Latent pathway-based Bayesian models to identify intervenable factors of racial disparities in breast cancer stage at diagnosis.

PURPOSE: We built Bayesian Network (BN) models to explain roles of different patient-specific factors affecting racial differences in breast cancer stage at diagnosis, and to identify healthcare related factors that can be intervened to reduce racial health disparities. METHODS: We studied women age 67-74 with initial diagnosis of breast cancer during 2006-2014 in the National Cancer Institute's SEER-Medicare dataset. Our models included four measured variables (tumor grade, hormone receptor status, screening utilization and biopsy delay) expressed through two latent pathways-a tumor biology path, and health-care access/utilization path. We used various Bayesian model assessment tools to evaluate these two latent pathways as well as each of the four measured variables in explaining racial disparities in stage-at-diagnosis. RESULTS: Among 3,010 Black non-Hispanic (NH) and 30,310 White NH breast cancer patients, respectively 70.2% vs 76.9% were initially diagnosed at local stage, 25.3% vs 20.3% with regional stage, and 4.56% vs 2.80% with distant stage-at-diagnosis. Overall, BN performed approximately 4.7 times better than Classification And Regression Tree (CART) (Breiman L, Friedman JH, Stone CJ, Olshen RA. Classification and regression trees. CRC press; 1984) in predicting stage-at-diagnosis. The utilization of screening mammography is the most prominent contributor to the accuracy of the BN model. Hormone receptor (HR) status and tumor grade are useful for explaining racial disparity in stage-at diagnosis, while log-delay in biopsy impeded good prediction. CONCLUSIONS: Mammography utilization had a significant effect on racial differences in breast cancer stage-at-diagnosis, while tumor biology factors had less impact. Biopsy delay also aided in predicting local and regional stages-at-diagnosis for Black NH women but not for white NH women.

Racial and ethnic disparities in benefits eligibility and spending among adults on the autism spectrum: A cohort study using the Medicare Medicaid Linked Enrollees Analytic Data Source.

BACKGROUND: Research on children and youth on the autism spectrum reveal racial and ethnic disparities in access to healthcare and utilization, but there is less research to understand how disparities persist as autistic adults age. We need to understand racial-ethnic inequities in obtaining eligibility for Medicare and/or Medicaid coverage, as well as inequities in spending for autistic enrollees under these public programs. METHODS: We conducted a cross-sectional cohort study of U.S. publicly-insured adults on the autism spectrum using 2012 Medicare-Medicaid Linked Enrollee Analytic Data Source (n = 172,071). We evaluated differences in race-ethnicity by eligibility (Medicare-only, Medicaid-only, Dual-Eligible) and spending. FINDINGS: The majority of white adults (49.87%) were full-dual eligible for both Medicare and Medicaid. In contrast, only 37.53% of Black, 34.65% Asian/Pacific Islander, and 35.94% of Hispanic beneficiaries were full-dual eligible for Medicare and Medicare, with most only eligible for state-funded Medicaid. Adjusted logistic models controlling for gender, intellectual disability status, costly chronic condition, rural status, county median income, and geographic region of residence revealed that Black beneficiaries were significantly less likely than white beneficiaries to be dual-eligible across all ages. Across these three beneficiary types, total spending exceeded $10 billion. Annual total expenditures median expenditures for full-dual and Medicaid-only eligible beneficiaries were higher among white beneficiaries as compared with Black beneficiaries. CONCLUSIONS: Public health insurance in the U.S. including Medicare and Medicaid aim to reduce inequities in access to healthcare that might exist due to disability, income, or old age. In contrast to these ideals, our study reveals that racial-ethnic minority autistic adults who were eligible for public insurance across all U.S. states in 2012 experience disparities in eligibility for specific programs and spending. We call for further evaluation of system supports that promote clear pathways to disability and public health insurance among those with lifelong developmental disabilities.

Disparities in Secure Messaging Uptake Between Patients and Physicians: Longitudinal Analysis of Two National Cross-Sectional Surveys.

BACKGROUND: Emails securely exchanged between patients and clinicians offer the promise of improved access to care and indirectly improved health outcomes. Yet research to date is mixed on who-among both patients and clinicians-is using secure messaging. OBJECTIVE: Using data from two large nationally representative cross-sectional surveys, this study aimed to compare the prevalence of secure messaging use among patients and their access to the functionality through their physicians, and to explore the clinical practice and physician characteristics and patient sociodemographic characteristics associated with the use of secure messaging. METHODS: We conducted regression analyses to identity statistical associations between self-reported secure messaging use and access, and the patient, practice, and physician characteristics from the National Health Interview Survey (NHIS) and the National Ambulatory Medical Care Survey (NAMCS). The NHIS data collected between 2013 and 2018, with approximately 150,000 adult individuals, were used to evaluate patient characteristics associated with email communication with clinicians. The NAMCS data included 7340 physicians who reported on secure messaging use between 2013 and 2016 and provided context on physician specialty, use of certified health information technology (IT), and practice size and ownership associated with secure messaging access and use. RESULTS: By 2016, two-thirds of ambulatory care visits were conducted by a physician who reported using secure messaging, up from 40.70% in 2013. The percentage of US residents who reported sending an email to their clinician, however, only increased from 7.22% to 16.67% between 2013 and 2018. We observed a strong positive association between certified health IT use and secure messaging use (odds ratio [OR] 11.46, 95% CI 7.55-17.39). Individuals who were black, had lower levels of education, had Medicaid or other public payer insurance, or those who were uninsured had reduced odds for using email to communicate with clinicians. No differences were observed in secure messaging use based on physician specialty, but significant differences were observed by practice size (OR 0.46, 95% CI 0.35-0.60 in solo practices vs nonsolo practices) and practice ownership (P<.001 for the different categories). CONCLUSIONS: This study is the first to use two large nationally representative surveys to produce longitudinal estimates on the access and use of patient-clinician email communication in the United States. The survey findings complement each other: one provides the patient perspective of their use and the other indicates potential patient access to secure messaging based on the use of the functionality by the physicians providing treatment. This study provides nationally representative data on the characteristics of patients and physicians who have access to and are using secure messaging. This information can be used to target interventions to promote adoption and use of secure messaging.

Needling Policy Makers and Sharpening the Debate: Do Syringe Exchange Programs Improve Health at the Population Level?

CONTEXT: In the midst of the current opioid epidemic, states have selected differing legislative routes implementing pathways to ensure access to clean needles and syringes. OBJECTIVE: To determine whether states that implemented laws supporting syringe exchange programs (SEPs) had reductions in transmission rates of hepatitis B, hepatitis C, and HIV infection compared with states without such laws. DESIGN AND SETTING: Utilizing a longitudinal panel design, we determined the legal status of SEPs in each state for years 1983-2016. Disease transmission rates for this period were estimated via a simple Poisson regression, with transmitted cases as the dependent variable, law categories as the predictor variables, and the log of state population as the exposure. The mean number of incident cases per state-year was also calculated. PARTICIPANTS: US states were utilized as the unit of analysis. RESULTS: Hepatitis B and hepatitis C mean transmission rate per 100 000 population declined in states with local ordinances/decriminalized statutes and legalized SEPs (hepatitis B: 71% and 81%, respectively, differences P < .001; hepatitis C: 8% and 38%, respectively, differences P < .001). Reductions in mean incident cases per state-year mirrored these findings. HIV infection among injection drug users yielded inconsistent results. CONCLUSIONS: Hepatitis B and hepatitis C transmission were reduced at the population level in states with SEP laws in a pattern reflecting the degree of legal intervention. HIV infection, based upon a smaller data set, showed a mixed impact. POLICY IMPLICATIONS: The results show promise that SEPs have population-level effects on disease transmission. States lacking SEPs should reconsider current policies.

Suicidal Ideation and Self-inflicted Injury in Medicare Enrolled Autistic Adults With and Without Co-occurring Intellectual Disability.

Suicidality is significantly more common in autistic adults than the general population, yet the factors that increase risk for suicidality among autistic adults remain largely unknown. We identified characteristics associated with suicidal ideation and suicide attempts/self-inflicted injury in a U.S. national sample of Medicare-enrolled autistic adults. We conducted a case-control study of autistic adults aged 18-59 years (n = 21,792). Younger age, white race, depression disorders, and psychiatric healthcare utilization were associated with increased odds of suicidal ideation and suicide attempts. Co-occurring intellectual disability was associated with significantly greater odds of a suicide attempt, but lower odds of suicidal ideation. Findings underscore the need for improved methods to identify ideation prior to attempt among adults with autism and intellectual disability.

Analyzing State Autism Private Insurance Mandates for Allied Health Services: A Pilot Study.

Due to the prevalence, severity, and costs associated with autism spectrum disorders (ASDs), it has become a public health issue. In response, state governments have adopted ASD-specific private insurance mandates requiring coverage of ASD screening, diagnosis, and treatment. Despite rapid uptake of these laws, differences exist in the type and levels of coverage, especially for allied health services including occupational therapy. We piloted a structured legal research methodology to code ASD insurance mandates that impact allied health service provisions. State private insurance mandates were obtained from WestlawNext. A coding methodology was piloted on 14 states and included variables for age and service limits, treatments covered, and medical necessity. Coding methods were feasible and highly reliable among raters. Ten of 12 states had a coverage mandate, many with specific provisions for allied health providers. A full analysis of all 50 states is warranted to identify provisions affecting allied health providers serving individuals with ASD.

Therapy access among children with autism spectrum disorder, cerebral palsy, and attention-deficit-hyperactivity disorder: a population-based study.

AIM: This study examined cross-sectional population-based rates in reported need and unmet need for occupational, physical, and speech therapy services in children with autism spectrum disorder (ASD) compared with children with attention-deficit-hyperactivity disorder (ADHD) and cerebral palsy (CP). METHOD: The 2005-2006 and 2009-2010 (USA) National Survey of Children with Special Health Care data sets were used to compare therapy need and unmet need among children younger than 18 years with ASD (n=5178), ADHD (n=20 566), and CP (n=1183). Bivariate approaches and multivariate logistic regression using imputed data were used to identify associations between child and family characteristics, and access to therapy services. RESULTS: After adjusting for other variables, children with ASD had a significantly greater likelihood of having an unmet therapy need compared with children with ADHD (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.36-2.03), but a similar unmet need as children with CP (OR 1.30, 95% CI 0.97-1.74). Factors associated with unmet need included survey year, younger child age, no health insurance, and increased functional and behavioral difficulties. INTERPRETATION: Children in our sample had greater unmet therapy needs in 2009 than in 2005. Caregiver-reported reasons for unmet need included cost and school resources. Research examining future trends in therapy access are warranted for children with ASD and CP. WHAT THIS PAPER ADDS: Children with complex diagnoses of autism spectrum disorder and cerebral palsy had reported unmet need for therapy services. High costs of therapy were the primary reported reason contributing to reduced access among children.

Differences in Perceived Need for Medical, Therapeutic, and Family Support Services Among Children With ASD.

OBJECTIVE: Identifying racial and ethnic differences in perceived need for treatment among families of children with autism spectrum disorder (ASD) will improve understanding of disparities in care seeking. We described racial and ethnic differences in perceived need for services that children with ASD and their families frequently use. METHODS: We conducted bivariate analyses of racial and ethnic categories and perceived need for 6 common services used by children with ASD as found in the 2005 to 2006 (n = 2123) and the 2009 to 2010 (n = 3055) National Survey of Children With Special Health Care Needs data sets. Multivariate logistic regressions within concatenated data sets were conducted to examine associations between racial and ethnic category and perceived service needs while controlling for predisposing, enabling, and child factors. RESULTS: Compared with caregivers of white non-Hispanic children with ASD, caregivers of Hispanic children reported less need for prescription medications in adjusted multivariate analyses. Caregivers of black non-Hispanic children with ASD reported less need for prescription medications and for child and family mental health services than caregivers of white non-Hispanic children. Both English-speaking Hispanic caregivers and black non-Hispanic caregivers reported greater need for occupational, speech, and physical therapy than white non-Hispanic caregivers. No racial or ethnic differences were found in perceived need for specialty medical care or respite care. CONCLUSIONS: Caregivers of children with ASD from different racial and ethnic backgrounds may differentially perceive need for different types of care. Their perceptions may in turn affect how they prioritize and seek care, independent of their child's specific needs.

Evaluating Emergency Department Asthma Management Practices in Florida Hospitals.

OBJECTIVE: To assess gaps in emergency department (ED) asthma management at Florida hospitals. DESIGN: Survey instrument with open- and closed-ended questions. Topics included availability of specific asthma management modalities, compliance with national guidelines, employment of specialized asthma care personnel, and efforts toward performance improvement. SETTING: Emergency departments at 10 large hospitals in the state of Florida. PARTICIPANTS: Clinical care providers and health administrators from participating hospitals. MAIN OUTCOME MEASURES: Compliance with national asthma care guideline standards, provision of specific recommended treatment modalities and resources, employment of specialized asthma care personnel, and engagement in performance improvement efforts. RESULTS: Our results suggest inconsistency among sampled Florida hospitals' adherence to national standards for treatment of asthma in EDs. Several hospitals were refining their emergency care protocols to incorporate guideline recommendations. Despite a lack of formal ED protocols in some hospitals, adherence to national guidelines for emergency care nonetheless remained robust for patient education and medication prescribing, but it was weaker for formal care planning and medical follow-up. CONCLUSIONS: Identified deficiencies in emergency asthma care present a number of opportunities for strategic mitigation of identified gaps. We conclude with suggestions to help Florida hospitals achieve success with ED asthma care reform. Team-based learning activities may offer an optimal strategy for sharing and implementing best practices.

Unmet Need for Therapy Among Children with Autism Spectrum Disorder: Results from the 2005-2006 and 2009-2010 National Survey of Children with Special Health Care Needs.

OBJECTIVES: We examined population-based trends in unmet need for therapy service in children with autism spectrum disorder (ASD) compared to other children with special health care needs (CSHCN), and identified factors associated with unmet need for therapy. METHODS: A pooled cross-sectional comparison of the 2005-2006 and 2009-2010 waves of the National Survey for Children with Special Health Care Needs (NS-CSHCN) was used. Weighted bivariate analyses were used to compare children ages 3-17 years with ASD (n = 5113) to other CSHCN (n = 71,294) on unmet need for therapy services. Survey weighted multivariate models were used to examine child, family, and contextual characteristics associated with unmet need. RESULTS: A greater percentage of children with ASD across both surveys were reported to need therapy than other children with CSHCN. Among children with a reported need, children with ASD were 1.4 times more likely to report an unmet need for therapy compared to other CSHCN (OR 1.42, 95 % CI 1.18-1.71). Variables significantly associated with unmet need for therapy services included not receiving a well-child visit in the past year (OR 5.81, CI 3.83-8.81), surveyed in 2009 (OR 1.42, CI 1.18-1.71), child being female (OR 1.27, CI 1.05-1.53), uninsured (OR 1.72, CI 1.15-2.56), and having greater functional limitation (OR 2.44, CI 1.80-3.34). CONCLUSIONS FOR PRACTICE: Children with ASD require supportive services such as occupational, physical, and speech therapy but are less likely to receive such services than other CSHCN. Receiving a well-child visit in the past year was strongly associated with receipt of needed therapy services.

Delivery system characteristics and their association with quality and costs of care: implications for accountable care organizations.

BACKGROUND: Implementation of accountable care organizations (ACOs) is currently underway, but there is limited empirical evidence on the merits of the ACO model. PURPOSE: The aim was to study the associations between delivery system characteristics and ACO competencies, including centralization strategies to manage organizations, hospital integration with physicians and outpatient facilities, health information technology, infrastructure to monitor community health and report quality, and risk-adjusted 30-day all-cause mortality and case-mixed-adjusted inpatient costs for the Medicare population. METHODOLOGY: Panel data (2006-2009) were assembled from Florida and multiple sources: inpatient hospital discharge, vital statistics, the American Hospital Association, the Healthcare Information and Management Systems Society, and other databases. We applied a panel study design, controlling for hospital and market characteristics. PRINCIPAL FINDINGS: Hospitals that were in centralized health systems or became more centralized over the study period had significantly larger reductions in mortality compared with hospitals that remained freestanding. Surprisingly, tightly integrated hospital-physician arrangements were associated with increased mortality; as such, hospitals may wish to proceed cautiously when developing specific types of alignment with local physician organizations. We observed no statistically significant differences in the growth rate of costs across hospitals in any of the health systems studied relative to freestanding hospitals. Although we observed quality improvement in some organizational types, these outcome improvements were not coupled with the additional desired objective of lower cost growth. This implies that additional changes not present during our study period, potentially changes in provider payment approaches, are essential for achieving the ACO objectives of higher quality of care at lower costs. PRACTICE IMPLICATIONS: Provider organizations implementing ACOs should consider centralizing service delivery as a viable strategy to improve quality of care, although the strategy did not result in lower cost growth.

Medication therapy management programs: promises and pitfalls.

BACKGROUND: Medication therapy management (MTM) is one form of a medication benefit program offered by public and private health providers and insurers. Although the term was first coined in 2003, MTM in its earlier forms has been used since the 1990s as a mechanism to improve health metrics for medically complex patients. Its role expanded with the passage of Medicare Part D, as a mandated component to help patients with multiple chronic conditions, high drug costs, and high utilization to improve the effectiveness and safety of their medication treatments.  OBJECTIVE: To review the evidence on MTM effectiveness in order to (a) provide information on its establishment and goals and (b) summarize research findings under 3 outcomes: economic, clinical, and humanistic.  METHODS: PubMed, a search engine service of the National Center for Biotechnology Information was utilized by trained research assistants to search for articles with the following key words: MTM, randomized controlled trials on MTM, evaluation of MTM, comprehensive medication review, medication action plan, special needs population, special needs plans, Medicaid, disease management, adherence, non-adherence, compliance, chronic conditions, disabling chronic conditions, and disability. Additional searches were conducted for key articles in references listed in the most recent review articles. The initial search identified nearly 300 articles. RESULTS: When evaluated, most studies found economic benefits, but the quality of research design and end point measures varied considerably across evaluations. Clinical outcomes encompassed a wide range of potential metrics, from service utilization, to individual patient and population outcomes, and quality of care. Quality measures such as provider-prescribing habits and medication adherence were frequently found to improve. As noted with the economic outcomes studies, overall rigor of study design was suboptimal, and often underpowered.  Few studies have focused on humanistic outcomes such as improved patient quality of life.  CONCLUSIONS: Evidence suggests that MTM services are a promising way to manage complex patients, but there are gaps in the literature largely because of the limited number of studies with strong designs. Stronger evaluation of MTM programs is warranted.

Service utilization of veterans dually eligible for VA and Medicare fee-for-service: 1999-2004.

OBJECTIVE: To examine care system choices for Veterans dually-eligible for VA and Medicare FFS following changes in VA eligibility policy, which expanded availability of VA health care services. DATA SOURCES: VA and Medicare FFS enrollment and outpatient utilization databases in 1999 and 2004. STUDY DESIGN: Multinomial logistic regression was used to examine odds of VA-only and Medicare-only utilization, relative to dual utilization, in 1999 and 2004. Observational cohort comprising a 5% random sample of dually-eligible Veterans: 73,721 in 1999 and 125,042 in 2004. PRINCIPAL FINDINGS: From 1999 to 2004, persons with the highest HCC risk scores had decreasing odds of exclusive VA reliance (OR=0.26 in 1999 and 0.17 in 2004, p<0.05), but had increasing odds of exclusive Medicare reliance (OR=0.43 in 1999 and 0.56 in 2004, p<0.05).Persons in high VA priority groups had decreasing odds of exclusive VA reliance, as well as decreasing odds of exclusive Medicare reliance, indicating increasing odds of dual use. Newly eligible Veterans with the highest HCC risk scores had higher odds of dual system use, while newly eligible Black Veterans had lower odds of dual system use. CONCLUSIONS: Veterans newly eligible for VA healthcare services, particularly those with the highest risk scores, had higher odds of dual system use compared to earlier eligibles. Providers should ensure coordination of care for Veterans who may be receiving care from multiple sources. Provisions of the Patient Protection and Affordable Care Act may help to ensure care coordination for persons receiving care from multiple systems.

Nursing home safety: does financial performance matter?

OBJECTIVES: This study examines the relationship between financial performance and selected safety measures of nursing homes in the State of Florida. METHODS: We used descriptive analysis on a total sample of 1,197. Safety information was from the Online Survey, Certification and Reporting (OSCAR) data of 2003 to 2005, while the financial performance measures were from the Medicare cost reports of 2002 to 2004. Finally, we examined the most frequently cited deficiencies as well as the relationship between financial performance and quality indicators. RESULTS: Nursing homes in the bottom quartile of financial performance perform poorly on most resident-safety measures of care; however, nursing homes in the top two financial categories also experienced a higher number of deficiencies. Nursing homes in the next to lowest quartile of financial performance category best perform on most of these safety measures. CONCLUSIONS: The results reinforce the need to monitor nursing home quality and resident safety in US nursing homes, especially among facilities with poor overall financial performance.

Malpractice paid losses and financial performance of nursing homes.

BACKGROUND: Florida's nursing home industry has experienced significant financial pressure over the past decade. One of the primary reasons is the dramatic increase in litigation activity for nursing home providers claiming negligent care and abuse. Although anecdotal reports indicate a higher cost because of malpractice in nursing facilities, few studies have examined the extent of malpractice paid losses and their effect on the financial performance of nursing homes. PURPOSE: The purpose of this study was to examine the impact of malpractice paid losses on the financial performance of nursing homes. METHODOLOGY/APPROACH: Medicare Cost Report data and Online Survey, Certification, and Reporting data for Florida skilled nursing facilities over the 6-year period from 2001 to 2006 were used to calculate the malpractice paid losses and the financial performance indicators as well as the nursing home organizational and market factors. Descriptive analysis and multivariate regression analysis were used to examine the effect of paid loss on financial performance. FINDINGS: The paid loss for malpractice claims was strongly associated with financial performance. Nursing facilities with malpractice paid losses had consistently lower total margins over the study period. The threat of nursing home litigation may create an incentive for nursing homes to improve quality of care; however, large paid claims can also force nursing homes into a financial situation where the organization no longer has the resources to improve quality. PRACTICE IMPLICATIONS: Nursing home managers must assess their malpractice litigation risk and identify tactics to mitigate these risks to better provide a safe and secure environment for the older persons. In addition, this research offers support for local, state, and federal policymakers to revisit the issue of malpractice litigation and the nursing home industry through its insight on the relationship of nursing home margins and litigation.

Primary care service areas: a new tool for the evaluation of primary care services.

OBJECTIVE: To develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians. DATA SOURCE/STUDY SETTING: The 1996-1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996). STUDY DESIGN: A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims. DATA COLLECTION/EXTRACTION METHODS: Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes. PRINCIPAL FINDINGS: The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005-1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical. CONCLUSIONS: Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.