STI Testing among Medicaid Enrollees Initiating PrEP for HIV Prevention in Six Southern States.

OBJECTIVES: The purpose of this study was to measure sexually transmitted infection (STI) testing among Medicaid enrollees initiating preexposure prophylaxis (PrEP) to prevent human immunodeficiency virus. Secondary data are in the form of Medicaid enrollment and claims data in six states in the US South. METHODS: Research partnerships in six states in the US South developed a distributed research network to accomplish study aims. Each state identified all first-time PrEP users in fiscal year 2017-2018 (combined N = 990) and measured the presence of STI testing for chlamydia, syphilis, and gonorrhea through 2019. Each state calculated the percentage of individuals with at least one STI test during 3-, 6-, and 12-month follow-up periods. RESULTS: The proportion of first-time PrEP users that received an STI test varied by state: 37% to 67% of all of the individuals in each state who initiated PrEP received a test within the first 6 months of PrEP treatment and 50% to 77% received a test within the first 12 months. CONCLUSIONS: Although the Centers for Disease Control and Prevention recommends STI testing at least every 6 months for PrEP users, our analysis of Medicaid data suggests that STI testing occurs less frequently than recommended in populations at elevated risk of syphilis, gonorrhea, and chlamydia.

Prenatal Syphilis Screening Among Medicaid Enrollees in 6 Southern States.

INTRODUCTION: The rates of syphilis among pregnant women and infants have increased in recent years, particularly in the U.S. South. Although state policies require prenatal syphilis testing, recent screening rates comparable across Southern states are not known. The purpose of this study is to measure syphilis screening among Medicaid enrollees with delivery in states in the U.S. South. METHODS: A total of 6 state-university research partnerships in the U.S. South developed a distributed research network to analyze Medicaid claims data using a common analytic approach for enrollees with delivery in fiscal years 2017-2018 and 2018-2019 (combined N=504,943). In 2020-2021, each state calculated the percentage of enrollees with delivery with a syphilis screen test during the first trimester, third trimester, and at any point during pregnancy. Percentages for those with first-trimester enrollment were compared with the percentages of those who enrolled in Medicaid later in pregnancy. RESULTS: Prenatal syphilis screening during pregnancy ranged from 56% to 91%. Screening was higher among those enrolled in Medicaid during the first trimester than in those enrolled later in pregnancy. CONCLUSIONS: Despite state laws requiring syphilis screening during pregnancy, screening was much lower than 100%, and states varied in syphilis screening rates among Medicaid enrollees. Findings indicate that access to Medicaid in the first trimester is associated with higher rates of syphilis screening and that efforts to improve access to screening in practice settings are needed.

New means, new measures: assessing prescription drug-seeking indicators over 10 years of the opioid epidemic.

BACKGROUND AND AIMS: Prescription drug-seeking (PDS) from multiple prescribers is a primary means of obtaining prescription opioids; however, PDS behavior has probably evolved in response to policy shifts, and there is little agreement about how to operationalize it. We systematically compared the performance of traditional and novel PDS indicators. DESIGN: Longitudinal study using a de-identified commercial claims database. SETTING: United States, 2009-18. PARTICIPANTS: A total of 318 million provider visits from 21.5 million opioid-prescribed patients. MEASUREMENTS: We applied binary classification and generalized linear models to compare predictive accuracy and average marginal effect size predicting future opioid use disorder (OUD), overdose and high morphine milligram equivalents (MME). We compared traditional indicators of PDS to a network centrality measure, PageRank, that reflects the prominence of patients in a co-prescribing network. Analyses used the same data and adjusted for patient demographics, region, SES, diagnoses and health services. FINDINGS: The predictive accuracy of a widely used traditional measure (N + unique doctors and N + unique pharmacies in 90 days) on OUD, overdose and MME decreased between 2009 and 2018, and performed no better than chance (50% accuracy) after 2015. Binarized PageRank measures however exhibited higher predictive accuracy than the traditional binary measures throughout 2009-2018. Continuous indicators of PDS performed better than binary thresholds, with days of Rx performing best overall with 77-93% predictive accuracy. For example, days of Rx had the highest average marginal effects on overdose and OUD: a 1 standard deviation increase in days of Rx was associated with a 6-8% [confidence intervals (CIs) = 0.058-0.061 and 0.078-0.082] increase in the probability of overdose and a 4-5% (CIs = 0.038-0.043 and 0.047-0.053) increase in the probability of OUD. PageRank performed nearly as well or better than traditional indicators of PDS, with predictive performance increasing after 2016. CONCLUSIONS: In the United States, network-based measures appear to have increasing promise for identifying prescription opioid drug-seeking behavior, while indicators based on quantity of providers or pharmacies appear to have decreasing utility.

Use of anti-TNF-α therapy in Crohn's disease is associated with increased incidence of multiple sclerosis.

OBJECTIVE: We investigated if anti-tumor necrosis factor-α (anti-TNF-α) drugs used in the treatment of inflammatory bowel disease (IBD) alter the incidence of MS and if so, to understand the magnitude of such an effect. METHODS: This is a retrospective cohort study of data from Truven Health Market Scan administrative claims database. The patients included in the study had to be ≥ 18 years of age. The presence of IBD was based on at least 2 claims of International Classification of Diseases (ICD-9 or 10) diagnosis codes. The IBD diagnosis index date had to precede the MS diagnosis index date for inclusion in the study. The diagnosis of multiple sclerosis (MS) was defined as having at least 2 claims for the disease (ICD 9, 340 and ICD 10 codes, G35) and at least one prescription claim for any of the drugs that were defined as MS therapy. RESULTS: Patients with IBD had 1.32 times the risk of MS incidence compared to healthy controls (adjusted incidence rate ratio (IRR): 1.32; 95% CI: 1.03 - 1.71; p = .0312). Patients with IBD exposed to anti-TNF-α therapies had a 43% increase in the incidence of MS compared to those with IBD without exposure (adjusted incidence rate: 1.43; 95% CI: .062 - 3.32; p = .3989). Among CD patients treated anti-TNF-α medications an increase in the incidence of MS, compared to CD patients not exposed to such medications was observed (IRR = 2.62; 95% CI: 1.00 to 6.83; p = 0.049), statistically significant. After adjusting for age/gender, patients with CD using anti-TNF-α agents had an increase of incidence in MS (adjusted IRR: 2.24; 95% CI: 0.85 - 5.94; p = .1035) but it was not statistically significant. CONCLUSIONS: Use of anti-TNF-α drugs in CD was associated with a statistically significant increase in the incidence of MS but this effect was lost when controlled for age/gender.

Healthcare Patterns of Pregnant Women and Children Affected by OUD in 9 State Medicaid Populations.

OBJECTIVES: State Medicaid programs are the largest single provider of healthcare for pregnant persons with opioid use disorder (OUD). Our objective was to provide comparable, multistate measures estimating the burden of OUD in pregnancy, medication for OUD (MOUD) in pregnancy, and related neonatal and child outcomes. METHODS: Drawing on the Medicaid Outcomes Distributed Research Network (MODRN), we accessed administrative healthcare data for 1.6 million pregnancies and 1.3 million live births in 9 state Medicaid populations from 2014 to 2017. We analyzed within- and between-state prevalences and time trends in the following outcomes: diagnosis of OUD in pregnancy, initiation, and continuity of MOUD in pregnancy, Neonatal Opioid Withdrawal Syndrome (NOWS), and well-child visit utilization among children with NOWS. RESULTS: OUD diagnosis increased from 49.6 per 1000 to 54.1 per 1000 pregnancies, and the percentage of those with any MOUD in pregnancy increased from 53.4% to 57.9%, during our study time period. State-specific percentages of 180-day continuity of MOUD ranged from 41.2% to 84.5%. The rate of neonates diagnosed with NOWS increased from 32.7 to 37.0 per 1000 live births. State-specific percentages of children diagnosed with NOWS who had the recommended well-child visits in the first 15 months ranged from 39.3% to 62.5%. CONCLUSIONS: Medicaid data, which allow for longitudinal surveillance of care across different settings, can be used to monitor OUD and related pregnancy and child health outcomes. Findings highlight the need for public health efforts to improve care for pregnant persons and children affected by OUD.

Innovative Solutions for State Medicaid Programs to Leverage Their Data, Build Their Analytic Capacity, and Create Evidence-Based Policy.

As states have embraced additional flexibility to change coverage of and payment for Medicaid services, they have also faced heightened expectations for delivering high-value care. Efforts to meet these new expectations have increased the need for rigorous, evidence-based policy, but states may face challenges finding the resources, capacity, and expertise to meet this need. By describing state-university partnerships in more than 20 states, this commentary describes innovative solutions for states that want to leverage their own data, build their analytic capacity, and create evidence-based policy. From an integrated web-based system to improve long-term care to evaluating the impact of permanent supportive housing placements on Medicaid utilization and spending, these state partnerships provide significant support to their state Medicaid programs. In 2017, these partnerships came together to create a distributed research network that supports multi-state analyses. The Medicaid Outcomes Distributed Research Network (MODRN) uses a common data model to examine Medicaid data across states, thereby increasing the analytic rigor of policy evaluations in Medicaid, and contributing to the development of a fully functioning Medicaid innovation laboratory.

Kentucky's Smoking Cessation Quitline: Annual Estimated Return on Investment to Employers.

PURPOSE: State-based smoking cessation telephone quitlines offer a cost-effective method of providing tobacco treatment at no cost to participants. The study objective was to assess the annual return on investment (ROI) to employers if they were to bear the entire responsibility from the Kentucky quitline. DESIGN: A retrospective design was used to estimate the annual ROI to employers from the Kentucky quitline. SETTING: The telephone quitline (1-800-QUIT-NOW) provided intake and follow-up data for all Kentucky participants who enrolled in the program from 2012 to 2014. PARTICIPANTS: All individuals aged 18+ who enrolled in the Kentucky quitline from 2012 to 2014. MEASURES: Successful tobacco cessation was assessed from follow-up surveys that took place after individuals completed the program. Cost savings to employers associated with tobacco cessation were gleaned from a published meta-analysis. The Kentucky quitline provided estimates for annual program expenses. ANALYSIS: The annual ROI was calculated as the difference between estimated annual cost savings due to smoking cessation and annual program expenses. RESULTS: From 2012 to 2014, 5425 individuals were enrolled in the quitline. The annual ROI to employers was estimated to be $998 680, with an ROI ratio of 6.2:1. CONCLUSIONS: Employers may receive a substantial ROI if they were to fund the Kentucky quitline. Study results may be used as evidence to support cost-sharing partnerships between public health agencies and employers to sustain funding for telephone quitlines.

Antenatal and intrapartum risk factors for use of emergency and restorative Medicaid dental services for children.

PURPOSE: To investigate the relationship between antenatal/intrapartum factors and Medicaid use. METHODS: Three databases were used: (1) birth records; (2) Medicaid files; and (3) Medicaid dental claims. RESULTS: Children of Caucasian mothers were 34 percent more likely to have more than one restorative claim versus children of African American mothers (odds ratio [OR] equals 1.34, 95 percent confidence interval [95% CI] equals 1.10 to 1.65, P<.005). Children born with low birth weight were 37 percent more likely to have emergency claims (OR equals 1.37, 95% CI equals 1.02 to 1.83, P=.03). The adjusted analysis found that Caucasian mothers had higher odds ratio of having a dental claim than African American mothers (P<.001): 33 percent for a restorative claim and 56 percent for an emergency claim. When race was analyzed, the odds of a restorative claim among African American mothers were 2.5 times higher in children delivered by C-section versus those vaginally delivered (OR equals 2.52, 95% CI equals 1.02-6.2, P<.001). CONCLUSIONS: This study found: an association between children of Caucasian mothers and the likelihood of experiencing claims; and a relationship between children born with low birth weight and C-section and the likelihood of use of Medicaid services.

Trends in controlled-release oxycodone (OxyContin) prescribing among Medicaid recipients in Kentucky, 1998-2002.

CONTEXT: Prescription opioid abuse has emerged as a public health problem, particularly in rural America. PURPOSE: To examine temporal and geographic trends in rates of controlled-release oxycodone (OxyContin) prescribing for Kentucky Medicaid recipients. METHODS: A cross-sectional analysis was completed in which the state was divided into 3 regions (distressed Appalachia, Appalachia, and other Kentucky), and data from Medicaid pharmacy claims from 1998 to 2002 were analyzed. Claims were further stratified by disability status. FINDINGS: Temporary Assistance for Needy Families Medicaid recipients in distressed Appalachia were more likely than those in other Kentucky regions to file controlled-release oxycodone claims in 1999, 2001, and 2002. Even after adjusting for the proportion of Temporary Assistance for Needy Families recipients in each region, the distressed region still had significantly higher rates (P< .05) than the non-Appalachian region of controlled-release oxycodone prescription claims among Temporary Assistance for Needy Families recipients. Similar findings were observed for disabled Medicaid recipients in 2002. CONCLUSIONS: Higher rates of claims for controlled-release oxycodone in the distressed Appalachian region of Kentucky suggest that economic and health factors unique to this area may be contributing to increased use of this product. The increased availability of controlled-release oxycodone in distressed Appalachian regions may facilitate abuse.