The effect of Medicaid waivers on ameliorating racial/ethnic disparities among children with autism.

OBJECTIVE: To examine the effects of Medicaid Home and Community-based Services (HCBS) waivers on reducing racial/ethnic disparities in unmet need for services among families of children with autism spectrum disorder (ASD). DATA SOURCES: Data from the 2003, 2007, and 2011 waves of the National Survey of Children's Health and the 2005 and 2010 waves of the National Survey of Children with Special Health Care Needs were used. Data on waiver characteristics were collected from source materials that were submitted in support of each state's waiver application. Waiver characteristics were combined to create a single waiver generosity variable. STUDY DESIGN: Quasi-difference-in-difference-in-difference models were used to determine the effect of waiver generosity on racial/ethnic disparities in unmet need among children with ASD. PRINCIPAL FINDINGS: Increased waiver generosity was associated with significantly reduced odds of having unmet need for black children with ASD compared with white children with ASD. Unmet needs among black children with ASD were roughly cut in half, a 13 percentage point decrease, with the implementation of an average generosity waiver. No significant differences were seen for Hispanic ethnicity. CONCLUSION: These findings suggest that Medicaid HCBS waivers have the potential to ameliorate disparities in unmet need among children with ASD. Future policy development should focus on replicating the most effective characteristics of these waivers.

Is venous blood gas performed in the Emergency Department predictive of outcome during acute on chronic hypercarbic respiratory failure?

BACKGROUND: During acute on chronic hypercarbic respiratory failure (AHRF), arterial pH is associated with non-invasive ventilation (NIV) failure and mortality. Venous blood gas (VBG) has been proposed as a substitute for arterial blood gas, based on a good agreement between venous and arterial values. We assessed the predictive value of admission VBG on intubation rate, NIV failure and mortality during AHRF. METHODS: Retrospective chart review of inpatients admitted between 2009 and 2015 with AHRF who had VBG performed on admission. Demographic, clinical and biological data were collected throughout the hospital course. RESULTS: 196 patients were included and hospital survival was not significantly associated with initial venous pH, PCO2 or HCO3-. Patients requiring intubation had significantly lower venous pH [7.29 (7.24-7.33) vs 7.31 (7.28-7.36), P = .04] while venous PCO2 and HCO3- did not differ as compared to non-intubated patients. Intubation within 48 h of admission was associated with significantly lower venous pH [7.28 (7.24-7.30) vs 7.32 (7.28-7.37), P = .002] and higher PCO2 [72 (63-92) mm Hg vs 62 (52-75) mm Hg, P = .04]. Among 69 patients receiving NIV, there were no differences in venous pH [7.29 (7.25-7.31) vs 7.30 (7.27-7.35), P = .3] or PCO2 [68 (44-74) mm Hg vs 70 (55-97) mm Hg, P = .23] associated with subsequent intubation. Using c statistics, we observed poor performances of venous pH, PCO2 or HCO3- for prediction of NIV failure, intubation or hospital mortality. CONCLUSIONS: Our results do not support the use of VBG on admission as a predictor for NIV failure, intubation and mortality during AHRF.

Spatial-temporal analysis of prostate cancer incidence from the Pennsylvania Cancer Registry, 2000-2011.

Prostate cancer is the most common cancer diagnosed among males, and the incidence in Pennsylvania, USA is considerably higher than nationally. Knowledge of regional differences and time trends in prostate cancer incidence may contribute to a better understanding of aetiologic factors and racial disparities in outcomes, and to improvements in preventive intervention and screening efforts. We used Pennsylvania Cancer Registry data on reported prostate cancer diagnoses between 2000 and 2011 to study the regional distribution and temporal trends of prostate cancer incidence in both Pennsylvania White males and Philadelphia metropolitan area Black males. For White males, we generated and mapped county-specific age-adjusted incidence and standardised incidence ratios by period cohort, and identified spatial autocorrelation and local clusters. In addition, we fitted Bayesian hierarchical generalised linear Poisson models to describe the temporal and aging effects separately in Whites state-wide and metropolitan Philadelphia blacks. Incidences of prostate cancer among white males declined from 2000-2002 to 2009-2011 with an increasing trend to some extent in the period 2006-2008 and significant variation across geographic regions, but less variation exists for metropolitan Philadelphia including majority of Black patients. No significant aging effect was detected for White and Black men, and the peak age group for prostate cancer risk varied by race. Future research should seek to identify potential social and environmental risk factors associated with geographical/racial disparities in prostate cancer. As such, there is a need for more effective surveillance so as to detect, reduce and control the cancer burden associated with prostate cancer.

Medicaid Waivers Targeting Children With Autism Spectrum Disorder Reduce The Need For Parents To Stop Working.

Several states have passed Medicaid home and community-based services waivers that expand eligibility criteria and available services for children with autism spectrum disorder. Although previous research has shown considerable variation in these waivers, little is known about the programs' impact on parents' workforce participation. We used nationally representative survey data combined with detailed information on state Medicaid waiver programs to determine the effects of waivers on whether parents of children with autism spectrum disorder had to stop working because of the child's condition. Increases in the Medicaid home and community-based services waiver cost limit and enrollment limit significantly reduced the likelihood that a parent had to stop working, although the results varied considerably by household income level. These findings suggest that the Medicaid waivers are effective policies to address the care-related needs of children with autism spectrum disorder.

The Effects of Medicaid Home and Community-based Services Waivers on Unmet Needs Among Children With Autism Spectrum Disorder.

BACKGROUND: Several states have passed Medicaid Home and Community-based Services (HCBS) waivers that expand eligibility criteria and available services for children with autism spectrum disorder (ASD). Previous research has shown considerable variation in these waivers, but little is known about the extent to which they address the health care needs of children with ASD. OBJECTIVE: To determine the effects of Medicaid HCBS waivers, and their characteristics, on unmet health care needs among children with ASD. METHODS: We used data from the 2003, 2007, and 2011 waves of the National Survey of Children's Health with detailed information on the Medicaid HCBS waiver programs of 35 states. Quasi-difference-in-difference-in-differences models were used to determine the effects of waivers and their characteristics on parent report of unmet health care needs of children with ASD compared with children without ASD. RESULTS: Greater waiver cost limits per child, estimated costs of services, and enrollment limits were associated with significant decreases in the adjusted rate of unmet health care needs, with considerable variation by household income level. CONCLUSIONS: These findings suggest that Medicaid HCBS waivers significantly decrease the unmet need for health care among children with ASD, most substantially among those who would not otherwise qualify for Medicaid. The findings regarding the effects of specific aspects of these waivers can inform the development of insurance policies in other states to address the needs of children with ASD.

Hepatic resection is associated with reduced postoperative opioid requirement.

BACKGROUND AND AIMS: Postoperative pain can significantly affect surgical outcomes. As opioid metabolism is liver-dependent, any reduction in hepatic volume can lead to increased opioid concentrations in the blood. The hypothesis of this retrospective study was that patients undergoing open hepatic resection would require less opioid for pain management than those undergoing open pancreaticoduodenectomy. MATERIAL AND METHODS: Data from 79 adult patients who underwent open liver resection and eighty patients who underwent open pancreaticoduodenectomy at our medical center between January 01, 2010 and June 30, 2013 were analyzed. All patients received both general and neuraxial anesthesia. Postoperatively, patients were managed with a combination of epidural and patient-controlled analgesia. Pain scores and amount of opioids administered (morphine equivalents) were compared. A multivariate lineal regression was performed to determine predictors of opioid requirement. RESULTS: No significant differences in pain scores were found at any time point between groups. Significantly more opioid was administered to patients having pancreaticoduodenectomy than those having a hepatic resection at time points: Intraoperative (P = 0.006), first 48 h postoperatively (P = 0.001), and the entire length of stay (LOS) (P = 0.002). Statistical significance was confirmed after controlling for age, sex, body mass index, and American Society of Anesthesiologists physical status classification (adjusted P = 0.006). Total hospital LOS was significantly longer after pancreaticoduodenectomy (P = 0.03). A multivariate lineal regression demonstrated a lower opioid consumption in the hepatic resection group (P = 0.03), but there was no difference in opioid use based on the type of hepatic resection. CONCLUSION: Patients undergoing open hepatic resection had a significantly lower opioid requirement in comparison with patients undergoing open pancreaticoduodenectomy. A multicenter prospective evaluation should be performed to confirm these findings.

Autoimmune conditions are associated with perioperative thrombotic complications in liver transplant recipients: A UNOS database analysis.

BACKGROUND: End stage liver disease (ESLD) is associated with significant thrombotic complications. In this study, we attempted to determine if patients with ESLD, due to oncologic or autoimmune diseases, are susceptible to thrombosis to a greater extent than patients with ESLD due to other causes. METHODS: In this retrospective study, we analyzed the UNOS database to determine the incidence of thrombotic complications in orthotopic liver transplant (OLT) recipients with autoimmune and oncologic conditions. Between 2000 and 2012, 65,646 OLTs were performed. We found 4,247 cases of preoperative portal vein thrombosis (PVT) and 1,233 cases of postoperative vascular thrombosis (VT) leading to graft failure. RESULTS: Statistical evaluation demonstrated that patients with either hepatocellular carcinoma (HCC) or autoimmune hepatitis (AIC) had a higher incidence of PVT (p = 0.05 and 0.03 respectively). Patients with primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC) and AIC had a higher incidence of postoperative VT associated with graft failure (p < 0.0001, p < 0.0001, p = 0.05 respectively). Patients with preoperative PVT had a higher incidence of postoperative VT (p < 0.0001). Multivariable logistic regression demonstrated that patients with AIC, and BMI ≥40, having had a transjugular intrahepatic portosystemic shunt, and those with diabetes mellitus were more likely to have preoperative PVT: odds ratio (OR)(1.36, 1.19, 1.78, 1.22 respectively). Patients with PSC, PBC, AIC, BMI ≤18, or with a preoperative PVT were more likely to have a postoperative VT: OR (1.93, 2.09, 1.64, 1.60, and 2.01, respectively). CONCLUSION: Despite the limited number of variables available in the UNOS database potentially related to thrombotic complications, this analysis demonstrates a clear association between autoimmune causes of ESLD and perioperative thrombotic complications. Perioperative management of patients at risk should include strategies to reduce the potential for these complications.