Pneumococcal vaccination coverage among US adults enrolled in Medicaid and newly diagnosed with underlying medical conditions.

BACKGROUND: Adults with chronic or immunocompromising conditions have an elevated risk of invasive pneumococcal disease, yet their pneumococcal vaccination rates remain low. METHODS: This retrospective cohort study used the IBM MarketScan® Multi-State Medicaid database to examine pneumococcal vaccination uptake among adults 19-64 years of age with underlying conditions. Gompertz accelerated failure time model was used to examine factors associated with vaccination. RESULTS: In the study population of 108,159 adults, the vaccination rate was 4.1% after 1 year of follow-up and 19.4% after 10 years. The mean time from initial diagnosis to vaccination was 3.9 years. Adults aged 35-49 and 50-64 years (relative to 19-34) or those receiving an influenza vaccination were more likely to receive a pneumococcal vaccination. Adults with HIV/AIDS were more likely, while adults with chronic heart or lung disease, alcohol or tobacco dependence, or cancer were less likely to be vaccinated than adults with diabetes mellitus. Adults diagnosed by specialists were less likely to be vaccinated than those diagnosed by primary care providers. CONCLUSIONS: The rates of pneumococcal vaccination among adults with Medicaid plans and underlying conditions were well under Healthy People Initiative targets. Insights into factors associated with vaccination can inform efforts to improve vaccination rates among this population.

Regional factors associated with pneumococcal vaccination coverage among U.S. adults with underlying chronic or immunocompromising conditions.

The Centers for Disease Control recommends pneumococcal vaccination for U.S. adults aged 19-64 years with chronic or immunocompromising conditions, however, vaccination coverage is low and regional variations in coverage are rarely studied. This study examined pneumococcal vaccination coverage at the metropolitan statistical area (MSAs) level and identified regional factors associated with pneumococcal vaccination using the combined IBM® Watson Health MarketScan® Commercial and Medicare Supplemental databases. Pneumococcal vaccination coverage, clinical and socioeconomic factors were calculated for each MSA. Ordinary least square and spatial regression models were used to examine factors associated with vaccination. Results indicated that the national pneumococcal vaccination coverage was 13.4% with a large variation across MSAs (0-34%). The spatial error model, model with the best fit, showed that proportions of the population who were ≥50 years of age, received an influenza vaccine, or had health maintenance organization health plans were positively associated with pneumococcal vaccination coverage. In summary, we found that national pneumococcal vaccination coverage was low and there was substantial variation across MSAs. Regional factors identified may help inform interventions to improve pneumococcal vaccination coverage across geographies.

Pneumococcal vaccination coverage among adults newly diagnosed with underlying medical conditions and regional variation in the U.S.

BACKGROUND: The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends pneumococcal vaccination for adults with chronic or immunocompromising conditions to prevent pneumococcal disease, yet vaccination rates are low and have limited information on regional variation. This study examines factors associated with pneumococcal vaccination in adults with underlying conditions and describes regional variation in vaccination across the U.S. METHODS: Using IBM MarketScan Commercial Database and Medicare Supplemental Database, this retrospective cohort study included adults ages 19-64 newly diagnosed with chronic (i.e. diabetes, chronic heart, lung, or liver disease, alcohol or tobacco dependence) or immunocompromising (i.e. cancer, chronic renal disease, organ transplant, HIV/AIDS, and asplenia) conditions in 2013. Adults were followed up until the time of pneumococcal vaccination, death, or December 31, 2019, whichever came first. Cox proportional hazards model was used to examine factors associated with vaccination. Vaccination rate was calculated by metropolitan statistical area (MSA) and visually represented on a U.S. map. RESULTS: 255,330 adults were included. Vaccination rate increased from 6.0% to 21.1% among adults with one year and five years of follow-up, respectively. It took 2.4 years on average for adults to receive vaccination after initial diagnosis. Adults ages 50-64, 35-49 (relative to 19-34) or receiving influenza vaccination were more likely to receive pneumococcal vaccinations. Adults with HIV/AIDS were more likely and those with other conditions were less likely to be vaccinated than those with diabetes. Adults being diagnosed by other providers were less likely to be vaccinated than those diagnosed by primary care providers. Vaccination rate varied largely across MSAs, ranging from 0.0% (Ames, IA; Cheyenne, WY) to 34.0% (Ann Arbor, MI). CONCLUSION: Pneumococcal vaccination remains low and most adults with underlying conditions are unvaccinated. Insights into factors associated with vaccination, including regional variability, can help to increase pneumococcal vaccination.

Access to and Engagement in Substance Use Disorder Treatment Over Time.

OBJECTIVE: This study evaluated whether access to and engagement in substance use disorder treatment has improved from 2010 to 2016. METHODS: Data submitted by commercial and Medicaid health plans, representing over 163 million beneficiaries from 2010 to 2016, were analyzed. RESULTS: For commercial plans, identification increased (from 1.0% to 1.6%, p<0.001), the initiation rate declined (from 41.9% to 33.7%, p<0.001), and the engagement rate also declined (from 15.8% to 12.1%, p<0.001). The decline in the initiation and engagement rates could not be explained by the increasing identification rates. For Medicaid plans, the identification rate increased (from 3.3% to 6.7%, p<0.001), and the initiation and engagement rates were unchanged. CONCLUSIONS: Although an increasing proportion of health plan members are being identified with substance use disorders, the majority of these individuals are not engaging in treatment.

Low screening and follow-up for unhealthy alcohol use among health plan beneficiaries.

OBJECTIVES: Alcohol misuse is a leading cause of preventable death in the United States. This pilot study examined rates of screening and follow-up for unhealthy alcohol use among health plan beneficiaries. STUDY DESIGN: We analyzed medical records and claims data from 4 health plans-2 nonintegrated Medicaid plans and 2 integrated plans serving Medicaid, Medicare, and commercial product lines. The nonintegrated plans used medical records, case management, and claims data to identify alcohol screening and follow-up services using a random sample of 108 (plan 1) and 120 (plan 2) adults. The integrated plans (plans 3 and 4) used provider electronic health record data for all adults. METHODS: We adapted the Physician Consortium for Performance Improvement Foundation's measure, Unhealthy Alcohol Use Screening & Brief Counseling, and applied it to plan populations for the 2014 and 2015 calendar years. We calculated rates of screening and follow-up for unhealthy alcohol use for each plan. RESULTS: Results from the Medicaid plans showed that between 40% and 46% of members had documentation of alcohol screening, but standardized alcohol screening tools were rarely used and screening results were inconsistently documented. Results from the integrated plans with multiple product lines showed wide variation: 5% to 69% of members were screened; of those, 3% to 31% screened positive. Among members who screened positive, 1% to 46% received follow-up care. CONCLUSIONS: Rates of screening and follow-up for unhealthy alcohol use are low in plan populations. There is room for improvement in documentation and quality of care for alcohol misuse.

Disparities in diabetes and hypertension care for individuals with serious mental illness.

OBJECTIVES: People with serious mental illnesses (SMI), including schizophrenia, bipolar disorder, and major depression, experience early mortality, partly due to comorbid physical health conditions such as diabetes and hypertension. This study examined the quality of diabetes and hypertension care for Medicaid and Medicare enrollees with SMI. STUDY DESIGN: We conducted a retrospective analysis of medical records and claims data from 3 health plans: a Medicaid plan for disabled adults, a Medicaid plan for low-income adults, and a Special Needs Plan for individuals dually enrolled in Medicaid and Medicare. The study population included 258 adults with SMI and diabetes and 241 adults with SMI and hypertension. METHODS: Existing quality measures for diabetes and hypertension from the Healthcare Effectiveness Data and Information Set (HEDIS) were adapted and applied to the SMI population for the 2012 calendar year. The rates of diabetes care and hypertension control for people with SMI were compared with national averages for Medicaid and Medicare managed care plans to examine disparities in care. RESULTS: Adults with SMI receive poor-quality care for diabetes and hypertension. Depending on the health plan, performance on the diabetes care and hypertension control HEDIS measures was 14 to 49 percentage points lower among the SMI population than the general Medicaid and Medicare populations. CONCLUSIONS: Findings highlight disparities in care for individuals with SMI compared with the general Medicaid and Medicare populations. Health plans demonstrated substantial room for improvement on almost all diabetes and hypertension HEDIS measures for the SMI population.

Follow-Up Care After Emergency Department Visits for Mental and Substance Use Disorders Among Medicaid Beneficiaries.

OBJECTIVE: This study examined whether characteristics of Medicaid beneficiaries were associated with receipt of follow-up care after discharge from the emergency department (ED) following a visit for mental or substance use disorders. METHODS: Medicaid fee-for-service claims from 15 states and the District of Columbia in 2008 were used to calculate whether adults received follow-up (seven and 30 days) after being discharged from the ED following a visit for mental disorders (N=31,952 discharges) or substance use disorders (N=13,337 discharges). Random-effects logistic regression was used to model the odds of receiving follow-up as a function of beneficiary characteristics. RESULTS: Receipt of follow-up varied widely across states and by beneficiary characteristics. The odds of seven- and 30-day follow-up after mental health ED discharges were lower among males; African Americans versus whites; and beneficiaries who qualified for Medicaid on the basis of income rather than disability, beneficiaries with depression and other mood disorders compared with other psychiatric diagnoses, and (at seven-day follow-up) beneficiaries who lived in rural versus metropolitan areas. In contrast, the odds of follow-up after substance use disorder ED discharges were lower among whites (seven-day follow-up) and among beneficiaries who qualified for Medicaid on the basis of disability rather than income, who were diagnosed as having drug use disorders rather than alcohol use disorders, or who lived in metropolitan versus suburban areas (seven- and 30-day follow-ups). CONCLUSIONS: State Medicaid programs have an opportunity to improve follow-up after ED visits for mental and substance use disorders, perhaps by focusing on groups of beneficiaries who are less likely to receive follow-up.

Balancing therapeutic safety and efficacy to improve clinical and economic outcomes in schizophrenia: a managed care perspective.

Schizophrenia is a serious mental disorder associated with high morbidity and mortality, reduced life expectancy, and increased economic burden. Antipsychotic agents used for the management of schizophrenia are often associated with undesirable adverse effects, such as weight gain and metabolic abnormalities, contributing to elevated risk of cardiovascular disease, diabetes, and mortality. Contributors to the growing economic burden of schizophrenia include direct (eg, medical care and hospitalization) and indirect costs (eg, lost productivity and mortality). Strategies to reduce these expenditures include the use of generic medications, improving treatment adherence, avoidance of switching antipsychotic therapies, reducing disease relapses, and appropriate management of cardiometabolic disease. Arguably, while pharmacy benefit and managed care strategies (eg, prior authorization, prescription caps, copayments and patient cost-sharing strategies, tiered formulary pricing, and gap coverage) are designed and implemented to reduce healthcare costs, they may have the unintended result of creating barriers to treatment access and thereby contribute to further adverse patient outcomes. Managed care professionals should be cognizant of the drivers of cost and the need for cardiometabolic monitoring to individualize care for patients with schizophrenia. Further, comprehensive disease management plans should be developed that include the monitoring of disease progression and treatment adherence, while factoring in medication and healthcare administration costs.