Changing patterns of medication use in patients with rheumatoid arthritis in a Medicaid population.

OBJECTIVE: To examine changes in patterns of medication utilization in patients with RA. METHODS: Data from Tennessee Medicaid (TennCare) databases (1995-2004) were used to identify adults with both a diagnosis of RA and at least one DMARD prescription each year. Annual age-specific utilization of DMARDs, glucocorticoids, NSAIDs and narcotics was measured on the last day of each year to determine the point prevalence of use of these agents. RESULTS: Records from 23 342 patients with treated RA were analysed. Most patients were females (78%) and white (74%). The median age was 57 yrs (interquartile range: 48-65). The proportion of patients who had a current DMARD prescription on the index date increased from 62% in 1995 to 71% in 2004 (P < 0.001). MTX was the most commonly used DMARD. By the end of 2004, 22% of patients had a current prescription for a biologic, and etanercept represented 51% of all biologic therapies. During the study period, the overall utilization of glucocorticoids decreased from 46% to 38% (P < 0.001), whereas NSAID utilization increased from 33% to 38% (P < 0.001), and use of narcotics increased from 38% to 55% (P < 0.001). A secondary analysis that identified RA patients based on diagnosis codes alone, showed similar patterns, but lower DMARD utilization which increased from 33% to 52% overall and from 0% to 16% for biologics. CONCLUSIONS: The utilization of DMARDs increased in TennCare patients with RA, and by 2004, use of biologics was substantial. Although glucocorticoid utilization decreased, use of both NSAIDs and narcotics increased.

Predictors of injury mortality in early childhood.

OBJECTIVE: To study the association between maternal/infant characteristics and mortality from injury for children 0 through 4 years of age. DESIGN: Historical cohort. SETTING: State of Tennessee. PARTICIPANTS: Children 0 through 4 years of age at any time between January 1, 1985 and December 31, 1994. We linked birth certificates and US census data to obtain information on maternal age, race, education, neighborhood income, parity, use of prenatal care, residence location, infant's gender, and gestational age. MAIN OUTCOME MEASURES: The outcome was death from injury, as determined from linked death certificates. The incidence density rates for each stratum (defined by maternal/child characteristics) were calculated by dividing the number of injury deaths by child years in the stratum. We used multivariate analysis to assess the independent contribution of each characteristic to risk of injury death. RESULTS: There were 1 035 504 children 0 through 4 years of age who contributed 3 414 436 child years. There were 803 deaths from injury, ie, 23.5 deaths per 100 000 child years. In the multivariate analysis, children had at least a 50% increased risk of injury mortality if they were born to a mother who had less than a high school education (relative risk [RR] = 2.88; 95% confidence interval [CI]: 1.92-4.34) compared with a college education, was <20 years of age (RR = 2.42; 95% CI: 1.76-3.31) compared with >30 years, or had >2 other children (RR = 2.97; 95% CI: 2.29-3.85) compared with no other children. Neither race nor income was significantly associated with childhood injury mortality in the multivariate analysis. Classification of children by maternal education, age, and parity defined a pronounced risk gradient in which high-risk children had an injury mortality rate >15 times that of low-risk children. The steep risk gradient was present for both infants (24-fold increase for high-risk children) and children 1 through 4 years of age (13-fold increase for high-risk children). If the injury mortality rate for all children were equal to that of the low-risk group, 614/803 (76.3%) of injury deaths would not have occurred. CONCLUSIONS: For young children, maternal education, age, and parity are strongly and independently associated with injury mortality. These factors define a steep gradient of risk, suggesting that many injury deaths could be prevented.

Comparison of perinatal outcomes among TennCare managed care organizations.

OBJECTIVE: To compare perinatal outcomes among the managed care organizations (MCOs) providing care to beneficiaries enrolled in TennCare, Tennessee's capitated Medicaid managed care program. DESIGN: Retrospective cohort analysis. SUBJECTS: Infants born in Tennessee during 1995 to women enrolled in TennCare. PRIMARY OUTCOME MEASURES: Prenatal care use, birth weight (BW), death in the first 60 days of life, and delivery of extremely low BW (<1000 g) infants in hospitals without level 3 neonatal intensive care units. RESULTS: During 1995, 34 402 infants were born to mothers enrolled in TennCare. The MCOs differed widely in the demographic characteristics of their enrollees. In addition, there were small differences in prenatal care utilization, but no differences in BW outcomes among the MCOs. In multivariate analysis, however, infants born to women enrolled in 1 MCO were 2.8 times more likely to die in the first 60 days of life than were infants born to women enrolled in the largest MCO (OR: 2.81; 95% CI: 1.31-6.03). Women enrolled in this same MCO seemed to have a higher proportion of extremely low BW (<1000 g) infants delivering in a hospital lacking a level 3 neonatal intensive care unit (38% vs 20% in the largest MCO). CONCLUSION: The differences among MCOs in early infant death and in the delivery of high-risk infants in hospitals lacking appropriate neonatal facilities suggest that monitoring of care delivery to vulnerable children should include assessment of appropriate use of specialized services.

Underutilization of controller and rescue medications among older adults with asthma requiring hospital care.

BACKGROUND: Asthma causes serious morbidity in older people, but pharmacologic therapy in older people with asthma has never been studied, at least in part because of the difficulty of defining asthma in this population. OBJECTIVE: To determine if older persons enrolled in Medicaid and hospitalized with an exacerbation of asthma receive appropriate outpatient asthma care. DESIGN: Descriptive pharmacoepidemiology of a group of older adults with asthma. SETTING: The Tennessee Medicaid Program. PARTICIPANTS: Persons aged 65 and older, enrolled in the Tennessee Medicaid program, identified through Medicaid's computerized database as having a hospital care visit for asthma in 1992 and who had their diagnosis confirmed by chart review. MEASUREMENT: Medication utilization. RESULTS: The source population included 93,686 persons aged 65 or older enrolled in the Tennessee Medicaid program. The group meeting study criteria included 512 patients with chronic asthma who had a hospital care visit for an asthma exacerbation. Eighty-one percent of these 512 persons with an asthma hospitalization confirmed by chart review were classified as having moderate to severe or potentially fatal asthma. These patients had had a median of 15 outpatient visits in the previous year, and more than half of them had an outpatient visit in the 14 days before their hospitalization. However, among those with moderate to severe or near fatal asthma only 25% filled prescriptions for inhaled corticosteroids, whereas 52% were taking theophylline, the most commonly prescribed asthma medication in this group. There was also high use of antibiotics (29%) and low use of rescue corticosteroids (5%) before the hospital care visit, despite frequent medical encounters. CONCLUSIONS: Despite widespread promulgation of the National Asthma Education Prevention Program guidelines, our study suggests that providers caring for indigent older subjects with moderate to severe or potentially fatal asthma were not following these guidelines. There was significant underutilization of inhaled anti-inflammatory agents, beta-agonists, and rescue corticosteroids in this population despite frequent outpatient medical care visits.

Persistently increased injury mortality rates in high-risk young children.

OBJECTIVE: To study trends in injury mortality for low- and high-risk young children. DESIGN AND METHODS: For Tennessee children 0 to 4 years of age, we used birth certificates to obtain data on maternal education, age, and parity; these risk factors were used to classify children into low- and high-risk groups. The outcome was death from injury, as determined from linked death certificates. Between 1978 and 1995, injury mortality rates were calculated for six 3-year periods for low- and high-risk children. RESULTS: There were 1.5 million children 0 to 4 years of age who contributed 4.9 million child-years. The high-risk group contributed 28% of all child-years. There were 673 injury deaths in the high-risk group, 48.9 deaths per 100,000 child-years, and 586 deaths in the low-risk group, 16.8 deaths per 100,000 child-years. The injury mortality rate for low-risk children decreased from 20.7 to 15.7 per 100,000 child-years between the 1978-1980 and 1981-1983 periods; thereafter it remained relatively stable. For high-risk children, the injury mortality rate decreased from 50.9 to 43.5 per 100,000 between the 1978-1980 and 1981-1983 periods, remained mostly unchanged through 1992, and then increased sharply in the 1993-1995 period to 64.1 per 100,000 child-years. The disparity between high- and low-risk children widened from 29.3 (95% confidence interval, 25.1-33.5) excess deaths per 100,000 for 1978 through 1991 to 46.9 (95% confidence interval, 35.9-57.9) in 1993 through 1995. CONCLUSIONS: In Tennessee, maternal education, age, and parity consistently identified a population of children at increased risk of injury mortality. For these high-risk children, there has been no substantial reduction in injury mortality in high-risk young children during the last 18 years.

Prenatal use of metronidazole and birth defects: no association.

OBJECTIVE: To determine whether the use of metronidazole by pregnant women increases the risk of birth defects in the offspring. METHODS: Two cohorts of pregnant women who delivered live-born or stillborn infants between January 1, 1983 and December 31, 1988 were identified from the Tennessee Medicaid enrollment files. The exposed cohort consisted of 1387 women who filled a prescription for metronidazole between 30 days before and 120 days after the onset of their last normal menstrual period. The unexposed cohort consisted of 1387 comparable women who did not fill a prescription for metronidazole during the same time. Medical records for 94% of the offspring of both study cohorts were then reviewed to ascertain the occurrence of birth defects. RESULTS: Pregnancy outcomes were similar for the exposed and unexposed cohort members. There was no excess of overall birth defect occurrence in the offspring of exposed women (risk ratio 1.2, 95% confidence interval 0.9-1.6), nor could an excess risk be detected for any category of birth defects. CONCLUSION: This study provides no evidence that prenatal use of metronidazole increases the risk of overall birth defect occurrence.

Serious maternal morbidity after childbirth: prolonged hospital stays and readmissions.

OBJECTIVE: To determine the frequency of and risk factors for serious morbidity resulting in a prolonged hospital stay or readmission among women enrolled in Tennessee's Medicaid program who delivered live or dead infants in 1991. METHODS: This retrospective cohort study included 33,251 women of white or black ethnicity. Main outcome measures included childbirth-related medical conditions serious enough to result in death, prolonged delivery hospitalization, or readmission within 60 days of delivery. RESULTS: Among 25,810 women with vaginal (78%) and 7441 (22%) women with cesarean deliveries, 2.6% and 8.9%, respectively, had at least one childbirth-related medical condition requiring prolonged delivery hospitalization or readmission, including infection (1.8% and 7.9%), hypertension-related complications (0.7% and 2.0%), or hemorrhage (0.5% and 2.4%). After controlling for other risk factors, maternal age over 32 years was independently associated with increased rate of serious morbidity among women who had vaginal (relative risk [RR] 1.9, 95% confidence interval [CI] 1.4, 2.7) or cesarean deliveries (RR 1.6, 95% CI 1.1, 2.2). Black women had approximately twice the rate of maternal morbidity with vaginal (RR 1.9, 95% CI 1.5, 2.4) or cesarean deliveries (RR 2.3, 95% CI 1.9, 2.9). Primiparous women who had vaginal or cesarean deliveries had a 60% (RR 1.6, 95% CI 1.3, 2.0) and 70% (RR 1.7, 95% CI 1.4, 2.0), respectively, greater risk of serious maternal morbidity than women with 1-3 prior births. CONCLUSION: Predictors of serious maternal morbidity included age over 32 years, black ethnicity, and primiparity.

Expanded Medicaid coverage for pregnant women to 100 percent of the federal poverty level.

Our objective was (1) to identify the subgroup of women most affected by the regulatory change expanding Tennessee Medicaid eligibility for pregnant women from 45% of the federal poverty level to 100% and (2) to examine whether increased enrollment correlated with greater use of prenatal care and improved reproductive outcomes. We linked Tennessee birth and fetal death certificates to Medicaid enrollment files. We compare outcome rates in the 12-month period before the change in the Medicaid regulations with similar rates for the 10-month period after the change had been in effect nine months. We found the increase in Medicaid enrollment that occurred after the expansion was greatest for teenage mothers. Among teens, Medicaid enrollment increased 18%, and the odds of receiving no prenatal care or only late (third-trimester) care were reduced 16% (95% confidence interval = 8%, 24%) after we controlled for potential confounders. However, there was no improvement in first-trimester use of prenatal care or in birth outcomes. This finding suggests the need to evaluate carefully subsequent regulatory changes, which sought to promote early prenatal care by removing barriers to early Medicaid enrollment in pregnancy.

Monitoring maternal mortality using vital records linkage.

We developed a method to identify maternal deaths (deaths to women within 365 days of delivery) by linking Tennessee vital records. A computerized algorithm compared personal identifiers from the death certificates of reproductive-aged women to maternal identifiers on birth and fetal death certificates. For each decedent record which met the study criteria, the algorithm calculated a "match score" by comparing common elements in both files. The algorithm awarded full credit for data elements that agree exactly, partial credit for elements in partial agreement, and subtracted credit for information that mismatched. Match scores ranged from 0 to 35 for the 9,009 deaths in women 10-55 years of age during the three study years, with the majority of scores (96.3%) being 0 for "no match." Match scores of 1 to 8 were obtained by 153 (1.7%) of decedent records, while scores greater than 9 were obtained by 184 (2.0%) of decedent records. We used nurse-abstracted hospital, autopsy, and coroner records as our standard to verify the linkages. Manual review of personal identifiers showed that scores of 12 or less were not a match while scores of 13 or more indicated "true" matches. Based on this cutoff, the linkage algorithm yielded 130 maternal deaths. Of these, 32 (25%) were classified as truly pregnancy-related upon medical record review by an obstetrician. The remaining 98 deaths were associated only temporally with pregnancy. During the same time period, 16 individuals were identified to the State Health Department on their death certificates as dying from pregnancy-related causes, including one not identified by the linkage process.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of Medicaid expansions on preterm birth.

OBJECTIVES: Inadequate prenatal care is thought to be a major modifiable risk factor for preterm birth, the leading cause of neonatal mortality. To improve high-risk women's financial access to prenatal care, the U.S. Medicaid program underwent major expansions during the 1980s. We evaluated these expansions over the nine-year period 1983 to 1991 in Tennessee to determine their effects on Medicaid enrollment, use of prenatal care, and preterm birth. METHODS: We used linked birth certificates, Medicaid data, and U.S. Census files to identify 610,056 singleton births to African-American or Caucasian women in Tennessee whose last menstrual period was between 1983 and 1991. These were classified by maternal characteristics to identify groups with the greatest postexpansion increases in Medicaid enrollment, which should have benefited most from the policy changes. Study outcomes were Medicaid enrollment by delivery, enrollment in the first trimester, inadequate prenatal care (modified Kessner index), and preterm (< 37 weeks) birth. We calculated the changes (delta expressed as births per 100) between 1983 and 1991 in percentages of births with each of these outcomes. RESULTS: The expansions led to pronounced increases in maternal Medicaid enrollment by delivery (21% of births in 1983 to 51% by 1991) and in the first trimester (from 10% to 37%). Married women with < 12 years of education, < 25 years of age, and < $12,500 mean neighborhood incomes (group 1) had the greatest increase, where enrollment and first-trimester enrollment increased from 24% to 86% and 7% to 68%, respectively. In group 1, the percentages of births with inadequate maternal use of prenatal care decreased substantially, from 12.8% in 1983 to 6.4% in 1991, a reduction of 6.4 births per 100 (95% confidence intervals [CI] = -7.6, -5.3). However, the preterm birth rate did not decrease (9.1% in 1983, 9.4% in 1991, change of 0.3[-0.7 to 1.2] births per 100). For other births, there were lesser increases in Medicaid enrollment, correspondingly lesser decreases in inadequate use of prenatal care, but no reductions in preterm birth rates. CONCLUSIONS: In Tennessee, the Medicaid expansions materially increased enrollment and use of prenatal care among high-risk women, but did not reduce the likelihood of preterm birth.

Use of healthcare resources among medically and surgically treated patients with gastroesophageal reflux disease: a population-based study.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disorder that may be effectively managed medically or surgically. Direct evaluations of medical resource use are needed to better understand the relative costs of these alternatives. This study compared medical care use for a group of patients receiving surgical treatment for GERD with that for a comparable group of patients receiving medical management. STUDY DESIGN: We conducted a retrospective matched cohort study of Tennessee Medicaid (TennCare) patients with GERD undergoing surgical treatment in 1996 and a group of patients who received medical therapy during the same period. Administrative TennCare data provided computerized records that could be used to identify patients and measure healthcare use. There were 7,502 people who met all of the conditions for inclusion in the study, including at least two encounters with a diagnosis of GERD. One hundred thirty-five of these who underwent fundoplication constituted the surgically treated cohort. The 250 persons in the medically treated cohort were selected randomly from the remaining nonsurgical patients and matched to the surgical cohort by age, gender, race, managed care organization, and acid suppression drug use in the baseline year. The principal outcome of interest was total use of medical resources, including prescription medication. RESULTS: The surgical and medical cohorts did not differ significantly by demographic characteristics or by baseline use of pharmaceuticals. During the baseline year the surgically treated patients were prescribed 302 (95% CI: 270-334) days ofGERD treatment and the matched medical patients were prescribed 292 (95% CI: 267-317) days of GERD treatment. Surgically treated patients used more GERD-related outpatient resources (physician visits and diagnostic testing) in the baseline year, particularly in the 3 months before operation, when they had a mean of more than four outpatient encounter-days. In the followup year, use of GERD-related pharmaceuticals decreased markedly in the surgical cohort. These patients were prescribed an average of 123 days (95% CI: 94-153) of therapy, which was only 36% of that for medical patients (339 days [95% CI: 308-370]). More than 29% of surgical patients were prescribed no GERD-related drugs in the followup year compared with 6% of the medically treated group. The mean number of inpatient days for the fundoplication procedure was 3.2 (95% CI: 2.7-3.6), with a range of 0 to 13 days. There were no differences between the two groups in other healthcare use. CONCLUSIONS: Our results show that in a 1-year period of followup, surgical treatment of severe gastroesophageal reflux disease led to a 64% postsurgical reduction in GERD medication use, with no increase in use of other medical services.

Improved outcomes for very low birth weight infants associated with the use of combined maternal corticosteroids and tocolytics.

OBJECTIVE: To determine the effects of maternal antenatal treatment with tocolytics, corticosteroids and the use of combined tocolytics and corticosteroids on the morbidity and mortality of very low birth weight infants. STUDY DESIGN: This retrospective study was conducted on all infants born in Tennessee in 1989 and 1990 who weighed < 1,500 g at birth and had no serious malformations. Registered nurses traveled to the delivery hospitals of all study subjects and abstracted information using a structured data collection form. Mortality was ascertained through the computerized linkage of birth and death certificates. Multiple logistic regression analysis was used to control for covariates. RESULTS: As compared to infants whose mothers received no treatment, infants whose mothers received both corticosteroids and tocolysis had a reduced risk of infant (odds ratio 0.38, 95% confidence interval 0.25-0.58) and neonatal mortality (OR 0.32, CI 0.19-0.51) as well as a reduced risk of seizures (OR 0.46, CI 0.23-0.93). Restricting the analysis of infants at 24-28 weeks' gestation and < 1,000 g at birth revealed similar findings regarding mortality. CONCLUSION: The use of combined corticosteroids with tocolytics was associated with better neonatal outcomes than the use of corticosteroids alone, tocolytics alone or no treatment.

ENDO-LAB: an integrated, portable endocrinology laboratory software system.

ENDO-LAB is an IBM PC-based system which performs calculations and record-keeping for the Vanderbilt University Medical Center Endocrinology Laboratory. It manages maintenance and quality control, and prints reports for regulatory agencies. The system was designed to minimize paperwork without changing laboratory procedures in any way. Key features of ENDO-LAB include a uniform user interface, and error detection mechanisms. The system is designed to detect data which has been incorrectly entered. In addition, where the efficacy of a test can be determined on the basis of limited data, preliminary graphs are screened as soon as possible, so that the user can terminate lengthy calculations whose outcome would be invalid or inconclusive. ENDO-LAB is an integrated system in that the same statistical and calibration programs can be applied to all of the analyses. The system is both extensible and portable; it has been successfully implemented outside Vanderbilt.

Prenatal exposure to prescribed drugs in Tennessee Medicaid, 1983-1988.

This report describes the prenatal exposure histories of 107,804 women to prescribed drugs other than vitamins, iron and other minerals. The data were obtained from Tennessee Medicaid pharmacy files linked to birth and fetal death certificates for 1983-1988. The utility of these data to other investigators in predicting power or estimating sample size for studies of drug exposure in pregnancy associated with adverse birth outcomes is discussed.

Evaluation of a program for prenatal care case management.

A prenatal care case-management program in Tennessee was evaluated to determine its effectiveness in improving the adequacy of prenatal care reducing the odds of preterm birth (gestation less than 37 weeks) and very low birth weight births (less than 1,500 g). The case-management program, Project HUG, included care provider referrals, visit scheduling, assistance with transportation and nutritional and health education. In a cohort of 66,051 Medicaid women with a birth during the period July 1989 through December 1991, 6% received HUG services. HUG participants had improved utilization of prenatal care, significantly decreased odds of inadequate perinatal care (an odds ratio of 0.71) and significantly increased odds of obtaining prenatal vitamins within 120 days of the last menstrual period (1.79). The apparent benefit of Project HUG was greater among blacks than among whites. However, there was no significant reduction in the incidence of preterm births or very low birth weight births among program participants

Presumptive eligibility for pregnant Medicaid enrollees: its effects on prenatal care and perinatal outcome.

OBJECTIVES: "Presumptive eligibility" permits pregnant prospective Medicaid enrollees to obtain services during the application period. The purpose of this study was to assess the effects of presumptive eligibility on the receipt of prenatal care and the occurrence of low-birthweight births and neonatal, perinatal, and infant mortality. METHODS: Outcome rates for pregnant women who enrolled in Tennessee Medicaid in the 6-month period before presumptive eligibility was enacted were compared with those obtained for pregnant women who enrolled in the 6-month period after presumptive eligibility had been in effect for 5 months. RESULTS: Women in the "after" group were 40% more likely to enroll and 30% more likely to obtain prenatal care in the first trimester. They were 300% more likely to fill a prescription for prenatal vitamins in the first trimester and 16% more likely to have begun prenatal care before the third trimester. However, they were similar to those enrolling in the "before" time period in terms of the occurrence of adverse perinatal outcomes. CONCLUSIONS: When barriers to prenatal care, including bureaucratic ones, are removed, low-income women will seek care earlier and more frequently.

The burden of influenza illness in children with asthma and other chronic medical conditions.

OBJECTIVE: Although influenza immunization is recommended for children with high-risk medical conditions, the majority of such children do not receive influenza vaccine. This study was designed to measure the burden of influenza among children with asthma and other chronic medical conditions. STUDY DESIGN: We performed a retrospective cohort study of children younger than 15 years with medically treated asthma or other chronic medical conditions enrolled in the Tennessee Medicaid program from 1973 to 1993. We determined rates of hospitalization for acute cardiopulmonary disease, outpatient visits, and antibiotic courses throughout the year. Annual differences between event rates when influenza virus was circulating and event rates during winter months when there was no influenza in the community were used to calculate influenza-attributable morbidity. RESULTS: Influenza accounted for an average of 19, 8, and 2 excess hospitalizations for cardiopulmonary disease yearly per 1000 high-risk children aged <1 year, 1 to <3 years, and 3 to <15 years, respectively. For every 1000 children, an estimated 120 to 200 outpatient visits and 65 to 140 antibiotic courses were attributable to influenza annually. CONCLUSIONS: Children younger than 15 years with asthma and other chronic medical conditions experience substantial morbidity requiring inpatient and outpatient care during influenza season. More effective targeting of this population for annual influenza immunization is warranted.

Validation of 1989 Tennessee birth certificates using maternal and newborn hospital records.

In 1989, the state of Tennessee adopted a new birth certificate which incorporates changes recommended by the National Center for Health Statistics in the revised US Standard Certificate of Live Birth. The data now being collected are intended to provide improved information for understanding maternal and infant health issues. To assess data quality, the authors compared information reported on the 1989 Tennessee birth certificates with the same data obtained from an ongoing case-control study in which the delivery hospital medical records of mothers and infants were reviewed by trained nurse abstractors using a structured data collection instrument. Cases (n = 1,016) were all infants born in Tennessee in 1989 with birth weights less than 1,500 g or other infants who died during the first 28 days of life. The infants were identified from linked birth-death certificate files. Control infants (n = 634) were randomly selected from the noncase population. The most reliable information obtained from birth certificates was descriptive demographic data and birth weight. The quality of information obtained from the new birth certificate checkboxes varied. Routine medical procedures were better reported on the birth certificates than relatively uncommon conditions and occurrences, even serious ones. Caution is needed in using birth certificate data for assessment of maternal medical risk factors, complications of labor and delivery, abnormal conditions of the newborn, and congenital anomalies, since sensitivity is low.

Perinatal outcomes following implementation of TennCare.

CONTEXT: The abrupt initiation of capitated Medicaid care in Tennessee (TennCare) in 1994 prompted many questions about changes in quality of care. OBJECTIVE: To evaluate the effect on perinatal outcomes of the transition to TennCare in 1994. DESIGN: Before and after retrospective cohort analysis. SETTING AND POPULATION: Births to women residing in Tennessee between 1990 and 1995 with complete demographic information on birth certificates, with a focus on women enrolled in Medicaid giving birth in 1993 (before TennCare) and 1995 (after TennCare). OUTCOME MEASURES: Late prenatal care (after the fourth month of pregnancy) or inadequate prenatal visits, low and very low birth weight, and death in the first 60 days of life. RESULTS: Tennessee residents had 72014 study births in 1993 and 72278 in 1995, of which 37543 (52.1%) and 35707 (49.4%) were to women enrolled in Medicaid at delivery. For these Medicaid births, there were no changes after TennCare in the proportions with late prenatal care (16.2% in 1993 vs 15.8% in 1995), inadequate prenatal visits (5.9% vs 5.6%), low birth weight (9.4% vs 9.0%), very low birth weight (1.6% vs 1.5%), and death in the first 60 days (0.6% both years). These findings were unchanged in multivariate analysis, in analysis of high-risk subgroups, and in analysis of women with demographics characteristic of Medicaid women. CONCLUSION: Study perinatal outcomes did not change among Medicaid births following the transition to TennCare.

Influenza-associated morbidity and mortality in young and middle-aged women.

CONTEXT: Data are limited on rates of influenza-associated hospitalizations and deaths among adults younger than 65 years. OBJECTIVE: To quantify serious morbidity and mortality from influenza for women younger than 65 years with and without certain chronic medical conditions, including human immunodeficiency virus infection. DESIGN: Retrospective cohort study. SETTING AND POPULATION: Women aged 15 to 64 years enrolled in the Tennessee Medicaid program from 1974 to 1993. MAIN OUTCOME MEASURE: All hospitalizations for and deaths from pneumonia, influenza, and other selected acute cardiopulmonary conditions for women with and without selected chronic medical conditions during 19 consecutive years. Influenza-attributable risk was calculated by subtracting event rates during peri-influenza season (November through April of each year when influenza virus was not circulating) from adjusted rates during influenza season (November through April when influenza virus was circulating). RESULTS: During the 19 years of the study, we identified 53607 acute cardiopulmonary hospitalizations and deaths. Rates of such events were consistently higher during influenza seasons than peri-influenza seasons. Among high-risk women, the estimated annual excess was 23 hospitalizations and deaths per 10000 women aged 15 to 44 years and 58 such events per 10000 women aged 45 to 64 years. The estimated annual excess mortality due to influenza was 2 deaths per 10000 high-risk women for both age groups combined. Among women with no identified high-risk conditions, estimated annual excess hospitalizations and deaths were 4 and 6 per 10000 women aged 15 to 44 and 45 to 64 years, respectively. CONCLUSIONS: Women younger than 65 years with certain chronic medical conditions experience substantial morbidity and mortality from acute cardiopulmonary events during influenza season. More effective targeting of these populations for annual influenza immunization is warranted.