Advance Care Planning (ACP) in Medicare Beneficiaries with Heart Failure.

BACKGROUND: Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice. OBJECTIVE: Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life. DESIGN: This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020. PARTICIPANTS: A total of 48,466 deceased patients diagnosed with heart failure on Medicare. MAIN MEASURES: Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services. KEY RESULTS: In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter. CONCLUSIONS: Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.

Supplemental Nutrition Assistance Program and Adherence to Antihypertensive Medications.

Importance: Nonadherence to antihypertensive medications is associated with uncontrolled blood pressure, higher mortality rates, and increased health care costs, and food insecurity is one of the modifiable medication nonadherence risk factors. The Supplemental Nutrition Assistance Program (SNAP), a social intervention program for addressing food insecurity, may help improve adherence to antihypertensive medications. Objective: To evaluate whether receipt of SNAP benefits can modify the consequences of food insecurity on nonadherence to antihypertensive medications. Design, Setting, and Participants: A retrospective cohort study design was used to assemble a cohort of antihypertensive medication users from the linked Medical Expenditure Panel Survey (MEPS)-National Health Interview Survey (NHIS) dataset for 2016 to 2017. The MEPS is a national longitudinal survey on verified self-reported prescribed medication use and health care access measures, and the NHIS is an annual cross-sectional survey of US households that collects comprehensive health information, health behavior, and sociodemographic data, including receipt of SNAP benefits. Receipt of SNAP benefits in the past 12 months and food insecurity status in the past 30 days were assessed through standard questionnaires during the study period. Data analysis was performed from March to December 2021. Exposure: Status of SNAP benefit receipt. Main Outcomes and Measures: The main outcome, nonadherence to antihypertensive medication refill adherence (MRA), was defined using the MEPS data as the total days' supply divided by 365 days for each antihypertensive medication class. Patients were considered nonadherent if their overall MRA was less than 80%. Food insecurity status in the 30 days prior to the survey was modeled as the effect modifier. Inverse probability of treatment (IPT) weighting was used to control for measured confounding effects of baseline covariates. A probit model was used, weighted by the product of the computed IPT weights and MEPS weights, to estimate the population average treatment effects (PATEs) of SNAP benefit receipt on nonadherence. A stratified analysis approach was used to assess for potential effect modification by food insecurity status. Results: This analysis involved 6692 antihypertensive medication users, of whom 1203 (12.8%) reported receiving SNAP benefits and 1338 (14.8%) were considered as food insecure. The mean (SD) age was 63.0 (13.3) years; 3632 (51.3%) of the participants were women and 3060 (45.7%) were men. Although SNAP was not associated with nonadherence to antihypertensive medications in the overall population, it was associated with a 13.6-percentage point reduction in nonadherence (PATE, -13.6 [95% CI, -25.0 to -2.3]) among the food-insecure subgroup but not among their food-secure counterparts. Conclusions and Relevance: This analysis of a national observational dataset suggests that patients with hypertension who receive SNAP benefits may be less likely to become nonadherent to antihypertensive medication, especially if they are experiencing food insecurity. Further examination of the role of SNAP as a potential intervention for preventing nonadherence to antihypertensive medications through prospectively designed interventional studies or natural experiment study designs is needed.

Preventive service utilization among adults with cystic fibrosis covered by private insurance is comparable to the general population.

BACKGROUND: As the life expectancy of the cystic fibrosis (CF) population is lengthening with modulator therapies, diligent age-appropriate screening and preventive care are increasingly vital for long-term health and wellbeing. METHODS: We performed a retrospective analysis comparing rates of receiving age- and sex-appropriate preventive services by commercially insured adult people with CF (PwCF) and adults without CF from the general population (GP) via the Truven Health MarketScan database (2012-2018). RESULTS: We captured 25,369 adults with CF and 488,534 adults from the GP in the United States. Comparing these groups, we found that 43% versus 39% received an annual preventive visit, 28% versus 28% were screened for chlamydia, 38% versus 37% received pap smears every 3 years (21-29-year-old females), 33% versus 31% received pap smears every 5 years (30-64-year-old females), 55% versus 44% received mammograms, 23% versus 21% received colonoscopies, and 21% versus 20% received dyslipidemia screening (all screening rates expressed per 100 person-years). In age-stratified analysis, 18-27-year-old PwCF had a lower rate of annual preventive visits compared to adults in the same age group of the GP (27% versus 42%). CONCLUSIONS: We discovered a comparable-to-superior rate of preventive service utilization in adults with CF relative to the GP, except in young adulthood from 18-27 years. Our findings establish the importance of meeting the primary care needs of adults with CF and call for development of strategies to improve preventive service delivery to young adults.

Implementing the Better Starts For All Pilot Mobile and Telehealth Intervention in Ohio Appalachia: Improving Access to Maternal Healthcare.

INTRODUCTION: Women in Ohio Appalachia experience greater maternal health disparities relative to the general U.S. population, resulting in poorer health outcomes. This paper describes the Ohio Better Starts for All (BSFA) program that provides mobile maternal health services in rural Ohio. METHODS: This three-year intervention was delivered through a community-clinical partnership in Ohio Appalachia. The program's preliminary evaluation and opportunities were informed by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RESULTS: Over six months, 86 patients were referred to the BSFA program, 54 (62.8 %) were seen by the maternal care team, and 14 out of 19 scheduled clinic days were held. Five clinics were canceled due to inclement weather, mobile unit breakdown, or provider COVID-19 infection. DISCUSSION: Maternal care providers must provide equitable care to patients, with particular attention to those who face substantial challenges accessing obstetric services. The BSFA program offers one promising solution to help women overcome barriers to accessing care.

Developing a multimodal maternal infant perinatal outpatient delivery system: the MOMI PODS program.

Progress in maternal child health has been hampered by poor rates of outpatient follow up for postpartum individuals. Primary care after delivery can effectively detect and treat several pregnancy-related complications and comorbidities, but postpartum linkage to primary care remains low. In this manuscript, we share the experience of implementing a novel mother-infant dyad program, the Multimodal Maternal Infant Perinatal Outpatient Delivery System (MOMI PODS), to improve primary care linkage and community resource access postpartum via integration into pediatric care structures. With a focus on providing care for people who are publicly insured, we designed a program to mitigate maternal morbidity risk factors in postpartum individuals with chronic disease or pregnancy complications. We discuss the systematic process of designing, executing, and evaluating a collaborative clinical program with involvement of internal medicine/pediatric, family medicine, and obstetric clinicians via establishing stakeholders, identifying best practices, drawing from the evidence base, designing training and promotional materials, training partners and providers, and evaluating clinic enrollment. We share the challenges encountered such as in achieving sufficient provider capacity, consistent provision of care, scheduling, and data tracking, as well as mitigation strategies to overcome these barriers. Overall, MOMI PODS is an innovative approach that integrates outpatient postpartum care into traditional pediatric structures to increase access, showing significant promise to improve healthcare utilization and promote postpartum health.

Establishing a clinical informatics umbilical cord: lessons learned in launching infrastructure to support dyadic mother/infant primary care.

The Multimodal Maternal Infant Perinatal Outpatient Delivery System (MOMI PODS) was developed to facilitate the pregnancy to postpartum primary care transition, particularly for individuals at risk for severe maternal morbidity, via a unique multidisciplinary model of mother/infant dyadic primary care. Specialized clinical informatics platforms are critical to ensuring the feasibility and scalability of MOMI PODS and a smooth perinatal transition into longitudinal postpartum primary care. In this manuscript, we describe the MOMI PODS transition and management clinical informatics platforms developed to facilitate MOMI PODS referrals, scheduling, evidence-based multidisciplinary care, and program evaluation. We discuss opportunities and lessons learned associated with our applied methods, as advances in clinical informatics have considerable potential to enhance the quality and evaluation of innovative maternal health programs like MOMI PODS.

The Evolution of Primary Care Telehealth Disparities During COVID-19: Retrospective Cohort Study.

BACKGROUND: Telehealth has become widely used as a novel way to provide outpatient care during the COVID-19 pandemic, but data about telehealth use in primary care remain limited. Studies in other specialties raise concerns that telehealth may be widening existing health care disparities, requiring further scrutiny of trends in telehealth use. OBJECTIVE: Our study aims to further characterize sociodemographic differences in primary care via telehealth compared to in-person office visits before and during the COVID-19 pandemic and determine if these disparities changed throughout 2020. METHODS: We conducted a retrospective cohort study in a large US academic center with 46 primary care practices from April-December 2019 to April-December 2020. Data were subdivided into calendar quarters and compared to determine evolving disparities throughout the year. We queried and compared billed outpatient encounters in General Internal Medicine and Family Medicine via binary logic mixed effects regression model and estimated odds ratios (ORs) with 95% CIs. We used sex, race, and ethnicity of the patient attending each encounter as fixed effects. We analyzed socioeconomic status of patients in the institution's primary county based on the patient's residence zip code. RESULTS: A total of 81,822 encounters in the pre-COVID-19 time frame and 47,994 encounters in the intra-COVID-19 time frame were analyzed; in the intra-COVID-19 time frame, a total of 5322 (11.1%) of encounters were telehealth encounters. Patients living in zip code areas with high utilization rate of supplemental nutrition assistance were less likely to use primary care in the intra-COVID-19 time frame (OR 0.94, 95% CI 0.90-0.98; P=.006). Encounters with the following patients were less likely to be via telehealth compared to in-person office visits: patients who self-identified as Asian (OR 0.74, 95% CI 0.63-0.86) and Nepali (OR 0.37, 95% CI 0.19-0.72), patients insured by Medicare (OR 0.77, 95% CI 0.68-0.88), and patients living in zip code areas with high utilization rate of supplemental nutrition assistance (OR 0.84, 95% CI 0.71-0.99). Many of these disparities persisted throughout the year. Although there was no statistically significant difference in telehealth use for patients insured by Medicaid throughout the whole year, subanalysis of quarter 4 found encounters with patients insured by Medicaid were less likely to be via telehealth (OR 0.73, 95% CI 0.55-0.97; P=.03). CONCLUSIONS: Telehealth was not used equally by all patients within primary care throughout the first year of the COVID-19 pandemic, specifically by patients who self-identified as Asian and Nepali, insured by Medicare, and living in zip code areas with low socioeconomic status. As the COVID-19 pandemic and telehealth infrastructure change, it is critical we continue to reassess the use of telehealth. Institutions should continue to monitor disparities in telehealth access and advocate for policy changes that may improve equity.

Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study.

BACKGROUND: Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes. METHODS: A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions. SETTING: Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest. DESIGN: 2 × 2 factorial design. INTERVENTIONS: Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce. OUTCOMES: Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months. DISCUSSION: Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity. CLINICALTRIALS: gov: NCT05472441.

A Portfolio Coach-Informed Professional Development Framework.

INTRODUCTION: A majority of US medical schools have incorporated faculty coach-supported educational portfolios into the curriculum. Existing research describes coach professional development, competencies, and program perceptions. However, limited research exists on how programs address coach professional development needs. Our sequential objectives were to (1) explore faculty coach professional development experiences within medical student coaching programs and (2) develop a preliminary framework for medical faculty coach professional development. METHODS: Faculty portfolio coaches who completed 4 years of a longitudinal coaching program were recruited to complete a semi-structured exit interview. Interviews were transcribed using detailed transcription. Two analysts inductively generated a codebook of parent and child codes to identify themes. They compared themes to the professional development model proposed by O'Sullivan and Irby. RESULTS: Of the 25 eligible coaches, 15 completed the interview. Our team organized themes into two broad domains paralleling the established model: program-specific professional development and career-relevant professional development. Four program-specific professional development themes emerged: doing; modeling; relating; and hosting. Three career-relevant professional development themes emerged: advancement; meaning; and understanding. We then applied themes within each domain to propose strategies to optimize coach professional development and develop a framework modeled after O'Sullivan and Irby. DISCUSSION: To our knowledge, we propose the first portfolio coach-informed framework for professional development. Our work builds on established standards, expert opinion, and research responsible for portfolio coach professional development and competencies. Allied health institutions with portfolio coaching programs can apply the framework for professional development innovation.

Understanding pediatric long COVID using a tree-based scan statistic approach: an EHR-based cohort study from the RECOVER Program.

Objectives: Post-acute sequalae of SARS-CoV-2 infection (PASC) is not well defined in pediatrics given its heterogeneity of presentation and severity in this population. The aim of this study is to use novel methods that rely on data mining approaches rather than clinical experience to detect conditions and symptoms associated with pediatric PASC. Materials and Methods: We used a propensity-matched cohort design comparing children identified using the new PASC ICD10CM diagnosis code (U09.9) (N = 1309) to children with (N = 6545) and without (N = 6545) SARS-CoV-2 infection. We used a tree-based scan statistic to identify potential condition clusters co-occurring more frequently in cases than controls. Results: We found significant enrichment among children with PASC in cardiac, respiratory, neurologic, psychological, endocrine, gastrointestinal, and musculoskeletal systems, the most significant related to circulatory and respiratory such as dyspnea, difficulty breathing, and fatigue and malaise. Discussion: Our study addresses methodological limitations of prior studies that rely on prespecified clusters of potential PASC-associated diagnoses driven by clinician experience. Future studies are needed to identify patterns of diagnoses and their associations to derive clinical phenotypes. Conclusion: We identified multiple conditions and body systems associated with pediatric PASC. Because we rely on a data-driven approach, several new or under-reported conditions and symptoms were detected that warrant further investigation.

Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes.

Importance: Gestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening. Objective: To describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum. Design, Setting, and Participants: This cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022. Main Outcomes and Measures: Primary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively. Results: A total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum. Conclusions and Relevance: In this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.

Hospice Transitions From the Perspective of the Caregiver: A Qualitative Study and Development of a Preliminary Hospice Transition Checklist.

Background: Relative to curative and traditional care delivery, hospice care has been associated with superior end of life (EOL) outcomes for both patient and caregiver. Still, comprehensive orientation and caregiver preparation for the transition to hospice is variable and often inadequate. From the perspective of the caregiver, it is unclear what information would better prepare them to support the transition of their loved one to hospice. Objectives: Our two sequential objectives were: 1) Explore caregivers' experiences and perceptions on the transition of their loved one to hospice; and 2) Develop a preliminary checklist of considerations for a successful transition. Design: We conducted semi-structured interviews and used a descriptive inductive/deductive thematic analysis to identify themes. Subjects: 19 adult caregivers of patients across the United States who had enrolled in hospice and died in the year prior (January - December 2019). Measurements: An interview guide was iteratively developed based on prior literature and expanded through collaborative coding and group discussion. Results: Four key themes for inclusion in our framework emerged: hospice intake, preparedness, burden of care and hospice resources. Conclusions: Focusing on elements of our preliminary checklist, such as educating families on goals of hospice or offering opportunities for respite care, into the orientation procedures may be opportunities to improve satisfaction with the transition and the entirety of the hospice experience. Future directions include testing the effectiveness of the checklist and adapting for expanded poputlations.

Psychological Distress in Young Adults with Acute Myeloid Leukemia Undergoing Induction Chemotherapy.

Young adults (YAs), aged 18-39 years, with acute myeloid leukemia (AML) navigate life disruptions amid an unpredictable illness trajectory. We conducted a secondary analysis of patient-reported outcomes for hospitalized YAs with high-risk AML receiving intensive chemotherapy, collected during a multisite randomized clinical trial. Of the 160 patients, 14 (8.8%) were YAs. At week 2 of hospitalization, YAs demonstrated significant worse quality of life (ß = -18.27; p = 0.036), higher anxiety (ß = 2.72; p = 0.048), and higher post-traumatic stress disorder (PTSD; ß = 10.34; p = 0.007) compared with older adults. Our analysis demonstrated a longitudinal presence of anxiety and PTSD, suggesting persistent unmet psychological needs for YAs with AML.

Guidelines for Artificial Intelligence in Medicine: Literature Review and Content Analysis of Frameworks.

BACKGROUND: Artificial intelligence (AI) is rapidly expanding in medicine despite a lack of consensus on its application and evaluation. OBJECTIVE: We sought to identify current frameworks guiding the application and evaluation of AI for predictive analytics in medicine and to describe the content of these frameworks. We also assessed what stages along the AI translational spectrum (ie, AI development, reporting, evaluation, implementation, and surveillance) the content of each framework has been discussed. METHODS: We performed a literature review of frameworks regarding the oversight of AI in medicine. The search included key topics such as "artificial intelligence," "machine learning," "guidance as topic," and "translational science," and spanned the time period 2014-2022. Documents were included if they provided generalizable guidance regarding the use or evaluation of AI in medicine. Included frameworks are summarized descriptively and were subjected to content analysis. A novel evaluation matrix was developed and applied to appraise the frameworks' coverage of content areas across translational stages. RESULTS: Fourteen frameworks are featured in the review, including six frameworks that provide descriptive guidance and eight that provide reporting checklists for medical applications of AI. Content analysis revealed five considerations related to the oversight of AI in medicine across frameworks: transparency, reproducibility, ethics, effectiveness, and engagement. All frameworks include discussions regarding transparency, reproducibility, ethics, and effectiveness, while only half of the frameworks discuss engagement. The evaluation matrix revealed that frameworks were most likely to report AI considerations for the translational stage of development and were least likely to report considerations for the translational stage of surveillance. CONCLUSIONS: Existing frameworks for the application and evaluation of AI in medicine notably offer less input on the role of engagement in oversight and regarding the translational stage of surveillance. Identifying and optimizing strategies for engagement are essential to ensure that AI can meaningfully benefit patients and other end users.

Mothers' Perspectives on a Mother/Infant Dyad Postpartum Primary Care Program Following Gestational Diabetes Mellitus: A Qualitative Pilot Study.

PURPOSE: The purpose of this study is to characterize mothers' experiences within a mother/infant dyad postpartum primary care program (Dyad) following gestational diabetes mellitus (GDM) to inform improvements in the delivery of care. METHODS: A qualitative pilot study of women (n = 10) enrolled in a mother/infant Dyad program was conducted in a primary care practice at a large, urban academic medical center. Respondents were asked a series of open-ended questions about their experience with GDM, the Dyad program, and health behaviors. Interviews were audio-recorded, transcribed verbatim, and analyzed using ground theory with NVivo 12 Plus software. RESULTS: Three key themes emerged: (1) Dyad program experience, (2) implementation of health behavior changes, and (3) acknowledgment of future GDM and type 2 diabetes mellitus (T2DM) health risks. Respondents felt that the program conveniently served mother and infant health care needs in a single appointment. Respondents also valued support from primary care providers when implementing health behavior changes. The Dyad program provided an opportunity for respondents to understand their current and future risk for developing GDM and T2DM. CONCLUSIONS: Postpartum women enrolled in the Dyad program received highly personalized primary care services. The results of our study will help integrate patient-centered strategies into models for GDM care to maintain patient engagement in postpartum clinical services.

Out-of-Network Care in Commercially Insured Pediatric Patients According to Medical Complexity.

BACKGROUND: Commercial health plans establish networks and require much higher cost sharing for out-of-network (OON) care. Yet, the adequacy of health plan networks for access to pediatric specialists, especially for children with medical complexity, is largely unknown. OBJECTIVE: To examine differences in OON care and associated cost-sharing payments for commercially insured children with different levels of medical complexity. DESIGN: Cross-sectional study using a nationwide commercial claims database. SUBJECTS: Enrollees 0-18 years old in employer-sponsored insurance plans. The Pediatric Medical Complexity Algorithm was used to classify individuals into 3 levels of medical complexity: children with no chronic disease, children with non-complex chronic diseases, and children with complex chronic diseases. MAIN OUTCOMES: OON care rates, cost-sharing payments for OON care and in-network care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing. RESULTS: The study sample included 6,399,006 individuals with no chronic disease, 1,674,450 with noncomplex chronic diseases, and 603,237 with complex chronic diseases. Children with noncomplex chronic diseases were more likely to encounter OON care by 6.77 percentage points with higher cost-sharing by $288 for OON care, relative to those with no chronic disease. For those with complex chronic diseases, these differences rose to 16.08 percentage points and $599, respectively. Among children who saw behavioral health providers, rates of OON care were especially high. CONCLUSIONS: Commercially insured children with medical complexity experience higher rates of OON care with higher OON cost-sharing payments compared with those with no chronic disease.

Mother-Infant Dyad program in primary care: evidence-based postpartum care following gestational diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM), a common complication of pregnancy, is associated with a 10-fold increased risk of type 2 diabetes mellitus (T2DM) compared to the general population. Evidence-based guidelines recommend that patients with GDM receive postpartum care for T2DM risk reduction including an oral glucose tolerance test (OGTT) 4-12 weeks after delivery, yet half of patients with GDM did not return for their postpartum visits by 12 weeks postpartum. Additionally, only 10% utilize primary care within 12 months of delivery and one-third of GDM patients receive timely postpartum OGTT. OBJECTIVE: To determine if the Mother-Infant Dyad postpartum primary care program provides a framework to link well-child visits with postpartum primary care visits to increase postpartum clinical interactions promoting longitudinal care, such as postpartum visit attendance and T2DM screening. STUDY DESIGN: All patients with a diagnosis of GDM that received care at a postpartum mother-infant dyad program at a Midwestern academic medical center internal medicine and pediatrics primary care clinic were enrolled. Clinic level data was obtained by baseline and 6-month post-enrollment surveys and chart review. A comparison population was identified from Medicaid claims data using propensity score matching to enable a comparison of program participants' outcomes to a population comprised of similar individuals diagnosed with GDM that received care at sites not participating in the Dyad program. Our primary outcome was completion of T2DM screening in the 4-12 week postpartum period. The secondary outcomes were postpartum visit attendance with a prenatal provider, and prediabetes diagnoses. RESULTS: A total of 75 mother-infant dyads were seen by the clinic. Of the enrolled women, 43% were Non-Hispanic White and 30% were Non-Hispanic Black; mean age was 30.75 years. The matched comparison group (n = 62) had a mean age of 30.75 years, were 43% Non-Hispanic White and 30% Non-Hispanic Black. Women who participated in the program were more likely to receive T2DM screenings than women who did not participate (87 vs. 79%, p<.001) and complete postpartum visits (95 vs. 58%, respectively; p<.001). Additionally, a higher rate of new prediabetes diagnoses was observed (12 vs. 6%, p < .001). CONCLUSION: The Mother-Infant Dyad postpartum primary care program improved T2DM screenings and postpartum visit attendance. In addition, a greater proportion of Dyad program participants experienced new prediabetes diagnoses that those in the comparison group. Our findings suggest that the dyad care model, in which women with GDM engage in postpartum primary care concurrent with well-child visits, can improve longitudinal postpartum care after a GDM diagnosis.