Cervical Cancer and a History of Incarceration: Examining a Social Determinant of Health.

Females who are incarcerated are disproportionately burdened by cancer, particularly cervical cancer. We measured the odds of cervical cancer compared with nonscreenable cancers for females who were incarcerated before diagnosis. By comparing a cancer for which screening and vaccination are available with cancers for which neither are available, we aimed to assess the relationship of incarceration with diseases for which preventive care mitigates risk. We created a novel data set combining cancer data from a large cancer center with incarceration data from the state department of corrections. We then estimated the odds of cervical cancer relative to nonscreenable cancers for those with and without a history of incarceration. Females with a history of incarceration had greater odds of being diagnosed with cervical cancer compared with nonscreenable cancers (odds ratio = 7.04; 95% confidence interval [CI]: 4.4-11.0) relative to those who had not been incarcerated. Adjusting for race and age, the odds of cervical cancer remained significantly greater for those with a history of incarceration (adjusted odds ratio = 3.86; 95% CI: 2.3-6.3). Our findings support the need for expanded cervical cancer screening and vaccination opportunities for incarcerated females and increased access to preventive health care after release.

Prevalence of Testing for Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Among Medicaid Enrollees Treated With Medications for Opioid Use Disorder in 11 States, 2016-2019.

BACKGROUND: Limited information exists about testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among Medicaid enrollees after starting medication for opioid use disorder (MOUD), despite guidelines recommending such testing. Our objectives were to estimate testing prevalence and trends for HIV, HBV, and HCV among Medicaid enrollees initiating MOUD and examine enrollee characteristics associated with testing. METHODS: We conducted a serial cross-sectional study of 505 440 initiations of MOUD from 2016 to 2019 among 361 537 Medicaid enrollees in 11 states. Measures of MOUD initiation; HIV, HBV, and HCV testing; comorbidities; and demographics were based on enrollment and claims data. Each state used Poisson regression to estimate associations between enrollee characteristics and testing prevalence within 90 days of MOUD initiation. We pooled state-level estimates to generate global estimates using random effects meta-analyses. RESULTS: From 2016 to 2019, testing increased from 20% to 25% for HIV, from 22% to 25% for HBV, from 24% to 27% for HCV, and from 15% to 19% for all 3 conditions. Adjusted rates of testing for all 3 conditions were lower among enrollees who were male (vs nonpregnant females), living in a rural area (vs urban area), and initiating methadone or naltrexone (vs buprenorphine). Associations between enrollee characteristics and testing varied across states. CONCLUSIONS: Among Medicaid enrollees in 11 US states who initiated medications for opioid use disorder, testing for human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and all 3 conditions increased between 2016 and 2019 but the majority were not tested.

Health Care Utilization After Paraprofessional-administered Substance Use Screening, Brief Intervention, and Referral to Treatment: A Multi-level Cost-offset Analysis.

BACKGROUND: Authorities recommend universal substance use screening, brief intervention, and referral to treatment (SBIRT) for all (ie, universal) adult primary care patients. OBJECTIVE: The objective of this study was to examine long-term (24-mo) changes in health care utilization and costs associated with receipt of universal substance use SBIRT implemented by paraprofessionals in primary care settings. RESEARCH DESIGN: This study used a difference-in-differences design and Medicaid administrative data to assess changes in health care use among Medicaid beneficiaries receiving SBIRT. The difference-in-differences estimates were used in a Monte Carlo simulation to estimate potential cost-offsets associated with SBIRT. SUBJECTS: The treatment patients were Medicaid beneficiaries who completed a 4-question substance use screen as part of an SBIRT demonstration program between 2006 and 2011. Comparison Medicaid patients were randomly selected from matched clinics in Wisconsin. MEASURES: The study includes 4 health care utilization measures: outpatient days; inpatient length of stay; inpatient admissions; and emergency department admissions. Each outcome was assigned a unit cost based on mean Wisconsin Medicaid fee-for-service reimbursement amounts. RESULTS: We found an annual increase of 1.68 outpatient days (P=0.027) and a nonsignificant annual decrease in inpatient days of 0.67 days (P=0.087) associated with SBIRT. The estimates indicate that the cost of a universal SBIRT program could be offset by reductions in inpatient utilization with an annual net cost savings of $782 per patient. CONCLUSIONS: Paraprofessional-delivered universal SBIRT is likely to yield health care cost savings and is a cost-effective mechanism for integrating behavioral health services in primary care settings.

Obesity and mortality after locoregional breast cancer diagnosis.

PURPOSE: Higher mortality after a breast cancer diagnosis has been observed among women who are obese. We investigated the relationships between body mass index (BMI) and all-cause or breast cancer-specific mortality after a diagnosis of locoregional breast cancer. METHODS: Women diagnosed in 2004 with AJCC Stage I, II, or III breast cancer (n = 5394) were identified from a population-based National Program of Cancer Registries (NPCR) patterns of care study (POC-BP) drawing from registries in seven U.S. states. Differences in overall and breast cancer-specific mortality were investigated using Cox proportional hazards regression models adjusting for demographic and clinical covariates, including age- and stage-based subgroup analyses. RESULTS: In women 70 or older, higher BMI was associated with lower overall mortality (HR for a 5 kg/m2 difference in BMI = 0.85, 95% CI 0.75-0.95). There was no significant association between BMI and overall mortality for women under 70. BMI was not associated with breast cancer death in the full sample, but among women with Stage I disease; those in the highest BMI category had significantly higher breast cancer mortality (HR for BMI ≥ 35 kg/m2 vs. 18.5-24.9 kg/m2 = 4.74, 95% CI 1.78-12.59). CONCLUSIONS: Contrary to our hypothesis, greater BMI was not associated with higher overall mortality. Among older women, BMI was inversely related to overall mortality, with a null association among younger women. Higher BMI was associated with breast cancer mortality among women with Stage I disease, but not among women with more advanced disease.

Use and employer costs of a pharmacotherapy smoking-cessation treatment benefit.

BACKGROUND: Employers cite a lack of information on the cost of insurance coverage for smoking-cessation treatment as a barrier to its provision. This study describes the use of a new insurance benefit for smoking-cessation pharmacotherapy, and its pharmaceutical costs to a large public employer between 2001 and 2003. METHODS: Annual enrollment and pharmaceutical claims data were collected from the health plans that contracted with the Wisconsin Department of Employee Trust Funds (ETF). State employees, retirees, and adult dependents who obtained health insurance through the ETF constituted our sample, approximately 150,000/year. Pharmacotherapy benefit use was defined as a paid claim for one of four U.S. Food and Drug Administration-approved smoking-cessation medications. Pharmaceutical cost was defined as the ingredient cost (+) dispensing fee (-) member copayment. Analyses included estimation of the proportion of smokers who used the benefit each year and across 3 years, the average annual cost per user, and the per member per month (PMPM) pharmaceutical cost to the employer. Data were collected from 2001 to 2004 and analyzed in 2005-2006. RESULTS: Annual benefit use among smokers ranged from 6% to 7% with a 3-year rate of approximately 17%. The PMPM cost of the covered pharmacotherapy was approximately 0.13 dollars. CONCLUSIONS: The cost to employers of providing insurance coverage for smoking-cessation pharmacotherapy to their employees is low. By informing insurance purchasing decisions, these results may facilitate the adoption of such coverage, with the goal of ultimately reducing the proportion of employees who smoke.

Purchasing health insurance coverage for smoking cessation treatment: employers describe the most influential information in this decision.

Employer provision of insurance coverage for smoking cessation treatment (SCT) remains spotty despite a body of treatment efficacy and cost-effectiveness evidence available to inform and support this health care purchasing decision. This qualitative study examined the information on which this coverage decision is made. In this study, state employers describe the content and sources of the most influential information in their decision to provide insurance coverage for SCT as well as a second health benefit for comparative purposes. We provide insight into the extent to which SCT evidence informs the SCT coverage decision and suggest topics and targets for research dissemination. We interviewed 55 employee benefit staff in 35 states. Responses were compared from states with and without SCT coverage to explore the types of information that may be more effective at promoting coverage. The content and sources of the information employers judged most useful varied notably between states with and without SCT coverage. Compelling evidence of the efficacy of SCT and its cost-effectiveness did not appear to play an influential role in the SCT decision among states without SCT coverage relative to states with SCT coverage. States with SCT coverage relied significantly on benefit consultants and actuaries for the information they described as most influential; in comparison, noncovered states reported service providers, staff, and the Internet as major information sources. To foster employers' provision of SCT coverage, research dissemination efforts should emphasize SCT efficacy and cost-effectiveness information and tailor communication to benefit consultants and actuaries in addition to employers themselves.

Use of a new comprehensive insurance benefit for smoking-cessation treatment.

INTRODUCTION: Uncertainty about levels of employee use of an insurance benefit for smoking-cessation treatment has presented a barrier to employers considering the adoption of such coverage. This study examined self-reported awareness and use of a new insurance benefit for smoking-cessation treatment among a sample of Wisconsin state employees, retirees, and adult dependents. METHODS: We evaluated the self-reported use of insurance coverage for smoking-cessation treatment during the first 2 years of its availability to the Wisconsin state employee, retiree, and adult dependent population. We conducted analyses of responses to smoking-related questions in 2001 and 2002 cross-sectional surveys of insured state employees, retirees, and adult dependents, weighted to represent this population. RESULTS: In 2002, benefit use among smokers aware of the benefit was 39.6%, and benefit use among smokers unaware of the benefit was 3.5%. Only 27.4% of smokers were aware of the benefit in 2002; use among all smokers was 13.6%. Of all smokers, 30.4% used smoking-cessation treatment medication (over-the-counter or covered) in 2002. Smoking prevalence was 15.6% in 2001 and 13.2% in 2002. CONCLUSION: In an educated employee population, self-reported smoking-cessation treatment benefit use was modest among all smokers during its first 2 years of availability. Benefit awareness was low in this educated population, which may help explain low use rates, particularly given the 30% of all smokers who attempted to quit smoking with the help of smoking-cessation treatment medication. These data provide use-rate estimates for states contemplating adoption of an evidence-based smoking-cessation treatment benefit.

Insurance coverage of smoking cessation treatment for state employees.

Public health experts recommend that health insurance include coverage for smoking cessation treatment as an evidence-based strategy to reduce smoking. As employers, states can implement this policy for more than 5 million individuals nationwide. This study identified the extent to which states require smoking cessation treatment insurance coverage for their employees; of 45 states, 29 required coverage for at least 1 US Public Health Service (PHS)-recommended treatment, and only 17 of 45 provided coverage that was fully consistent with PHS recommendations.