveness ratio of this program for antenatal care and no demand-side generation for facility delivery is US$13,739 per life saved. The cost-effectiveness ratio adding in an additional demand-side generation for facility births reduces to US$9,806 per life saved. CONCLUSION: These results show that mHealth programs are inexpensive and save a number of lives for the dollar investment and could save additional lives and funds if women were also encouraged to seek facility delivery.

A preliminary assessment of financial stability, efficiency, health systems and health outcomes using performance-based contracts in Belize.

Over the last 10 years, Belize has implemented a National Health Insurance (NHI) program that uses performance-based contracts with both public and private facilities to improve financial sustainability, efficiency and service provision. Data were collected at the facility, district and national levels in order to assess trends in financial sustainability, efficiency payments, year-end bonuses and health system and health outcomes. A difference-in-difference approach was used to assess the difference in technical efficiency between private and public facilities. The results show that per capita spending on services provided by the NHI program has decreased over the period 2006-2009 from BZ$177 to BZ$136. The private sector has achieved higher levels of technical efficiency, but lower percentages of efficiency and year-end bonus payments. Districts with contracts through the NHI program showed greater improvements in facility births, nurse density, reducing maternal mortality, diabetes deaths and morbidity from bronchitis, emphysema and asthma than districts without contracts over the period 2006-2010. This preliminary assessment of Belize's pay-for-performance system provides some positive results, however further research is needed to use the lessons learned from Belize to implement similar reforms in other systems.

Guatemala: the economic burden of illness and health system implications.

OBJECTIVES: To assess the economic burden of ill health in Guatemala, the characteristics of Guatemala's health system that potentially explain this burden, and to identify policies to help ameliorate it. METHODS: Data from the 2000 and 2006 Living Standard Measurement Surveys are used to assess levels of financial burden from ill health, along with information on health system characteristics of Guatemala and recent reform experiences of several middle- and low-income countries. RESULTS: Despite some gains over the period from 2000 to 2006, there continues to be both a high level and inequitable distribution of financial burden associated with ill health in Guatemala. Low levels of insurance coverage, a heavy concentration of the uninsured among the less well off and rural populations, as well as their low levels of access to public services are important drivers of out of pocket spending on health. Households with older members also appear to be at increased risk for out of pocket payments. CONCLUSIONS: High levels of catastrophic health spending and poverty co-exist with significant economic inequality and poverty in Guatemala. With health system features and a large informal sector similar to many other developing countries, recent international experience can provide useful lessons to help Guatemala devise innovative financing and payment mechanisms to address these concerns.

The health of the Delta Region: a story of increasing disparities.

The Delta region of the U.S. has substantial disparities in health outcomes. For four of the leading causes of death in the United States (cardiovascular disease, cancer, stroke, and injury) residents of the Delta region are between 1.16 (cancer) and 1.45 (injury) times as likely to die as residents of the United States in general. Delta region residents are also more likely to have higher BMI, higher blood pressure, more diabetes, and are more likely to smoke. From 1968 to 1982, mortality rates in the Delta region and in the U.S. fell rapidly and in parallel. Beginning in the 1980s, these two rates continued to decline but began to diverge, with less improvement in the Delta region than in the United States in general. From 1968 to 1982, mortality disparities in the Delta were about 90 excess deaths per 100,000. By 2004, mortality disparities in the Delta had doubled to about 187 excess deaths per 100,000. Put differently, the Delta region had approximately 18,000 excess deaths in 2004, deaths that would not have occurred had the region achieved the average rate of mortality experienced by the remainder of the nation.

The population health and income nexus in the Mississippi River Delta Region and beyond.

The association between health and income has been well established using cross-country panel data. This paper explores this association further using data for corresponding cross sections of counties in the United States in 1970 and 2000. Special attention is paid to the stability of the associations over time and to differences between counties in the Mississippi River Delta Region and those in the rest of the United States. Regression results show that income is positively correlated with improvements in life expectancy over the period 1970 to 2000. This relationship strengthens from 1970 to 2000 for the U.S. and the non-Delta region and weakens slightly for the Delta region. Decomposition analysis shows that income explains more of the improvements in life expectancy from 1970 to 2000 for the Delta region (49%) than for the U.S. (35%) or the non-Delta region (32%). Factors other than income are less important in the Delta region during this time period. In 1970, income (64%) explains more of the difference in health between the Delta and non-Delta counties than non-income factors (36%). By the year 2000, non-income factors (77%) explain more of the disparities in health between the Delta and non-Delta countries than income factors (23%). For the year 2000, if the Delta region were to count on increased income to improve life expectancy to the average of the non-Delta region, it would need to increase its income level by 135%. The analysis indicates that population health in the Mississippi River Delta Region lags behind the rest of the United States not only because of lower income levels, but more importantly because of lower contributions to health of non-income factors.

Is decentralization good for logistics systems? Evidence on essential medicine logistics in Ghana and Guatemala.

Efficient logistics systems move essential medicines down the supply chain to the service delivery point, and then to the end user. Experts on logistics systems tend to see the supply chain as requiring centralized control to be most effective. However, many health reforms have involved decentralization, which experts fear has disrupted the supply chain and made systems less effective. There is no consensus on an appropriate methodology for assessing the effectiveness of decentralization in general, and only a few studies have attempted to address decentralization of logistics systems. This paper sets out a framework and methodology of a pioneering exploratory study that examines the experiences of decentralization in two countries, Guatemala and Ghana, and presents suggestive results of how decentralization affected the performance of their logistics systems. The analytical approach assessed decentralization using the principal author's 'decision space' approach, which defines decentralization as the degree of choice that local officials have over different health system functions. In this case the approach focused on 15 different logistics functions and measured the relationship between the degree of choice and indicators of performance for each of the functions. The results of both studies indicate that less choice (i.e. more centralized) was associated with better performance for two key functions (inventory control and information systems), while more choice (i.e. more decentralized) over planning and budgeting was associated with better performance. With different systems of procurement in Ghana and Guatemala, we found that a system with some elements of procurement that are centralized (selection of firms and prices fixed by national tender) was positively related in Guatemala but negatively related in Ghana, where a system of 'cash and carry' cost recovery allowed more local choice. The authors conclude that logistics systems can be effectively decentralized for some functions while others should remain centralized. These preliminary findings, however, should be subject to alternative methodologies to confirm the findings.

Decentralization and equity of resource allocation: evidence from Colombia and Chile.

OBJECTIVE: To investigate the relation between decentralization and equity of resource allocation in Colombia and Chile. METHODS: The "decision space" approach and analysis of expenditures and utilization rates were used to provide a comparative analysis of decentralization of the health systems of Colombia and Chile. FINDINGS: Evidence from Colombia and Chile suggests that decentralization, under certain conditions and with some specific policy mechanisms, can improve equity of resource allocation. In these countries, equitable levels of per capita financial allocations at the municipal level were achieved through different forms of decentralization--the use of allocation formulae, adequate local funding choices and horizontal equity funds. Findings on equity of utilization of services were less consistent, but they did show that increased levels of funding were associated with increased utilization. This suggests that improved equity of funding over time might reduce inequities of service utilization. CONCLUSION: Decentralization can contribute to, or at least maintain, equitable allocation of health resources among municipalities of different incomes.