The Impact of the Affordable Care Act Medicaid Expansion on Acute Diabetes Complications Among Community Health Center Patients.

OBJECTIVE: This study evaluates whether patients residing in expansion states have a greater increase in outpatient diagnoses of acute diabetes complications than those living in non-expansion states following the implementation of the Affordable Care Act (ACA). METHODS: This retrospective cohort study uses electronic health records (EHR) from 10,665 non-pregnant patients, aged 19 to 64 years old who were diagnosed with diabetes in 2012 or 2013 from 347 community health centers (CHCs) across 16 states (11 expansion and 5 non-expansion states). Patients included had ≥1 outpatient ambulatory visit in each of these periods: pre-ACA: 2012 to 2013, post-ACA: 2014 to 2016, and post-ACA: 2017 to 2019. Acute diabetes-related complications were identified using International Classification Diseases (ICD-9-CM and ICD-10-CM) codes classification and could occur on or after diagnosis of diabetes. We performed difference-in-differences (DID) analysis using a generalized estimating equation to compare the change in rates of acute diabetes complications by year and by Medicaid expansion status. RESULTS: There was a greater increase after year 2015 in visits related to abnormal blood glucose among patient living in Medicaid expansion states than in non-expansion states (2017 DID = 0.041, 95% CI = 0.027-0.056). Although both visits due to any acute diabetes complications and infection-related diabetes complications were higher among patients living in Medicaid expansion states, there was no difference in the trend overtime between expansion and non-expansion states. CONCLUSION: We found a significantly greater rate of visits for abnormal blood glucose in patients receiving care in expansion states relative to patients in CHCs in non-expansion states starting in 2015. Additional resources for these clinics, such as the ability to provide blood glucose monitoring devices or mailed/delivered medications, could substantially benefit patients with diabetes.

Primary and mental health service use in community health center patients before and after cancer diagnosis.

BACKGROUND: Cancer survivors face increased risk for chronic diseases resulting from cancer, preexisting conditions, and cancer treatment. Having an established primary care clinic or health insurance may influence patients' receipt of recommended preventive care necessary to manage, treat, or diagnose new conditions. This study sought to understand receipt of healthcare in community health centers (CHCs) before and after cancer diagnosis among cancer survivors. We also examined the type of care received and assessed whether being established with a CHC or the type of health insurance affected the use of services. METHODS: Using electronic health record data and linked cancer registries from 5,649 CHC patients in three states from 2012 through 2018, we obtained monthly rates of primary care and mental health/behavioral health (MHBH) visits and the probability of receipt of care before and after a cancer diagnosis. RESULTS: Seventy-five percent of CHC patients diagnosed with cancer returned to their primary CHC for care within 2-years of their diagnosis. Among those who returned, there was a sharp increase in primary and MHBH care shortly before their diagnosis. Significantly more primary care (pre: 19.6%, post: 21.9%, p < 0.001) and MHBH care (pre: 1.2%, post: 1.6%, p < 0.001) was received after diagnosis than before. However, uninsured patients had fewer visits after their diagnosis than before. CONCLUSION: Use of preventive care for cancer survivors is particularly important. Having an established primary care clinic may help to ensure survivors receive recommended screening and care.

Changes in diabetes prescription patterns following Affordable Care Act Medicaid expansion.

INTRODUCTION: Most patients with diabetes mellitus are prescribed medications to control their blood glucose. The implementation of the Affordable Care Act (ACA) led to improved access to healthcare for patients with diabetes. However, impact of the ACA on prescribing trends by diabetes drug category is less clear. This study aims to assess if long-acting insulin and novel agents were prescribed more frequently following the ACA in states that expanded Medicaid compared with non-expansion states. RESEARCH DESIGN AND METHODS: In this analysis of a natural experiment, prescriptions reimbursed by Medicaid (US public insurance) for long-acting insulins, metformin, and novel agent medications (DPP4 inhibitors, sodium/glucose cotransporter 2 inhibitor antagonists, and glucagon-like peptide-1 receptor agonists) from 2012 to 2017 were obtained from public records. For each medication category, we performed difference-in-differences (DID) analysis modeling change in rate level from pre-ACA to post-ACA in Medicaid expansion states relative to Medicaid non-expansion states. RESULTS: Expansion and non-expansion states saw a decline in both metformin and long-acting insulin prescriptions per 100 enrollees from pre-ACA to post-ACA. These decreases were larger in non-expansion states relative to expansion states (metformin: absolute DID = +0.33, 95% CI=0.323 to 0.344) and long-acting insulin (absolute DID: +0.11; 95% CI=0.098 to 0.113). Novel agent prescriptions in expansion states (+0.08 per 100 enrollees) saw a higher absolute increase per 100 Medicaid enrollees than in non-expansion states (absolute DID= +0.08, 95% CI=0.079 to 0.086). CONCLUSIONS: There was a greater absolute increase for prescriptions of novel agents in expansion states relative to non-expansion states after accounting for number of enrollees. Reducing administrative barriers and improving the ability of providers to prescribe such newer therapies will be critical for caring for patients with diabetes-particularly in Medicaid non-expansion states.

Long-acting buprenorphine vs. naltrexone opioid treatments in CJS-involved adults (EXIT-CJS).

The EXIT-CJS (N = 1005) multisite open-label randomized controlled trial will compare retention and effectiveness of extended-release buprenorphine (XR-B) vs. extended-release naltrexone (XR-NTX) to treat opioid use disorder (OUD) among criminal justice system (CJS)-involved adults in six U.S. locales (New Jersey, New York City, Delaware, Oregon, Connecticut, and New Hampshire). With a pragmatic, noninferiority design, this study hypothesizes that XR-B (n = 335) will be noninferior to XR-NTX (n = 335) in retention-in-study-medication treatment (the primary outcome), self-reported opioid use, opioid-positive urine samples, opioid overdose events, and CJS recidivism. In addition, persons with OUD not eligible or interested in the RCT will be recruited into an enhanced treatment as usual arm (n = 335) to examine usual care outcomes in a quasi-experimental observational cohort.

The Affordable Care Act: Effects of Insurance on Diabetes Biomarkers.

OBJECTIVE: We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers. RESEARCH DESIGN AND METHODS: This was a retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE (Accelerating Data Value Across a National Community Health Center Network) network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (n = 25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre- to post-ACA expansion. Primary outcomes included changes from 24 months pre- to 24 months post-ACA in glycosylated hemoglobin (HbA1c), systolic (SBP) and diastolic (DBP) blood pressure, and LDL cholesterol levels. RESULTS: Newly insured patients exhibited a reduction in adjusted mean HbA1c levels (8.24% [67 mmol/mol] to 8.17% [66 mmol/mol]), which was significantly different from continuously uninsured patients, whose HbA1c levels increased (8.12% [65 mmol/mol] to 8.29% [67 mmol/mol]; difference-in-differences [DID] -0.24%; P < 0.001). Newly insured patients showed greater reductions than continuously uninsured patients in adjusted mean SBP (DID -1.8 mmHg; P < 0.001), DBP (DID -1.0 mmHg; P < 0.001), and LDL (DID -3.3 mg/dL; P < 0.001). Among patients with elevated HbA1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured patients to have a controlled HbA1c measurement by 24 months post-ACA (hazard ratio 1.25; 95% CI 1.02-1.54]. CONCLUSIONS: Post-ACA, newly insured patients had greater improvements in diabetes-related biomarkers than continuously uninsured, discontinuously insured, or continuously insured patients. Findings suggest that health insurance gain via ACA facilitates access to appropriate diabetes care, leading to improvements in diabetes-related biomarkers.

Development of an algorithm to link electronic health record prescriptions with pharmacy dispense claims.

Objective: Medication adherence is an important aspect of chronic disease management. Electronic health record (EHR) data are often not linked to dispensing data, limiting clinicians' understanding of which of their patients fill their medications, and how to tailor care appropriately. We aimed to develop an algorithm to link EHR prescribing to claims-based dispensing data and use the results to quantify how often patients with diabetes filled prescribed chronic disease medications. Materials and Methods: We developed an algorithm linking EHR prescribing data (RxNorm terminology) to claims-based dispensing data (NDC terminology), within sample of adult (19-64) community health center (CHC) patients with diabetes from a network of CHCs across 12 states. We demonstrate an application of the method by calculating dispense rates for a set of commonly prescribed diabetes and cardio-protective medications. To further inform clinical care, we computed adjusted odds ratios of dispense by patient-, encounter-, and clinic-level characteristics. Results: Seventy-six percent of cardio-protective medication prescriptions and 74% of diabetes medications were linked to a dispensing record. Age, income, ethnicity, insurance, assigned primary care provider, comorbidity, time on EHR, and clinic size were significantly associated with odds of dispensing. Discussion: EHR prescriptions and pharmacy dispense data can be linked at the record level across different terminologies. Dispensing rates in this low-income population with diabetes were similar to other populations. Conclusion: Record linkage resulted in the finding that CHC patients with diabetes largely had their chronic disease medications dispensed. Understanding factors associated with dispensing rates highlight barriers and opportunities for optimal disease management.