Road traffic density and recurrent asthma emergency department visits among Medicaid enrollees in New York State 2005-2015.

BACKGROUND: Environmental exposures such as traffic may contribute to asthma morbidity including recurrent emergency department (ED) visits. However, these associations are often confounded by socioeconomic status and health care access. OBJECTIVE: This study aims to assess the association between traffic density and recurrence of asthma ED visits in the primarily low income Medicaid population in New York State (NYS) between 2005 and 2015. METHODS: The primary outcome of interest was a recurrent asthma ED visit within 1-year of index visit. Traffic densities (weighted for truck traffic) were spatially linked based on home addresses. Bivariate and multivariate logistic regression analyses were conducted to identify factors predicting recurrent asthma ED visits. RESULTS: In a multivariate model, Medicaid recipients living within 300-m of a high traffic density area were at a statistically significant risk of a recurrent asthma ED visit compared to those in a low traffic density area (OR = 1.31; 95% CI:1.24,1.38). Additionally, we evaluated effect measure modification for risk of recurrent asthma visits associated with traffic exposure by socio-demographic factors. The highest risk was found for those exposed to high traffic and being male (OR = 1.87; 95% CI:1.46,2.39), receiving cash assistance (OR = 2.11; 95% CI:1.65,2.72), receiving supplemental security income (OR = 2.21; 95% CI:1.66,2.96) and being in the 18.44 age group (OR = 1.59;95% CI 1.48,1.70) was associated with the highest risk of recurrent asthma ED visit. Black non-Hispanics (OR = 2.35; 95% CI:1.70,3.24), Hispanics (OR = 2.13; 95% CI:1.49,3.04) and those with race listed as "Other" (OR = 1.89 95% CI:1.13,3.16) in high traffic areas had higher risk of recurrent asthma ED visits as compared to White non-Hispanics in low traffic areas. CONCLUSION: We observed significant persistent disparities in asthma morbidity related to traffic exposure and race/ethnicity in a low-income population. Our findings suggest that even within a primarily low-income study population, socioeconomic differences persist. These differences in susceptibility in the extremely low-income group may not be apparent in health studies that use Medicaid enrollment as a proxy for low SES.

Evaluation of patient-focused interventions to promote colorectal cancer screening among new york state medicaid managed care patients.

BACKGROUND: The objective of this study was to evaluate an ongoing initiative to improve colorectal cancer (CRC) screening uptake in the New York State (NYS) Medicaid managed care population. METHODS: Patients aged 50 to 75 years who were not up to date with CRC screening and resided in 2 NYS regions were randomly assigned to 1 of 3 cohorts: no mailed reminder, mailed reminder, and mailed reminder + incentive (in the form of a $25 cash card). Screening prevalence and the costs of the intervention were summarized. RESULTS: In total, 7123 individuals in the Adirondack Region and 10,943 in the Central Region (including the Syracuse metropolitan area) were included. Screening prevalence in the Adirondack Region was 7.2% in the mailed reminder + incentive cohort, 7.0% in the mailed reminder cohort, and 5.8% in the no mailed reminder cohort. In the Central Region, screening prevalence was 7.2% in the mailed reminder cohort, 6.9% in the mailed reminder + incentive cohort, and 6.5% in the no mailed reminder cohort. The cost of implementing interventions in the Central Region was approximately 53% lower than in the Adirondack Region. CONCLUSIONS: Screening uptake was low and did not differ significantly across the 2 regions or within the 3 cohorts. The incentive payment and mailed reminder did not appear to be effective in increasing CRC screening. The total cost of implementation was lower in the Central Region because of efficiencies generated from lessons learned during the first round of implementation in the Adirondack Region. More varied multicomponent interventions may be required to facilitate the completion of CRC screening among Medicaid beneficiaries.

Prevalence of contraindicated combinations amid behavioral and mental health medications filled in a pediatric population.

BACKGROUND: Behavioral or mental health disorders are common in children, adolescents, and young adults. Medication use is increasingly common, with few data describing drug-drug combinations in ambulatory settings. The objectives of this study were to describe the pharmaco-epidemiology of behavioral and mental health (BMH) medications among children, adolescents, and young adults in New York Medicaid and assess the prevalence of contraindicated drug pairs within this population. METHODS: This observational cross-sectional study evaluated New York State Medicaid managed care and fee-for-service enrollees under 21 years of age dispensed BMH medications in 2014. Main outcomes included number of members with prescriptions filled; number filling > 1 medication prescription concurrently for ≥ 30 days (polypharmacy), and number and nature of potentially contraindicated drug pairs. RESULTS: Of 2,430,434 children, adolescents, and young adults, 422,486 (17.4%) had a visit associated with a BMH diagnosis and 141,363 (5.8%) received one or more BMH medications. With 84 distinct medications evaluated, polypharmacy was common, experienced by 53,388 individuals (37.8% of those with a prescription filled), generating 11,115 distinct drug combinations. 392 individuals filled prescriptions for a contraindicated pair of ≥ 2 BMH medications for 30 days or longer. With ≥ 1 day overlap, 651 were exposed to contraindicated medications. The most common contraindicated pairs increased potential risk for prolonged QT interval and serotonin syndrome (n = 378 and n = 250 patients, respectively). Most combinations involved ziprasidone (3247.1 per 10,000 ziprasidone prescriptions filled). CONCLUSIONS: With nearly 6% of members dispensed a BMH medication, contraindicated drug pairs were uncommon. However, any of those combinations represent a potential risk. Clinicians should attend to the balance of potential risks and benefits before contraindicated pairs are dispensed. The methodology described could serve as a basis for monitoring such rare instances and might reduce harm.

Impact of New York State's Medicaid Breast Cancer Selective Contracting Policy on Access and Quality of Care Outcomes.

The New York State Medicaid Breast Cancer Selective Contracting policy was implemented in 2009 and mandates that Medicaid enrollees receive breast cancer surgery at high-volume hospital and ambulatory surgery facilities. This article evaluates the policy's impact on 8 access and quality of care measures prepolicy and postpolicy implementation. Linked New York State (NYS) Cancer Registry, Statewide Planning and Research Cooperative System, and NYS Medicaid encounter and claim data were used to calculate measures. Interrupted time series analysis was conducted to estimate the change in measure rates prepolicy and postpolicy implementation. Findings indicate that the policy was successful in shifting surgeries from low- to high-volume facilities and that high-volume facilities outperformed low-volume facilities on several access and quality of care measures.

The impact of financial incentives on utilization and outcomes of diabetes prevention programs among Medicaid managed care adults in New York state.

Diabetes prevalence has risen rapidly and has become a global health challenge. The Diabetes Prevention Program (DPP) has been shown to prevent or delay the development of diabetes among individuals with prediabetes. Yet, diabetes prevention studies within the Medicaid population are limited and results are mixed. This study aimed to evaluate the impact of different financial incentive strategies on the utilization of the DPP for Medicaid managed care adults in New York State. A four-arm randomized controlled trial was conducted among Medicaid managed care adult enrollees diagnosed with prediabetes and/or obesity. Study participants were offered a 16-week DPP with various incentive strategies based on class attendance and weight loss as follows: Attendance-Only, Weight-Loss Only, and both Attendance and Weight-Loss. A control group was offered DPP with no incentives for attendance or weight loss. We evaluated the impact of incentives on achievement of the program completion and weight-loss milestone. Participants who received incentives for the Attendance-Only class were least likely to be lost to follow-up, more likely to complete the program, and had two times higher percentage of meeting the weight-loss milestone compared to the control group. Results for the other incentive cohorts were mixed. A strong positive association was observed for participants who attended 9 or more classes and weight-loss regardless of incentive strategies. Providing monetary incentives for DPP class attendance had a positive impact on program completion and achieving the weight-loss milestone. However, the results from this study indicate that participant enrollment and retention remained challenges despite the incentives.

Effect of Process- and Outcome-Based Financial Incentives on Weight Loss Among Prediabetic New York Medicaid Patients: A Randomized Clinical Trial.

PURPOSE: To determine whether different financial incentives are effective in promoting weight loss among prediabetic Medicaid recipients. DESIGN: Four-group, multicenter, randomized clinical trial. SETTING AND PARTICIPANTS: Medicaid managed care enrollees residing in New York, aged 18 to 64 years, and diagnosed as prediabetic or high risk for diabetes (N = 703). INTERVENTION: In a 16-week program, participants were randomly assigned to one of 4 arms: (1) control (no incentives), (2) process incentives for attending weekly Diabetes Prevention Program sessions, (3) outcome incentives for achieving weekly weight loss goals, and (4) combined process and outcome incentives. MEASURES: Weight loss over a 16-week period; proportion who completed educational sessions; proportion who met weight loss goals. ANALYSIS AND RESULTS: No intervention arm achieved greater reduction in weight than control (outcome incentive -6.6 lb [-9.1 to -4.1 lb], process incentive -7.3 lb [-9.5 to -5.1 lb], combined incentive -5.8 lb [-8.8 to -2.8 lb], control -7.9 lb [-11.1 to -4.7 lb]; all P > .29). Session attendance in the process incentive arm (50%) was significantly higher than control (31%; P < .0001) and combined incentive arms (28%; P < .0001), but not significantly higher than the outcome incentive arm (38%). CONCLUSION: Process incentives increased session attendance, but when combined at half strength with outcome incentives did not achieve that effect. There were no significant effects of either process or outcomes incentives on weight loss.

Financial Incentives for Chronic Disease Management: Results and Limitations of 2 Randomized Clinical Trials With New York Medicaid Patients.

PURPOSE: To identify whether financial incentives promote improved disease management in Medicaid recipients diagnosed with hypertension or diabetes, respectively. DESIGN: Four-group, multicenter, randomized clinical trials. SETTING AND PARTICIPANTS: Between 2013 and 2016, New York State Medicaid managed care members diagnosed with hypertension (N = 920) or with diabetes (N = 959). INTERVENTION: Participants in each 6-month trial were randomly assigned to 1 of 4 arms: (1) process incentives-earned by attending primary care visits and/or receiving prescription medication refills, (2) outcome incentives-earned by reducing systolic blood pressure (hypertension) or hemoglobin A1c (HbA1c; diabetes) levels, (3) combined process and outcome incentives, and (4) control (no incentives). MEASURES: Systolic blood pressure (hypertension) and HbA1c (diabetes) levels, primary care visits, and medication prescription refills. Analysis and Results: At 6 months, there were no statistically significant differences between intervention arms and the control arm in the change in systolic blood pressure, P = .531. Similarly, there were no significant differences in blood glucose control (HbA1c) between the intervention arms and control after 6 months, P = .939. The majority of participants had acceptable systolic blood pressure (<140 mm Hg) or blood glucose (<8.0%) levels at baseline and throughout the study. CONCLUSION: Financial incentives-regardless of whether they were delivered based on disease-relevant outcomes, process activities, or a combination of the two-have a negligible impact on health outcomes for Medicaid recipients diagnosed with either hypertension or diabetes in 2 studies in which, among other design and operational limitations, the majority of recipients had relatively well-controlled diseases at the time of enrollment.