Variation in Hospital Risk-Adjusted Mortality Rates Following Transcatheter Aortic Valve Replacement in the United States: A Report From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

BACKGROUND: The use of transcatheter aortic valve replacement (TAVR) to treat aortic stenosis in the United States is growing, yet little is known about the variation in procedural outcomes in community practice. We developed a TAVR in-hospital mortality risk model and used it to quantify variation in mortality rates across United States (US) TAVR centers. METHODS AND RESULTS: We analyzed data from 22 248 TAVR procedures performed at 318 sites participating in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry (November 2011 to October 2014). A Bayesian hierarchical model was developed to estimate hospital-specific risk-adjusted mortality rates adjusting for 40 patient baseline factors. A total of 1130 in-hospital deaths (5.1%) were observed. Reliability-adjusted risk-adjusted mortality rate estimates ranged from 3.4% to 7.7% with an interquartile range of 4.8% to 5.4%. A patient's predicted odds of dying was 80% higher if treated by a hospital 1 standard deviation above the mean compared with a hospital 1 standard deviation below the mean (odds ratio =1.8; 95% credible interval, 1.4%-2.2%). CONCLUSIONS: Risk modeling of TAVR in-hospital mortality revealed variation in risk-adjusted mortality rates during the US early commercial experience. Transcatheter Valve Therapy Registry analyses using this model will support research, feedback reporting, and the identification of factors associated with quality.

State of dental care among Medicaid-enrolled children in the United States.

OBJECTIVE: To evaluate the prevalence of dental care visits (DCV) in 2007 in the United States among Medicaid-enrolled children from birth to age 18 and measure progress since 2002. METHODS: By using Medicaid research files and information from the Centers for Medicare & Medicaid Services 416 Early Periodic Screening, Diagnostic, and Treatment forms, we calculated the prevalence of DCV in 50 states and the District of Columbia, stratifying by age, race, type of health plan, and Children's Health Insurance Program status. RESULTS: The prevalence of having DCV ranged from 12% depending on age, to 49% with a median value of 33% but did not exceed 50% in any state. The median percent change between 2002 and 2007 was 16%. DCV among toddlers and infants were low in all but 3 states and in most states peaked at age of school entry to >60% in some states. In most states, there were few racial differences in the prevalence of DCV. Children enrolled in Primary Care Case Management tended to have the highest DCV, the effect of Children's Health Insurance Program enrollment on the number of DCV was generally positive. CONCLUSIONS: To our knowledge, this is the first study to evaluate the prevalence of dental care by using paid Medicaid claims. Consistent with other reports, levels of DCV were low; but when the number of DCV was stratified by age and type plan, striking patterns emerged suggesting that a combination of school programs and having a medical home may have a positive impact on dental care.

Injury prevalence among children and adolescents with mental retardation.

Childhood injuries lead to increased morbidity and result in significant costs to public insurance programs. People with mental retardation, most of whom are covered by Medicaid, are at high risk for injury, which has implications for community inclusion, a central policy goal. Medicaid data from inpatient, outpatient, and long-term care settings represent an important new resource for injury surveillance in this population. Injury prevalence for 8.4 million Medicaid-eligible children in 26 states was measured using 1999 eligibility and claims data; 36.9% Medicaid beneficiaries ages 1 to 20 with mental retardation had at least one injury claim as compared with 23.5% of those without mental retardation. Prevalence rates are reported by gender and age for a variety of injury types.

Quality of care for women undergoing a hysterectomy: effects of insurance and race/ethnicity.

OBJECTIVE: We assessed the quality of hospital care for women who underwent a hysterectomy to compare Medicaid-covered women with privately insured women and minority women with White women. METHODS: We evaluated medical decisions, inpatient care, quality of inpatient care, and outcomes. RESULTS: Quality of hospital care was equivalent for Medicaid-covered women compared with privately insured women and for non-Hispanic Black women compared with White women. Medicaid-covered women (40%) and Black women (68%) were more likely to have a complication compared with privately insured women and White women, respectively. CONCLUSIONS: Increased complications after hysterectomy may result in increased economic burdens to Medicaid. Further studies of the racial/ethnic and sociodemographic issues are needed so that disparities may be adequately addressed.

Effect of compliance with health supervision guidelines among US infants on emergency department visits.

BACKGROUND: There are few studies that demonstrate the health benefit of compliance with early periodic health supervision. OBJECTIVE: To examine the association between emergency department (ED) use and compliance with prevailing guidelines for periodic health supervision for conditions that potentially could be avoided among a national cohort of US children. DESIGN: This was a historic cohort study that combined maternal and primary care physician reports of the use of preventive care services for infants during the first 7 months of life from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-up study. A preventive care scale used in Cox proportional hazards survival regression predicted the time to the first ED visit for selected diagnoses and all-cause visits controlling for illness severity. RESULTS: Among children with incomplete well-child care in the first 6 months of life, there was an increased risk of having an ED visit for an upper respiratory tract infection (hazard ratio, 2.3; 95% confidence interval, 1.6-3.2), gastroenteritis (hazard ratio, 1.8; 95% confidence interval, 1.0-3.0), asthma (hazard ratio, 2.1; 95% confidence interval, 1.0-4.3), and all-cause ED visits (hazard ratio, 1.6; 95% confidence interval, 1.4-1.98). CONCLUSIONS: Because of the positive effect compliance with national guidelines for early well-child care has on lowering the risk of experiencing ED use, national efforts to improve the quality of child health services for young children should focus on increasing compliance with periodic preventive care for young children.

Medicaid and the Health of Children.

The Medicaid program has evolved and expanded since its inception in 1965, providing health insurance coverage for ever-increasing numbers of children living in poverty. During the first 35 years of Medicaid, the program has expanded coverage to include preventive services for children, expanded eligibility criteria to include uninsured children not receiving welfare. The Medicaid program has encouraged innovation in the form of managed care and primary care case management. Most recently, the State Children's Health Insurance Program (SCHIP) has given States freedom in providing more children with coverage. Medicaid has had a powerful influence on the health of the Nation's children. Because of Medicaid coverage, fewer children die, and children have less severe illnesses, fewer hospitalizations, fewer emergency department visits, more preventive care, and more immunizations than they would have had they not been insured.

Overview.

This issue features child and adolescent health care, focusing especially on the effectiveness of the 1989 Omnibus Budget Reconciliation Act (OBRA 89), which expanded health benefits to more children and pregnant women in Medicaid. Also featured: the effectiveness of some managed health care plans for Medicaid-eligible children, and injury hospitalizations in California in 1992. Some of the material is particularly relevant to the Children's Health Insurance Program (CHIP), which is the current effort to insure the Nation's working poor.

Hospitalizations for Injury Among Medicaid Children: California, 1992.

Little is known about the incidence and cost of injuries for Medicaid children. This article provides data on hospital utilization and payments for injuries among Medicaid children, using the Health Care Financing Administration's (HCFA) State Medicaid Research Files. During 1992, there were nearly 17,000 injury hospitalizations for California's Medicaid children (758 per 100,000 enrollees), representing over $93 million in program payments. The most frequent injury hospitalizations were fractures and dislocations. Disabled children and 18- to 20-year-old males experienced the highest hospital utilization rates. These findings will assist Medicaid policymakers in targeting prevention efforts to reduce incidence and program payments for children's injuries.