Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation.

BACKGROUND: Transcatheter left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation, but the predictors of LAAO use in routine care are unclear. We aimed to assess the utilization trends of LAAO and compare the change in characteristics of LAAO users versus OACs since its marketing. METHODS: Using the US Medicare claims database (March 15, 2015, to December 31, 2020), we identified patients with atrial fibrillation, ≥65 years, and CHA2DS2-VASc score ≥2 (men) or ≥3 (women), with either first implantation of an LAAO device or initiation of OACs, including apixaban, dabigatran, rivaroxaban, edoxaban, or warfarin. Patient characteristics, measured 365 days before the first LAAO or OAC use date, were compared using logistic regression. RESULTS: There were 30 058 LAAO recipients (mean age, 77.74 years; female, 42.1%) and 792 600 OAC initiators (mean age, 78.48; female, 53.3%). In 2020, patients had higher odds of initiating LAAO use than in 2015 (0.52 versus 9.32%; adjusted odds ratio [aOR], 13.64 [95% CI, 12.56-14.81]). Old age (ie, >85 versus 65-75 years; aOR, 0.84 [95% CI, 0.80-0.88]), female sex (aOR, 0.74 [95% CI, 0.71-0.76]), Black race (aOR, 0.63 [95% CI, 0.58-0.68]) versus White race, and Medicaid eligibility (aOR, 0.61 [95% CI, 0.58-0.64]) were associated with lower odds of receiving LAAO. Among clinical characteristics, frailty, cancer, fractures, and venous thromboembolism were associated with lower odds of LAAO use, while history of intracranial and extracranial bleeding, coagulopathy, and falls were associated with higher odds of receiving LAAO. CONCLUSIONS: Among patients with atrial fibrillation receiving stroke-preventive therapy, LAAO use increased rapidly from 2015 to 2020 and was positively associated with the risk factors for OAC complications but negatively associated with old age, advanced frailty, and cancer. Black race and female sex were associated with a lower likelihood of receiving LAAO.

Comparison of EHR Data-Completeness in Patients with Different Types of Medical Insurance Coverage in the United States.

Prior studies have demonstrated that misclassification of study variables due to electronic health record (EHR)-discontinuity can be mitigated by restricting EHR-based analyses to subjects with high predicted EHR-continuity based on a simple algorithm. In this study, we compared EHR continuity in populations covered by Medicare, Medicaid, or commercial insurance. Using claims-linked EHRs from a multicenter network in Massachusetts, including Medicare (MA EHR-Medicare cohort) and Medicaid (MA EHR-Medicaid cohort) claims data; and TriNetX (TriNetX cohort) claims-linked EHR data from 11 US-based healthcare organizations, we assessed (1) EHR-continuity quantified by proportion of encounters captured by EHR (capture proportion (CP)); (2) area under receiver operating curve (AUROC) of previously validated model to identify patients with high EHR-continuity (CP ≥ 0.6); (3) misclassification of 40 patient characteristics, quantified by average standardized absolute mean difference (ASAMD). Study participants were ≥ 65 years (Medicare) or ≥ 18 years (Medicaid, TriNetX) with ≥ 365 days of continuous insurance enrollment overlapping with an EHR encounter. We found that the mean CP was 0.30, 0.18, and 0.19 and AUROC of the prediction model to identify patients with high EHR-continuity was 0.92, 0.89, and 0.77 in the MA EHR-Medicare, MA EHR-Medicaid, and TriNetX cohorts, respectively. Restricting to patients with predicted EHR-continuity percentile of top 20%, 50%, and 50% in MA EHR-Medicare, MA EHR-Medicaid, and TriNetX cohorts resulted in acceptable levels of misclassification (ASAMD < 0.1). Using a prediction model to identify cohorts with high EHR-continuity can improve validity, but cutoffs to achieve this goal vary by population.

A Quasi-Experimental Assessment of the Effect of the 2009 WIC Food Package Revisions on Breastfeeding Outcomes.

Breastfeeding rates among infants participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are consistently lower than those of WIC nonparticipants. The 2009 WIC food package revisions were intended to incentivize breastfeeding among the WIC population. To examine the effectiveness of this policy change, we estimated an intent-to-treat regression-adjusted difference-in-difference model with propensity score weighting, an approach that allowed us to control for both secular trends in breastfeeding and selection bias. We used novel data from the Feeding Infants and Toddlers Survey from 2008 and 2016. We defined our treatment group as infants eligible for WIC based on household income and our control group as infants in households with incomes just above the WIC eligibility threshold. The breastfeeding outcomes we analyzed were whether the infants were ever breastfed, breastfed through 6 months, and breastfed exclusively through 6 months. We observed significant increases in infants that were ever breastfed in both the treatment group (10 percentage points; p < 0.01) and the control group (15 percentage points; p < 0.05); however, we did not find evidence that the difference between the two groups was statistically significant, suggesting that the 2009 revisions may not have had an effect on any of these breastfeeding outcomes.

The Impact of the Affordable Care Act Medicaid Expansions on the Sources of Health Insurance Coverage of Undergraduate Students in the United States.

This article examines how the Affordable Care Act Medicaid expansions affected the sources of health insurance coverage of undergraduate students in the United States. We show that the Affordable Care Act expansions increased the Medicaid coverage of undergraduate students by 5 to 7 percentage points more in expansion states than in nonexpansion states, resulting in 17% of undergraduate students in expansion states being covered by Medicaid postexpansion (up from 9% prior to the expansion). In contrast, the growth in employer and private direct coverage was 1 to 2 percentage points lower postexpansion for students in expansion states compared with nonexpansion states. Our findings demonstrate that policy efforts to expand Medicaid eligibility have been successful in increasing the Medicaid coverage rates for undergraduate students in the United States, but there is evidence of some crowd out after the expansions-that is, some students substituted their private and employer-sponsored coverage for Medicaid.

Factors Associated With the Acceptance of New TRICARE and Medicare Patients by Health Care Providers.

We use data from the 2012-2015 TRICARE Standard Survey to examine factors that affect civilian health care providers' acceptance of patients covered by the U.S. Department of Defense's TRICARE insurance program and Medicare. We find that 74% of physicians report that they accept new TRICARE patients compared with 83% accepting new Medicare patients; in contrast, only 36% of mental health providers report that they accept new Medicare and/or TRICARE patients. Among the most common reasons provided by both physicians and mental health providers for not accepting either insurance type are insufficient reimbursement or their specialty not being covered; lack of awareness of TRICARE is also frequently cited, particularly among mental health providers. These findings suggest that successful strategies to increase provider acceptance of TRICARE and Medicare may include improving reimbursement rates and specialty coverage and increasing provider awareness of TRICARE through outreach programs.

The Impact of Affordable Care Act Medicaid Expansions on Applications to Federal Disability Programs.

In this paper, we estimate the impact of Medicaid expansions via the Patient Protection and Affordable Care Act (ACA) on applications to federal disability programs in 14 states that expanded Medicaid in January 2014. We use a difference-in-differences regression model to compare disability application rates in geographic areas within states that expanded Medicaid to rates in areas of non-expansion states that were carefully selected using a matching approach that accounts for state Medicaid policies pre-ACA as well as demographic and socioeconomic characteristics that might influence disability application rates. We find a slower decrease in Supplemental Security Income (SSI) application rates after Medicaid expansions in expansion states relative to non-expansion states, with application rates declining in both state groups from 2014 through 2016. Our analysis of the impact of the Medicaid expansions on Social Security Disability Insurance (SSDI) application rates was inconclusive for reasons we discuss in the paper.

Estimating the hospital costs of inpatient harms.

OBJECTIVE: To estimate the additional hospital costs associated with inpatient medical harms occurring during an index inpatient admission and costs from subsequent readmissions within 90 days. DATA SOURCE: 2009 to 2011 Healthcare Cost and Utilization Project's State Inpatient Databases from 12 states. STUDY DESIGN: We compare hospital costs incurred by patients experiencing a specific harm during their hospital stay to the costs incurred by similar patients who did not experience that harm. DATA EXTRACTION: We extracted records for adult patients admitted for a reason other than rehabilitation or mental health, were at risk of a harm, and were admitted for less than a year. PRINCIPAL FINDINGS: The costliest inpatient harms, such as surgical site infections and severe pressure ulcers, are associated with approximately $30 000 in additional index stay costs per harm. Less costly harms, such as catheter- or hospital-associated urinary tract infections and venous thromboembolism, can add $6000 to $13 000. Birth and obstetric traumas add as little as $100. CONCLUSIONS: Our analysis represents rigorous estimates of the hospital costs of a variety of inpatient harms; these should be of interest to health care administrators and policy makers to identify areas for cost savings to the health care system.

Health Insurance Costs and Employee Compensation: Evidence from the National Compensation Survey.

This paper examines the relationship between rising health insurance costs and employee compensation. I estimate the extent to which total compensation decreases with a rise in health insurance costs and decompose these changes in compensation into adjustments in wages, non-health fringe benefits, and employee contributions to health insurance premiums. I examine this relationship using the National Compensation Survey, a panel dataset on compensation and health insurance for a sample of establishments across the USA. I find that total hourly compensation reduces by $0.52 for each dollar increase in health insurance costs. This reduction in total compensation is primarily in the form of higher employee premium contributions, and there is no evidence of a change in wages and non-health fringe benefits. These findings show that workers are absorbing at least part of the increase in health insurance costs through lower compensation and highlight the importance of examining total compensation, and not just wages, when examining the relationship between health insurance costs and employee compensation. Copyright © 2016 John Wiley & Sons, Ltd.

How do working-age people with disabilities spend their time? New evidence from the American Time Use Survey.

We use the American Time Use Survey to examine the extent to which adults with disabilities-defined using both the new six-question sequence on disability and the traditional work-limitation question-spend more time on health-related activities and less time on other activities than those without disabilities. We find that men and women who both reported a work limitation and responded "yes" to any of the questions in the six-question disability sequence spend approximately 40 to 50 more minutes per week, respectively, on health-related activities. We also find that most working-age men and women who report a disability work fewer hours per day than men and women without disabilities. The largest difference is for men and women who report both types of disability; these individuals spend, on average, 5 fewer hours per day in paid work than men and women without disabilities. On average, most of the decrease in paid work time is offset by more time spent on leisure activities (defined as activities that provide direct utility, such as entertainment, social activities, attending recreational events, and general relaxation) and sleeping, which is likely due to these being default activities for individuals whose medical issues and environment constrain them from participating in other activities.