Evaluation of a collaborative model between managed care and affordable housing on acute care costs.

OBJECTIVES: This study evaluated a collaborative service model between the largest Medicaid managed care organization (MCO) in Texas, Superior HealthPlan, and the affordable housing provider Prospera Housing Community Services. STUDY DESIGN: Using a quasi-experimental 2-groups research design, we compared health care outcomes and costs between a sample of 104 participants served by the Prospera+Superior collaborative model and a group of 104 participants who had health care coverage through the Superior HealthPlan Medicaid MCO but did not live at Prospera properties (ie, Superior-only group). METHODS: Data from medical claims were analyzed to examine change in outcomes 12 months before and after implementation of the Prospera+Superior collaborative model in 2019. RESULTS: The Prospera+Superior group had a 56% lower rate of emergency department/urgent care visits and spent $2061 less in prescription costs than the Superior-only group after implementation. CONCLUSIONS: These findings provide needed evidence of the clinical and economic value of forming multisector collaborative models between MCOs and other community providers.

Quantifying the Implementation and Cost of a Multisite Antibiotic Stewardship Intervention for Asymptomatic Bacteriuria.

Objective: The intensity of an antibiotic stewardship intervention to achieve clinical impact is not known. We conducted a multisite dissemination project of an intervention to reduce treatment of asymptomatic bacteriuria (ASB) and studied: (1) the association between implementation metrics and clinical outcomes and (2) the cost of implementation. Design/Setting/Participants: A central site facilitated a multimodality intervention to decrease unnecessary urine cultures and antibiotic treatment in patients with ASB at 4 Veterans Affairs medical centers. Methods: The intervention consisted of a decision support aid algorithm and interactive teaching cases that provided in the moment audit and feedback on how to manage ASB. Implementation outcomes included minutes spent in intervention delivery, number of healthcare professionals reached, and number of sessions delivered. Clinical outcomes included days of antibiotic therapy (DOT), length of antibiotic therapy (LOT), and number of urine cultures ordered per 1000 bed days. Personnel reported weekly time logs. Results: Minutes spent in intervention delivery were inversely correlated with two clinical outcomes, DOT (R -0.3, P = .04) and LOT (R -0.3, P = .02). Number of healthcare professionals reached and number of sessions delivered were not correlated with clinical outcomes of DOT (R -0.003, P = .98, R = -0.059, P = .69) or LOT (R +0.073, P = .62, R -0.102, P = .49). Physician champions spent an average of 3.8% of effort on the intervention. The implementation cost was USD 22,299/year per site on average. Conclusions: The amount of time local teams spent in delivery of an antibiotic stewardship intervention was correlated with the desired decrease in antibiotic use. Implementing this successful antibiotic stewardship intervention required minimal time.

Geographic Variations and the Associated Factors in Adherence to and Persistence with Adjuvant Hormonal Therapy for the Privately Insured women Aged 18-64 with Breast Cancer in Texas.

The purpose of this study is to examine the geographical patterns of adjuvant hormonal therapy adherence and persistence and the associated factors in insured Texan women aged 18-64 with early breast cancer. A retrospective cohort study was conducted using 5-year claims data for the population insured by the Blue Cross Blue Shield of Texas (BCBSTX). Women diagnosed with early breast cancer who were taking tamoxifen or aromatase inhibitors (AIs) for adjuvant hormonal therapy with at least one prescription claim were identified. Adherence to adjuvant hormonal therapy and persistence with adjuvant hormonal therapy were calculated as outcome measures. Women without a gap between two consecutively dispensed prescriptions of at least 90 days were considered to be persistently taking the medications. Patient-level multivariate logistic regression models with repeated regional-level adjustments and a Cox proportional hazards model with mixed effects were used to determine the geographical variations and patient-, provider-, and area-level factors that were associated with adjuvant hormonal therapy adherence and persistence. Of the 938 women in the cohort, 627 (66.8%) initiated adjuvant hormonal therapy. Most of the smaller HRRs have significantly higher or lower rates of treatment adherence and persistence rates relative to the median regions. The use of AHT varies substantially from one geographical area to another, especially for adherence, with an approximately two-fold difference between the lowest and highest areas, and area-level factors were found to be significantly associated with the compliance of AHT. There are geographical variations in AHT adherence and persistence in Texas. Patient-level and area-level factors have significant associations explaining these patterns.

Assessment of US Preventive Services Task Force Guideline-Concordant Cervical Cancer Screening Rates and Reasons for Underscreening by Age, Race and Ethnicity, Sexual Orientation, Rurality, and Insurance, 2005 to 2019.

Importance: Cervical cancer screening rates are suboptimal in the US. Population-based assessment of reasons for not receiving screening is needed, particularly among women from historically underserved demographic groups. Objective: To estimate changes in US Preventive Service Task Force guideline-concordant cervical cancer screening over time and assess the reasons women do not receive up-to-date screening by sociodemographic factors. Design, Setting, and Participants: This pooled population-based cross-sectional study used data from the US National Health Interview Survey from 2005 and 2019. A total of 20 557 women (weighted, 113.1 million women) aged 21 to 65 years without previous hysterectomy were included. Analyses were conducted from March 30 to August 19, 2021. Exposures: Sociodemographic factors, including age, race and ethnicity, sexual orientation, rurality of residence, and health insurance type. Main Outcomes and Measures: Primary outcomes were US Preventive Services Task Force guideline-concordant cervical cancer screening rates and self-reported primary reasons for not receiving up-to-date screening. For 2005, up-to-date screening was defined as screening every 3 years for women aged 21 to 65 years. For 2019, up-to-date screening was defined as screening every 3 years with a Papanicolaou test alone for women aged 21 to 29 years and screening every 3 years with a Papanicolaou test alone or every 5 years with high-risk human papillomavirus testing or cotesting for women aged 30 to 65 years. Population estimation included sampling weights. Results: Among 20 557 women (weighted, 113.1 million women) included in the study, most were aged 30 to 65 years (16 219 women; weighted, 86.3 million women [76.3%]) and had private insurance (13 571 women; weighted, 75.8 million women [67.0%]). With regard to race and ethnicity, 997 women (weighted, 6.9 million women [6.1%]) were Asian, 3821 women (weighted, 19.5 million women [17.2%]) were Hispanic, 2862 women (weighted, 14.8 million women [13.1%]) were non-Hispanic Black, 12 423 women (weighted, 69.0 million women [61.0%]) were non-Hispanic White, and 453 women (weighted, 3.0 million women [2.7%]) were of other races and/or ethnicities (including Alaska Native and American Indian [weighted, 955 000 women (0.8%)] and other single and multiple races or ethnicities [weighted, 2.0 million women (1.8%)]). In 2019, women aged 21 to 29 years had a significantly higher rate of overdue screening (29.1%) vs women aged 30 to 65 years (21.1%; P < .001). In both age groups, the proportion of women without up-to-date screening increased significantly from 2005 to 2019 (from 14.4% to 23.0%; P < .001). Significantly higher rates of overdue screening were found among those of Asian vs non-Hispanic White race and ethnicity (31.4% vs 20.1%; P = .01), those identifying as LGBQ+ (gender identity was not assessed because of a small sample) vs heterosexual (32.0% vs 22.2%; P < .001), those living in rural vs urban areas (26.2% vs 22.6%; P = .04), and those without insurance vs those with private insurance (41.7% vs 18.1%; P < .001). The most common reason for not receiving timely screening across all groups was lack of knowledge, ranging from 47.2% of women identifying as LGBQ+ to 64.4% of women with Hispanic ethnicity. Previous receipt of a human papillomavirus vaccine was not a primary reason for not having up-to-date screening (<1% of responses). From 2005 to 2019, among women aged 30 to 65 years, lack of access decreased significantly as a primary reason for not receiving screening (from 21.8% to 9.7%), whereas lack of knowledge (from 45.2% to 54.8%) and not receiving recommendations from health care professionals (from 5.9% to 12.0%) increased significantly. Conclusions and Relevance: This cross-sectional study found that cervical cancer screening that was concordant with US Preventive Services Task Force guidelines decreased in the US between 2005 and 2019, with lack of knowledge reported as the biggest barrier to receiving timely screening. Campaigns addressing patient knowledge and provider communication may help to improve screening rates, and cultural adaptation of interventions is needed to reduce existing disparities.

Prospective association between receipt of the economic impact payment and mental health outcomes.

BACKGROUND: The Coronavirus Aid, Relief, and Economic Security Act of 2020 provided 'economic impact payments' (EIPs) of $1200 to US adults with annual personal income of $75 000 or less. This study examined the prospective association between EIP receipt and mental health outcomes. METHODS: A nationally representative sample of 3169 middle-income and low-income US adults completed a baseline assessment of their health and well-being in May-June 2020 and a 3-month follow-up assessment during the period of the COVID-19 pandemic when EIPs were distributed. RESULTS: Controlling for sociodemographic characteristics, EIP recipients had higher odds of reporting a positive COVID-19 test, endorsing a history of post-traumatic stress disorder and reporting any illicit drug use in the past month than participants who did not receive EIP. Participants who did not receive EIP were more likely to report a history of anxiety disorder or alcohol use disorder and recent suicidal ideation than EIP recipients. There was no association between EIP receipt and financial distress, although over one-third to over half of EIP recipients were not employed at baseline. Between baseline and 3-month follow-up, receipt of EIP was significantly associated with reduced medical conditions and alcohol use problems, but increased depression, suicidal ideation and COVID-19 era-related stress. CONCLUSION: The EIP provided a brief income stimulus to many adults in need but was not associated with improvements in financial distress or mental health among middle-income and low-income recipients. Long-term income security and employment may be more important to improving and sustaining positive mental health outcomes.

Estimation of Utility Values for Computing Quality-adjusted Life Years Associated With Homelessness.

BACKGROUND: There is a lack of data-driven evidence about the burden of homelessness, and lack of a holistic measure of effectiveness for evaluating interventions targeting homelessness. Quality-adjusted life years (QALYs) can help holistically capture the burden of homelessness, and facilitate the valuation and comparison of interventions designed to address homelessness. OBJECTIVE: This study estimated utility values required to compute the QALYs associated with homelessness, and also examined individual-level characteristics that affect these values. RESEARCH DESIGN: The study is cross-sectional and derived from a large national survey conducted during the coronavirus disease 2019 pandemic. SUBJECTS: A sample of 6607 middle- and low-income adults in the United States. MEASURES: A self-completion standard gamble survey was used to estimate utility values associated with homelessness. Linear regression was used to analyze the association between individual-level characteristics and these utility values. RESULTS: The study estimated the average utility value associated with homelessness as 43.4% among the study participants. This implies that 1 year of life as a homeless individual is perceived to be equivalent to less than half a year of life as a stably housed individual in good health. The study also found that individuals who have experienced homelessness and financial distress value life as a homeless person considerably less than those who have not had these experiences. CONCLUSIONS: The method developed in this study can be used to estimate QALYs in studies evaluating homelessness interventions, thereby establishing the societal value of these interventions and informing policy and budgetary decision-making. Future studies estimating the utility values associated with homelessness in the general population, as well as specific homeless groups, are required to provide more generalizable evidence.

Health care costs associated with primary care physicians versus nurse practitioners and physician assistants.

BACKGROUND: Significant primary care provider (PCP) shortage exists in the United States. Expanding the scope of practice for nurse practitioners (NPs) and physician assistants (PAs) can help alleviate this shortage. The Department of Veterans' Affairs (VA) has been a pioneer in expanding the role of NPs and PAs in primary caregiving. PURPOSE: This study evaluated the health care costs associated with VA patients cared for by NPs and PAs versus primary care physicians (physicians). METHODS: A retrospective data analysis using two separate cohorts of VA patients, one with diabetes and the other with cardiovascular disease (CVD), was performed. The associations between PCP type and health care costs were analyzed using ordinary least square regressions with logarithmically transformed costs. RESULTS: The analyses estimated 12% to 13% (US dollars [USD] 2,626) and 4% to 5% (USD 924) higher costs for patients assigned to physicians as compared with those assigned to NPs and PAs, after adjusting for baseline patient sociodemographics and disease burden, in the diabetes and CVD cohort, respectively. Given the average patient population size of a VA medical center, these cost differences amount to a total difference of USD 14 million/year per center and USD 5 million/year per center for diabetic and CVD patients, respectively. IMPLICATIONS FOR PRACTICE: This study highlights the potential cost savings associated with primary caregiving by NPs and PAs. In light of the PCP shortage, the study supports increased involvement of NPs and PAs in primary caregiving. Future studies examining the reasons for these cost differences by provider type are required to provide more scientific evidence for regulatory decision making in this area.

Enhanced dispatch and rendezvous doubles the catchment area and number of patients treated on a mobile stroke unit.

INTRODUCTION: Mobile Stroke Units (MSUs) deliver acute stroke treatment on-scene in coordination with Emergency Medical Services (EMS). One criticism of the MSU approach is the limited range of a single MSU. The Houston MSU is evaluating MSU implementation, and we developed a rendezvous approach as an innovative solution to expand the range and number of patients treated. METHODS: In addition to direct 911 dispatch of our MSU to the scene within our 7-mile catchment area, we empowered more distant EMS units to activate the MSU. We also monitored EMS radio communications to identify possible patients. For these distant patients, the MSU met the EMS unit en route to the stroke center and treated the patient at that intermediate location. The distribution of the distance from MSU base station to site of stroke and time from 911 alert to tissue plasminogen activator (tPA) bolus were compared between patients treated on-scene and by rendezvous using Wilcoxon rank sum test. RESULTS: Over 4 years, 338 acute ischemic stroke patients were treated with tPA on our MSU. Of these, 169 (50%) were treated on-scene after MSU dispatch at a median of 6.4 miles (IQR 6.4 miles) from MSU base station. 169 (50%) were treated by 'rendezvous' pathway with assessment and treatment of stroke a median of 12.4 miles from base (IQR 5.5 miles) (p< 0.0001). Time (min) from MSU alert to tPA bolus did not differ: 36.0 ± 10.0 for on-scene vs 37.0 ± 10.0 with rendezvous (p=0.65). 13% of patients alerted via direct 911 dispatch were treated vs 44% of rendezvous patients. CONCLUSION: Adding a rendezvous approach to an MSU dispatch pathway doubles the range of operations and the number of patients treated by an MSU in an urban area, without incurring delay.

Factors Associated With Childhood Vaccination Adherence in Kindergartens of the Houston Independent School District.

OBJECTIVE: Adequate childhood vaccination rates are crucial for successful control of infectious diseases. Nevertheless, exemption requests, lack of health care access and information and other barriers can reduce vaccination adherence rates, and increase the risk of epidemics. This study aimed to identify factors associated with kindergarten vaccination adherence in the Houston Independent School District (HISD). DESIGN AND SETTING: This study was a retrospective observational data analysis. The study used data from 155 elementary schools of the HISD. The data sets included were (1) Elementary School Profile Reports (2015-2016) and (2) Annual Report of Immunization Status (2016-2017). Logistic regression was used to examine the association between vaccination adherence in schools and the school's student demographic and economic profile, student behavior indicators, teacher profile, and school rank. MAIN OUTCOME MEASURE: A binary variable measuring adequate vaccination adherence rates in schools is the main outcome variable. RESULTS: Lower vaccination adherence among the kindergarten students was associated with higher enrollment, a higher percentage of African American students and students with English as second language, and a lower percentage of gifted/talented students in the schools. CONCLUSIONS: The school characteristics that were found to be significantly associated with kindergarten student vaccination adherence in this study are the ones that have historically been associated with socioeconomic determinants of health and socioeconomic privilege. Hence, the findings of this study suggest the need for development of policies and interventions that can help overcome the barriers associated with low socioeconomic status, language, and marginalization in order to improve vaccination rates in school districts. These include culturally appropriate polices and health promotion, patient navigation, and educational interventions that can overcome the challenges faced by socially and economically vulnerable minorities and immigrant communities in order to improve vaccination rates.

Outcomes, care utilization, and expenditures in adolescent pregnancy complicated by diabetes.

BACKGROUND AND OBJECTIVE: Adolescence and pregestational diabetes separately increase risks of adverse pregnancy outcomes, but little is known about their combined effect. To analyze pregnancy outcomes, healthcare utilization, and expenditures in adolescent pregnancies with and without pregestational diabetes using a national claims database. METHODS: Retrospective study using Truven Health MarketScan Commercial Claims and Encounters Database, 2011 to 2015. Females 12 to 19 years old, continuously enrolled for at least 12 months before a livebirth until 2 months after, were included. Pregestational diabetes, diabetes complications (ketoacidosis, retinopathy, neuropathy, nephropathy), comorbidities, and pregnancy outcomes (preeclampsia, preterm delivery, high birthweight, cesarean delivery) were identified using claims data algorithms. Healthcare utilization and payer expenditure were tabulated per enrollee. Multivariate logistic regressions assessed pregnancy outcomes; multivariate OLS regression assessed payer expenditures. RESULTS: About 33 502 adolescents were included. Adolescents without diabetes had pregnancy outcomes consistent with national estimates. Adolescents with uncomplicated diabetes had increased odds of preeclampsia adjusted odds ratios 2.41 (95% confidence interval 1.93-3.02), preterm delivery 1.50 (1.21-1.87), high birthweight 1.84 (1.50-2.27), and cesarean delivery 1.81 (1.52-2.15). Diabetes with ketoacidosis and/or end-organ damage had higher odds of preeclampsia 5.62 (2.77-11.41), preterm delivery 5.81 (3.00-11.25), high birthweight 2.38 (1.08-5.24), and cesarean delivery 3.43 (1.78-6.64). Adolescents with diabetes utilized significantly more outpatient and inpatient care during pregnancy. Payer expenditures increased by 45.3% (34.8-55.9%) among adolescents with diabetes and by 82.6% (49.1-116.0%) among adolescents with diabetes complicated by ketoacidosis and/or end-organ damage. CONCLUSION: Compared with normal adolescent pregnancies, pregestational diabetes significantly increases risks of adverse pregnancy outcomes and significantly escalates healthcare utilization and cost.

How we use hospice: Hospice enrollment patterns and costs in elderly ovarian cancer patients.

OBJECTIVE: To describe disparities in patterns of hospice use and end-of-life costs among ovarian cancer patients. METHODS: Using Texas Cancer Registry-Medicare data, ovarian cancer patients deceased 2005-2012 with >12 months of continuous Medicare coverage before death were included. Descriptive statistics and multivariable logistic regressions were used to evaluate patterns of hospice use. Cost and resource utilization was obtained from Medicare claims and analyzed using a non-parametric Mann-Whitney test. RESULTS: 2331 patients were assessed: 1788 (77%) white, 359 (15%) Hispanic, 158 (7%) black and 26 (1%) other. 1756 (75%) enrolled in hospice prior to death but only 1580 (68%) died with hospice. 176 (10%) of 1756 patients unenrolled and died without hospice. 346 (20%) unenrolled from hospice multiple times. From 2008 to 2012, patients were less likely to unenroll from hospice prior to death. Black patients were more likely to unenroll from hospice prior to death (OR 2.07 [1.15-3.73]; p = 0.02) compared to white patients. The median amount paid by Medicare during the last six months of life was $38,530 for those in hospice compared to $49,942 if never enrolled in hospice (p < 0.0001) and was higher for black and Hispanic patients compared to white patients. 30% hospice unenrolled patients and 40% multiply enrolled hospice patients received at least one life extending or invasive care procedure following unenrollment from hospice. CONCLUSION: Recently, more patients remain enrolled in hospice, but black patients have a higher risk of unenrollment. Hospice enrollment was associated with lower costs as long as a patient did not unenroll from hospice.

Factors Affecting Racial Disparities in End-of-Life Care Costs Among Lung Cancer Patients: A SEER-Medicare-based Study.

OBJECTIVES: Racial disparities exist in end-of-life lung cancer care, which could potentially lead to considerable racial differences in end-of-life care costs. This study for the first time estimates the racial differences in end-of-life care costs among lung cancer patients, and identifies and quantifies factors that contribute the most to these differences using a statistical decomposition method. METHODS: This is a retrospective analysis of patients 66 years and older, diagnosed with stage I-IV lung cancer, who died on or before December 31, 2013, using the Surveillance Epidemiology and End Result-Medicare data from 1991 to 2013. Ordinary least square regression of logarithmically transformed cost was used to estimate racial differences in end-of-life care costs among lung cancer patients. Blinder-Oaxaca decomposition was used to identify and quantify factors that contributed the most to these differences. RESULTS: Non-Hispanic blacks had 10% to 13% higher end-of-life care costs as compared with non-Hispanic whites. Geographic variations, baseline comorbidity indices and stage at diagnosis contributed the most to explaining the racial differences in costs, with geographic variation explaining most of the differences. However, the observed factors could only explain 25% to 32% of the racial differences in end-of-life care costs. CONCLUSIONS: Geographic differences in access to timely and appropriate care, and provider practice patterns, should be examined to understand the reasons behind geographic variations in racial disparity. Provider-level educational interventions to reduce small area practice variations and differential management of patients by race, as well as racially sensitive patient-level educational and navigational interventions might be critical in improving quality of care and reducing costs during end-of-life.

Association between financial burden and adjuvant hormonal therapy adherence and persistent use for privately insured women aged 18-64 years in BCBS of Texas.

PURPOSE: The objective of this study is to understand an impact of financial burden on the adjuvant hormonal therapy (AHT) adherence and persistence for insured women aged 18-64 with early breast cancer in Texas. METHODS: We conducted a retrospective cohort study using claims data for population insured by Blue Cross Blue Shield of Texas from the year 2008 to 2013. Outcomes include adherence to adjuvant hormonal therapy, which was measured by medication possession ratio and persistence on AHT, which is the duration of time from initiation to discontinuation of therapy. Multivariate logistic regression models with repeated regional-level adjustments were used to explore the odds of AHT adherence. Cox proportional hazards model was conducted to assess time to the first 90+-day gap for persistence and a Kaplan-Meier curve were used to estimate probabilities to calculate the percentages of women who experienced 90+-day gaps in AHT. RESULTS: Of the 938 women in the cohort, 627 (66.8%) initiated the treatment. By year 1, 66.9% of women were adherent to the therapy, and by year 5, only 29% of those were adherent. The percentage of women with no gap in therapy greater than 90 days was 80.8%. Both higher out-of-pocket costs spent on all prescription drugs except AHT and AHT-specific out-of-pocket costs were negatively associated with adherence to AHT as well as continuing AHT as recommended. CONCLUSIONS: Financial burdens including both non-AHT medication and AHT-specific out-of-pocket costs were significantly associated with adherence and persistence to the therapy.

End-of-Life Racial and Ethnic Disparities Among Patients With Ovarian Cancer.

Purpose To assess disparities in end-of-life care among patients with ovarian cancer. Patients and Methods Using Texas Cancer Registry-Medicare data, we assessed patients with ovarian cancer deceased in 2000 to 2012 with at least 13 months of continuous Medicare coverage before death. Descriptive statistics and multivariate logistic regressions were conducted to evaluate end-of-life care, including chemotherapy in the final 14 days of life, intensive care unit (ICU) admission in the final 30 days of life, more than one emergency room (ER) or hospital admission in the final 30 days of life, invasive or life-extending procedures in the final 30 days of life, enrollment in hospice, enrollment in hospice during the final 3 days of life, and enrollment in hospice while not hospitalized. Results A total of 3,666 patients were assessed: 2,819 (77%) were white, 553 (15%) Hispanic, 256 (7%) black, and 38 (1%) other. A total of 2,642 (72%) enrolled in hospice before death, but only 2,344 (64%) died while enrolled. The median hospice enrollment duration was 20 days. In the final 30 days of life, 381 (10%) had more than one ER visit, 505 (14%) more than one hospital admission, 593 (16%) ICU admission, 848 (23%) invasive care, and 418 (11%) life-extending care. In the final 14 days of life, 357 (10%) received chemotherapy. Several outcomes differed for minorities compared with white patients. Hispanic and black patients were less likely to enroll and die in hospice (black odds ratio [OR], 0.66; 95% CI, 0.50 to 0.88; P = .004; Hispanic OR, 0.76; 95% CI, 0.61 to 0.94; P = .01). Hispanic patients were more likely to be admitted to an ICU (OR, 1.37; 95% CI, 1.05 to 1.78; P = .02), and black patients were more likely to have more than one ER visit (OR, 2.20; 95% CI, 1.53 to 3.16; P < .001) and receive a life-extending procedure (OR, 2.13; 95% CI, 1.49 to 3.04; P < .001). Conclusion We found being a minority was associated with receiving intensive and invasive end-of-life care among patients with ovarian cancer.

The Immediate Impact of the 2009 USPSTF Screening Guideline Change on Physician Recommendation of a Screening Mammogram: Findings from a National Ambulatory and Medical Care Survey-Based Study.

Regular screening is considered the most effective method to reduce the mortality and morbidity associated with breast cancer. Nevertheless, contradictory evidence about screening mammograms has led to periodic changes and considerable variations among different screening guidelines. This study is the first to examine the immediate impact of the 2009 US Preventive Services Task Force (USPSTF) guideline modification on physician recommendation of mammograms. The study included visits by women aged 40 years and older without prior breast cancer from the National Ambulatory and Medical Care Survey 2008-2010. Bivariate and multiple logistic regressions were used to determine the factors associated with mammography recommendation. Approximately 29,395 visits were included and mammography was recommended during 1350 visits; 50-64-year-old women had 72% higher odds, and 65-74-year-old women had twice the odds of getting a mammogram recommendation compared with 40-49-year-old women in 2009. However, there was no difference in recommendation by age groups in 2008 and 2010. Obstetricians and gynecologists did not modify their recommendation behavior in 2009, unlike all other specialists who reduced their recommendation for 40-49-year-old women in 2009. Other characteristics associated with mammogram recommendations were certain patient comorbidities, physician specialty and primary care physician status, health maintenance organization status of the clinic, and certain visit characteristics. This study demonstrated a temporary effect of the USPSTF screening guideline change on mammogram recommendation. However, in light of conflicting recommendations by different guidelines, the physicians erred toward the more rigorous guidelines and did not permanently reduce their mammogram recommendation for women aged 40-49 years.

Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: Implications for care under the Affordable Care Act.

BACKGROUND: The objective was to compare quality of diabetes and cardiovascular disease (CVD) care between advanced practice providers (APPs) and physicians in a primary care setting. METHODS: We identified diabetes (n=1,022,588) and CVD (n=1,187,035) patients receiving primary care between October 2013 and September 2014 in 130 Veterans Affairs facilities. We compared glycemic control (hemoglobin A1c <7%) in diabetic patients, blood pressure (BP) <140/90 mmHg in diabetic or CVD patients, cholesterol control (low-density lipoprotein cholesterol<100 mg/dL, receiving a statin) in diabetic or CVD patients, and those receiving a ß-blocker (with history of myocardial infarction in the last 2 years) among patients receiving care from physicians and APPs. We also compared the proportion meeting composite measure (glycemic, BP, and cholesterol control in diabetic patients; BP, cholesterol control, and receipt of ß-blocker among eligible CVD patients). RESULTS: Diabetic patients receiving care from APPs were statistically more likely to have glycemic (50% vs 51.4%, odds ratio [OR] 1.06 [1.05-1.08]) and BP control (77.5% vs 78.4%, OR 1.04 [1.03-1.06]), whereas patients receiving care from physicians were more likely to have cholesterol control (receipt of statin 68% vs 66.5%, OR 0.94 [0.93-0.95]) in adjusted models, although these differences are not clinically significant. Similar results were seen in CVD patients. Few patients met the composite measure (27.1% and 27.6% of diabetic and 54.0% and 54.8% of CVD patients receiving care from physicians and APPs, respectively). CONCLUSIONS: Diabetes and CVD care quality was comparable between physicians and APPs with clinically insignificant differences. Regardless of provider type, there is a need to improve performance on eligible measures in diabetes or CVD patients.

The Role of Socioeconomic Status and Health Care Access in Breast Cancer Screening Compliance Among Hispanics.

OBJECTIVES: Considerable disparities in breast cancer screening exist between Hispanic and non-Hispanic white (NHW) women. Identifying and quantifying the factors contributing to these racial-ethnic disparities can help shape interventions and policies aimed at reducing these disparities. This study, for the first time, identified and quantified individual-level sociodemographic and health-related factors that contribute to racial-ethnic disparities in breast cancer screening using the nonlinear Blinder-Oaxaca decomposition method. METHODS: Analysis of the retrospective pooled cross-sectional Medical Expenditure Panel Survey data from 2000 to 2010 was conducted. Women aged 40 years and older were included in the study. Logistic regressions were used to estimate racial-ethnic disparities in breast cancer screening. Nonlinear Blinder-Oaxaca decomposition method was used to identify and quantify the contribution of each individual-level factor toward racial-ethnic disparities. RESULTS: Based on the unadjusted analyses, Hispanic women had lower odds of receiving mammogram screening (MS) (odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.69-0.80) and breast cancer screening (OR: 0.75; 95% CI: 0.70-0.81) as compared with NHW women. However, the relationship reversed in adjusted analyses, such that Hispanic women had higher odds of receiving MS (OR: 1.27; 95% CI: 1.16-1.40) and breast cancer screening (OR: 1.28; 95% CI: 1.17-1.40) as compared with NHW women. The Blinder-Oaxaca decomposition estimated that improving insurance status, access to care, education, and income will considerably increase screening rates among Hispanic women. CONCLUSIONS: The study projects that improving health care access and health education will considerably increase breast cancer screening compliance among Hispanic women. Policies like the Affordable Care Act, and patient navigation and health education interventions, might considerably reduce screening disparities in the Hispanic population.

CMF-regimen preferred as first-course chemotherapy for older and sicker women with breast cancer: Findings from a SEER-Medicare-based population study.

OBJECTIVE: The objective of this study was to determine the sociodemographic and clinical characteristics associated with Cyclophosphamide, Methotrexate, and 5-Fluorouracil (CMF) utilization as a first-course chemotherapy regimen among female Medicare patients with early-stage breast cancer. METHODS: A longitudinal study was conducted with women 66 years and older, diagnosed with stage I to III breast cancer from 1993 to 2004, and receiving chemotherapy using the Surveillance, Epidemiology, and End Result-Medicare data. First-course CMF chemotherapy was defined as chemotherapy initiation within 6 months of breast cancer diagnosis, with at least 1 claim of CMF each within 1 year of diagnosis. Logistic regression was used to perform the analysis. RESULTS: Older and sicker women, living in census tracts with lower average education, and diagnosed with advanced stage, hormone receptor-negative tumors have a higher probability of CMF administration. Receipt of lymph node dissection and nonreceipt of radiation therapy were also associated with CMF administration. CMF administration has declined over the years and has significant regional variation. CONCLUSIONS: Reduction in CMF use overtime indicates the increased use of newer and more effective systemic therapies among breast cancer patients. In spite of the reduction in CMF use over time, CMF is more frequently administered to older and sicker women, possibly because of higher risk of anthracycline-induced toxicities in these patients. Clinical guidelines have no recommendations for CMF administration in breast cancer patients with certain clinical characteristics. Hence, it is important to understand if the associations observed in this study can be clinically justified in order to reduce unjustified use of less-effective regimens.

Implementing a mobile stroke unit program in the United States: why, how, and how much?

IMPORTANCE: There are many ways a mobile stroke unit (MSU) might prove valuable for patients with ischemic and hemorrhagic stroke, such as earlier recognition, more accurate triage, improved management of blood pressure and other critical physiological variables, and eventually earlier implementation of effective therapies. The MSU may be particularly valuable for treatment of patients with acute ischemic stroke with tissue plasminogen activator (tPA) within 4.5 hours of symptom onset, the most evidence-based effective emergency treatment for the most prevalent stroke diagnosis. OBJECTIVES: To review existing data on prehospital stroke treatment, especially relevant to MSU technology, to identify gaps in our understanding of MSU feasibility, especially relevant to applying the MSU strategy in the United States, and to describe the Houston MSU program and clinical trial. EVIDENCE REVIEW: Published data from English-language journals in PubMed from 1995 to present reviewing early treatment with tPA and prehospital stroke evaluation and treatment. FINDINGS: The MSU may result in an overall shift toward earlier evaluation and treatment with tPA, particularly into the first hour after symptom onset, leading to substantially better outcomes. As a result of improved clinical outcomes owing to earlier treatment, the costs of an MSU program may be offset by a reduction in the costs of long-term stroke care and an increase in quality-adjusted life-years, thereby supporting more widespread use of this technology. To make MSU deployment more practical, the vascular neurologist aboard the MSU must be replaced by a remote vascular neurologist connected to the MSU by telemedicine, reducing manpower requirements and costs. CONCLUSIONS AND RELEVANCE: The MSU strategy could dramatically transform the way acute stroke is managed in the United States. A prospective study evaluating the logistics, outcomes, and cost-effectiveness of this approach is needed and under way.

Risk of manic switch associated with antidepressant therapy in pediatric bipolar depression.

OBJECTIVE: The purpose of this study was to assess the risk of manic switch associated with antidepressants in Medicaid-enrolled pediatric patients with bipolar depression. METHODS: This retrospective cohort study involved 2003-2007 Medicaid Analytic eXtract (MAX) data from four geographically diverse states. The study sample included children and adolescents (ages 6-18 years) who had received a diagnosis of bipolar disorder on two or more separate occasions or during a hospital discharge, followed by a diagnosis of depression. According to the pharmacotherapy received by these patients in the 30 days around the index bipolar depression diagnosis, patients were categorized into five mutually exclusive groups. Manic switch was defined as having received a diagnosis of mania within 6 weeks after the initiation of bipolar depression treatment. Relative risks of manic switch between antidepressant monotherapy/polytherapy and their alternatives were assessed using Cox proportional hazards model. The robustness of the conventional Cox proportional hazards model toward possible bias caused by unobserved confounders was tested using instrumental variable analysis, and the uncertainty regarding manic switch definition was tested by altering the duration of follow-up. RESULTS: After applying all the selection criteria, 179 antidepressant monotherapy, 1047 second-generation antipsychotic (SGA) monotherapy, 570 mood stabilizer monotherapy, 445 antidepressant polytherapy, and 1906 SGA-mood stabilizer polytherapy users were identified. In Cox proportional hazard analyses, both antidepressant monotherapy and polytherapy exhibited higher risk of manic switch than their alternatives (antidepressant monotherapy vs. SGA monotherapy, hazard ratio [HR]=2.87 [95% CI: 1.10-7.49]; antidepressant monotherapy vs. mood stabilizer monotherapy, HR=1.41 [95% CI: 0.52-3.80); antidepressant polytherapy vs. SGA-mood stabilizer polytherapy, HR=1.61 [95% CI: 0.90-2.89]). However, only the comparison between antidepressant monotherapy and SGA monotherapy was statistically significant. The instrumental variable analysis did not detect endogeneity of the treatment variables. Extending the follow-up period from 6 weeks to 8 and 12 weeks generated findings consistent with the main analysis. CONCLUSIONS: Study findings indicated a higher risk of manic switch associated with antidepressant monotherapy than with SGA monotherapy in pediatric patients with bipolar depression. The finding supported the clinical practice of cautious prescribing of antidepressants for brief periods.