Composition of buprenorphine prescribing networks in Medicaid and association with quality of care.

INTRODUCTION: Despite Medicaid's outsized role in delivering and financing medications for opioid use disorder (MOUD), little is known about the extent to which buprenorphine prescriber networks vary across Medicaid health plans, and whether network characteristics affect quality of treatment received. In this observational cross-sectional study, we used 2018-2019 Medicaid claims in Oregon to assess network variation in the numbers and types of buprenorphine prescribers, as well as the association of prescriber and network characteristics with quality of care. METHODS: We describe prescribers (MD/DOs and advanced practice providers) of OUD-approved buprenorphine formulations to patients with an OUD diagnosis, across networks. For each patient who initiated buprenorphine treatment during 2018, we assigned a "usual prescriber" and assessed four measures of quality in the 180d following initiation: 1) continuous receipt of buprenorphine; 2) receipt of any behavioral health counseling services; 3) receipt of any urine drug screen; and 4) receipt of any prescription for a benzodiazepine. We used multivariable linear regressions to examine the association of prescriber and network characteristics with quality of buprenorphine care following initiation. RESULTS: We identified 645 providers who prescribed buprenorphine to 20,739 eligible Medicaid enrollees with an OUD diagnosis. The composition of buprenorphine prescriber networks varied in terms of licensing type, specialty, and panel size, with the majority of prescribers providing buprenorphine to small panels of patients. In the 180 days following initiation, a third of patients were maintained on buprenorphine; 69.9 % received behavioral health counseling; 88.4 % had a urine drug screen; and 11.3 % received a benzodiazepine prescription. In regression analyses, while no single network characteristic was associated with higher quality across all examined measures, each one unit increase in prescriber-to-enrollee ratio was associated with a 1.18 p.p. increase in the probability of continuous buprenorphine maintenance during the 180 days following initiation (95 % confidence interval = [0.21, 2.15], p = 0.017). CONCLUSIONS: Medicaid plans may be able to leverage their networks to provide higher quality care. Our findings, which should be interpreted as descriptive only, suggest that higher prescriber-to-enrollee ratio is associated with increased buprenorphine maintenance. Future research should focus on isolating the causal relationships between MOUD prescribing network design and patient outcomes.

Differences in healthcare utilization between enrollees of fully integrated dual eligible special needs plans versus non-fully integrated plans.

BACKGROUND: Policymakers advocate care integration models to enhance Medicare and Medicaid service coordination for dually eligible individuals. One rapidly expanding model is the fully integrated dual eligible (FIDE) plan, a sub-type of the dual eligible special needs plan (D-SNP) in which a parent insurer manages Medicare and Medicaid spending for dually eligible individuals. We examined healthcare utilization differences among dually eligible individuals aged 65 years or older enrolled in D-SNPs by plan type (FIDE vs non-FIDE). METHODS: Using 2018 Medicare Advantage encounters and Medicaid claims of FIDE and non-FIDE enrollees in six states (AZ, CA, FL, NY, TN, WI), we compared healthcare utilization between plan types, adjusting for enrollee characteristics and county indicators. We applied propensity score weighting to address differences between FIDE and non-FIDE plan enrollees. RESULTS: In our main analysis, which included all dually eligible individuals in our sample, we observed no significant difference in healthcare utilization between FIDE and non-FIDE plan enrollees. However, we identified some differences in healthcare utilization between FIDE and non-FIDE plan enrollees in subgroup analyses. For example, among home and community-based service (HCBS) users, FIDE plan enrollees had 6.0 fewer hospitalizations per 1000 person-months (95% CI: -7.9, -4.0) and were 7.0 percentage points more likely to be discharged to home (95% CI: 2.6, 11.5) after hospitalization, compared to non-FIDE plan enrollees. CONCLUSION: While we found no differences in healthcare utilization between FIDE and non-FIDE plan enrollees when considering all dually eligible individuals in our sample, some differences emerged when focusing on subgroups. For example, HCBS users with FIDE plans had fewer hospitalizations and were more likely to be discharged to their home following hospitalization, compared to HCBS users with non-FIDE plans. These findings suggest that FIDE plans may improve care coordination for specific subsets of dually eligible individuals.

Diagnosis of Perinatal Mental Health Conditions Following Medicaid Expansion to Include Low-Income Immigrants.

Importance: For some low-income people, access to care during pregnancy is not guaranteed through Medicaid, based on their immigration status. While states have the option to extend Emergency Medicaid coverage for prenatal and postpartum care, many states have not expanded coverage. Objective: To determine whether receipt of first prenatal care services and subsequently receipt of postpartum care through extensions of Emergency Medicaid coverage were associated with increases in diagnosis and treatment of perinatal mental health conditions. Design, Setting, and Participants: This cohort study used linked Medicaid claims and birth certificate data from 2010 to 2020 with a difference-in-difference design to compare the rollout of first prenatal care coverage in 2013 and then postpartum services in Oregon in 2018 with a comparison state, South Carolina, which did not cover prenatal or postpartum care as part of Emergency Medicaid and only covered emergent conditions and obstetric hospital admissions. Medicaid claims and birth certificate data were linked by Medicaid identification number prior to receipt by the study team. Participants included recipients of Emergency Medicaid who gave birth in Oregon or South Carolina. Data were analyzed from April 1 to October 15, 2023. Exposure: Medicaid coverage of prenatal care and Medicaid coverage of postpartum care. Main Outcomes and Measures: The main outcome was the diagnosis of a perinatal mental health condition within 60 days postpartum. Secondary outcomes included treatment of a mood disorder with medication or talk therapy. Results: The study sample included 43 889 births to Emergency Medicaid recipients who were mainly aged 20 to 34 years (32 895 individuals [75.0%]), multiparous (33 887 individuals [77.2%]), and living in metropolitan areas (32 464 individuals [74.0%]). Following Oregon's policy change to offer prenatal coverage to pregnant individuals through Emergency Medicaid, there was a significant increase in diagnosis frequency (4.1 [95% CI, 1.7-6.5] percentage points) and a significant difference between states in treatment for perinatal mental health conditions (27.3 [95% CI, 13.2-41.4] percentage points). Postpartum Medicaid coverage (in addition to prenatal Medicaid coverage) was associated with an increase of 2.6 (95% CI, 0.6-4.6) percentage points in any mental health condition being diagnosed, but there was no statistically significant difference in receipt of mental health treatment. Conclusions and Relevance: These findings suggest that changing Emergency Medicaid policy to include coverage for prenatal and 60 days of postpartum care for immigrants is foundational to improving maternal mental health. Expanded postpartum coverage length, or culturally competent interventions, may be needed to optimize receipt of postpartum treatment.

Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce: Qualitative Study.

Many states are experiencing a behavioral health workforce crisis, particularly in the public behavioral health system. An understanding of the factors influencing the workforce shortage is critical for informing public policies to improve workforce retention and access to care. The aim of this study was to assess factors contributing to behavioral health workforce turnover and attrition in Oregon. Semistructured qualitative interviews were conducted with 24 behavioral health providers, administrators, and policy experts with knowledge of Oregon's public behavioral health system. Interviews were transcribed and iteratively coded to reach consensus on emerging themes. Five key themes emerged that negatively affected the interviewees' workplace experience and longevity: low wages, documentation burden, poor physical and administrative infrastructure, lack of career development opportunities, and a chronically traumatic work environment. Large caseloads and patients' high symptom acuity contributed to worker stress. At the organizational and system levels, chronic underfunding and poor administrative infrastructure made frontline providers feel undervalued and unfulfilled, pushing them to leave the public behavioral health setting or behavioral health altogether. Behavioral health providers are negatively affected by systemic underinvestment. Policies to improve workforce shortages should target the effects of inadequate financial and workplace support on the daily work environment.

Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012-2017.

BACKGROUND: Little is known about the timing and frequency of postpartum hospital encounters and postpartum visit attendance and how they may be associated with insurance types. Research on health insurance and its association with postpartum care utilization is often limited to the first 6 weeks. OBJECTIVE: To assess whether postpartum utilization (hospital encounters within 1 year postpartum and postpartum visit attendance within 12 weeks) differs by insurance type at birth (Medicaid, high deductible health plans, and other commercial plans) and whether rates of hospital encounters differ by postpartum visit attendance and insurance status. METHODS: Time-to-event analysis of Oregon hospital births from 2012 to 2017 using All Payer All Claims data. We conducted weighted Cox Proportional Hazard regressions and accounted for differences in insurance type at birth using multinomial propensity scores. RESULTS: Among 202,167 hospital births, 24.9% of births had at least 1 hospital encounter within 1 year postpartum. Births funded by Medicaid had a higher risk of a postpartum emergency department (ED) visit (hazard ratio: 2.05, 95% CI: 1.99, 2.12) and lower postpartum visit attendance (hazard ratio: 0.71, 95% CI: 0.70, 0.72) compared with commercial plans. Among Medicaid beneficiaries, missing the postpartum visit in the first 6 weeks was associated with a lower risk of subsequent readmissions (adjusted hazard ratio 0.77, 95% CI: 0.68, 0.87) and ED visits (adjusted hazard ratio: 0.87 (0.85, 0.88). CONCLUSIONS: Medicaid beneficiaries received more care in the ED within 1 year postpartum compared with those enrolled in other commercial plans. This highlights potential issues in postpartum care access.

Access, Utilization, and Quality of Behavioral Health Integration in Medicaid Managed Care.

Importance: Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change. Objective: To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health. Design, Setting, and Participants: This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023. Main Outcomes and Measures: Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures. Results: This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care. Conclusions and Relevance: The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.

State-Level Adverse Outcomes Among Long-Term Services and Supports Users With Alzheimer's Disease and Related Dementias.

Home- and community-based services (HCBS) users, on average, experience hospitalizations more frequently than nursing facility residents. However, little is known about state-level variation in such adverse events among these groups. Using 2018 Medicare and Medicaid claims for dual-eligible beneficiaries with Alzheimer's disease and related dementias, we described hospitalization and emergency department (ED) visit rates among HCBS users and nursing facility residents and observed substantial state-level variation. In addition, consistent with prior evidence, we found more frequent hospitalizations and ED visits among HCBS users than nursing facility residents. The magnitude of this difference varied considerably across states, and the degree of variation was greatest among beneficiaries with six or more comorbid conditions. Our findings represent a crucial initial exploration of the state-level variation in adverse events among HCBS users and nursing facility residents, paving the way for further investigations into factors that contribute to this variability.

Postpartum Expansion of Emergency Medicaid is Associated with Increased Receipt of Recommended Glycemic Screening and Care.

Oregon expanded Emergency Medicaid coverage to 60 days of postpartum care in 2018, facilitating ongoing care for conditions such as gestational diabetes. We linked Medicaid claims and birth certificates from 2010 to 2019 in Oregon and South Carolina, which did not expand postpartum care. We used a difference-in-difference design to measure the effects of postpartum care coverage among Emergency Medicaid recipients with gestational diabetes. Primary outcomes were receipt of recommended glucose tolerance testing and new diagnosis of Type 2 diabetes. Our sample included 2,270 live births among a predominantly multiparous, Latina population. Postpartum coverage was associated with a significant increase in receipt of a recommended glucose tolerance test (23.1 percentage points, 95% CI 16.9-29.3) and in diagnosis of Type 2 diabetes (4.6 percentage points, 95% CI 3.3-65.9). Expansion of postpartum coverage increased recommended screenings and care among Emergency Medicaid enrollees with pregnancies complicated by gestational diabetes.

State- and County-Level Geographic Variation in Opioid Use Disorder, Medication Treatment, and Opioid-Related Overdose Among Medicaid Enrollees.

Importance: The opioid crisis disproportionately affects Medicaid enrollees, yet little systematic evidence exists regarding how prevalence of and health care utilization for opioid use disorder (OUD) vary across geographical areas. Objectives: To characterize state- and county-level variation in claims-based prevalence of OUD and rates of medication treatment for OUD and OUD-related nonfatal overdose among Medicaid enrollees. Design, Setting, and Participants: This cross-sectional study used data from the Transformed Medicaid Statistical Information System Analytic Files from January 1, 2016, to December 31, 2018. Participants were Medicaid enrollees with or without OUD in 46 states; Washington, DC; and Puerto Rico who were aged 18 to 64 years and not dually enrolled in Medicare. The analysis was conducted between September 2022 and April 2023. Exposure: Calendar-year OUD prevalence. Main Outcomes and Measures: The main outcomes were claims-based measures of OUD prevalence and rates of medication treatment for OUD and opioid-related nonfatal overdose. Individual records were aggregated at the state and county level, and variation was assessed within and across states. Results: Of the 76 390 817 Medicaid enrollee-year observations included in our study (mean [SD] enrollee age, 36.5 [1.6] years; 59.0% female), 2 280 272 (3.0%) had a claims-based OUD (mean [SD] age, 38.9 [3.6] years; 51.4% female). Of enrollees with OUD, 41.2% were eligible due to Medicaid expansion, 46.4% had other substance use disorders, 55.8% had mental health conditions, 55.2% had claims indicating some form of OUD medication, and 5.8% had claims indicating an overdose during a calendar year. Claims-based outcomes exhibited substantial variation across states: OUD prevalence ranged from 0.6% in Arkansas and Puerto Rico to 9.7% in Maryland, rates of OUD medication treatment ranged from 17.7% in Kansas to 82.8% in Maine, and rates of overdose ranged from 0.3% in Mississippi to 10.5% in Illinois. Pronounced variation was also found within states (eg, OUD prevalence in Maryland ranged from 2.2% in Prince George's County to 21.6% in Cecil County). Conclusions and Relevance: In this cross-sectional study of Medicaid enrollees from 2016 to 2018, claims-based prevalence of OUD and rates of OUD medication treatment and opioid-related overdose varied substantially across and within states. Further research appears to be needed to identify important factors influencing this variation.

Estimating the Cardiovascular Disease Risk Reduction of a Quality Improvement Initiative in Primary Care: Findings from EvidenceNOW.

BACKGROUND: This study estimates reductions in 10-year atherosclerotic cardiovascular disease (ASCVD) risk associated with EvidenceNOW, a multi-state initiative that sought to improve cardiovascular preventive care in the form of (A)spirin prescribing for high-risk patients, (B)lood pressure control for people with hypertension, (C)holesterol management, and (S)moking screening and cessation counseling (ABCS) among small primary care practices by providing supportive interventions such as practice facilitation. DESIGN: We conducted an analytic modeling study that combined (1) data from 1,278 EvidenceNOW practices collected 2015 to 2017; (2) patient-level information of individuals ages 40 to 79 years who participated in the 2015 to 2016 National Health and Nutrition Examination Survey (n = 1,295); and (3) 10-year ASCVD risk prediction equations. MEASURES: The primary outcome measure was 10-year ASCVD risk. RESULTS: EvidenceNOW practices cared for an estimated 4 million patients ages 40 to 79 who might benefit from ABCS interventions. The average 10-year ASCVD risk of these patients before intervention was 10.11%. Improvements in ABCS due to EvidenceNOW reduced their 10-year ASCVD risk to 10.03% (absolute risk reduction: -0.08, P ≤ .001). This risk reduction would prevent 3,169 ASCVD events over 10 years and avoid $150 million in 90-day direct medical costs. CONCLUSION: Small preventive care improvements and associated reductions in absolute ASCVD risk levels can lead to meaningful life-saving benefits at the population level.

Medicaid Reimbursement For Psychiatric Services: Comparisons Across States And With Medicare.

Medicaid is characterized by low rates of provider participation, often attributed to reimbursement rates below those of commercial insurance or Medicare. Understanding the extent to which Medicaid reimbursement for mental health services varies across states may help illuminate one lever for increasing Medicaid participation among psychiatrists. We used publicly available Medicaid fee-for-service schedules from state Medicaid agency websites in 2022 to construct two indices for a common set of mental health services provided by psychiatrists: a Medicaid-to-Medicare index to benchmark each state's Medicaid reimbursement with that of Medicare for the same set of services, and a state-to-national Medicaid index comparing each state's Medicaid reimbursement with an enrollment-weighted national average. On average, Medicaid paid psychiatrists at 81.0 percent of Medicare rates, and a majority of states had a Medicaid-to-Medicare index that was less than 1.0 (median, 0.76). State-to-national Medicaid indices for psychiatrists' mental health services ranged from 0.46 (Pennsylvania) to 2.34 (Nebraska) but did not correlate with the supply of Medicaid-participating psychiatrists. As policy makers look to reimbursement rates as one strategy to address ongoing mental health workforce shortages, comparing Medicaid payment across states may help benchmark ongoing state and federal proposals.

Geographic Variation In Effective Contraceptive Use Among Medicaid Recipients In 2018.

Medicaid is the largest payer for publicly funded contraception, serving millions of women across the United States. However, relatively little is known about the extent to which effective contraceptive services vary geographically for Medicaid recipients. This study used national Medicaid claims to assess county-level variation in rates of provision of the most or moderately effective methods of contraception and provision of long-acting reversible contraception (LARC) across forty states and Washington, D.C., in 2018. County-level rates of most or moderately effective contraceptive use varied almost fourfold across states, from a low of 10.8 percent to a high of 44.4 percent. Rates of LARC provision varied almost tenfold, from a low of 1.0 percent to a high of 9.6 percent. Despite the fact that contraception is a core benefit within Medicaid, access and use vary substantially across and within states. Medicaid agencies have a variety of options to ensure that people have access to a choice of the full range of contraceptive methods, including removing or loosening utilization controls, incorporating quality metrics or value-based payments into contraceptive services, and adjusting reimbursement to remove barriers to the clinical provision of LARC.

Geographical Variations In Emergency Department Visits For Mental Health Conditions For Medicaid Beneficiaries.

Despite Medicaid's importance as a payer and source of coverage for mental health care, relatively little is known about how prevalence, access, and quality might vary among Medicaid beneficiaries. This study used national Medicaid data from 2018 to assess regional variations in emergency department (ED) visits for mental health conditions, a measure that may reflect unmet needs for behavioral health care. We found substantial variations, with rates in the region with the highest visit rates eight times higher than those in the region with the lowest rates. Many regions with high rates of ED visits for mental health conditions also had high rates of outpatient mental health use. Regional patterns differed substantially, with some regions exhibiting high rates of ED visits related to anxiety but low rates for schizophrenia and vice versa. The presence of large variations in ED visits for mental health conditions, with substantial differences in the composition across regions, suggests a need for context-specific solutions, including assessments of the ways in which mental health benefits are structured at the state Medicaid agency level and of differences in provider accessibility and an understanding of the types of mental illness underlying high rates of use.

A Medicaid Benefit for Health-Related Social Needs.

This Viewpoint explores a recent advancement to improve outcomes and reduce costs within state Medicaid programs, Section 1115 demonstration waivers.

The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services-Evidence from early adopters.

OBJECTIVE: To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve-out" model to a "carve-in" model integrating the financing of behavioral and physical health care. DATA SOURCES/STUDY SETTING: Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders. STUDY DESIGN: This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions. DATA COLLECTION: Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach. PRINCIPAL FINDINGS: The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness. CONCLUSIONS: Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve-in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care.

Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care.

Importance: Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown. Objective: To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states. Design, Setting, and Participants: This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022. Exposure: ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. Main Outcomes and Measures: The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. Results: There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented. Conclusions and Relevance: These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.

Catholic sole community hospitals are associated with decreased receipt of postpartum permanent contraception among Medicaid recipients.

OBJECTIVES: To examine the association of Catholic hospitals with receipt of postpartum tubal ligation and long acting, reversible contraception among Medicaid recipients. STUDY DESIGN: We conducted a retrospective cohort study of live births from January 1, 2016 to October 31, 2016 to female Medicaid beneficiaries in the United States between ages 21 and 44. Our main exposure was the presence of a Catholic-affiliated sole community hospital, and our primary outcome was highly effective postpartum contraception. We examined rates of postpartum permanent contraception, along with the use of a long acting, reversible form of contraception (LARC) at 3 and 60 days are postpartum. We compared counties that had only a Catholic-affiliated hospital with counties with only a non-Catholic hospital. RESULTS: Our study population included 14,545 postpartum Medicaid beneficiaries. Study participants came from 88 counties across 10 United States states. Only 7.7% of women in counties with Catholic sole community hospitals received permanent contraception by 3 days postpartum, compared to 11.3% in counties with non-Catholic sole community hospitals (RD: -3.92%; 95% CI: -6.01%, -1.83%). This difference was not mitigated by receipt of outpatient procedures or long-acting, reversible contraception. Importantly, women residing in counties with Catholic sole community hospitals were much less likely to return postpartum for an outpatient visit between 8 and 60 days postpartum than women in counties with non-Catholic sole community hospitals (35.4% vs 45.4%, RD: -9.29%; 95% CI: -16.71%, -1.86%). CONCLUSIONS: In counties where the only hospital was Catholic, Medicaid recipients giving birth were significantly less likely to receive permanent contraception and to return for postpartum care. IMPLICATIONS: Catholic hospitals are increasing in the United States, which may restrict access to postpartum contraception, particularly in rural areas. We found that Medicaid recipients giving birth at a Catholic sole community hospital were less likely to receive permanent contraception and to return for care.

Emergency Department Pediatric Readiness Among US Trauma Centers: A Machine Learning Analysis of Components Associated With Survival.

OBJECTIVE: We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers. BACKGROUND: ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown. METHODS: This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival. RESULTS: There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present. CONCLUSIONS: ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined.