Health impact and cost-effectiveness of expanding routine immunization coverage in India through Intensified Mission Indradhanush.

Many children do not receive a full schedule of childhood vaccines, yet there is limited evidence on the cost-effectiveness of strategies for improving vaccination coverage. Evidence is even scarcer on the cost-effectiveness of strategies for reaching 'zero-dose children', who have not received any routine vaccines. We evaluated the cost-effectiveness of periodic intensification of routine immunization (PIRI), a widely applied strategy for increasing vaccination coverage. We focused on Intensified Mission Indradhanush (IMI), a large-scale PIRI intervention implemented in India in 2017-2018. In 40 sampled districts, we measured the incremental economic cost of IMI using primary data, and used controlled interrupted time-series regression to estimate the incremental vaccination doses delivered. We estimated deaths and disability-adjusted life years (DALYs) averted using the Lives Saved Tool and reported cost-effectiveness from immunization programme and societal perspectives. We found that, in sampled districts, IMI had an estimated incremental cost of 2021US$13.7 (95% uncertainty interval: 10.6 to 17.4) million from an immunization programme perspective and increased vaccine delivery by an estimated 2.2 (-0.5 to 4.8) million doses over a 12-month period, averting an estimated 1413 (-350 to 3129) deaths. The incremental cost from a programme perspective was $6.21 per dose ($2.80 to dominated), $82.99 per zero-dose child reached ($39.85 to dominated), $327.63 ($147.65 to dominated) per DALY averted, $360.72 ($162.56 to dominated) per life-year saved and $9701.35 ($4372.01 to dominated) per under-5 death averted. At a cost-effectiveness threshold of 1× per-capita GDP per DALY averted, IMI was estimated to be cost-effective with 90% probability. This evidence suggests IMI was both impactful and cost-effective for improving vaccination coverage, though there is a high degree of uncertainty in the results. As vaccination programmes expand coverage, unit costs may increase due to the higher costs of reaching currently unvaccinated children.

The association of a disability-targeted cash transfer programme with disability status and health-care access: a quasi-experimental study using a nationwide cohort of 4·3 million Chinese adults living with severe disabilities.

BACKGROUND: Cash transfer is a crucial policy tool to address inequality. The objective of this study was to investigate the association between China's disability-targeted cash transfer programme and disability status, as well as equitable access to rehabilitation and medical services. METHODS: For this quasi-experimental study, we drew data from the nationwide administrative cohort of individuals with disabilities between Jan 1, 2015, and Dec 31, 2019. Individuals were enrolled in the cohort if they were aged 18 years or older, had severe disabilities as defined by the Chinese Government, and had available cash transfer information for at least 4 consecutive years, without having started receiving cash transfer benefits at the time of enrolment. We used a quasi-experimental design with propensity score matching to estimate the effects of cash transfers on disability status, access to rehabilitation services, and access to medical treatment. The primary outcomes were development of new disability and reduction of existing disabilities. Secondary outcomes were use of rehabilitation services, financial barriers as a major obstacle to accessing rehabilitation services, use of medical services by individuals who had an illness in the previous 2 weeks, and financial barriers as a major obstacle to accessing medical services. FINDINGS: From an initial pool of 51 356 125 individuals with disabilities registered in the administrative system, 2 686 024 individuals were eligible for analysis, of whom 2 165 335 (80·6%) were cash transfer beneficiaries and 520 689 (19·4%) non-beneficiaries. After propensity score matching, the cohort included 4 330 122 adults with severe disabilities. Cash transfer beneficiaries had significantly lower odds of developing new disabilities over time than non-beneficiaries (odds ratio [OR] 0·90, 95% CI 0·86-0·94; p<0·0001) and higher odds of having a reduced number of disabilities over time (1·17, 1·10-1·25; p<0·0001). Compared with non-beneficiaries, cash transfer beneficiaries were more likely to use rehabilitation services (2·12, 2·11-2·13; p<0·0001) and medical services (1·74, 1·69-1·78; p<0·0001), and less likely to report financial hardship to access rehabilitation services (0·53, 0·52-0·54; p<0·0001) and medical services (0·88, 0·84-0·93; p<0·0001) at the study endpoint. INTERPRETATION: The receipt of cash transfers was associated with improved disability status and increased access to disability-related services. The findings suggest that cash transfers could be a potential method for promoting universal health coverage among individuals living with disabilities. FUNDING: China National Natural Science Foundation.

Immediate Postpartum Long-Acting Reversible Contraceptive Use Following State-Specific Changes in Hospital Medicaid Reimbursement.

Importance: Facilitating access to the full range of contraceptive options is a health policy goal; however, inpatient provision of postpartum long-acting reversible contraceptive (LARC) methods has been limited due to lack of hospital reimbursement. Between March 2014 and January 2015, the Medicaid programs in 5 states began to reimburse hospitals for immediate postpartum LARC separately from the global maternity payment. Objective: To examine the association between Medicaid policies and provision of immediate postpartum LARC, and to examine hospital characteristics associated with policy adoption. Design, Setting, and Participants: This cross-sectional study used interrupted time series analysis. The setting was population-based in Georgia, Iowa, Maryland, New York, and Rhode Island. Participants included individuals who gave birth in these states between 2011 and 2017 (n = 3 097 188). Statistical analysis was performed from June 2021 to August 2022. Exposures: Childbirth after the start of Medicaid's reimbursement policy. Main Outcomes and Measures: Immediate postpartum LARC (outcome), teaching hospital, Catholic-owned or operated, obstetrical care level, and urban or rural location (hospital characteristics). Results: The study included a total of 1 521 491 births paid for by Medicaid and 1 575 697 paid for by a commercial payer between 2011 and 2017. Prior to Medicaid reimbursement changes, 489 389 of 726 805 births (67%) were to individuals between 18 and 29 years of age, 219 363 of 715 905 births (31%) were to non-Hispanic Black individuals, 227 639 of 715 905 births (32%) were to non-Hispanic White individuals, 155 298 of 715 905 births (22%) were to Hispanic individuals, and 113 605 of 715 905 births (16%) were to individuals from other non-Hispanic racial groups. Among Medicaid-paid births, the policies were associated with an increase in the rate of immediate postpartum LARC provision in all states, although results for Maryland were not consistent across sensitivity analyses. The change in trend ranged from a quarterly increase of 0.05 percentage points in Maryland (95% CI, 0.01-0.08 percentage points) and 0.05 percentage points in Iowa (95% CI, 0.00-0.11 percentage points) to 0.82 percentage points (95% CI, 0.73-0.91 percentage points) in Rhode Island. The policy was also associated with an increase in immediate postpartum LARC provision among commercially paid births in 4 of 5 states. After the policy, only 38 of 366 hospitals (10%) provided more than 1% of birthing people with immediate postpartum LARC. These adopting hospitals were less likely to be Catholic (0% [0 of 31] vs 17% [41 of 245]), less likely to be rural (10% [3 of 31] vs 33% [81 of 247]), more likely to have the highest level of obstetric care (71% [22 of 31] vs 29% [65 of 223]) and be teaching hospitals (87% [27 of 31] vs 43% [106 of 246]) compared with nonadopting hospitals. Conclusions and Relevance: This cross-sectional study's findings suggest that Medicaid policies that reimburse immediate postpartum LARC may increase access to this service; however, policy implementation has been uneven, resulting in unequal access.

Lower Socioeconomic Position Is Associated with Greater Activity in and Integration within an Allostatic-Interoceptive Brain Network in Response to Affective Stimuli.

Socioeconomic inequities shape physical health and emotional well-being. As such, recent work has examined the neural mechanisms through which socioeconomic position (SEP) may influence health. However, there remain critical gaps in knowledge regarding the relationships between SEP and brain function. These gaps include a lack of research on: (1) the association between SEP and brain functioning in later life, (2) relationships between SEP and functioning of the whole brain beyond specific regions of interest, and (3) how neural responses to positive affective stimuli differ by SEP. The current study addressed these gaps by examining the association between SEP (i.e., education, income) and neural responses to affective stimuli among 122 mid- to late-life adults. During MRI scanning, participants viewed 30 positive, 30 negative, and 30 neutral images; activation and network connectivity analyses explored associations between SEP and neural responses to these affective stimuli. Analyses revealed that those with lower SEP showed greater neural activity to both positive and negative images in regions within the allostatic-interoceptive network, a system of regions implicated in representing and regulating physiological states of the body and the external environment. There were no positive associations between SEP and neural responses to negative or positive images. In addition, graph-theory network analyses showed that individuals with lower SEP demonstrated greater global efficiency within the allostatic-interoceptive network and executive control network, across all task conditions. The findings suggest that lower SEP is associated with enhanced neural sensitivity to affective cues that may be metabolically costly to maintain over time and suggest a mechanism by which SEP might get "under the skull" to influence mental and physical well-being.

Association of Medicaid Reimbursement for Immediate Postpartum Long-acting Reversible Contraception With Infant Birth Outcomes.

IMPORTANCE: Together, preterm birth and low birth weight are the second-leading cause of infant mortality in the US and occur disproportionately among Medicaid-paid births and among the infants of Black birthing persons. In 2012, South Carolina's Medicaid program began to reimburse hospitals for immediate postpartum long-acting reversible contraception (LARC) separately from the global maternity payment. OBJECTIVE: To examine the association between South Carolina's policy change and infant health. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study using a difference-in-differences analysis included individuals with a South Carolina Medicaid-paid childbirth between January 2009 and December 2015. Data were analyzed from December 2020 to July 2021. EXPOSURES: Medicaid-paid childbirth after March 2012 in South Carolina hospitals that had implemented the policy. MAIN OUTCOMES AND MEASURES: Immediate postpartum LARC uptake, subsequent birth within 4 years, subsequent short-interval birth, days to subsequent birth, subsequent preterm, and low-birth-weight birth within 4 years. RESULTS: The study sample included 186 953 Medicaid-paid births between January 2009 and December 2015 in South Carolina (81 110 births from 2009 to 2011, 105 843 births from 2012 to 2015, and 46 414 births in exposure hospitals). The policy was associated with an absolute 5.6-percentage point (95% CI, 3.7-7.4) increase in the probability of receiving an immediate postpartum LARC overall, with significantly larger effects for non-Hispanic Black individuals than non-Hispanic White individuals (difference in coefficients 3.54; 95% CI, 1.35-5.73; P = .002). The policy was associated with a 0.4-percentage point (95% CI, -0.7 to -0.1) decrease in the probability of subsequent preterm birth and a 0.3-percentage point (95% CI, -0.7 to 0) decrease in the probability of subsequent low birth weight. No significant difference in the association between the policy and preterm birth or low-birth-weight birth between non-Hispanic Black and non-Hispanic White individuals was found. The policy was associated with a 0.6-percentage point (95% CI, -1.2 to -0.1) decrease in the probability of short-interval birth and a 27-day (95% CI, 11-44) increase in days to next birth among non-Hispanic Black individuals. The policy was associated with a significant decrease in the probability of a subsequent birth overall; however, confidence in this result is attenuated somewhat by nonparallel trends for this outcome before the policy change. CONCLUSIONS AND RELEVANCE: Findings of this cohort study suggest policies increasing access to immediate postpartum LARC may improve birth outcomes but should be accompanied by other policy efforts to reduce inequity in these outcomes.

Associations between ACA-related policies and a clinical recommendation with HPV vaccine initiation.

PURPOSE: We examined associations between the 2010 Affordable Care Act (ACA) provisions, 2011 Advisory Committee on Immunization Practices (ACIP) recommendation, and 2014 ACA-related health insurance reforms with HPV vaccine initiation rates by sex and health insurance type. METHODS: Using 2009-2015 public and private health insurance claims for 551,764 males and females aged 9-26 years (referred to as youth) from Maine, New Hampshire, and Massachusetts, we conducted linear regression models to examine the associations between three policy changes and HPV vaccine initiation rates by sex and health insurance type. RESULTS: In 2009, HPV vaccine initiation rates for males and females were 0.003 and 0.604 per 100 enrollees, respectively. Among males, the 2010 ACA provisions and ACIP recommendation were associated with significant increases in HPV vaccine uptake among those with private plans (0.207 [0.137, 0.278] and 0.419 [0.353, 0.486], respectively) and Medicaid (0.157 [0.083, 0.230] and 0.322 [0.257, 0.386], respectively). Among females, the 2010 ACA provisions were associated with significant increases in HPV vaccine uptake among Medicaid enrollees only (0.123 [0.033, 0.214]). The ACA-related health insurance reforms were associated with significant increases in HPV vaccine uptake for male and female Medicaid enrollees (0.257 [0.137, 0.377] and 0.214 [0.102, 0.327], respectively), but no differences among privately insured youth. By 2015, there were no differences in HPV vaccine initiation rates between males (0.278) and females (0.305). CONCLUSIONS: Both ACA provisions and the ACIP recommendation were associated with significant increases in HPV vaccine initiation rates among privately and publicly insured males in three New England states, closing the gender gap. In contrast, females and youth with private insurance did not exhibit the same changes in HPV vaccine uptake over the study period.

Medicaid expansions, preconception insurance, and unintended pregnancy among new parents.

OBJECTIVE: To assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first-time parents. DATA SOURCE: This study used individual-level data from the national Pregnancy Risk Assessment Monitoring System (2006-2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy. STUDY DESIGN: Outcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female-identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year. DATA COLLECTION/EXTRACTION METHODS: The sample included all individuals aged 20-44 with a first live birth in 2009-2017. PRINCIPAL FINDINGS: Among all first-time parents, a 10-percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high-school degree or less. CONCLUSIONS: Increasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first-time parents.

Impact of campaign-style delivery of routine vaccines: a quasi-experimental evaluation using routine health services data in India.

The world is not on track to achieve the goals for immunization coverage and equity described by the World Health Organization's Global Vaccine Action Plan. Many countries struggle to increase coverage of routine vaccination, and there is little evidence about how to do so effectively. In India in 2016, only 62% of children had received a full course of basic vaccines. In response, in 2017-18 the government implemented Intensified Mission Indradhanush (IMI), a nationwide effort to improve coverage and equity using a campaign-style strategy. Campaign-style approaches to routine vaccine delivery like IMI, sometimes called 'periodic intensification of routine immunization' (PIRI), are widely used, but there is little robust evidence on their effectiveness. We conducted a quasi-experimental evaluation of IMI using routine data on vaccine doses delivered, comparing districts participating and not participating in IMI. Our sample included all districts that could be merged with India's 2016 Demographic and Health Surveys data and had available data for the full study period. We used controlled interrupted time-series analysis to estimate the impact of IMI during the 4-month implementation period and in subsequent months. This method assumes that, if IMI had not occurred, vaccination trends would have changed in the same way in the participating and not participating districts. We found that, during implementation, IMI increased delivery of 13 infant vaccines, with a median effect of 10.6% (95% confidence interval 5.1% to 16.5%). We did not find evidence of a sustained effect during the 8 months after implementation ended. Over the 12 months from the beginning of implementation, we estimated reductions in the number of under-immunized children that were large but not statistically significant, ranging from 3.9% (-6.9% to 13.7%) to 35.7% (-7.5% to 77.4%) for different vaccines. The largest effects were for the first doses of vaccines against diphtheria-tetanus-pertussis and polio: IMI reached approximately one-third of children who would otherwise not have received these vaccines. This suggests that PIRI can be successful in increasing routine immunization coverage, particularly for early infant vaccines, but other approaches may be needed for sustained coverage improvements.

Medicaid Payments For Immediate Postpartum Long-Acting Reversible Contraception: Evidence From South Carolina.

In 2012 South Carolina's Medicaid program was the first state Medicaid program to separate payment for the immediate postpartum placement of long-acting reversible contraception (intrauterine devices and contraceptive implants) from its global maternity payment. Examining data on all Medicaid-insured South Carolina women giving birth from 2010 to 2014, we found that the new policy achieved its explicit goal: increasing the availability of immediate postpartum long-acting reversible contraception. Among adolescents, for whom most pregnancies are unintended, this represented new use of long-acting reversible options, rather than substitution for sterilization or for short-acting reversible methods. Therefore, the new policy also significantly increased use of highly effective postpartum contraception in an age group that is particularly vulnerable to closely spaced, higher-risk repeat pregnancies. However, fewer than half of facilities began to offer immediate postpartum long-acting reversible contraceptives after the policy change. Additional policy approaches may be needed to achieve widespread availability of this option.

The price of quality care: cross-sectional associations between out-of-pocket payments and quality of care in six low-income countries.

OBJECTIVE: To assess the relationship between out-of-pocket (OOP) payments and primary health care quality in six low-income countries: Afghanistan, the Democratic Republic of the Congo (DRC), Haiti, Nepal, Senegal and Tanzania. METHODS: We examined the association between OOP payments and quality of care during antenatal care and sick child care visits using Service Provision Assessments data. We defined four process quality outcomes from observations of clinical care: visit duration, history-taking items asked, exam items performed, and counselling items delivered. The outcome is the total amount paid for services. We used multilevel models to test the relationship between OOP payments and each quality measure in public, private non-profit and private for-profit facilities controlling for patient, provider, and facility characteristics. RESULTS: Across the six countries, an average of 42% of the 29 677 observed clients paid for their visit. In the adjusted models, OOP payments were positively associated with the visit duration during sick child visits, with history-taking and exam items during antenatal care visits, and with counselling in private for-profit facilities for both visit types. These associations were strong particularly in Afghanistan, the DRC and Haiti; for example, a high-quality antenatal care visit in the DRC would cost approximately USD 1.12 more than a visit with median quality. CONCLUSION: Provider effort was associated with higher OOP payments for sick child and antenatal care services in the six countries studied. While many families are already spending high amounts on care, they must often spend even more to receive higher quality care.

Associations between insurance-related affordable care act policy changes with HPV vaccine completion.

BACKGROUND: Although all 11- or 12-year-olds in the US were recommended to receive a 3-dose series of the human papillomavirus (HPV) vaccine within a 12-month period prior to 2016, rates of completion of the HPV vaccine series remained suboptimal. The effects of the Affordable Care Act (ACA), including private insurance coverage with no cost-sharing and health insurance expansions, on HPV vaccine completion are largely unknown. The aim of this study was to examine the associations between the ACA's 2010 provisions and 2014 insurance expansions with HPV vaccine completion by sex and health insurance type. METHODS: Using 2009-2015 public and private health insurance claims from Maine, New Hampshire, and Massachusetts, we identified 9-to-26-year-olds who had at least one HPV vaccine dose. We conducted a logistic regression model to examine the associations between the ACA policy changes with HPV vaccine completion (defined as receiving a 3-dose series within 12 months from the date of initiation) as well as interactions by sex and health insurance type. RESULTS: Over the study period, among females and males who initiated the HPV vaccine, 27.6 and 28.0%, respectively, completed the series within 12 months. Among females, the 2010 ACA provision was associated with a 4.3 percentage point increases in HPV vaccine completion for the privately-insured (0.043; 95% CI: 0.036-0.061) and a 5.7 percentage point increase for Medicaid enrollees (0.057; 95% CI: 0.032-0.081). The 2014 health insurance expansions were associated with a 9.4 percentage point increase in vaccine completion for females with private insurance (0.094; 95% CI: 0.082-0.107) and a 8.5 percentage point increase for Medicaid enrollees (0.085; 95% CI: 0.068-0.102). Among males, the 2014 ACA reforms were associated with a 5.1 percentage point increase in HPV vaccine completion for the privately-insured (0.051; 95% CI: 0.039-0.063) and a 3.4 percentage point increase for Medicaid enrollees (0.034; 95% CI: 0.017-0.050). In a sensitivity analysis, findings were similar with HPV vaccine completion within 18 months. CONCLUSIONS: Despite low HPV vaccine completion overall, both sets of ACA provisions were associated with increases in completion among females and males. Our results suggest that expanding Medicaid across the remaining states could increase HPV vaccine completion among publicly-insured youth and prevent HPV-related cancers.

Children with attention-deficit/hyperactivity disorder spend more time in hyperconnected network states and less time in segregated network states as revealed by dynamic connectivity analysis.

Previous studies in children with attention-deficit/hyperactivity disorder (ADHD) have observed functional brain network disruption on a whole-brain level, as well as on a sub-network level, particularly as related to the default mode network, attention-related networks, and cognitive control-related networks. Given behavioral findings that children with ADHD have more difficulty sustaining attention and more extreme moment-to-moment fluctuations in behavior than typically developing (TD) children, recently developed methods to assess changes in connectivity over shorter time periods (i.e., "dynamic functional connectivity"), may provide unique insight into dysfunctional network organization in ADHD. Thus, we performed a dynamic functional connectivity (FC) analysis on resting state fMRI data from 38 children with ADHD and 79 TD children. We used Hidden semi-Markov models (HSMMs) to estimate six network states, as well as the most probable sequence of states for each participant. We quantified the dwell time, sojourn time, and transition probabilities across states. We found that children with ADHD spent less total time in, and switched more quickly out of, anticorrelated states involving the default mode network and task-relevant networks as compared to TD children. Moreover, children with ADHD spent more time in a hyperconnected state as compared to TD children. These results provide novel evidence that underlying dynamics may drive the differences in static FC patterns that have been observed in ADHD and imply that disrupted FC dynamics may be a mechanism underlying the behavioral symptoms and cognitive deficits commonly observed in children with ADHD.

Association Between Medicaid Prescription Drug Limits and Access to Medications and Health Care Use Among Young Adults With Disabilities.

Importance: Prescription drugs are necessary for managing complex physical and mental health conditions for more than 10 million Medicaid beneficiaries with disabilities. However, some state Medicaid programs limit the number of prescription drugs that beneficiaries can obtain monthly, which may decrease access to essential medications. Objective: To examine the association between exposure to the 3-drug limit at age 21 years in Arkansas and Texas and prescription drug and health care use among beneficiaries with disabilities enrolled in Medicaid. Design Setting and Participants: In this cohort study of 28 046 young adults with disabilities, difference-in-differences analysis was performed using Medicaid Analytic eXtract claims data from January 1, 2007, to December 31, 2012. Analyses were completed December 1, 2020. The analyses included Medicaid beneficiaries with disabilities in Arkansas and Texas (ie, drug cap states) or 15 comparison states without drug cap policies who became age 21 years during the study period and were continuously enrolled in fee-for-service Medicaid in the year before and after that point. Exposures: Exposure to the 3-drug prescription limit at age 21 years in 2 drug cap states. Main Outcomes and Measures: Monthly total prescriptions and prescriptions for drugs to treat mental health conditions, total prescription drug spending, and inpatient and emergency department visits and spending in the 12 months before and after becoming age 21 years. Results: Among 28 046 young adults with disabilities, 8214 (29.3%) resided in drug cap states and were subject to the 3-drug limit at age 21 years. Most individuals were male (drug cap states: 61.4%, comparison states: 60.6%), and the minority were White individuals (drug cap states: 36.7%, comparison states: 49.4%). More than one-half of individuals with disabilities were diagnosed with a mental health condition before age 21 years (drug cap states: 57.0%, comparison states: 60.0%). In the year before the analyzed individuals became aged 21 years, the mean (SD) number of prescriptions per beneficiary per month was 1.58 (2.16) in drug cap states vs 1.82 (1.91) in comparison states. The drug cap policy was associated with 19.6% (95% CI, -21.3% to -17.8%; P < .001) fewer monthly prescriptions and 16.5% (95% CI, -21.9% to -10.8%; P < .001) fewer prescriptions for drugs for mental health conditions but was not associated with total prescription drug spending. The drug cap policy was associated with 13.6% (95% CI, 1.9% to 26.6%; P = .02) more inpatient admissions. Conclusions and Relevance: In this cohort study of young adults with disabilities, drug cap policies were associated with lower rates of access to important medications and higher rates of hospitalization among individuals in states with drug cap policies vs those without these policies.

Equity and Distributional Impact on Stunting of a Nutritional Package Targeting Children Aged 6-36 Months in China: Findings from a Modeling Study.

BACKGROUND: Despite rapid economic development, child stunting remains a persistent problem in China. Stunting prevalence varies greatly across geographical regions and wealth groups. To address child undernutrition, the Ying Yang Bao (YYB) nutritional package has been piloted in China since 2001. OBJECTIVE: We aimed to evaluate the distributional impact of a hypothetical rollout of the YYB nutritional package on child stunting across provinces and wealth groups in China, with a specific focus on equity. METHODS: We used data from China Family Panel Studies and built on extended cost-effectiveness analysis methods. We estimated the distributional impact of a 12-month YYB program targeting children aged 6-36 months across 25 provinces and two wealth groups along three dimensions: the cost of the YYB program; the number of child stunting cases averted by YYB; and the cost per stunting case averted. Children in each province were divided into poverty and non-poverty groups based on the international poverty line of $5.50 per day. We also conducted a range of sensitivity analyses. RESULTS: We showed that 75% coverage of YYB could avert 1.9 million stunting cases among children aged 6-36 months, including 1.3 million stunting cases among children living under the poverty line, at a total cost of ¥5.4-6.2 billion ($1.5-1.8 billion) depending on the type of YYB delivery. The cost per stunting case averted would greatly vary across Chinese provinces and wealth groups, ranging from ¥800 (around $220, Chongqing province) to ¥23,300 (around $6600, Jilin province). In most provinces, the cost per stunting case averted would be lower for children living under the poverty line. CONCLUSIONS: YYB could be a pro-poor nutritional intervention package that brings substantial health benefits to poor and marginalized Chinese children, but with large variations in value for money across provinces and wealth groups. This analysis points to the need for prioritization across provinces and a targeted approach for YYB rollout in China.

BRCA1/2 Testing in Massachusetts Among Women With Private Insurance or Medicaid, 2011-2015.

PURPOSE: Testing for BRCA1/2 mutations has increased among privately insured women in the United States. However, little is known about testing rates or trends among women with Medicaid. We sought to determine whether BRCA1/2 testing rates differed between women with private insurance compared with women with Medicaid in a state where both insurance types cover the test, and to compare testing trends from 2011 to 2015. METHODS: We conducted a retrospective cohort study of medical claims from January 2011 through June 2015. We included Massachusetts women aged 18-64 with private insurance or Medicaid and at least 12 months of continuous enrollment. We used multivariable linear regression to examine the association of insurance type, age, and time with testing rates. RESULTS: Mean monthly BRCA1/2 testing rates were lower among women with Medicaid compared with those with private insurance. Among privately insured women, mean monthly rates rose from 9.3 per 100,000 in 2011 to 18.4 per 100,000 in 2015, while among Medicaid-insured women, rates increased from 3.7 to 14.7. There was no difference in the monthly rate of increase in both groups (P=0.07). In adjusted analyses, rates were lower among Medicaid-insured women (7 fewer tests per month than privately insured women, P<0.001), and differed by age, with women aged 44-54 most likely to receive testing and women 18-34 the least likely. CONCLUSION: BRCA1/2 testing rates were lower among women insured by Medicaid compared with those with private insurance, though rates increased from 2011 to 2015 among both groups of women at a similar rate.

Quality of clinical management of children diagnosed with malaria: A cross-sectional assessment in 9 sub-Saharan African countries between 2007-2018.

BACKGROUND: Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries. METHODS AND FINDINGS: We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7%), malaria (29.7%), and/or gastrointestinal infection (19.7%). Among the 7,340 children with a malaria diagnosis, 32.5% (95% CI: 30.3%-34.7%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4% to 57.1% across countries. In the more recent surveys (2013-2018), 40.7% (95% CI: 37.7%-43.6%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20% of children diagnosed with malaria received no antimalarial at all, and nearly 10% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2% (95% CI: 34.2%-40.1%) would have received a blood test and appropriate antimalarial (44.4% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied. CONCLUSIONS: In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care.

Rural-urban disparities in colonoscopies after the elimination of patient cost-sharing by the Affordable Care Act.

INTRODUCTION: Improving the prevention and early detection of colorectal cancer is a priority for reducing rural-urban disparities in colorectal cancer mortality. By eliminating out-of-pocket (OOP) costs for preventive colonoscopies, the Affordable Care Act (ACA) could have reduced rural-urban disparities in screening. METHODS: We used the Maine Health Data Organization All-Payer Claims Database including all commercially-insured and Medicare beneficiaries aged 50-75 between 2009 and 2012. Rural-urban commuting areas were used to classify rural/urban residence. ICD-9 and CPT codes identified colonoscopies. We summed all OOP payments per patient-day. An interrupted time series model estimated the impact of the ACA on trends in rural-urban disparities in colonoscopy rates and OOP costs. RESULTS: Before the ACA, colonoscopy rates were 16% lower in rural than urban areas (5.1% vs. 6.1% of enrollees annually) and median OOP costs were nearly double ($195 vs. $98). The ACA reduced median OOP payments by $94 (p = .001) initially and $4 monthly (p = .038) in rural areas, and $63 (p < .001) in urban areas. The rural-urban gap in OOP payments dropped by $4 monthly (p = .007). The ACA also reduced rural-urban disparities in colonoscopy rates (disparity decrease of 0.005 (6%) monthly, p < .001). The rural-urban gap in colonoscopy rates declined 40% relative to the pre-ACA period by December 2012. CONCLUSIONS: The ACA was associated with significant reductions in rural-urban disparities in colonoscopies in Maine, suggesting that OOP costs are an important barrier for rural residents. Further research is needed to determine whether increased uptake, particularly in rural areas, translated into better patient outcomes for colorectal cancer.

The effect of the Affordable Care Act on patient out-of-pocket cost and use of preventive cancer screenings in Massachusetts.

In an effort to increase use of preventive health care, The Patient Protection and Affordable Care Act (ACA) eliminated cost-sharing for preventive cancer screening services for the privately insured. The impact on patient spending and use of these screenings is still poorly understood. We used an interrupted time series analysis with the Massachusetts All-Payer Claims Database (2009-2012) to assess changes in trends in costs and use of breast, cervical and colorectal cancer screenings after the ACA policy. We find that the ACA was associated with a 0.024 (95% CI: -0.031, -0.017, p < 0.001) and 0.424 (95% CI: -0.481, -0.368, p < 0.001) percentage point decrease in the likelihood of a copayment each week for preventive breast and cervical cancer screenings respectively. The likelihood of copayment for colon cancer screening declined throughout the study period, with the rate of decline slowing following the ACA (trend in percent of screenings with copayment -0.130 before vs -0.071 after ACA, p = 0.014). Overall, we find only weak evidence that the ACA policy increased screenings. We find no significant effect on utilization for cervical cancer or colon cancer screening. For breast cancer screening, we find a small immediate increase in the utilization rate in the month after the policy change, with no change in trend after the ACA policy. Policy makers may need to consider other complementary policy options to increase screening rates.