Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 4.306
Filtrar
2.
J Ment Health Policy Econ ; 23(2): 61-75, 2020 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-32621726

RESUMEN

BACKGROUND: Boarding of patients in hospital emergency departments (EDs) occurs routinely across the U.S. ED patients with behavioral health conditions are more likely to be boarded than other patients. However, the existing literature on ED boarding of psychiatric patients remains largely descriptive and has not empirically related mental health system capacity to psychiatric boarding. Nor does it show how the mental health system could better address the needs of populations at the highest risk of ED boarding. AIMS OF THE STUDY: We examined extent and determinants of "boarding" of patients with severe mental illness (SMI) in hospital emergency departments (ED) and tested whether greater mental health system capacity may mitigate the degree of ED boarding. METHODS: We linked Oregon's ED Information Exchange, hospital discharge, and Medicaid data to analyze encounters in Oregon hospital EDs from October 2014 through September 2015 by 7,103 persons aged 15 to 64 with SMI (N = 34,207). We additionally utilized Medicaid claims for years 2010-2015 to identify Medicaid beneficiaries with SMI. Boarding was defined as an ED stay over six hours. We estimated a recursive simultaneous-equation model to test the pathway that mental health system capacity affects ED boarding via psychiatric visits. RESULTS: Psychiatric visits were more likely to be boarded than non-psychiatric visits (30.2% vs. 7.4%). Severe psychiatric visits were 1.4 times more likely to be boarded than non-severe psychiatric visits. Thirty-four percent of psychiatric visits by children were boarded compared to 29.6% for adults. Statistical analysis found that psychiatric visit, substance abuse, younger age, black race and urban residence corresponded with an elevated risk of boarding. Discharge destinations such as psychiatric facility and acute care hospitals also corresponded with a higher probability of ED boarding. Greater supply of mental health resources in a county, both inpatient and intensive community-based, corresponded with a reduced risk of ED boarding via fewer psychiatric ED visits. DISCUSSION: Psychiatric visit, severity of psychiatric diagnosis, substance abuse, and discharge destinations are among important predictors of psychiatric ED boarding by persons with SMI. A greater capacity of inpatient and intensive community mental health systems may lead to a reduction in psychiatric ED visits by persons with SMI and thereby decrease the extent of psychiatric ED boarding. IMPLICATIONS FOR HEALTH POLICIES: Continued investment in mental health system resources may reduce psychiatric ED visits and mitigate the psychiatric ED boarding problem.


Asunto(s)
Ocupación de Camas/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Pacientes Internos/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Trastornos Mentales/terapia , Adolescente , Adulto , Humanos , Trastornos Mentales/psicología , Persona de Mediana Edad , Oregon , Admisión del Paciente/estadística & datos numéricos , Calidad de la Atención de Salud , Trastornos Relacionados con Sustancias/complicaciones , Estados Unidos , Adulto Joven
3.
Natl Vital Stat Rep ; 69(3): 1-11, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32510315

RESUMEN

Objectives-This report presents data on recent trends for three sexually transmitted infections (STIs)-chlamydia, gonorrhea, and syphilis-reported among women giving birth in the United States from 2016 through 2018, and rates by selected characteristics for 2018. Methods-Data are from birth certificates and are based on 100% of births registered in the United States for 2016, 2017, and 2018. Birth certificate data on infections during pregnancy are recommended to be collected from the mother's medical records (1). Mothers are to be reported as having an infection if there is a confirmed diagnosis or documented treatment for the infection in their medical record (2). Results-Among women giving birth in 2018, the overall rates of chlamydia, gonorrhea, and syphilis were 1,843.9, 310.2, and 116.7 per 100,000 births, respectively. The rates for these STIs increased 2% (chlamydia), 16% (gonorrhea), and 34% (syphilis) from 2016 through 2018. In 2018, rates of chlamydia and gonorrhea decreased with advancing maternal age, whereas those for syphilis decreased with maternal age through 30-34 years and then increased for women aged 35 and over. In 2018, rates of all three STIs were highest for non-Hispanic black women, women who smoked during pregnancy, women who received late or no prenatal care, and women for whom Medicaid was the principal source of payment for the delivery. Among women aged 25 and over, rates of each of the STIs decreased with increasing maternal education.


Asunto(s)
Complicaciones Infecciosas del Embarazo/epidemiología , Enfermedades de Transmisión Sexual/epidemiología , Adulto , Certificado de Nacimiento , Infecciones por Chlamydia/epidemiología , Infecciones por Chlamydia/etnología , Grupos de Población Continentales/estadística & datos numéricos , Parto Obstétrico/economía , Escolaridad , Femenino , Gonorrea/epidemiología , Gonorrea/etnología , Humanos , Edad Materna , Medicaid/estadística & datos numéricos , Embarazo , Complicaciones Infecciosas del Embarazo/etnología , Atención Prenatal/estadística & datos numéricos , Enfermedades de Transmisión Sexual/etnología , Fumar/epidemiología , Fumar/etnología , Sífilis/epidemiología , Sífilis/etnología , Estados Unidos/epidemiología , Adulto Joven
4.
Med Care ; 58(6): 497-503, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32412941

RESUMEN

BACKGROUND: Rates of low birthweight and prematurity vary 2-fold across states in the United States, with increased rates among states with higher concentrations of racial minorities. Medicaid expansion may serve as a mechanism to reduce geographic variation within states that expanded, by improving health and access to care for vulnerable populations. OBJECTIVE: The objective of this study was to identify the association of Medicaid expansion with changes in county-level geographic variation in rates of low birthweight and preterm births, overall and stratified by race/ethnicity. RESEARCH DESIGN: We compared changes in the coefficient of variation and the ratio of the 80th-to-20th percentiles using bootstrap samples (n=1000) of counties drawn separately for all births and for white, black, and Hispanic births, separately. MEASURES: County-level rates of low birthweight and preterm birth. RESULTS: Before Medicaid expansion, counties in expansion states were concentrated among quintiles with lower rates of adverse birth outcomes and counties in nonexpansion states were concentrated among quintiles with higher rates. In expansion states, county-level variation, measured by the coefficient of variation, declined for both outcomes among all racial/ethnic categories. In nonexpansion states, geographic variation reduced for both outcomes among Hispanic births and for low birthweight among white births, but increased for both outcomes among black births. CONCLUSIONS: The decrease in county-level variation in adverse birth outcomes among expansion states suggests improved equity in these states. Further reduction in geographic variation will depend largely on policies or interventions that reduce racial disparities in states that did and did not expand Medicaid.


Asunto(s)
Grupos de Población Continentales/estadística & datos numéricos , Recién Nacido de Bajo Peso , Medicaid/estadística & datos numéricos , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Nacimiento Prematuro/etnología , Afroamericanos/estadística & datos numéricos , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Encuestas Epidemiológicas , Hispanoamericanos/estadística & datos numéricos , Humanos , Recién Nacido , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Análisis Espacial , Estados Unidos/epidemiología
5.
PLoS Med ; 17(5): e1003119, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32421717

RESUMEN

BACKGROUND: Criminal justice involvement is common among pregnant women with opioid use disorder (OUD). Medications for OUD improve pregnancy-related outcomes, but trends in treatment data among justice-involved pregnant women are limited. We sought to examine trends in medications for OUD among pregnant women referred to treatment by criminal justice agencies and other sources before and after the Affordable Care Act's Medicaid expansion. METHODS AND FINDINGS: We conducted a serial, cross-sectional analysis using 1992-2017 data from pregnant women admitted to treatment facilities for OUD using a national survey of substance use treatment facilities in the United States (N = 131,838). We used multiple logistic regression and difference-in-differences methods to assess trends in medications for OUD by referral source. Women in the sample were predominantly aged 18-29 (63.3%), white non-Hispanic, high school graduates, and not employed. Over the study period, 26.3% (95% CI 25.7-27.0) of pregnant women referred by criminal justice agencies received medications for OUD, which was significantly less than those with individual referrals (adjusted rate ratio [ARR] 0.45, 95% CI 0.43-0.46; P < 0.001) or those referred from other sources (ARR 0.51, 95% CI 0.50-0.53; P < 0.001). Among pregnant women referred by criminal justice agencies, receipt of medications for OUD increased significantly more in states that expanded Medicaid (n = 32) compared with nonexpansion states (n = 18) (adjusted difference-in-differences: 12.0 percentage points, 95% CI 1.0-23.0; P = 0.03). Limitations of this study include encounters that are at treatment centers only and that do not encompass buprenorphine prescribed in ambulatory care settings, prisons, or jails. CONCLUSIONS: Pregnant women with OUD referred by criminal justice agencies received evidence-based treatment at lower rates than women referred through other sources. Improving access to medications for OUD for pregnant women referred by criminal justice agencies could provide public health benefits to mothers, infants, and communities. Medicaid expansion is a potential mechanism for expanding access to evidence-based treatment for pregnant women in the US.


Asunto(s)
Medicina Basada en la Evidencia/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides/terapia , Adulto , Femenino , Hispanoamericanos , Humanos , Patient Protection and Affordable Care Act , Embarazo , Estudios Retrospectivos , Estados Unidos , Adulto Joven
6.
PLoS One ; 15(4): e0231417, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32271845

RESUMEN

OBJECTIVE: Evaluate how the use of a Section 1115 waiver in Arkansas was associated with health insurance coverage compared to Medicaid expansion states that did not use a waiver. METHODS: Difference in difference analysis was conducted of 1,320,790 adults aged 19-64 with family incomes at or below 138% of the federal poverty level from the 2010-2017 American Community Survey. Arkansas was compared to states that expanded without a waiver in calendar year 2014. States that expanded Medicaid with an approved Section 1115 waiver during the study period or expanded without a waiver after 2014 or did not expand Medicaid were excluded from the analysis. The outcome measures were no health insurance coverage, Medicaid coverage, employer sponsored private insurance, and non-group direct purchase private insurance. RESULTS: Arkansas's use of a waiver to expand Medicaid was associated with a lower uninsured rate (-3.7%, p< 0.001), a higher Medicaid coverage rate (2.0%, p< 0.001), and a higher non-group, direct purchase private insurance coverage rate (2.9%, p< 0.001) compared to states that expanded Medicaid in 2014 without a waiver. CONCLUSION: Compared to states that implemented traditional Medicaid expansion, we found that Arkansas's waiver was associated with increases in health insurance coverage rates.


Asunto(s)
Cobertura del Seguro/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Adulto , Arkansas , Femenino , Humanos , Seguro de Salud/estadística & datos numéricos , Masculino , Pacientes no Asegurados/estadística & datos numéricos , Persona de Mediana Edad , Patient Protection and Affordable Care Act , Pobreza , Estados Unidos , Adulto Joven
7.
Ann Epidemiol ; 45: 54-60, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32327270

RESUMEN

PURPOSE: Health and mortality of people released from incarceration have received increased attention, and yet little is known about the postrelease experiences of those hospitalized during incarceration. METHODS: For persons incarcerated and released from the North Carolina (NC) state prison system between January 1, 2008, and June 30, 2015, we examined postrelease mortality from 2008 to 2016 by history of prison hospitalization. RESULTS: Among 111,479 released persons, 0.9% (n = 1010) were hospitalized during their incarceration, and of those, 10.5% (n = 106) died during follow-up compared with 3.2% (3511/110,469) of other released persons. Those hospitalized in prison had a higher postrelease death rate (adjusted hazard ratio: 2.44), a lower 8-year conditional probability of survival (0.80 vs. 0.94), and were more likely to die from chronic causes (79.2% vs. 51.0%) than other released persons. The postrelease standardized mortality rate among men hospitalized in prison was 3.1 times higher than that of those not hospitalized and 7.1 times the rate of all NC men. CONCLUSIONS: People hospitalized during incarceration constitute a particularly vulnerable, yet relatively easily identifiable priority population to focus health interventions supporting continuity of care after prison release. Yet such efforts may be particularly challenging in NC and other Medicaid non-expansion states.


Asunto(s)
Hospitalización/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Mortalidad , Prisioneros/estadística & datos numéricos , Prisiones , Adulto , Causas de Muerte , Femenino , Humanos , Masculino , Persona de Mediana Edad , North Carolina/epidemiología , Prisioneros/psicología , Factores de Riesgo , Estados Unidos
8.
Ann Epidemiol ; 45: 24-31.e3, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32336655

RESUMEN

PURPOSE: HIV pre-exposure prophylaxis (PrEP) is highly efficacious, and yet most individuals indicated for it are not currently using it. To provide guidance for health policymakers, researchers, and community advocates, we developed county-level PrEP use estimates and assessed locality and policy associations. METHODS: Using data from a national aggregator, we applied a validated crosswalk procedure to generate county-level estimates of PrEP users in 2018. A multilevel Poisson regression explored associations between PrEP use and (1) state policy variables of Medicaid expansion and state Drug Assistance Programs (PrEP-DAPs) and (2) county-level characteristics from the U.S. Census Bureau. Outcomes were PrEP per population (prevalence) and PrEP-to-need ratio (PnR), defined as the ratio of PrEP users per new HIV diagnosis. Higher levels of PrEP prevalence or PnR indicate more PrEP users relative to the total population or estimated need, respectively. RESULTS: Our 2018 county-level data set included a total of 188,546 PrEP users in the United States. Nationally, PrEP prevalence was 70.3/100,000 population and PnR was 4.9. In an adjusted model, counties with a 5% higher proportion of black residents had 5% lower PnR (rate ratio (RR): 0.95, 95% confidence interval (CI): 0.93, 0.96). Similarly, counties with higher concentration of residents uninsured or living in poverty had lower PnR. Relative to states without Medicaid expansion or PrEP-DAPs, states with only one of those programs had 25% higher PrEP prevalence (RR: 1.25, 95% CI: 1.09, 1.45), and states with both programs had 99% higher PrEP prevalence (RR: 1.99, 95% CI: 1.60, 2.48). There was a significant linear trend across the three policy groups, and similar findings for the relation between PnR and the policy groups. CONCLUSIONS: In a data set comprising approximately 80% of PrEP users in the United States, we found that Medicaid expansion and PrEP-DAPs were associated with higher PrEP use in states that adopted those policies, after controlling for potential confounders. Future research should identify which components of PrEP support programs have the most success and how to best promote PrEP among groups most impacted by the epidemic. States should support the admirable health decisions of their residents to get on PrEP by implementing policies that facilitate access.


Asunto(s)
Fármacos Anti-VIH/administración & dosificación , Infecciones por VIH/prevención & control , Medicaid/estadística & datos numéricos , Formulación de Políticas , Profilaxis Pre-Exposición/estadística & datos numéricos , Adulto , Anciano , Fármacos Anti-VIH/provisión & distribución , Femenino , Infecciones por VIH/epidemiología , Política de Salud , Humanos , Gobierno Local , Masculino , Persona de Mediana Edad , Profilaxis Pre-Exposición/métodos , Características de la Residencia , Estados Unidos/epidemiología
9.
J Surg Oncol ; 121(8): 1191-1200, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-32227342

RESUMEN

BACKGROUND AND OBJECTIVES: A previous analysis of breast cancer care after the 2014 Medicaid expansion in Kentucky demonstrated delays in treatment despite a 12% increase in insurance coverage. This study sought to identify factors associated with treatment delays to better focus efforts for improved breast cancer care. METHODS: The Kentucky Cancer Registry was queried for adult women diagnosed with invasive breast cancer between 2010 and 2016 who underwent up-front surgery. Demographic, tumor, and treatment characteristics were assessed to identify factors independently associated with treatment delays. RESULTS: Among 6225 patients, treatment after Medicaid expansion (odds ratio [OR] = 2.18, 95% confidence interval [CI] = 1.874-2.535, P < .001), urban residence (OR = 1.362, 95% CI = 1.163-1.594, P < .001), treatment at an academic center (OR = 1.988, 95% CI = 1.610-2.455, P < .001), and breast reconstruction (OR = 3.748, 95% CI = 2.780-5.053, P < .001) were associated with delay from diagnosis to surgery. Delay in postoperative chemotherapy was associated with older age (OR = 1.155,95% CI = 1.002-1.332, P = .0469), low education level (OR = 1.324, 95% CI = 1.164-1.506, P < .001), hormone receptor positivity (OR = 1.375, 95% CI = 1.187-1.593, P < .001), and mastectomy (OR = 1.312, 95% CI = 1.138-1.513, P < .001). Delay in postoperative radiation was associated with younger age (OR = 1.376, 95% CI = 1.370-1.382, P < .001), urban residence (OR = 1.741, 95% CI = 1.732-1.751, P < .001), treatment after Medicaid expansion (OR = 2.007, 95% CI = 1.994-2.021, P < .001), early stage disease (OR = 5.661, 95% CI = 5.640-5.682, P < .001), and mastectomy (OR = 1.884, 95% CI = 1.870-1.898, P < .001). CONCLUSIONS: Patient, tumor, and socioeconomic factors influence the timing of breast cancer treatment. Improving timeliness of treatment will likely require improvements in outreach, education, and healthcare infrastructure.


Asunto(s)
Neoplasias de la Mama/terapia , Medicaid/estadística & datos numéricos , Tiempo de Tratamiento/estadística & datos numéricos , Factores de Edad , Anciano , Neoplasias de la Mama/economía , Neoplasias de la Mama/epidemiología , Quimioterapia Adyuvante , Estudios de Cohortes , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Cobertura del Seguro/estadística & datos numéricos , Kentucky/epidemiología , Modelos Logísticos , Mastectomía , Mastectomía Segmentaria , Persona de Mediana Edad , Radioterapia Ayuvante , Sistema de Registros , Estados Unidos
10.
PLoS One ; 15(3): e0229787, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32126120

RESUMEN

OBJECTIVE: To identify the geographic, organisational, and payment correlates of buprenorphine and methadone treatment among substance abuse treatment (SAT) providers. METHODS: Secondary analyses of the National Survey of Substance Abuse Treatment Services (NSSATS) from 2007-16 were conducted. We provide bivariate descriptive statistics regarding substance abuse treatment services which offered buprenorphine and methadone treatment from 2007-16. Using multiple logistic regression, we regressed geographic, organisational, and payment correlates on buprenorphine and methadone treatment. RESULTS: Buprenorphine is increasingly offered at SAT facilities though uptake remains comparatively low outside of the northeast. SAT facilities run by tribal governments or Indian Health Service which offer buprenorphine remain low compared to privately operated SAT facilities (AOR = 0.528). The odds of offering buprenorphine among facilities offering free or no charge treatment (AOR = 0.838) or a sliding fee scale (AOR = 0.464) was lower. SAT facilities accepting Medicaid payments showed higher odds of offering methadone treatment (AOR = 2.035). CONCLUSIONS: Greater attention towards the disparities in provision of opioid agonist therapies is warranted, especially towards the reasons why uptake has been moderate among civilian providers. Additionally, the care needs of Native Americans facing opioid-related use disorders bears further scrutiny.


Asunto(s)
Antagonistas de Narcóticos/uso terapéutico , Tratamiento de Sustitución de Opiáceos/estadística & datos numéricos , Epidemia de Opioides/prevención & control , Trastornos Relacionados con Opioides/rehabilitación , Centros de Tratamiento de Abuso de Sustancias/estadística & datos numéricos , Analgésicos Opioides/efectos adversos , Buprenorfina/economía , Buprenorfina/uso terapéutico , Costo de Enfermedad , Geografía , Disparidades en Atención de Salud/economía , Disparidades en Atención de Salud/organización & administración , Disparidades en Atención de Salud/estadística & datos numéricos , Humanos , Medicaid/economía , Medicaid/estadística & datos numéricos , Metadona/economía , Metadona/uso terapéutico , Antagonistas de Narcóticos/economía , Tratamiento de Sustitución de Opiáceos/economía , Tratamiento de Sustitución de Opiáceos/tendencias , Trastornos Relacionados con Opioides/economía , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/etiología , Centros de Tratamiento de Abuso de Sustancias/economía , Centros de Tratamiento de Abuso de Sustancias/organización & administración , Encuestas y Cuestionarios/estadística & datos numéricos , Estados Unidos/epidemiología
11.
Med Care ; 58(6): 519-525, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32149923

RESUMEN

BACKGROUND: Following birth, women may access preventive care in adult settings or, with their infants, in pediatric settings. Preventive care can improve future birth outcomes and long-term health, particularly for women with health risks. METHODS: This cohort study linked mother-infant Medicaid claims from 12 states for 2007-2011 births. Pregnancy claims identified health risk categories: maternal cardiovascular (diabetes, hypertension, pre-eclampsia, obesity), maternal mental health (depression, anxiety), and premature birth. Claims for 1 year following birth identified adult and pediatric preventive visits. Logistic regression assessed the relationship between visits and risks, adjusting for maternal demographics, perinatal health care utilization, year, and state. RESULTS: Of 594,888 mother-infant dyads with Medicaid eligibility for 1 year following birth, 36% had health risks. In total, 38% of all dyads, and 33% with health risks, had no adult preventive visits. Dyads had a median of 1 (IQR, 0-2) adult and 3 (IQR, 2-5) pediatric preventive visits. A total of 72% of dyads had more preventive visits in pediatric than adult settings. In regression, preterm birth was associated with lower odds of any adult preventive visits [odds ratio (OR), 0.97; 95% confidence interval (CI), 0.95-0.99], and maternal health risks with higher odds (cardiovascular OR, 1.19; 95% CI, 1.18-1.21; mental health OR, 1.87; 95% CI, 1.84-1.91), compared with dyads without risk. CONCLUSIONS: Maternal health risks were associated with increased adult preventive visits, but 38% of dyads had no adult preventive visits in the year following birth. Most dyads had more opportunities for preventive care in pediatric settings than adult settings.


Asunto(s)
Medicaid/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Complicaciones del Embarazo/epidemiología , Servicios Preventivos de Salud/estadística & datos numéricos , Adulto , Femenino , Humanos , Lactante , Recién Nacido , Revisión de Utilización de Seguros , Modelos Logísticos , Masculino , Embarazo , Estudios Retrospectivos , Factores Socioeconómicos , Estados Unidos , Adulto Joven
12.
Med Care ; 58(6): 526-533, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32205790

RESUMEN

OBJECTIVE: The objective of this study was to examine how pre-Affordable Care Act (ACA) state-level Medicaid expansions affect dual enrollment and utilization of Veterans Health Administration (VA) and Medicaid-funded care. RESEARCH DESIGN: We employed difference-in-difference analysis to determine the association between pre-ACA Medicaid expansions in New York and Arizona in 2001 and VA utilization. Participants' dual enrollment in Medicaid and VA, the distribution of their annual hospital admissions and emergency department (ED) visits between VA and Medicaid were dependent variables. We controlled for age, race, sex, disease burden, distance to VA facilities and income-based eligibility for VA services. MEASURES: Secondary data collected from 1999 to 2006 in 2 states expanding Medicaid and 3 demographically similar nonexpansion states. We obtained residency, enrollment and utilization data from VA's Corporate Data Warehouse and Medicaid Analytic Extract files. RESULTS: For low-income Veterans, Medicaid expansion was associated with increased dual enrollment of 4.87 percentage points (99% confidence interval: 4.48-5.25), a 4.63-point decline in VA proportion of admissions (-5.87 to -3.38), and a 11.70-point decrease in the VA proportion of ED visits (-13.06 to -10.34). Results also showed increases in the number of total (VA plus Medicaid) annual per-capita hospitalizations and ED visits among the group of VA enrollees most likely to be eligible for expansion. CONCLUSIONS: This study shows slight usage shifts when Veterans gain access to non-VA care. It highlights the need to overcome care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional expansions of public health insurance programs such as Medicare-for-All.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Pobreza/estadística & datos numéricos , Servicios de Salud para Veteranos/estadística & datos numéricos , Adulto , Factores de Edad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Factores Sexuales , Factores Socioeconómicos , Estados Unidos
13.
Med Care ; 58(6): 574-578, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32221101

RESUMEN

BACKGROUND: Health care access increased for low-income Americans under the Affordable Care Act (ACA). It is unknown whether these changes in access were associated with improved self-reported health. OBJECTIVE: Determine changes in health care access, health behaviors, and self-reported health among low-income Americans over the first 4 years of the ACA, stratified by state Medicaid expansion status. DESIGN: Interrupted time series and difference-in-differences analysis. SUBJECTS: Noninstitutionalized US adults (18-64 y) in low income households (<138% federal poverty level) interviewed in the Behavioral Risk Factor Surveillance System 2011-2017 (N=505,824). MEASURES: Self-reported insurance coverage, access to a primary care physician, avoided care due to cost; self-reported general health, days of poor physical health, days of poor mental health days, and days when poor health limited usual activities; self-reported health behaviors, use of preventive services, and diagnoses. RESULTS: Despite increases in access, the ACA was not associated with improved physical or general health among low-income adults during the first 4 years of implementation. However, Medicaid expansion was associated with fewer days spent in poor mental health (-1.1 d/mo, 95% confidence interval: -2.1 to -0.5). There were significant changes in specific health behaviors, preventive service use, and diagnosis patterns during the same time period which may mediate the relationship between the ACA rollout and self-reported health. CONCLUSION: In nationally-representative survey data, we observed improvements in mental but not physical self-reported health among low-income Americans after 4 years of full ACA implementation.


Asunto(s)
Estado de Salud , Medicaid/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Pobreza/estadística & datos numéricos , Adolescente , Adulto , Anciano , Sistema de Vigilancia de Factor de Riesgo Conductual , Femenino , Conductas Relacionadas con la Salud , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Análisis de Series de Tiempo Interrumpido , Masculino , Salud Mental , Persona de Mediana Edad , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Servicios Preventivos de Salud/estadística & datos numéricos , Autoinforme , Estados Unidos , Adulto Joven
14.
Am J Surg ; 219(4): 571-577, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32147020

RESUMEN

INTRODUCTION: Bariatric surgery is an effective treatment for obesity resulting in both sustained weight loss and reduction in obesity-related comorbidities. It is uncertain how sociodemographic factors affect postoperative outcomes. METHODS: The National Inpatient Sample was queried for patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2005 to 2014. Factors associated with selection of SG over RYGB, increased postoperative length of stay (LOS) greater than 3 days, and inpatient mortality were compared by race, insurance status, and other clinical and hospital factors. RESULTS: The database captured 781,413 patients, of which 525,986 had a RYGB and 255,428 had SG. There was an increase in the incidence of SG over RYGB over time. Among the self-pay/uninsured, the increased incidence began several years earlier than other groups. Black patients had greater odds of increased postoperative LOS (OR 1.40) and in-hospital mortality (OR 2.11). CONCLUSION: Sociodemographic factors are associated with differences in temporal trends in the adoption of SG versus RYGB for surgical weight loss.


Asunto(s)
Gastrectomía/tendencias , Derivación Gástrica/tendencias , Mortalidad Hospitalaria , Tiempo de Internación/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Comorbilidad , Grupos de Población Continentales/estadística & datos numéricos , Conjuntos de Datos como Asunto , Femenino , Financiación Personal/estadística & datos numéricos , Humanos , Renta/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Masculino , Medicaid/estadística & datos numéricos , Pacientes no Asegurados/estadística & datos numéricos , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Sector Privado , Factores Raciales , Factores Sexuales , Estados Unidos/epidemiología , Adulto Joven
15.
JAMA Netw Open ; 3(1): e1920310, 2020 01 03.
Artículo en Inglés | MEDLINE | ID: mdl-32003819

RESUMEN

Importance: Between 2015 and 2017, Ohio had the second highest number of opioid-related deaths. In July 2015, the Ohio General Assembly approved a law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol. This change in the law allowed pharmacists to have more opportunity to participate in the management of patients who were addicted to opioids. Objective: To determine the association between the implementation of an Ohio law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol and naloxone dispensing rates. Design, Setting, and Participants: A segmented regression analysis of an interrupted time series was performed for 30 consecutive months to evaluate the change in the naloxone dispensing rate before and after the implementation of the state law. Ohio Medicaid naloxone claims and Kroger Pharmacy naloxone claims for all 88 counties in Ohio were examined. Any patient 18 years or older with at least 1 naloxone order dispensed through Ohio Medicaid or by a Kroger Pharmacy in Ohio during the study period of July 16, 2014, to January 15, 2017, was included in the study. Data were analyzed from April 23, 2018, to July 7, 2019. Exposures: The primary independent variable was implementation of an Ohio law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol, which took effect in July 2015. Main Outcomes and Measures: The primary outcome measure was the naloxone dispensing rate per month per county. Results: In the Ohio Medicaid population, the number of naloxone orders dispensed after the policy was implemented increased by 2328%, from 191 in the prepolicy period to 4637 in the postpolicy period. The rate of naloxone orders dispensed per month per county after the policy was implemented increased by 4% in the Ohio Medicaid population and 3% in the Kroger Pharmacy population compared with the prepolicy period. The rate of naloxone orders dispensed after the policy was implemented increased by 18% per month in low-employment counties compared with high-employment counties in the Ohio Medicaid population. Conclusions and Relevance: The implementation of a state law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol was associated with an increase in the number of naloxone orders dispensed in the Ohio Medicaid and Kroger Pharmacy populations. Moreover, a significant increase was observed in the naloxone dispensing rate among the Ohio Medicaid population in counties with low employment and high poverty.


Asunto(s)
Sobredosis de Droga/tratamiento farmacológico , Prescripciones de Medicamentos/estadística & datos numéricos , Prescripciones de Medicamentos/normas , Naloxona/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Pautas de la Práctica en Medicina/legislación & jurisprudencia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Medicaid/legislación & jurisprudencia , Medicaid/estadística & datos numéricos , Persona de Mediana Edad , Ohio , Estudios Retrospectivos , Estados Unidos , Adulto Joven
16.
JAMA Netw Open ; 3(1): e1920316, 2020 01 03.
Artículo en Inglés | MEDLINE | ID: mdl-32003820

RESUMEN

Importance: Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear. Objective: To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion. Design, Setting, and Participants: This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018. Main Outcomes and Measures: Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students. Results: The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status. Conclusions and Relevance: Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.


Asunto(s)
Empleo/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Estudiantes/estadística & datos numéricos , Adulto , Femenino , Humanos , Masculino , Michigan , Persona de Mediana Edad , Patient Protection and Affordable Care Act , Encuestas y Cuestionarios , Estados Unidos , Adulto Joven
17.
Med Care ; 58(6): 549-556, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32028524

RESUMEN

BACKGROUND: Medicaid expansion substantially increased health insurance coverage, but its effect on the delivery of preventative health care is unclear. OBJECTIVE: The objective of this study was to assess the impact of Medicaid expansion on the receipt of 15 different measures of preventive care including cancer screening, cardiovascular risk reduction, diabetes care, and other primary care measures. RESEARCH DESIGN: We performed serial cross-sectional analysis of Behavioral Risk Factor Surveillance System (BRFSS) survey data from 2012 to 2017. We used a quasi-experimental design with difference-in-differences (DiD) analyses to examine changes in preventative health care delivery over 3 time periods in Medicaid expansion compared with nonexpansion states. SUBJECTS: We included low-income (<138% federal poverty level) nonelderly (age younger than 65 y) adults residing in 46 US states. MEASURES: Our predictor was residing in a Medicaid expansion state (24 states) versus nonexpansion state (19 states). Our primary outcomes were preventative health care services, which we categorized as cancer screening (breast cancer, cervical cancer, and colorectal cancer); cardiovascular risk reduction (serum cholesterol screening in low-risk groups, serum cholesterol monitoring in high-risk groups, and aspirin use); diabetes care (serum cholesterol monitoring, hemoglobin A1c monitoring, foot examination, eye examination, and influenza vaccination, and pneumonia vaccination); and other primary care measures [influenza vaccination, alcohol use screening, and human immunodeficiency virus (HIV) screening]. RESULTS: Survey responses from 500,495 low-income nonelderly adults from 2012 to 2017 were included in the analysis, representing 68.2 million US adults per year. Of the 15 outcomes evaluated, we did not detect statistically significant differences in cancer screening (3 outcomes), cholesterol screening or monitoring (2 outcomes), diabetes care (6 outcomes), or alcohol use screening (1 outcome) in expansion compared with nonexpansion states. Aspirin use (DiD 8.8%, P<0.001), influenza vaccination (DiD 1.4%, P=0.016), and HIV screening (DiD 1.9%, P=0.004) increased in expansion states compared with nonexpansion states. CONCLUSIONS: Medicaid expansion was associated with an increase in aspirin use, influenza vaccination, and HIV screening in expansion states. Despite improvements in access to care, including health insurance, having a primary care doctor, and routine visits, Medicaid expansion was not associated with improvements in cancer screening, cholesterol monitoring, diabetes care, or alcohol use screening. Our findings highlight implementation challenges in delivering high-quality primary care to low-income populations.


Asunto(s)
Medicaid/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Pobreza/estadística & datos numéricos , Servicios Preventivos de Salud/estadística & datos numéricos , Adolescente , Adulto , Sistema de Vigilancia de Factor de Riesgo Conductual , Enfermedades Cardiovasculares/prevención & control , Estudios Transversales , Diabetes Mellitus/terapia , Detección Precoz del Cáncer/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Vacunas contra la Influenza/administración & dosificación , Masculino , Persona de Mediana Edad , Factores Socioeconómicos , Estados Unidos , Adulto Joven
18.
AIDS Educ Prev ; 32(1): 25-35, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-32073307

RESUMEN

The objective of this study was to measure HIV screening rates and variables associated with screening among new enrollees in California's Low Income Health Program (LIHP). A logit model was used to estimate associations between HIV screening and enrollment, claims, and encounter data for enrollees. HIV prevalence among new LIHP enrollees was 1.2%xd. Among 42,550 new LIHP enrollees with no prior HIV diagnosis, only 27% received screening within 12 months of their first medical evaluation. A total of 350 new HIV diagnoses were identified (incidence rate of 0.8%), exceeding the 0.1% level at which the Centers for Disease Control and Prevention (CDC) recommends routine HIV screening. California reduced screening barriers by removing required written informed consent and pretest counseling; the Affordable Care Act (ACA) eliminated cost-sharing and enhanced access. Removing financial and administrative barriers to HIV screening is necessary, but may be insufficient to reach CDC's recommended screening targets.


Asunto(s)
Prestación de Atención de Salud/organización & administración , Infecciones por VIH/diagnóstico , Tamizaje Masivo/estadística & datos numéricos , Medicaid/estadística & datos numéricos , California/epidemiología , Femenino , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Promoción de la Salud , Humanos , Masculino , Tamizaje Masivo/métodos , Medicaid/economía , Patient Protection and Affordable Care Act , Pobreza , Prevalencia , Estados Unidos
19.
Am J Surg ; 219(4): 557-562, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32007235

RESUMEN

BACKGROUND: The "white-flight" phenomenon of the mid-20th century contributed to the perpetuation of residential segregation in American society. In light of recent reports of racial segregation in our healthcare system, could a contemporary "white-flight" phenomenon also exist? METHODS: The New York Statewide Planning and Research Cooperative System was used to identify all Manhattan and Bronx residents of New York city who underwent elective cardiothoracic, colorectal, general, and vascular surgeries from 2010 to 2016. Primary outcome was borough of surgical care in relation to patient's home borough. Multivariable analyses were performed. RESULTS: White patients who reside in the Bronx are significantly more likely than racial minorities to travel into Manhattan for elective surgical care, and these differences persist across different insurance types, including Medicare. CONCLUSIONS: Marked race-based differences in choice of location for elective surgical care exist in New York city. If left unchecked, these differences can contribute to furthering racial segregation within our healthcare system.


Asunto(s)
Conducta de Elección , Grupos de Población Continentales/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Ubicación de la Práctica Profesional/estadística & datos numéricos , Femenino , Disparidades en Atención de Salud , Humanos , Seguro de Salud/estadística & datos numéricos , Masculino , Medicaid/estadística & datos numéricos , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Ciudad de Nueva York/epidemiología , Participación del Paciente , Factores Raciales , Estados Unidos
20.
BMC Health Serv Res ; 20(1): 100, 2020 Feb 10.
Artículo en Inglés | MEDLINE | ID: mdl-32041586

RESUMEN

BACKGROUND: Length of hospital stay (LOS) for hip fracture treatments is associated with mortality. In addition to patient demographic and clinical factors, hospital and payer type may also influence LOS, and thus mortality, among hip fracture patients; accordingly, outcome disparities between groups may arise from where patients are treated and from their health insurance type. The purpose of this study was to examine if where hip fracture patients are treated and how they pay for their care is associated with outcome disparities between patient groups. Specifically, we examined whether LOS differed between patients treated at safety-net and non-safety-net hospitals and whether LOS was associated with patients' insurance type within each hospital category. METHODS: A sample of 48,948 hip fracture patients was extracted from New York State's Statewide Planning and Research Cooperative System (SPARCS), 2014-2016. Using means comparison and X2 tests, differences between safety-net and non-safety-net hospitals on LOS and patient characteristics were examined. Relationships between LOS and hospital category (safety-net or non-safety-net) and LOS and insurance type were further evaluated through negative binomial regression models. RESULTS: LOS was statistically (p ≤ 0.001) longer in safety-net hospitals (7.37 days) relative to non-safety-net hospitals (6.34 days). Treatment in a safety-net hospital was associated with a LOS that was 11.7% (p = 0.003) longer than in a non-safety-net hospital. Having Medicaid was associated with a longer LOS relative to having commercial health insurance. CONCLUSION: Where hip fracture patients are treated is associated with LOS and may influence outcome disparities between groups. Future research should examine whether outcome differences between safety-net and non-safety-net hospitals are associated with resource availability and hospital payer mix.


Asunto(s)
Disparidades en Atención de Salud , Fracturas de Cadera/terapia , Tiempo de Internación/estadística & datos numéricos , Proveedores de Redes de Seguridad/estadística & datos numéricos , Adolescente , Adulto , Anciano , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Seguro de Salud/estadística & datos numéricos , Masculino , Medicaid/estadística & datos numéricos , Persona de Mediana Edad , New York , Estados Unidos , Adulto Joven
SELECCIÓN DE REFERENCIAS
DETALLE DE LA BÚSQUEDA