Clinical and healthcare utilization outcomes during the 6 months following COVID infection in children.

BACKGROUND: We aimed to identify the impact of COVID infection in children in the US prior to vaccine availability on clinical and healthcare utilization outcomes within 6 months of infection. METHODS: Using claims data from a large national insurer, we identified 223,842 children with a COVID diagnosis in May 2020-March 2021 and matched them to 223,842 children with a COVID test and no diagnosis. We compared the two cohorts' outcomes during the 6 months after infection/test. RESULTS: Uncommon acute adverse events occurring in <0.5% of cases, including MIS-C (relative risk (RR) = 45.2), myocarditis (RR = 10.3), acute heart failure (RR = 2.14), sepsis (RR = 2.02), and viral pneumonia (RR = 2.43) were more frequent in the COVID cohort (all p < 0.001). Development of arrhythmias (RR = 1.24, p < 0.001) and atherosclerotic cardiovascular disease (RR = 1.41, p = 0.007) were more common in the COVID group, while behavioral health disorders were less common (RR = 0.94, p < 0.001). Lab testing and imaging were slightly higher in the COVID group (RR ranging 1.05-1.11 depending on the service and timeframe), though medical costs did not increase. CONCLUSION: Severe disease and diagnoses of new conditions are rare in children following COVID infection. We observed an increase in cardiac complications, though they may not last long term. IMPACT: Few studies have analyzed the association between COVID infection and medium-term outcomes in children. Our study of >447,000 geographically and socioeconomically diverse children in the US found that uncommon acute adverse events, including myocarditis, MIS-C, and acute heart failure, were more frequent in children with COVID than matched controls, and development of arrhythmias and cardiovascular disease were 1.2 and 1.4 times more common, respectively. Six-month healthcare utilization was similar between cohorts. We provide data on the risks of COVID in children, particularly with respect to cardiac complications, that decision makers may find useful when weighing the benefits and harms of preventive measures.

The association between hypertensive disorders during pregnancy and maternal and neonatal outcomes: a retrospective claims analysis.

BACKGROUND: Hypertensive disorders during pregnancy continue to increase in prevalence and are associated with several adverse outcomes and future cardiovascular risk for mothers. This study evaluated the association of hypertensive disorders compared to no hypertension during pregnancy with neonatal and maternal outcomes. We then evaluated risk factors associated with progression from a less to more severe hypertensive disorder during pregnancy. METHODS: We conducted a propensity-matched retrospective cohort study utilizing Medicaid claims data from a national insurer. The study population consisted of mothers with and without hypertensive disorders who delivered between 7/1/2016-12/31/2018 and their infants. Hypertensive disorders included gestational hypertension, chronic hypertension, preeclampsia, and superimposed preeclampsia. Propensity score matching was used to match mothers without to those with hypertensive disorders. Regression models were used to compare maternal and neonatal outcomes. Stepwise logistic regression was used to determine characteristics associated with the progression of gestational hypertension to preeclampsia or chronic hypertension to superimposed preeclampsia. RESULTS: We observed the highest risk of cesarean delivery (odds ratio [OR]:1.61 and 1.99) in mothers and preterm delivery (OR:2.22 and 5.37), respiratory distress syndrome (OR:2.39 and 4.19), and low birthweight (OR:3.64 and 9.61) in babies born to mothers with preeclampsia or superimposed preeclampsia compared to no hypertension, respectively (p < 0.05 for all outcomes). These outcomes were slightly higher among chronic or gestational hypertension compared to no hypertension, however, most were not statistically significant. Risk of neonatal intensive care unit utilization was higher among more severe hypertensive disorders (OR:2.41 for preeclampsia, OR:4.87 for superimposed preeclampsia). Obesity/overweight and having a history of preeclampsia during a prior pregnancy were most likely to predict progression from gestational/chronic hypertension to preeclampsia/superimposed preeclampsia. CONCLUSION: Mothers and neonates born to mothers with preeclampsia or superimposed preeclampsia experienced more adverse outcomes compared to those without hypertension. Mothers and neonates born to mothers with gestational hypertension had outcomes similar to those without hypertension. Outcomes for those with chronic hypertension fell in between gestational hypertension and preeclampsia. Obesity/overweight and having a history of preeclampsia during a prior pregnancy were strong risk factors for hypertension progression.

Telehealth and Outpatient Visits Among Individuals with Chronic Conditions by Socioeconomic Status in the First Year of the COVID-19 Pandemic: Observational Cohort Study.

Objective: We investigated telehealth usage for individuals with chronic conditions by neighborhood-level socioeconomic status (SES) during the first year of the COVID-19 pandemic. Methods: We split the population of 2.3 million commercially insured adults in the United States with at least one chronic condition in claims into four quartiles of SES using address of residence. After balancing groups on baseline characteristics, we examined telehealth and total outpatient evaluation and management (E&M) visits from March 2020 to February 2021. Results: Quartile 4 (highest SES) had more telehealth visits per person (0.054-0.100 more visits over each 3-month period) and a higher percentage of visits that were telehealth (1.8-5.9 percentage points higher) than other quartiles. Quartile 4 had higher levels of total outpatient E&M use throughout the year. Differences in telehealth between Quartiles 1 and 3 were small. Conclusions: Commercially insured individuals in the highest SES quartile had higher use of telehealth and total E&M visits than other quartiles.

The Impact of the COVID-19 Pandemic on Health Care Utilization Among Insured Individuals With Common Chronic Conditions.

OBJECTIVE: The COVID pandemic has had a significant impact on the US health care system. Our primary objective was to understand the impact of the COVID pandemic on non-COVID-related health care utilization among insured individuals with chronic conditions. Our secondary objective was to examine the differential impact by individual characteristics. MAIN DATA SOURCE: Medical and pharmacy claims data for individuals enrolled in a large insurer across the United States. RESEARCH DESIGN: A retrospective and repeated cross-sectional study. Overall and condition-specific health care utilization and cost metrics in (1) March 1 to June 15 and (2) June 16 to September 30, 2020 were compared with the same months during 2016-2019. SUBJECTS: Members of all ages with a diagnosis of diabetes, cardiovascular disease, or chronic kidney disease with commercial or Medicare Advantage insurance. RESULTS: Most non-COVID-related health care utilization decreased drastically on March 1 to June 15, 2020 [odds ratio (OR) range across condition-specific tests: 0.55-0.69; incidence rate ratio (IRR) range for hospitalization/emergency department (ED) visit/outpatient visit: 0.65-0.77] but returned to closer to pre-COVID levels by June 16 to September 30, 2020 [OR range across condition-specific tests: 0.93-1.08; IRR range for hospitalization/ED visit/outpatient visit: 0.77-0.97]. Our study found an enormous increase in telehealth use on March 1 to June 15, 2020 (90-170 times prepandemic levels). A differential impact was observed by age, sex, region of residence, and insurance type. IMPLICATIONS: Further investigation is needed to assess the impact of these changes in health care utilization on long-term health outcomes.

Let it go: the flexible engagement and disengagement of monitoring processes in a non-focal prospective memory task.

Remembering to perform a delayed intention is referred to as prospective memory (PM). In two studies, participants performed an Eriksen flanker task with an embedded PM task (they had to remember to press F1 if a pre-specified cue appeared). In study 1, participants performed a flanker task with either a concurrent PM task or a delayed PM task (instructed to carry out the intention in a later different task). In the delayed PM condition, the PM cues appeared unexpectedly early and we examined whether attention would be captured by the PM cue even though they were not relevant. Results revealed ongoing task costs solely in the concurrent PM condition but no significant task costs in the delayed PM condition showing that attention was not captured by the PM cue when it appeared in an irrelevant context. In study 2, we compared a concurrent PM condition (exactly as in Study 1) to a PM forget condition in which participants were told at a certain point during the flanker task that they no longer had to perform the PM task. Analyses revealed that participants were able to switch off attending to PM cues when instructed to forget the PM task. Results from both studies demonstrate the flexibility of monitoring as evidenced by the presence versus absence of costs in the ongoing flanker task implying that selective attention, like a lens, can be adjusted to attend or ignore, depending on intention relevance.

Virtual Visits for Acute, Nonurgent Care: A Claims Analysis of Episode-Level Utilization.

BACKGROUND: Expansion of virtual health care-real-time video consultation with a physician via the Internet-will continue as use of mobile devices and patient demand for immediate, convenient access to care grow. OBJECTIVE: The objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions. METHODS: A cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy. RESULTS: A total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%, P=.99) and RHC visits (28.59%, P=.51). During the episode, lab rates for virtual visits (12.56%) were lower than in-person locations (RHC: 36.79%, P<.001; UCC: 39.01%, P<.001; ED: 53.15%, P<.001; PCP: 37.40%, P<.001), and imaging rates for virtual visits (6.62%) were typically lower than in-person locations (RHC: 5.97%, P=.11; UCC: 8.77%, P<.001; ED: 43.06%, P<.001; PCP: 11.26%, P<.001). RHC, UCC, ED, and PCP were estimated to be $36, $153, $1735, and $162 more expensive than virtual visit episodes, respectively, including medical and pharmacy costs. CONCLUSIONS: Virtual care appears to be a low-cost alternative to care administered in other settings with lower testing rates. The similar follow-up rate suggests adequate clinical resolution and that patients are not using virtual visits as a first step before seeking in-person care.

Long term cost outcomes among commercially insured patients undergoing bariatric surgical procedures.

Objective: Bariatric procedures have become safer in recent years, warranting new data on long-term costs. This study examined the impact of bariatric procedures on a person's long-term healthcare costs up to 10 years and if it differed by socio-economic status (SES). Methods: This retrospective observational study compared the downstream health care cost of patients with obesity who had undergone bariatric surgery (BS) between 2009 and 2018 to a 1:1 matched group of members with obesity but no surgery. Results: 167,764 individuals from administrative claims data with an obesity diagnosis were included; 83,882 in the BS group and 83,882 in the non-surgical group. In follow-up years 2-10, the BS group was associated with lower total medical healthcare cost compared to the non-surgical group (cost ratios ranged 0.85-0.93, p values < 0.05). When stratifying the BS group by SES quartiles, there were no significant cost differences by SES (cost ratios ranged from 0.96 to 1.05, most p values > 0.05). Conclusions: BS was associated with lower long-term follow-up medical cost and cost savings appeared similar among the SES quartiles in the BS group. The study results may help policy makers and employers in designing benefits and extending coverage for bariatric surgical procedures.

Observational Analysis of a Generalized, Health Plan-led Community Health Worker Intervention in Medicaid.

INTRODUCTION/OBJECTIVES: In 2018, a Medicaid managed care plan launched a new community health worker (CHW) initiative in several counties within a state, designed to improve the health and quality of life of members who could benefit from additional services. The CHW program involved telephonic and face-to-face visits from CHWs who provided support, empowerment, and education to members, while identifying and addressing health and social issues. The primary objective of this study was to evaluate the impact of a generalized (not disease-specific), health plan-led CHW program on overall healthcare use and spending. METHODS: This retrospective cohort study used data from adult members who received the CHW intervention (N = 538 participants) compared to those who were identified for participation but were unable to be reached (N = 435 nonparticipants). Outcomes measures included healthcare utilization, including scheduled and emergency inpatient admissions, emergency department (ED) visits, and outpatient visits; and healthcare spending. The follow-up period for all outcome measures was 6 months. Using generalized linear models, 6-month change scores were regressed on baseline characteristics to adjust for between-group differences (eg, age, sex, comorbidities) and an indicator for group. RESULTS: Program participants experienced a greater increase in outpatient evaluation and management visits (0.09 per member per month [PMPM]) than the comparison group during the first 6 months of the program. This greater increase was observed across in-person (0.07 PMPM), telehealth (0.03 PMPM), and primary care (0.06 PMPM) visits. There was no observed difference in inpatient admissions, ED utilization or allowed medical spending and pharmacy spending. CONCLUSIONS: A health plan-led CHW program successfully increased multiple forms of outpatient utilization in a historically disadvantaged population of patients. Health plans may be particularly well positioned to finance, sustain, and scale programs that address social drivers of health.

Immunotherapy in combination with chemotherapy vs. immunotherapy alone for advanced non-small cell lung cancer and programmed death ligand 1 score <50.

INTRODUCTION: Little is known about the effectiveness of immunotherapy alone or with chemotherapy for patients with non-small cell lung cancer (NSCLC) and programmed death ligand 1 (PD-L1) expression <50 %. We examined the outcomes of PD-L1 therapy vs. PD-L1 therapy in combination with chemotherapy as first-line treatment among NSCLC patients with PD-L1 score <50 %. METHODS: We used administrative claims and prior authorization data of a national insurer from November 2015 to July 2021. We selected patients with Stage IIIb/IV NSCLC and PD-L1 expression <50 %. Each patient was required to have ≥1 claim of a PD-L1 or PD-1 inhibitor. Treatment groups were propensity-score matched 1:1 on baseline characteristics. We measured PD-L1 therapy duration, incident immune-related adverse events (irAEs), healthcare utilization, costs, and overall survival (OS). RESULTS: In the matched sample totaling 176 patients, mean duration of PD-L1 therapy was similar (4.1 [SD 3.3] months combination vs. 4.0 [SD 4.9] months monotherapy, p = 0.800). IrAEs were similar, both for FDA-recognized irAEs (48.9 % combination, 48.9 % monotherapy, p = 0.710) and other types (34.1 % combination, 39.8 % monotherapy, p = 0.473). The combination group had more all-cause inpatient stays, ER visits, and outpatient visits (all p < 0.001). Total adjusted all-cause medical cost was $112,833 (95 % CI $5,548-$251,973) higher for combination therapy. We saw no difference in OS (adjusted hazard ratio 1.09 [95 % CI 0.72-1.65]). CONCLUSION: This study found no difference in adverse drug effects or survival between PD-L1 monotherapy compared to combination therapy for patients with Stage IIIb/IV NSCLC and PD-L1 expression <50 %, though the combination therapy cohort had higher healthcare utilization and costs. MICROABSTRACT: Use of immunotherapy alone or combined with chemotherapy for patients with non-small cell lung cancer and programmed death ligand 1 expression <50 % is understudied. Our observational study using claims and authorization data from a matched sample of 176 patients found no difference in survival or the rate of adverse drug effects between groups, although the chemo-immunotherapy cohort generated higher overall healthcare costs.

The Association Between Mammography Screening Frequency and Breast Cancer Treatment and Outcomes: A Retrospective Cohort Study.

OBJECTIVE: Guidelines for optimal frequency of screening mammography vary by professional society. Sparse evidence exists on the association between screening frequency and breast cancer treatment options. The main objective was to examine differences in cancer treatment rendered for U.S. women with different numbers of screenings prior to breast cancer diagnosis. Cancer stage at diagnosis and health care cost were assessed in secondary analyses. METHODS: This IRB-exempt retrospective study used administrative claims data to identify women aged 44 or older with various numbers of mammographic screenings ≥11 months apart, during the four years prior to incident breast cancer diagnosis from January 2010 to December 2018. Outcomes were assessed over the six months following diagnosis. Generalized linear regression models were used to compare women with differing numbers of mammograms, adjusting for patient characteristics. RESULTS: Claims data review identified 25 492 women who met inclusion criteria. There was a stepwise improvement in each of these screening categories such that women with four screenings, compared to women with only one screening, experienced higher rates of lumpectomy (70% vs 55%) and radiation therapy (48% vs 36%), lower rates of mastectomy (27% vs 34%) and chemotherapy (28% vs 36%), less stage 3 or 4 cancer at diagnosis (15% vs 29%), and lower health care costs within six months postdiagnosis (P < 0.001). Results were similar in a subgroup limited to women aged 44 to 49 at diagnosis. CONCLUSION: Potential benefits of more frequent screening include less aggressive treatment and lower health care costs among women who develop breast cancer.

Association Between Oncology Clinical Pathway Utilization and Toxicity and Cost Outcomes in Patients With Metastatic Solid Tumors.

PURPOSE: This retrospective observational study compared cancer care toxicity and cost outcomes for patients with metastatic cancer with nine different cancer types prescribed on- versus off-pathway regimens. METHODS: This study used claims and authorization data from a national insurer between January 1, 2018, and October 31, 2021. Participants included adults with metastatic breast, lung, colorectal, pancreatic, melanoma, kidney, bladder, gastric, or uterine cancer, who were prescribed first-line anticancer regimens. Multivariable regressions were used to assess outcomes including counts of emergency room visits or hospitalizations, use of supportive care medications, immune-related adverse events (IRAEs), and health care costs. RESULTS: Of the 8,357 patients in the study, 5,453 (65.3%) were prescribed on-pathway regimens. The on-pathway proportion trended downward, from 74.3% in 2018 to 59.8% in 2021. The on- and off-pathway groups had a similar proportion of patients with treatment-related hospitalization (adjusted odds ratio [aOR], 1.080; P = .201) and IRAEs (aOR, 0.961; P = .497). More all-cause hospitalizations (aOR, 1.679; P = .013) were observed among patients with melanoma treated on-pathway. The on-pathway group had higher use of supportive care drugs in bladder cancer (aOR, 4.602; P < .001) and colorectal cancer (aOR, 4.465; P < .001), and lower use in breast (aOR, 0.668; P = .001) and lung cancer (aOR, 0.550; P < .001). On average, on-pathway patients incurred $17,589 less total health care cost (P < .001), and $22,543 lower chemotherapy cost (P < .001) than those from the off-pathway group. CONCLUSION: Our findings suggest that use of on-pathway regimens was associated with significant cost savings. Toxicity outcomes were variable by disease, but overall, there were similar numbers of treatment-related hospitalizations and IRAEs compared to off-pathway regimens. This cross-institutional study provides evidence to support the use of clinical pathway regimens for patients with metastatic cancer.

Association of Patient, Physician, and Practice-Level Factors with Uptake of Payer-Led Oncology Clinical Pathways.

Importance: Payers use oncology clinical pathways programs to increase evidence-based drug prescribing and control drug spending. However, compliance with these programs has been low, which may decrease their efficacy, and factors associated with pathway compliance are unknown. Objective: To determine extent of pathway compliance and identify factors associated with pathway compliance using characteristics of patients, practices, and the companies that develop cancer treatment pathways. Design, Setting, and Participants: This cohort study comprised patients with claims and administrative data from a national insurer and a pathways health care professional between July 1, 2018, and October 31, 2021. Adult patients with metastatic breast, lung, colorectal, pancreatic, melanoma, kidney, bladder, gastric, and uterine cancer being treated in the first line were included. Six months of continuous insurance coverage prior to the date of treatment initiation was required for determination of baseline characteristics. Stepwise logistic regression was used to identify factors associated with pathway compliance. Main Outcomes and Measures: Use of a pathway program-endorsed treatment regimen in the first-line setting for metastatic cancer. Results: Among 17 293 patients (mean [SD] age, 60.7 [11.2] years; 9183 [53.1%] women; mean [SD] Black patients per census block, 0.10 [0.20]), 11 071 patients (64.0%) were on-pathway, and 6222 (36.0%) were off-pathway. Factors associated with increased pathway compliance were higher health care utilization during the 6-month baseline period (measured in inpatient visits and emergency department visits) (5220 on-pathway inpatient visits [47.2%] vs 2797 off-pathway [45.0%]; emergency department visits, 3304 [27.1%] vs 1503 [24.2%]; adjusted odds ratio [aOR] for inpatient visits, 1.32; 95% CI, 1.22-1.43; P < .001), volume of patients with this insurance provider per physician (mean [SD] visits: on-pathway, 128.0 [258.3] vs off-pathway, 121.8 [161.4]; aOR, 1.12; 95% CI, 1.04-1.20; P = .002), and practice participation in the Oncology Care Model (on-pathway participation, 2601 [23.5%] vs 1305 [21.0%]; aOR, 1.13; 95% CI, 1.04-1.23; P = .004). Higher total medical cost during the 6-month baseline period were associated with decreased pathway compliance (mean [SD] costs: on-pathway, $55 990 [$69 706] vs $65 955 [$74 678]; aOR, 0.86; 95% CI, 0.83-0.88; P < .001). There was heterogeneity in odds of pathway compliance between different malignancies. Pathway compliance rates trended down from the reference year of 2018. Conclusions and Relevance: In this cohort study, despite generous financial incentives, compliance with payer-led pathways remained at historically reported low rates. Factors such as increasing exposure to the program due to the number of patients impacted and participation in other value-based payment programs, such as the Oncology Care Model, were positively associated with compliance; factors such as the type of cancer and patient complexity may have played a role, but the directionality of potential effects was unclear.

Provider Charges And State Surprise Billing Laws: Evidence From New York And California.

Surprise billing laws that allow dispute arbitration relying on provider charges may incentivize out-of-network providers to increase their charges to increase upcoming or future out-of-network payments. Although the federal No Surprises Act forbids arbitrators from considering charges during payment disputes over surprise bills covered by the act, states with existing laws can continue to use the specified state laws, which may allow the consideration of charges. This analysis examined provider charges in two such states, using claims data to compare trends in billed charges for out-of-network care during surprise bill scenarios involving nonemergency inpatient hospitalizations. The analysis considered New York, where state law uses arbitration tied to charges; California, where state law uses a payment standard rather than charges; and a comparison group of states without a law regarding surprise billing. We estimated that provider out-of-network charges for the nonemergency out-of-network bills we studied increased by $1,157 (24 percent) in New York after the passage of New York's surprise billing law and decreased by $752 (25 percent) in California compared to states without surprise billing laws. Assistant surgeons and surgical assistants had a large increase in charges in New York from before to after the law's passage, which may have driven the overall increase in charges.

Impaired consciousness in temporal lobe seizures: role of cortical slow activity.

Impaired consciousness requires altered cortical function. This can occur either directly from disorders that impair widespread bilateral regions of the cortex or indirectly through effects on subcortical arousal systems. It has therefore long been puzzling why focal temporal lobe seizures so often impair consciousness. Early work suggested that altered consciousness may occur with bilateral or dominant temporal lobe seizure involvement. However, other bilateral temporal lobe disorders do not impair consciousness. More recent work supports a 'network inhibition hypothesis' in which temporal lobe seizures disrupt brainstem-diencephalic arousal systems, leading indirectly to depressed cortical function and impaired consciousness. Indeed, prior studies show subcortical involvement in temporal lobe seizures and bilateral frontoparietal slow wave activity on intracranial electroencephalography. However, the relationships between frontoparietal slow waves and impaired consciousness and between cortical slowing and fast seizure activity have not been directly investigated. We analysed intracranial electroencephalography recordings during 63 partial seizures in 26 patients with surgically confirmed mesial temporal lobe epilepsy. Behavioural responsiveness was determined based on blinded review of video during seizures and classified as impaired (complex-partial seizures) or unimpaired (simple-partial seizures). We observed significantly increased delta-range 1-2 Hz slow wave activity in the bilateral frontal and parietal neocortices during complex-partial compared with simple-partial seizures. In addition, we confirmed prior work suggesting that propagation of unilateral mesial temporal fast seizure activity to the bilateral temporal lobes was significantly greater in complex-partial than in simple-partial seizures. Interestingly, we found that the signal power of frontoparietal slow wave activity was significantly correlated with the temporal lobe fast seizure activity in each hemisphere. Finally, we observed that complex-partial seizures were somewhat more common with onset in the language-dominant temporal lobe. These findings provide direct evidence for cortical dysfunction in the form of bilateral frontoparietal slow waves associated with impaired consciousness in temporal lobe seizures. We hypothesize that bilateral temporal lobe seizures may exert a powerful inhibitory effect on subcortical arousal systems. Further investigations will be needed to fully determine the role of cortical-subcortical networks in ictal neocortical dysfunction and may reveal treatments to prevent this important negative consequence of temporal lobe epilepsy.

Bridging Health and Temporary Housing Services for Medicaid Members Experiencing Homelessness: Program Impact on Health Care Utilization, Costs, and Well-being.

This study assesses the effect of participation in a temporary housing program on health care utilization, health services cost, and overall well-being for Medicaid members experiencing homelessness. Medicaid administrative claims were used in difference-in-differences analyses to compare utilization and cost of participants with those of individuals on a waiting list for the program (non-participants). Surveys were used to assess changes in well-being of participants from program entry to exit. Compared with non-participants, program participants had 0.20 fewer emergency department visits (p=.04), and 0.14 more primary care physician visits (p=.01) per person per month following program entry compared with prior to entry; medical costs were not significantly different. Compared with program entry, participants self-reported improved rates of social support at program exit. This study demonstrated the effectiveness of a local public-private partnership in reducing emergency utilization, increasing primary care visits, and improving social support.

Antibiotic dispensing following pediatric visits in the US emergency departments and outpatient settings from 2006 to 2016.

This study measured rates and trends in antibiotic dispensing for emergency department (ED) and outpatient visits by age groups. This retrospective analysis used data from the National Institutes of Health Collaboratory Distributed Research Network. The analysis included children (aged > 3 months to <12 years) and adolescents (aged 12 to <19 years) with or without an antibiotic dispensed within 3 days following visits for infectious diagnoses occurring from 2006 to 2016, with no antibiotic fills 90 days prior. Diagnoses were classified as: 1) respiratory tract infections (RTIs) for which antibiotics are mostly indicated; 2) RTIs for which antibiotics are mostly not indicated; 3) respiratory conditions for which antibiotics are never indicated; 4) infectious conditions beyond RTIs regardless of antibiotic indication. The largest annual decrease in any dispensed antibiotics (5% per year) was seen in ED visits for not indicated RTIs and never indicated respiratory conditions (incidence rate ratio [IRR] 0.95, 95% confidence interval [CI] 0.95-0.96). In outpatient settings, a 2% per year decrease was seen for not indicated RTIs and never indicated respiratory conditions (IRR 0.98, 95% CI 0.98-0.98). Broad-spectrum antibiotics had a 1% per year increase in outpatient settings for mostly indicated RTIs (IRR 1.01, 95% CI 1.01-1.01). Compared with adolescents, broad-spectrum antibiotic dispensing rates and trends were consistently higher for children regardless of diagnosis or care setting. Using national claims data, this real-world analysis found uneven decreases in potentially inappropriate antibiotic dispensing, suggesting the need for antibiotic stewardship interventions to become more common in outpatient settings.

Disconnected: a survey of users and nonusers of telehealth and their use of primary care.

OBJECTIVE: The study sought to assess awareness, perceptions, and value of telehealth in primary care from the perspective of patients. MATERIALS AND METHODS: We conducted a cross-sectional, Web-based survey of adults with access to telehealth services who visited healthcare providers for any of the 20 most-commonly seen diagnoses during telehealth visits. Three groups were studied: registered users (RUs) of telehealth had completed a LiveHealth Online (a health plan telehealth service provider) visit, registered nonusers (RNUs) registered for LiveHealth Online but had not conducted a visit, and nonregistered nonusers (NRNUs) completed neither step. RESULTS: Of 32 831 patients invited, 3219 (9.8%) responded and 766 met eligibility criteria and completed surveys: 390 (51%) RUs, 117 (15%) RNUs, and 259 (34%) NRNUs. RUs were least likely to have a primary care usual source of care (65.6% vs 78.6% for RNUs vs 80.0% for NRNUs; P < .001). Nearly half (46.8%) of RUs were unable to get an appointment with their doctor, and 34.8% indicated that their doctor's office was closed. Among the 3 groups, RUs were most likely to be employed (89.5% vs 88.9% vs 82.2%; P = .007), have post-high school education (94.4% vs 93.2% vs 86.5%; P = .003), and live in urban areas (81.0% vs 69.2% vs 76.0%; P = .021). CONCLUSIONS: Telehealth users reported that they relied on live video for enhanced access and were less connected to primary care than nonusers were. Telehealth may expand service access but risks further fragmentation of care and undermining of the primary care function absent better coordination and information sharing with usual sources of patients' care.

Untreated Sleep Apnea: An Analysis of Administrative Data to Identify Risk Factors for Early Nonadherence.

STUDY OBJECTIVES: Discontinuation of positive airway pressure (PAP) treatment for obstructive sleep apnea (OSA) is widely reported, but research has not adequately addressed nonadherence with diagnostic testing for sleep disorders and initiation of PAP. This study sought to identify drivers of nonadherence with diagnostic sleep testing and PAP treatment initiation among patients preauthorized for these services. METHODS: This observational cohort study used preauthorization records from a sleep management program and administrative medical claims from a large commercial health insurer. Participants included adults preauthorized for sleep testing and a subset in whom OSA was diagnosed and who were preauthorized for PAP treatment. Outcome measures were nonadherence with diagnostic sleep testing and PAP treatment initiation, identified as lack of a claim for a preauthorized service within 3 months of preauthorization of that service. Risk factors for nonadherence included patient demographics, prescribing factors, signs and symptoms of OSA, comorbidities, and prior health service utilization. RESULTS: Of 51,749 patients preauthorized for diagnostic testing, 23.5% did not undergo testing. Among 19,968 patients preauthorized for PAP treatment, 11.1% did not initiate treatment. Testing and treatment ordered by primary care providers, residence outside the Midwest region, and two or fewer office visits within 6 months before preauthorization were strong predictors of nonadherence. Apnea-hypopnea index score < 30 events/h was also a strong predictor of nonadherence with treatment initiation. CONCLUSIONS: This study adds to existing knowledge about risk factors for nonadherence with sleep testing and treatment initiation following preauthorization. Health plans and providers should develop strategies to better engage patients with higher risk of nonadherence.