Telehealth Utilization During the COVID-19 Pandemic Among People With Functional Disabilities in the U.S.: A Preliminary Analysis of National Health Interview Survey 2020 Data.

Introduction: Telehealth has been widely promoted and adopted at multiple levels in the U.S. healthcare system during the COVID-19 pandemic. However, this rapid expansion of telehealth services may have further exacerbated health inequities among marginalized groups. Methods: Using the 2020 National Health Interview Survey, this study compared patterns of telehealth use between people with functional disabilities and people without disabilities during the first year of the pandemic. Results: In the multivariable-adjusted logistic regression models, respondents with moderate disabilities were significantly more likely to report telehealth use, not pandemic related (OR=1.25, 95% CI=1.03, 1.52) and telehealth use, pandemic related (OR=1.43, 95% CI=1.28, 1.60) than people without disabilities. Similarly, respondents with severe disabilities were significantly more likely to report telehealth use, not pandemic related (OR=1.46, 95% CI=1.07, 2.00) and telehealth use, pandemic related (OR=2.06, 95% CI=1.72, 2.46). In addition, telehealth use varied by the number of limitations and disability type. Conclusions: People with functional disabilities were more likely to report telehealth use than people without disabilities. Furthermore, these associations strengthened with increasing disability severity and number of limitations while varying by disability type. Additional studies are warranted to explore ways of providing patient-centered telehealth to responsively meet various healthcare needs of people with functional disabilities and improve their health outcomes.

Association of Medicaid expansion with 2-year survival and time to treatment initiation in gastrointestinal cancer patients: A National Cancer Database study.

INTRODUCTION: We evaluated whether Medicaid expansion (ME) was associated with improved 2-year survival and time to treatment initiation (TTI) among patients with gastrointestinal (GI) cancer. METHODS: GI cancer patients diagnosed 40-64 years were queried from the National Cancer Database. Those diagnosed from 2010 to 2012 were considered pre-expansion; those diagnosed from 2014 to 2016 were considered post-expansion. Cox models estimated hazard ratios and 95% confidence intervals (CIs) for 2-year overall survival. Generalized estimating equations (GEE) estimated odds ratios (OR) and 95% CI of TTI within 30- and 90 days. Multivariable Difference-in-Difference models were used to compare expansion/nonexpansion cohorts pre-/post-expansion, adjusting for patient, clinical, and hospital factors. RESULTS: 377,063 patients were included. No significant difference in 2-year survival was demonstrated across ME and non-ME states overall or in site-based subgroup analysis. In stage-based subgroup analysis, 2-year survival significantly improved among stage II cancer, with an 8% decreased hazard of death at 2 years (0.92; 0.87-0.97). Those with stage IV had a 4% increased hazard of death at 2 years (1.04; 1.01-1.07). Multivariable GEE models showed increased TTI within 30 days (1.12; 1.09-1.16) and 90 days (1.22; 1.17-1.27). Site-based subgroup analyses indicated increased likelihood of TTI within 30 and 90 days among colon, liver, pancreas, rectum, and stomach cancers, by 30 days for small intestinal cancer, and by 90 days for esophageal cancer. In subgroup analyses, all stages experienced improved odds of TTI within 30 and 90 days. CONCLUSION: ME was not associated with significant improvement in 2-year survival for those with GI cancer. Although TTI increased after ME for both cohorts, the 30- and 90-day odds of TTI was higher for those from ME compared with non-ME states. Our findings add to growing evidence of associations with ME for those diagnosed with GI cancer.

Hearing Impairment, Mental Health Services Use, and Perceived Unmet Needs Among Adults With Serious Mental Illness: A Cross-Sectional Study.

PURPOSE: Individuals with hearing impairment have higher risks of mental illnesses. We sought to develop a richer understanding of how the presence of any hearing impairment affects three types (prescription medication, outpatient services, and inpatient services) of mental health services utilization (MHSU) and perceived unmet needs for mental health care; also, we aimed to identify sociodemographic factors associated with outpatient mental health services use among those with hearing impairment and discuss potential implications under the U.S. health care system. METHOD: Using secondary data from the 2015-2019 National Survey on Drug Use and Health, our study included U.S. adults aged ≥ 18 years who reported serious mental illnesses (SMIs) in the past year. Multivariable logistic regression was used to examine associations of hearing impairment with MHSU and perceived unmet mental health care needs. RESULTS: The study sample comprised 12,541 adults with SMIs. Prevalence of MHSU (medication: 55.5% vs. 57.5%; outpatient: 37.1% vs. 44.2%; inpatient: 6.6% vs.7.1%) and unmet needs for mental health care (47.5% vs. 43.3%) were estimated among survey respondents who reported hearing impairment and those who did not, respectively. Those with hearing impairment were significantly less likely to report outpatient MHSU (OR = 0.73, 95% CI [0.60, 0.90]). CONCLUSIONS: MHSU was low while perceived unmet needs for mental health care were high among individuals with SMIs, regardless of hearing status. In addition, patients with hearing impairment were significantly less likely to report outpatient MHSU than their counterparts. Enhancing communication is essential to improve access to mental health care for those with hearing impairment.

People With Functional Disability and Access to Health Care During the COVID-19 Pandemic: A US Population-based Study.

INTRODUCTION: The COVID-19 pandemic and nationwide restriction measures have disrupted health care delivery and access for the general population. There is limited evidence about access to care issues (delayed and forgone care) due to the pandemic among people with disability (PWD). METHODS: This study used the 2020 National Health Interview Survey data. Disability status was defined by disability severity (moderate and severe disability), type, and the number of disabling limitations. Descriptive analysis and multivariate logistic regression (adjusted for sociodemographic and health-related characteristics) were conducted to estimate delayed/forgone care (yes/no) between PWD and people without disability (PWoD). RESULTS: Among 17,528 US adults, 40.7% reported living with disability. A higher proportion of respondents with severe and moderate disability reported delaying care than PWoD (severe=33.2%; moderate=27.5%; PWoD=20.0%, P <0.001). The same was true for forgone medical care (severe=26.6%; moderate=19.0%; PWoD=12.2%, P <0.001). Respondents with a moderate disability {delayed [odds ratio (OR)=1.33, 95% confidence interval (CI)=1.19, 1.49]; forgone [OR=1.46, 95% CI=1.28, 1.67]} and a severe disability [delayed (OR=1.52, 95% CI=1.27, 1.83); forgone (OR=1.84, 95% CI=1.49, 2.27)] were more likely to report delayed medical care and forgone medical care compared with PWoD. These findings were consistent across the models using disability type and the number of limitations. CONCLUSIONS: PWD were more likely to experience COVID-19-related delays in or forgone medical care compared with PWoD. The more severe and higher frequency of disabling limitations were associated with higher degrees of delayed and forgone medical care. Policymakers need to develop disability-inclusive responses to public health emergencies and postpandemic care provision among PWD.

Examining the relationship between metformin dose and cancer survival: A SEER-Medicare analysis.

Cancer is a major health problem in the U.S and type 2 diabetes mellitus (T2DM) is known to increase the risk for the development of many cancers. Metformin, a first-line therapy for treating T2DM, is increasingly being used for its anticancer effects; however, the literature is limited on the effect of metformin dose on overall survival in patients with stage IV cancer. Overall survival was defined as the time interval from the date of diagnosis to the last known follow-up or death from any cause. Subjects who were alive on December 31, 2016 were censored. In this cohort study we examined the relationship between metformin dose and overall survival in persons with both T2DM and stage IV lung, breast, colorectal, prostate, or pancreas cancers. We used a retrospective study design with Cox proportional hazards regression analysis of the 2007-2016 of the Surveillance Epidemiology and End Results-Medicare (SEER) dataset. Of the 7,725 patients, 2,981(38.5%) had been prescribed metformin. Patients who used metformin had significantly better overall survival in both unadjusted (Unadjusted HR, 0.73; 95% CI, 0.69-0.76; p < 0.001) and adjusted models (adjusted HR, 0.77; 95% CI, 0.73-0.81; p < 0.001). The overall survival between patients who took metformin with average daily dose ≥ 1000mg or < 1000mg were not statistically significant (aHR, 1.00; 95% CI, 0.93-1.08; p = 0.90). Metformin use regardless of dose is associated with increased overall survival in older adults with stage IV cancer.

Endocrine adherence in male versus female breast cancer: a seer-medicare review.

PURPOSE: Breast cancer in men (BC-M) is almost exclusively hormone receptor positive. We conducted a large review of the SEER-Medicare linked database to compare endocrine therapy adherence, discontinuation, and survival outcomes of male versus female patients with breast cancer. METHODS: Study data were obtained through the SEER-Medicare linked database. The study included patients age ≥ 65 years-old diagnosed with breast cancer between 2007 and 2015. The primary endpoints were rates of adherence and discontinuation of endocrine therapy (ET). Adherence was defined as a gap of less than 90 days in-between consecutive Medicare prescriptions. Discontinuation was defined as a gap of greater than 12 months in-between Medicare prescriptions. Secondary endpoint was the association of use of ET with overall survival (OS). RESULTS: Of the 363 male patients on ET, 214 patients (59.0%) were adherent to the therapy, and 149 patients (41.0%) were nonadherent. Of the 20,722 females on ET, 10,752 (51.9%) were adherent to the therapy, and 9970 (48.1%) were nonadherent. 39 male patients (10.7%) discontinued therapy, while 324 (89.3%) did not discontinue therapy. 1849 female patients (8.9%) discontinued therapy, while 18,873 (91.1%) patients did not. Men were significantly more adherent than women (p = 0.008), but there was no significant difference in discontinuation among men and women (p = 0.228). Survival was significantly improved in both men (HR 0.77, 95% CI 0.60-0.99, p = 0.039) and women (HR 0.84, 95% CI 0.81-0.87, p < 0.001) on ET. CONCLUSION: Identification of contributing factors impacting adherence and discontinuation is needed to allow physicians to address barriers to long term use of ET.

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.

Association of functional disability with mental health services use and perceived unmet needs for mental health care among adults with serious mental illness.

BACKGROUND: Approximately 13.1 million U.S. adults experienced serious mental illness (SMI) in 2019. Persons with disability (PWD) have higher risks of SMI. Ensuring adequate access to mental health (MH) services for PWD is imperative to ameliorate this burden. METHODS: Using the 2015-2019 National Survey on Drug Use and Health, we obtained study variables for U.S. adults with SMI in the past year and used multivariable logistic regression models to examine the association of disability with MH services and perceived unmet needs. RESULTS: The sample comprised 12,532 respondents, representing 11,143,650 U.S. adults with SMI. Overall, PWD had higher proportions of using prescription medications (64.7% vs. 46.2%), outpatient treatment (48.4% vs. 36.5%) and inpatient treatment (8.6% vs. 4.7%) compared to persons without disability; however, the prevalence of perceived unmet MH service needs was also higher (46.3% vs. 39.4%) among PWD. Multivariable logistic regression models showed presence of any disability, cognitive and ≥2 limitations were significantly associated with MH services use (all p<0.01). However, PWD were significantly more likely to report perceived unmet MH service needs (p<0.01 for any disability as well as cognitive, complex activity, and ≥2 limitations). LIMITATIONS: Due to data limitations, disability status and SMI may be misclassified for some respondents, and the results may not be generalized to all individuals with SMI. CONCLUSION: While PWD were more likely to use MH services, they also had higher odds of unmet MH needs. These results call for more effective and tailored mental health services for PWD.

Associations of patient-centered medical home with quality of care, patient experience, and health expenditures: A STROBE-compliant cross-sectional study.

ABSTRACT: In efforts to improve the delivery of quality primary care, patient-centered medical home (PCMH) model has been promoted. However, evidence on its association with health outcomes has been mixed. The aim of this study was to assess the performance of PCMH model on quality of care, patient experience, health expenditures.This was a cross-sectional study of the 2015-2016 Medical Expenditure Panel Survey-Medical Organization Survey linked data, including 5748 patient-provider pairs. We examined twenty-four quality of care measures (18 high-value and 6 low-value care services), health service utilization, patient experience (patient-provider communication, satisfaction), and health expenditure.Of 5748 patients, representing a weighted population of 56.2 million American adults aged 18 years and older, 44.2% were cared for by PCMH certified providers. 9.3% of those with PCMHs had at least one inpatient stay in the past year, which was comparable to the 11.4% among those with non-PCMHs. Similarly, 17.4% of respondents cared for by PCMH and 18.5% cared for by non-PCMH had at least one ED visit. Overall, we found no significant differences in quality of care measures (neither high-nor low-value of care) between the two groups. The overall satisfaction, the experience of access to care, and communication with providers were also comparable. Patients who were cared for by PCMHs had less total health expenditure (difference $217) and out-of-pocket spending (difference $91) than those cared for by non-PCMHs; however, none of these differences reached the statistical significance (adjusted P > 0.05 for all).This study found no meaningful difference in quality of care, patient experience, health care utilization, or health care expenditures between respondents cared for by PCMH and non-PCMH. Our findings suggest that the PCMH model is not superior in the quality of care delivered to non-PCMH providers.

Real-world experience of carfilzomib-associated cardiovascular adverse events: SEER-Medicare data set analysis.

Carfilzomib was approved for the treatment of multiple myeloma in 2012 and since then there have been concerns for cardiovascular toxicity from its use. With this study, we aim to further study the hazards and underlying risk factors for cardiovascular adverse events associated with carfilzomib. This study was conducted using Surveillance, Epidemiology, and End Results (SEER)-Medicare data set of multiple myeloma from 2001 to 2015. Data were analyzed for hazards ratio of cardiovascular adverse events between carfilzomib users and nonusers. We identified 7330 patients with multiple myeloma of whom 815 were carfilzomib users. Carfilzomib users had a statistically significant hazard ratio of 1.41 with p < 0.0001 for all cardiovascular adverse events as compared to nonusers. Carfilzomib use was significantly associated with increased risk of heart failure (HR 1.47, p = 0.0002), ischemic heart disease (HR 1.45, p = 0.0002), and hypertension (HR 3.33, p < 0.0001), whereas there was no association between carfilzomib use and cardiac conduction disorders (arrhythmia and heart blocks). Carfilzomib users were at higher risk of new-onset edema (HR 5.09, p < 0.0001), syncope (HR 4.27, p < 0.0001), dyspnea (HR 1.33, p < 0.0001), and chest pain (HR 1.18, p < 0.0001) as compared to carfilzomib nonusers. Age above 75 years, preexisting cardiovascular disease, obesity, and twice a week carfilzomib schedule were significant risk factors associated with cardiovascular adverse events in carfilzomib users. The median time of the onset for all cardiovascular adverse events was 3.1 months. This study has identified a significantly higher likelihood of cardiovascular adverse events in elderly Medicare patients receiving carfilzomib.

Socioeconomic and Demographic Characteristics of US Adults Who Purchase Prescription Drugs From Other Countries.

Importance: Little is known about the current use of imported drugs and the factors associated with individual purchase of medications outside the US. Objective: To evaluate the proportion of the US adult population that purchases medications in other countries and the patient factors associated with the behavior. Design, Setting, and Participants: This retrospective cross-sectional study used data from the 2015-2017 National Health Interview Survey. The study sample included 61 238 individuals 18 years or older who reported use of prescribed medication by a physician or other practitioner. Data analysis was performed in November 2019. Main Outcomes and Measures: Self-reported experience of purchasing prescription drugs from countries outside the US in the past 12 months. Internet use behaviors for health care included searches for health information and filling of a prescription online. Medication-taking behaviors included skipping or delaying filling a prescription and using alternative therapies to save money. Survey design-adjusted analysis was used to estimate and compare characteristics between those who purchased medications outside the US and those did not. Multivariable logistic regression was fitted to examine the association of medication purchases with internet use and medication-taking behavior factors. Results: Among 61 238 US adults taking prescription medications (mean [SD] age, 50.5 [18.5] years; 56.5% female; 70.8% white), the estimated prevalence of purchasing of medication outside the US was 1.5% (95% CI, 1.4%-1.7%; 2.3 million US individuals). Those who purchased medications outside the US were more likely to be older (age >64 years; adjusted odds ratio [aOR], 1.68; 95% CI, 1.24-2.29), to be from Hispanic (aOR, 1.70; 95% CI, 1.23-2.35) or immigrant populations (aOR, 3.20; 95% CI, 2.44-4.20), and to have higher educational attainment (bachelor's degree; aOR, 1.79; 95% CI, 1.27-2.54), lower family income (low income; aOR, 1.41; 95% CI, 1.06-1.87), and lack of insurance (aOR, 3.14; 95% CI, 2.33-4.21). Data analyses indicated that online health information-seeking behavior (aOR, 1.62; 95% CI, 1.33-1.98) or use of an online pharmacy (aOR, 2.30; 95% CI, 1.83-2.90) was associated with a greater likelihood of medication purchases outside the US. Individuals who skipped medications (aOR, 3.86; 95% CI, 3.05-4.88) or delayed filling a prescription (aOR, 4.04, 95% CI, 3.23-5.06) also had higher odds of purchasing medication outside the US. Conclusions and Relevance: The findings suggest that patients are not using prescription purchases outside the US to meet their medication needs. However, monitoring to promote safe administration of medications imported into the US should be continued.

Financial burden of cancer care under the Affordable Care Act: Analysis of MEPS-Experiences with Cancer Survivorship 2011 and 2016.

PURPOSE: To examine whether the implementation of Affordable Care Act (ACA) reduced the financial burden associated with cancer care among non-elderly cancer survivors. METHODS: Using data from the MEPS-Experiences with Cancer Survivorship Survey, we examined whether there was a difference in financial burden associated with cancer care between 2011 (pre-ACA) and 2016 (post-ACA). Two aspects of financial burden were considered: (1) self-reported financial burden, whether having financial difficulties associated with cancer care and (2) high-burden spending, whether total out-of-pocket (OOP) spending incurred in excess of 10% or 20% of family income. Generalized linear regression models were estimated to adjust the OOP expenditures (reported in 2016 US dollar). RESULTS: Our sample included adults aged 18-64 with a confirmed diagnosis of any cancer in 2011 (n = 655) and in 2016 (n = 490). There was no apparent difference in the prevalence of cancer survivors reporting any financial hardship or being with high-burden spending between 2011 and 2016. The mean OOP decreased by $268 (95% CI, - 384 to - 152) after the ACA. However, we found that the mean premium payments increased by $421 (95% CI, 149 to 692) in the same period. CONCLUSIONS: The ACA was associated with reduced OOP for health services but increased premium contributions, resulting in no significant impact on perceived financial burden among non-elderly cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: The financial hardship of cancer survivorship points to the need for the development of provisions that help cancer patients reduce both perceived and materialized burden of cancer care under ongoing health reform.

Cone-beam CT assessment of implant-related anatomy landmarks of the anterior mandible in a Chinese population.

PURPOSE: To investigate the prevalence, location, and morphology of the mandibular lingual foramen (MLF), mandibular incisive canal (MIC), and anterior loop of the inferior alveolar canal (ALC) in a Chinese population using cone-beam CT (CBCT). MATERIALS AND METHODS: From 2014 to 2016, CBCT images from patients with various scanning purposes were obtained from the database of the Affiliated Stomatology Hospital of Kunming Medical University, China. Imaging analyses of the MLF, MIC, and ALC were performed via the NNT viewer software. The prevalence, location, length, classification of MLF, and its distances to the alveolar crest and the lower border of mandible were investigated, and the prevalence and length of MIC and the prevalence of ALC were also studied. RESULTS: This study examined 1008 subjects, 521 (51.7%) males, and 487 (48.3%) females. 916 (90.9%) subjects showed the medial lingual foramina (LF), a single medial LF with the supraspinous-type predominating. Lateral LF were observed in 547 (54.3%) subjects mostly located in the premolar areas. 876 (86.9%) subjects had the MIC on the left side, whereas 877 (87.0%) had the MIC on the right side. The ALC was present in 147 (14.6%) subjects. CONCLUSIONS: This study showed a high prevalence of LF and MIC in the Southwest Chinese population. Therefore, caution should be taken during the implant treatment at the anterior mandible region.