Management of cardiovascular risk in the usual care of Medicaid recipients.

Uncontrolled risk factors contribute substantially to cardiovascular disease burden. With retrospective chart review, we examined rates of cardiovascular risk factor assessment and intervention during the course of usual care for a representative sample of 3,742 adult North Carolina Medicaid recipients with diagnosed hypertension managed by a primary care provider. Most patients had been established with their provider for at least three years. Ninety-six percent had multiple modifiable risk factors. Blood pressure and cholesterol were above goal for 52.9% and 37.2% of patients, respectively. Among those with uncontrolled blood pressure, only 44.3% had intensification of therapy within the prior year. Half of patients with cholesterol above goal were treated with medication; and half of current smokers had documented advice to quit. Documentation of aspirin use or counseling was rare. Despite Medicaid coverage and access to care, many effective strategies to prevent cardiovascular events were underutilized, even among patients at highest risk.

Prevention and treatment of childhood obesity: care received by a state medicaid population.

Based on chart review for a representative cluster sample of North Carolina Medicaid enrollees aged 3 to 5 years (n = 1951) and 13 to 16 years (n = 1922) years, this study describes prevalence, practice patterns, and comorbidities related to overweight/obese immediately prior to 2007 Expert Recommendations. In total, 16% of children in both age groups were overweight, and 20% (ages 3-5 years) and 25% (ages 13-16 years) were obese. For 3- to 5-year-olds, body mass index percentile was infrequently recorded (22%) or plotted on growth charts (24%), and weight status category was rarely documented (10%). Results were similar for adolescents (21%, 20%, and 12%, respectively). In both groups, documentation of counseling in nutrition or physical activity was rare (16% for ages 3-5 years; 7% for ages 13-16 years). In adolescents, approximately 20% received recommended laboratory screening and overweight/ obesity was significantly associated with chart-documented asthma, back pain, prediabetes, gastroesophageal reflux disease, hypertension, and sleep apnea. Whether improvements in documentation of care followed these new guidelines deserves further research.

Racial disparities in blood pressure control and treatment differences in a Medicaid population, North Carolina, 2005-2006.

INTRODUCTION: Racial disparities in prevalence and control of high blood pressure are well-documented. We studied blood pressure control and interventions received during the course of a year in a sample of black and white Medicaid recipients with high blood pressure and examined patient, provider, and treatment characteristics as potential explanatory factors for racial disparities in blood pressure control. METHODS: We retrospectively reviewed the charts of 2,078 black and 1,436 white North Carolina Medicaid recipients who had high blood pressure managed in primary care practices from July 2005 through June 2006. Documented provider responses to high blood pressure during office visits during the prior year were reviewed. RESULTS: Blacks were less likely than whites to have blood pressure at goal (43.6% compared with 50.9%, P = .001). Blacks above goal were more likely than whites above goal to have been prescribed 4 or more antihypertensive drug classes (24.7% compared with 13.4%, P < .001); to have had medication adjusted during the prior year (46.7% compared with 40.4%, P = .02); and to have a documented provider response to high blood pressure during office visits (35.7% compared with 30.0% of visits, P = .02). Many blacks (28.0%) and whites (34.3%) with blood pressure above goal had fewer than 2 antihypertensive drug classes prescribed. CONCLUSION: In this population with Medicaid coverage and access to primary care, blacks were less likely than whites to have their blood pressure controlled. Blacks received more frequent intervention and had greater use of combination antihypertensive therapy. Care patterns observed in the usual management of high blood pressure were not sufficient to achieve treatment goals or eliminate disparities.

Level of blood pressure above goal and clinical inertia in a Medicaid population.

Failure to adjust hypertension therapy despite elevated blood pressure (BP) levels is an important contributor to lack of BP control. One possible explanation is that small elevations above goal BP are not concerning to clinicians. BP levels farther above goal, however, should be more likely to prompt clinical action. We reviewed 1 year's worth of primary care records of 3742 North Carolina Medicaid recipients 21 years and older with hypertension (a total of 15,516 office visits) to examine variations in hypertension management stratified by level of BP above goal and the association of BP level above goal with documented antihypertensive medication change. Among the 53% of patients not at goal BP, 42% were within 10/5 mm Hg of goal; 11% had a BP 40/20 mm Hg or higher above goal. Higher level of BP above goal was independently associated with antihypertensive medication change. Compared with visits at which BP was less than 10/5 mm Hg above goal, the adjusted odds of medication change were 7.9 (95% Confidence Interval 6.2-10.2) times greater at visits when patients' BP was 40/20 mm Hg or higher above goal. However, even when BP was above goal at this level, treatment change occurred only 46% (95% Confidence Interval 40.2-51.8) of the time.

Racial/ethnic differences in quality of care for North Carolina Medicaid recipients.

BACKGROUND: National health care quality measures suggest that racial and ethnic minority populations receive inferior quality of care compared to whites across many health services. As the largest insurer of low-income and minority populations in the United States, Medicaid has an important opportunity to identify and address health care disparities. METHODS: Using 2006 Healthcare Effectiveness Data and Information Set (HEDIS) measures developed by the National Committee for Quality Assurance (NCQA), we examined quality of care for cancer screening, diabetes, and asthma among all eligible non-dual North Carolina Medicaid recipients by race and ethnicity. RESULTS: In comparison to non-Latino whites, non-Latino African Americans had higher rates of screening for breast cancer (40.7% vs. 36.7%), cervical cancer (60.5% vs. 54.6%), and colorectal cancer (25.5% vs. 20.6%) and lower rates of LDL testing among people with diabetes (61.8% vs. 65.7%) and appropriate asthma medication use (88.7% vs. 97.0%). A1C testing and retinal eye exam rates among people with diabetes were similar. Smaller racial/ethnic minority groups had favorable quality indicators across most measures. LIMITATIONS: Comparability of findings to national population-based quality measures and other health plan HEDIS measures is limited by lack of case-mix adjustment. CONCLUSIONS: For the health services examined, we did not find evidence of large racial and ethnic disparities in quality of care within the North Carolina Medicaid program. There is substantial room for improvement, however, in cancer screening and preventive care for Medicaid recipients as a whole.

Recommendation for and receipt of cancer screenings among medicaid recipients 50 years and older.

BACKGROUND: Persons of low socioeconomic status, including those with Medicaid coverage, are more likely to be diagnosed with cancer at an advanced stage, but little is known about cancer screening practices among Medicaid recipients. Our objective was to identify cancer screening rates among older Medicaid recipients seen in a primary care setting, and to identify patient and physician characteristics associated with screening. METHODS: We used a stratified cluster sampling design to select a representative sample of 1951 North Carolina Medicaid recipients 50 years and older. Medical records were reviewed in the office of the primary care provider. Principal outcomes were the documentation of physician recommendations for and patient receipt of screening examinations for colorectal, breast, and cervical cancer. RESULTS: Documentation that colorectal, breast, and cervical cancer screening was recommended by the primary care provider was found for only 52.7%, 60.4%, and 51.5% of eligible patients, respectively. Documented rates of adequate screening were 28.2% for colorectal cancer, 31.7% for mammography within 2 years, and 31.6% for Papanicolaou test within 3 years. When medical record and claims data were combined, approximately half of eligible patients had evidence of screening. Length of the patient-physician relationship and African American race were positively associated with screening. CONCLUSIONS: Cancer screening rates among older Medicaid recipients fall far short of national objectives. Lack of a screening recommendation by the physician, rather than patient refusal of recommended tests, accounted for most instances of screening delinquency. Efforts to increase cancer screening rates among Medicaid recipients must address patient, physician, and organizational barriers to the routine identification and delivery of preventive services.