Use of Big Data and Ethical Issues for Populations With Substance Use Disorder.

With expanding data availability and computing power, health research is increasingly relying on big data from a variety of sources. We describe a state-level effort to address aspects of the opioid epidemic through public health research, which has resulted in an expansive data resource combining dozens of administrative data sources in Massachusetts. The Massachusetts Public Health Data Warehouse is a public health innovation that serves as an example of how to address the complexities of balancing data privacy and access to data for public health and health services research. We discuss issues of data protection and data access, and provide recommendations for ethical data governance. Keeping these issues in mind, the use of this data resource has the potential to allow for transformative research on critical public health issues.

Physician Referrals During Prenatal Care.

OBJECTIVE: Referrals are an important component of patient care, and have been increasing over time. During pregnancy, people have intensive contact with the healthcare system, but little is known about the involvement of different physicians for pregnant patients during this period. This study examines referral patterns during prenatal care visits. METHODS: Using the 2006-2015 National Ambulatory Medical Care Survey and national birth certificate data, we estimate the number of referrals per pregnancy from prenatal care visits with OB/GYN and family medicine physicians. We use multivariable regression analysis to compare the probability of receiving a referral during a prenatal visit for visits with family medicine and OB/GYN physicians, controlling for visit, patient, and physician characteristics. Analyses are weighted to make results nationally representative. RESULTS: 224,335,436 prenatal visits over 19,893,015 pregnancies were included; 60% of these visits were covered by private insurance. On average, 0.3 referrals are made per pregnancy (95% confidence interval [CI] 0.22, 0.38). A prenatal visit with an OB was 5.5% points less likely to result in a referral than a visit with a family medicine physician, controlling for other characteristics. CONCLUSIONS: Referrals are relatively common in prenatal care, and are more commonly initiated by family medicine physicians than by OB/GYNs. Understanding the contribution of multiple clinicians to a pregnant person's health during the prenatal period and how coordination among clinicians impacts care receipt is an important next step. As healthcare becomes more specialized, better understanding care teams of individuals during the perinatal period is important for improving prenatal care.

Association of Follow-Up After an Emergency Department Visit for Mental Illness with Utilization Based Outcomes.

Follow-up within 30 days of an emergency department (ED) visit for mental illness is a new and widely-used quality measure. However, no empirical evidence validates associations between follow-up and subsequent utilization based outcomes. Using Massachusetts all payer claims data, we identified insured individuals with an ED visit for mental illness. Multivariate regression analysis estimated associations between follow-up within 30 days after an ED visit for mental illness with costs, hospitalizations, and additional ED visits in 180 days following the index visit. 63,814 index ED visits were included (56.5% female, mean [SD] age 38.0 [12.1] years, 48% Medicaid covered). 31% of index ED principal diagnoses were for major depressive disorder, 3% schizophrenia, 5% bipolar disorder, 34% anxiety disorder, 0.6% post-traumatic stress disorder, 8% other psychoses, and 19% other mental illness diagnoses. Only 33% of patients had a follow-up visit for mental illness within 30 days. Adjusted regression analyses show timely follow-up is associated with increased costs in the 180 days after (average marginal effect = $1622; 95% confidence interval [CI] 1459, 1786), an increased probability of inpatient hospitalization (2.7 percentage points; 95% CI 0.021, 0.032), and a small reduction in the probability of at least one additional ED visit (- 1.7 percentage points; 95% CI - 0.026 to 0.009). Overall follow-up rates are low; follow-up within 30 days of an ED visit for mental illness is associated with increased costs and increased probability of hospitalization in the follow-up period. It is not known whether increased rates of utilization improve patient outcomes, potentially by receiving appropriate more intensive care.

Changes in Medicaid Acceptance by Substance Abuse Treatment Facilities After Implementation of Federal Parity.

BACKGROUND: Adequate access for mental illness and substance use disorder (SUD) treatment, particularly for Medicaid enrollees, is challenging. Policy efforts, including the Mental Health Parity and Addiction Equity Act (MHPAEA), have targeted expanded access to care. With MHPAEA, more Medicaid plans were required to increase their coverage of SUD treatment, which may impact provider acceptance of Medicaid. OBJECTIVES: To identify changes in Medicaid acceptance by SUD treatment facilities after the implementation of MHPAEA (parity). RESEARCH DESIGN: Observational study using an interrupted time series design. SUBJECTS: 2002-2013 data from the National Survey of Substance Abuse Treatment Services (N-SSATS) for all SUD treatment facilities was combined with state-level characteristics. MEASURES: Primary outcome is whether a SUD treatment facility reported accepting Medicaid insurance. RESULTS: Implementation of MHPAEA was associated with a 4.6 percentage point increase in the probability of an SUD treatment facility accepting Medicaid (P<0.001), independent of facility and state characteristics, time trends, and key characteristics of state Medicaid programs. CONCLUSIONS: After parity, more SUD treatment facilities accepted Medicaid payments, which may ultimately increase access to care for individuals with SUD. The findings underscore how parity laws are critical policy tools for creating contexts that enable historically vulnerable and underserved populations with SUD to access needed health care.

Supplemental Security Income enrollment and health care and social assistance employment and wages.

We examine the relationship between disabled working-age Supplemental Security Income (SSI) enrollment and health care and social assistance employment and wages. County-level data are gathered from government and other publicly available sources for 3144 US counties (2012 to 2015). Population-weighted linear regression analyses examine associations between each health care and social assistance employment and wage measure and SSI enrollment, controlling for factors associated with health care and social assistance employment and wages. Results show positive associations between county-level percent of the population enrolled in the SSI program and health care and social assistance employment and wages with strong associations identified for social assistance employment. A one standard deviation increase in SSI enrollment is associated with a 5.6% increase in the health care and social assistance sector employment percent compared with the mean and 9.7% and 7.3% increases in health care and social assistance sector employment and wage shares, respectively, when compared with the means. We find working-age adult SSI enrollment is positively associated with employment outcomes, primarily in the social assistance organization subsector and in lower wage paying jobs. Evolving federal disability policy may influence existing and future SSI enrollment, which has implications for health care workforce employment and composition.

Reductions in Diagnostic Imaging With High Deductible Health Plans.

BACKGROUND: Diagnostic imaging utilization grew rapidly over the past 2 decades. It remains unclear whether patient cost-sharing is an effective policy lever to reduce imaging utilization and spending. MATERIALS AND METHODS: Using 2010 commercial insurance claims data of >21 million individuals, we compared diagnostic imaging utilization and standardized payments between High Deductible Health Plan (HDHP) and non-HDHP enrollees. Negative binomial models were used to estimate associations between HDHP enrollment and utilization, and were repeated for standardized payments. A Hurdle model were used to estimate associations between HDHP enrollment and whether an enrollee had diagnostic imaging, and then the magnitude of associations for enrollees with imaging. Models with interaction terms were used to estimate associations between HDHP enrollment and imaging by risk score tercile. All models included controls for patient age, sex, geographic location, and health status. RESULTS: HDHP enrollment was associated with a 7.5% decrease in the number of imaging studies and a 10.2% decrease in standardized imaging payments. HDHP enrollees were 1.8% points less likely to use imaging; once an enrollee had at least 1 imaging study, differences in utilization and associated payments were small. Associations between HDHP and utilization were largest in the lowest (least sick) risk score tercile. CONCLUSIONS: Increased patient cost-sharing may contribute to reductions in diagnostic imaging utilization and spending. However, increased cost-sharing may not encourage patients to differentiate between high-value and low-value diagnostic imaging services; better patient awareness and education may be a crucial part of any reductions in diagnostic imaging utilization.

Access is Not Enough: Characteristics of Physicians Who Treat Medicaid Patients.

BACKGROUND: Access to physicians is a major concern for Medicaid programs. However, little is known about relationships between physician participation in Medicaid and the individual-level and practice-level characteristics of physicians. METHODS: We used the 2011 Massachusetts All Payer Claims Database, containing all commercial and Medicaid claims; we linked with data on physician characteristics. We measured Medicaid participation intensity (fraction of the physician's patient panel with Medicaid) for primary care physicians (PCPs) and medical specialists. We measured influence of physicians within a patient referral network using eigenvector centrality. We used regression models to associate Medicaid intensity with physician individual-level and practice-level characteristics. FINDINGS: About 92.6% of physicians treated at least 1 Medicaid patient, but the median physician's panel contained only 5.7% Medicaid patients. Medicaid intensity was associated with physician training and influence for PCPs and specialists. For medical specialists, a 1 percentage point increase in Medicaid intensity was associated with a lower probability of being board certified (-0.22 percentage points; 95% CI, -0.30, -0.14), lower probability of attending a domestic medical school (-0.14 percentage points; 95% CI, -0.22, -0.05), having attended a less well-ranked domestic medical school (0.23 ranks; 95% CI, 0.15, 0.30), and having slightly less influence in the referral network. PCPs displayed similar results but high Medicaid intensity physicians had substantially less influence in the referral network. CONCLUSIONS: Medicaid participation intensity shows substantial variation across physicians, indicating limits of binary participation measures. Physicians with more Medicaid patients had characteristics often perceived by patients to be of lower quality.

Association of Postpartum Mental Illness Diagnoses with Severe Maternal Morbidity.

Background: This study aimed to determine whether birthing people who experience severe maternal morbidity (SMM) are more likely to be diagnosed with a postpartum mental illness. Materials and Methods: Using the Massachusetts All Payer Claims Database, this study used modified Poisson regression analysis to assess the association of SMM with mental illness diagnosis during the postpartum year, accounting for prenatal mental illness diagnoses and other patient characteristics. Results: There were 128,161 deliveries identified, with 55.0% covered by Medicaid. Of these, 3.1% experienced SMM during pregnancy and/or delivery hospitalization, and 20.1% had a mental illness diagnosis within 1 year postpartum. In adjusted regression analyses, individuals with SMM had a 10.6% increased risk of having any mental illness diagnosis compared to individuals without SMM, primarily due to an increased risk of a depression or post-traumatic stress disorder diagnosis among people with SMM than those without SMM. Conclusions: Individuals who experienced SMM had a higher risk of a mental illness diagnosis in the postpartum year. Given increases in SMM in the United States in recent decades, policies to mitigate mental health sequelae of SMM are urgently needed.

Changes in dental visits and oral health for children by race and ethnicity during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic created new barriers to oral health care, which may worsen oral health and exacerbate disparities. The authors quantified changes in children's dental care receipt and oral health outcomes during the pandemic and examined differences among racial and ethnic groups. METHODS: Using the National Survey of Children's Health (163,948 child observations from 2017-2021), the authors used weighted modified Poisson models to examine caregiver-reported receipt of a dental visit (for any reason and for preventive care) and adverse oral health outcomes (teeth in fair or poor condition; difficulty with toothaches, cavities, or bleeding gums) from 2017 through 2019 (prepandemic) compared with 2020 and 2021. The authors examined outcomes within and across racial and ethnic groups. RESULTS: Children from all racial and ethnic groups experienced declines in receipt of dental visits, but there were limited changes in adverse oral health outcomes during 2020 and 2021. Prepandemic disparities in receipt of dental visits persisted for Black children and Asian children compared with White children. Hispanic children experienced larger increases in risk of experiencing both adverse oral health outcomes compared with White children in 2020 and in having teeth in fair or poor condition in 2021. CONCLUSIONS: The pandemic did not create new disparities in receipt of dental visits or oral health outcomes, but disparities in care persisted, and the oral health of Hispanic children was affected differentially. PRACTICAL IMPLICATIONS: Continued monitoring of dental visits and adverse oral health outcomes by race and ethnicity is critical to ensuring all children have access to oral health care. This information can help develop targeted interventions to improve children's oral health, including for minoritized racial and ethnic groups.

Preventive Primary Care in the Postpartum Year: The Role of Medicaid Delivery System Reform.

INTRODUCTION: Preventive and primary care in the postpartum year is critical for future health and may be increased by primary care focused delivery system reform including implementation of Medicaid Accountable Care Organizations (ACO). This study examined associations of Massachusetts Medicaid ACO implementation with preventive visits in the postpartum year. METHODS: The Massachusetts All-Payer Claims Database was used to identify births to privately-insured or Medicaid ACO-eligible individuals from January 1, 2016 to February 28, 2019. Comparing these groups before and after implementation, a propensity score weighted difference-in-difference design was used to analyze associations of Medicaid ACO implementation with any preventive care visit and any primary care physician (PCP) preventive visit within one year postpartum, controlling for other characteristics. Analyses were performed in 2023 and 2024. RESULTS: Of the 110,601 births in the study population, 35.5% had any preventive care visit and 23.0% had any preventive PCP visit in the year postpartum, with higher rates of preventive visits among privately-insured individuals. In adjusted difference-in-difference analyses, relative to the pre-period, there was a 2.7 percentage point (pp) decrease (95% confidence interval [CI]: -4.3pp, -1.2pp) and 3.5 pp decrease (95% CI: -4.9pp, -2.0pp) in use of any preventive visits and any PCP preventive visits, respectively, for Medicaid-insured versus privately-insured individuals after ACO implementation. CONCLUSIONS: Implementation of Massachusetts Medicaid ACOs was associated with decreases in receipt of preventive visits and preventive PCP visits for Medicaid-insured individuals relative to privately-insured individuals. Medicaid ACOs should consider potential implications of primary care access in the postpartum year for health across the lifecourse.

Health Insurance Type and Outpatient Specialist Care Among Children With Asthma.

Importance: Although children with asthma are often successfully treated by primary care clinicians, outpatient specialist care is recommended for those with poorly controlled disease. Little is known about differences in specialist use for asthma among children with Medicaid vs private insurance. Objective: To examine differences among children with asthma regarding receipt of asthma specialist care by insurance type. Design, Setting, and Participants: In this cross-sectional study using data from the Massachusetts All Payer Claims Database (APCD) between 2014 to 2020, children with asthma were identified and differences in receipt of outpatient specialist care by whether their insurance was public (Medicaid and the Children's Health Insurance Program) or private were examined. Eligible participants included children with asthma in 2015 to 2020 aged 2 to 17 years. Data analysis was conducted from January 2023 to April 2024. Exposure: Medicaid vs private insurance. Main Outcomes and Measures: The primary outcome was receipt of specialist care (any outpatient visit with a pulmonology, allergy and immunology, or otolaryngology physician). Multivariable logistic regression models estimated differences in receipt of specialist care by insurance type accounting for child and area characteristics including demographics, health status, persistent asthma, calendar year, and zip code characteristics. Additional analyses examined if the associations of specialist care with insurance type varied by asthma persistence and severity, and whether associations varied over time. Results: Among 198 101 unique children, there were 432 455 child-year observations (186 296 female [43.1%] and 246 159 male [56.9%]; 211 269 aged 5 to 11 years [48.9%]; 82 108 [19.0%] with persistent asthma) including 286 408 (66.2%) that were Medicaid insured and 146 047 (33.8%) that were privately insured. Although persistent asthma was more common among child-year observations with Medicaid vs private insurance (57 381 [20.0%] vs 24 727 [16.9%]), children with Medicaid were less likely to receive specialist care. Overall, 64 239 child-year observations (14.9%) received specialist care, with substantially lower rates for children with Medicaid vs private insurance (34 093 child-year observations [11.9%] vs 30 146 child-year observations [20.6%]). Regression-based estimates confirmed these disparities; children with Medicaid had 55% lower odds of receiving specialist care (adjusted odds ratio, 0.45; 95% CI, 0.43 to 0.47) and a regression-adjusted 9.7 percentage point (95% CI, -10.4 percentage points to -9.1 percentage points) lower rate of receipt of specialist care. Compared with children with private insurance, there was an additional 3.2 percentage point (95% CI, 2.0 percentage points to 4.4 percentage points) deficit for children with Medicaid with persistent asthma. Conclusions and Relevance: In this cross-sectional study, children with Medicaid were less likely to receive specialist care, with the largest gaps among those with persistent asthma. These findings suggest that closing this care gap may be one approach to addressing ongoing disparities in asthma outcomes.

Differences in Health Care Utilization for Asthma by Children with Medicaid versus Private Insurance.

Asthma is the most common chronic disease in children, disproportionately affects families with lower incomes, and is a leading reason for acute care visits and hospitalizations. This retrospective cohort study used the Massachusetts All Payer Claims Database (2014-2018) to examine differences in acute care utilization and quality of care for asthma between Medicaid- and privately insured children in Massachusetts. Outcomes included acute care use (emergency department [ED] or hospitalization), ED visits with asthma, routine asthma visits, and filled prescriptions for asthma medications. Multivariable logistic regression was used to account for differences in demographics, ZIP codes, health status, and asthma severity. Overall, 10.0% of Medicaid-insured children and 5.6% of privately insured were classified as having asthma. Among 317,596 child-year observations for children with asthma, 64.4% were insured by Medicaid. Medicaid-insured children had higher rates of any acute care use (50.4% vs. 30.0%) and ED visits with an asthma diagnosis (27.2% vs. 13.3%) compared to privately insured children. Only 65.4% of Medicaid enrollees had at least one routine asthma visit compared to 74.3% of privately insured children. Most children received at least one asthma medication (88.6% Medicaid vs. 83.3% privately insured), but a higher percentage of Medicaid-insured children received at least one rescue medication (84.0% vs. 73.7%), and a lower percentage of Medicaid-insured (46.1% vs. 49.2%) received a controller medication. These results suggest that opportunities for improvement in childhood asthma persist, particularly for children insured by Medicaid.

Transitions in health insurance among continuously insured patients with schizophrenia.

Changes in health insurance coverage may disrupt access to and continuity of care, even for those who remain insured. Continuity of care is especially important in schizophrenia, which requires ongoing medical and pharmaceutical treatment. However, little is known about continuity of insurance coverage among those with schizophrenia. The objective was to examine the probability of insurance transitions for individuals with schizophrenia who were continuously insured and whether this varied across insurance types. The Massachusetts All-Payer Claims Database identified individuals with schizophrenia aged 18-64 who were continuously insured during a two-year period between 2014 and 2018. A logistic regression estimated the association of having an insurance transition - defined as having a change in insurance type - with insurance type at the start of the period, adjusting for age, sex, ZIP code in the lowest quartile of median income, and ZIP code with concentrated poverty. Overall, 15.1% had at least one insurance transition across a 24-month period. Insurance transitions were most frequent among those with plans from the Marketplace. In regression adjusted results, individuals covered by the traditional Medicaid program were 20.2 percentage points [pp] (95% confidence interval [CI]: 24.6 pp, 15.9 pp) less likely to have an insurance transition than those who were insured by a Marketplace plan. Insurance transitions among individuals with schizophrenia were common, with more than one in six people having at least one transition in insurance type during a two-year period. Given that even continuously insured individuals with schizophrenia commonly experience insurance transitions, attention to insurance transitions as a barrier to care access and continuity is warranted.

Maternal Health Equity in Medicaid Accountable Care Organizations: Early Lessons from the Massachusetts Experience.

There are substantial inequities by race and ethnicity in maternal health care utilization and health outcomes across the perinatal period. As Medicaid covers 42% of births nationally and almost two-thirds of births to Black birthing people, state Medicaid financing and delivery system reforms have substantial scope to impact these inequities. Twenty-one states have implemented Medicaid Accountable Care Organizations (ACOs) at some point since 2015. Using public documents and interviews with ACO administrators, we examine the implications of Massachusetts Medicaid ACOs, implemented in March 2018, for maternal health equity. Although these Medicaid ACOs have the potential to impact maternal health equity, they face many challenges in doing so. We review future steps within Massachusetts Medicaid ACOs and Medicaid programs more generally to incorporate policies that may better address racial and ethnic inequities.

Maternity care clinician inclusion in Medicaid Accountable Care Organizations.

BACKGROUND: Medicaid Accountable Care Organizations (ACO) are increasingly common, but the network breadth for maternity care is not well described. The inclusion of maternity care clinicians in Medicaid ACOs has significant implications for access to care for pregnant people, who are disproportionately insured by Medicaid. PURPOSE: To address this, we evaluate obstetrician-gynecologists (OB/GYN), maternal-fetal medicine specialists (MFM), certified nurse midwives (CNM), and acute care hospital inclusion in Massachusetts Medicaid ACOs. METHODOLOGY/APPROACH: Using publicly available provider directories for Massachusetts Medicaid ACOs (n = 16) from December 2020 -January 2021, we quantify obstetrician-gynecologists, maternal-fetal medicine specialists, CNMs, and acute care hospital with obstetric department inclusion in each Medicaid ACO. We compare maternity care provider and acute care hospital inclusion across and within ACO type. For Accountable Care Partnership Plans, we compare maternity care clinician and acute care hospital inclusion to ACO enrollment. RESULTS: Primary Care ACO plans include 1185 OB/GYNs, 51 MFMs, and 100% of Massachusetts acute care hospitals, but CNMs were not easily identifiable in the directories. Across Accountable Care Partnership Plans, a mean of 305 OB/GYNs (median: 97; range: 15-812), 15 MFMs (Median: 8; range: 0-50), 85 CNMs (median: 29; range: 0-197), and half of Massachusetts acute care hospitals (median: 23.81%; range: 10%-100%) were included. CONCLUSION AND PRACTICE IMPLICATIONS: Substantial differences exist in maternity care clinician inclusion across and within ACO types. Characterizing the quality of included maternity care clinicians and hospitals across ACOs is an important target of future research. Highlighting maternal healthcare as a key area of focus for Medicaid ACOs-including equitable access to high-quality obstetric providers-will be important to improving maternal health outcomes.

Content Analysis of Patient-Facing Information Related to Preeclampsia.

BACKGROUND: Previous research has shown pregnant people are not knowledgeable about preeclampsia, a significant cause of maternal morbidity and mortality. This lack of knowledge may impact their ability to report symptoms, comply with recommendations, and receive appropriate follow-up care. Pregnant people commonly seek information from sources outside their treating clinician, including pregnancy-specific books and online sources. We examined commonly used preeclampsia information sources to evaluate whether pregnant people are receiving up-to-date, guideline-based information. METHODS: We conducted a content analysis of preeclampsia-related information in top-ranking websites and bestselling pregnancy books. We used American College of Obstetricians and Gynecologists preeclampsia guidelines to construct a codebook, which we used to examine source content completeness and accuracy. For each source, we analyzed information about preeclampsia diagnosis, patient-reported symptoms, risk factors, prevention, treatment, and complications. RESULTS: Across 19 included sources (13 websites and 6 books), we found substantial variation in completeness and accuracy of preeclampsia information. We found high rates of mentions for preeclampsia symptoms. Risk factors were more commonly included in online sources than book sources. Most sources mentioned treatment options, including blood pressure medication and giving birth; however, one-third of online sources positively mentioned the nonrecommended treatment of bed rest. Prevention methods, including prenatal aspirin for high-risk pregnancies, and long-term complications of preeclampsia were infrequently mentioned. CONCLUSIONS: Varying rates of accuracy in patient-facing preeclampsia information mean there is substantial room for improvement in these sources. Ensuring pregnant people receive current guideline-based information is critical for improving outcomes and implementing shared decision-making.

Association Between Insurance Type and Fluoride Varnish Application During Well-Child Visits in Massachusetts.

OBJECTIVE: To compare rates of fluoride varnish (FV) applications during well-child visits for children covered by Medicaid and private medical insurance in Massachusetts. METHODS: This cross-sectional study analyzed well-child visits for children aged 1 to 5 years paid by Medicaid and private insurance during 2016.Çô18 in Massachusetts. Multivariate regression models, with all covariates interacting with insurance type, were used to calculate odds ratios and adjusted predicted probabilities of fluoride varnish during well-child visits by calendar year and age. RESULTS: Across 957,551 well-child visits, 40.0% were paid by private insurers. Unadjusted rates of fluoride varnish were significantly lower among well-child visits paid by private insurers (6.6%) than visits paid by Medicaid (14.2%). In the fully interacted regression model, the odds of a visit including fluoride varnish were significantly lower for older children than for children aged 1 for visits paid by both insurance types. Adjusted rates of fluoride varnish increased significantly from 2016 to 2018 for both insurance types. Moreover, rates were higher among visits for children covered under Medicaid than privately insured children in all years, and the differences by insurance type declined over time (2016: 8.0% points, 95% confidence interval.á=.á.êÆ8.7 to .êÆ7.3, 2018: 5.3% points, 95% confidence interval.á=.á.êÆ6.6 to .êÆ3.9). CONCLUSIONS: Rates of fluoride varnish applications during well-child visits were low for both Medicaid and private insurance despite growth from 2016 to 2018 in Massachusetts. Low rates are concerning because this is a recommended service with the potential to help address racial, geographic, and income-based disparities in access and oral health outcomes.

Influenza Vaccinations Among Privately and Publicly Insured Children With Asthma.

OBJECTIVE: Annual influenza vaccination rates for children remain well below the Healthy People 2030 target of 70%. We aimed to compare influenza vaccination rates for children with asthma by insurance type and to identify associated factors. METHODS: This cross-sectional study examined influenza vaccination rates for children with asthma by insurance type, age, year, and disease status using the Massachusetts All Payer Claims Database (2014-2018). We used multivariable logistic regression to estimate the probability of vaccination accounting for child and insurance characteristics. RESULTS: The sample included 317,596 child-year observations for children with asthma in 2015-18. Fewer than half of children with asthma received influenza vaccinations; 51.3% among privately insured and 45.1% among Medicaid insured. Risk modeling reduced, but did not eliminate, this gap; privately insured children were 3.7 percentage points (pp) more likely to receive an influenza vaccination than Medicaid-insured children (95% confidence interval [CI]: 2.9-4.5pp). Risk modeling also found persistent asthma was associated with more vaccinations (6.7pp higher; 95% CI: 6.2-7.2pp), as was younger age. The regression-adjusted probability of influenza vaccination in a non-office setting was 3.2pp higher in 2018 than 2015 (95% CI: 2.2-4.2pp), and significantly lower for children with Medicaid. CONCLUSIONS: Despite clear recommendations for annual influenza vaccinations for children with asthma, low rates persist, particularly for children with Medicaid. Offering vaccines in non-office settings such as retail pharmacies may reduce barriers, but we did not observe increased vaccination rates in the first years after this policy change.

Barriers and Facilitators to Optimal Fluoride Varnish Application.

OBJECTIVE: National guidelines recommend that all children under age six receive fluoride varnish (FV) in medical settings. However, application rates remain low. This study aimed to update understanding of barriers and facilitators to guideline concordant FV application. METHODS: We conducted virtual semi-structured interviews with a purposive sample (eg, FV application rates, geographic location, practice size and type) of pediatric primary care clinicians and medical assistants in Massachusetts between February 1 and June 30, 2022. The Consolidated Framework for Implementation Research (CFIR) served as the study's theoretical framework and data were analyzed using a modified grounded theory approach. RESULTS: Of the 31 participants, 90% identified as White and 81% as female. Major themes, which linked to four CFIR domains, included: variation in perceived adequacy of reimbursement; differences in FV application across practice types; variation in processes, protocols, and priorities; external accountability for quality of care; and potential levers for change. Important subthemes included challenges for small practices; role of quality measures in delivering guideline-concordant preventive oral health care; and desire for preventive care coordination with dentists. CONCLUSIONS: This study suggests that potential barriers and facilitators to guideline concordant FV application exist at multiple levels that may warrant further study. Examples include testing the effectiveness of quality measures for FV application and testing strategies for implementing consistent processes and protocols for improving FV application rates.

Transitions in Health Insurance During the Perinatal Period Among Patients With Continuous Insurance Coverage.

Importance: Although health insurance continuity is important during the perinatal period to improve birth outcomes and reduce maternal morbidity and mortality, insurance disruptions are common. However, little is known about insurance transitions among insurance types for individuals who remained insured during the perinatal period. Objective: To examine insurance transitions for birthing individuals with continuous insurance, including those with Medicaid and Medicaid managed care coverage, before, during, and after pregnancy. Design, Setting, and Participants: This cohort study used January 1, 2014 to December 31, 2018 data from the Massachusetts All-Payer Claims Database. The sample included deliveries from January 1, 2015, to December 31, 2017, to birthing individuals aged 18 to 44 years old with continuous insurance for 12 months before and after delivery. Data were analyzed from November 9, 2021, to September 2, 2022. Exposure: Insurance type at delivery. Main Outcomes and Measures: The primary outcome was a binary indicator of any transition in insurance type from 12 months before and/or after delivery. The secondary outcomes were measures of any predelivery transition (12 months before delivery month) and any transition during the postpartum period (delivery month to 12 months post partum). Multivariate logit regression models were used to analyze the association of an insurance transition in the perinatal period with insurance type in the delivery month, controlling for age and socioeconomic status based on a 5-digit zip code. Results: The analytic sample included 97 335 deliveries (mean [SD] maternal age at delivery, 30.4 [5.5] years). Of these deliveries, 23.4% (22 794) were insured by Medicaid and 28.1% (27 347) by Medicaid managed care in the delivery month. A total of 37.1% of the sample (36 127) had at least 1 insurance transition during the 12 months before and/or after delivery. In regression-adjusted analyses, those individuals covered by Medicaid and Medicaid managed care at delivery were 47.0 (95% CI, 46.3-47.7) percentage points and 50.1 (95% CI, 49.4-50.8) percentage points, respectively, more likely to have an insurance transition than those covered by private insurance. Those covered by Marketplace plans at delivery had a 33.1% (95% CI, 31.4%-34.8%) regression-adjusted predicted probability of having a postpartum insurance transition. Conclusions and Relevance: Results of this study showed that insurance transitions during the perinatal period occurred for more than 1 in 3 birthing individuals with continuous insurance and were more common among those with Medicaid or Medicaid managed care at delivery. Further research is needed to examine the role of insurance transitions in health care use and outcomes during the perinatal period.