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1.
South Med J ; 113(5): 254-260, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32358621

RESUMO

OBJECTIVES: Hospitalized patients with acute and chronic pancreatitis (AP and CP) are prone to frequent readmissions to different hospitals. The rate of care fragmentation and its impact on important outcomes are unknown. The aims of this study were to evaluate the rate and predictors of care fragmentation in patients hospitalized with AP and CP using a nationally representative sample, and to analyze the impact of care fragmentation on mortality, cost, and hospital readmissions. METHODS: We identified all adult hospitalizations with a primary diagnosis of AP or CP in the 2010-2014 National Readmissions Database, which captures statewide readmissions. We calculated 30- and 90-day readmission and care fragmentation rates. Readmission to a nonindex hospital was considered care fragmentation. Logistic regression was used to determine hospital and patient factors independently associated with 30-day care fragmentation. Patients readmitted within 30 days were followed for 60 days postdischarge from the first readmission. Mortality during the first readmission, hospitalization costs, and rates of 60-day readmission were compared between those with and without care fragmentation. RESULTS: There were 479,427 admissions with AP and 25,513 with CP. The rates of 30- and 90-day readmissions were 13.5% and 22.9% for AP and 26.9% and 44.7%% for CP. The rates of 30- and 90-day care fragmentation were 28% and 32% for AP and 33% and 38% for CP. Younger age (younger than 45 y), male patients, length of stay <5 days, ≥4 Elixhauser comorbidities, and self-pay or Medicaid insurance were associated with increased risk of 30-day care fragmentation. Large hospital size, routine discharge, and metropolitan location were associated with lower risk. Patients who had the first readmission to a nonindex hospital had a higher mortality (2% vs 1.6%, P = 0.005), length of stay (6.5 vs 5.6 days, P < 0.0001), mean hospitalization cost ($16,731 vs $13,368, P < 0.0001), and 60-day readmission (48.4% vs 42.9%) compared with those readmitted to the index hospital. CONCLUSIONS: In patients with AP and CP, one-third of 90-day readmissions occur at a nonindex hospital. Care fragmentation is associated with increased mortality, readmissions, and cost of care.


Assuntos
Continuidade da Assistência ao Paciente/estatística & dados numéricos , Mortalidade Hospitalar , Tempo de Internação/estatística & dados numéricos , Pancreatite Crônica/terapia , Pancreatite/terapia , Readmissão do Paciente/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Comorbidade , Feminino , Tamanho das Instituições de Saúde , Hospitalização , Hospitais Urbanos , Humanos , Modelos Logísticos , Masculino , Medicaid , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Fatores Sexuais , Estados Unidos , Adulto Jovem
2.
Am Surg ; 86(3): 195-199, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32223797

RESUMO

Patients presenting with localized breast cancer have a five-year survival of 99 per cent, whereas survival falls to 27 per cent in advanced disease. This obviates the importance of early diagnosis and treatment. Our study evaluates the impact of Ohio's Medicaid expansion and the passage of the Affordable Care Act (ACA) on the stage at which Ohioans were diagnosed with breast cancer. Data were collected for 3056 patients presenting with breast cancer between 2006 and 2016 in the Dayton area. Patients were divided into groups based on cancer stage. The percentage of patients presenting with advanced disease (stage 3 or 4) was compared both before and after ACA implementation and Ohio Medicaid expansion. These results were also compared with statewide data maintained by the Ohio Department of Health. Compared with pre-ACA, the number of uninsured patients post-ACA was noted to fall 83 per cent, the number of patients presenting with Medicaid increased by five times, and the proportion of patients younger than 65 years presenting with breast cancer increased by approximately 7 per cent. These changes notwithstanding, no difference was identified in the percentage of patients presenting with advanced breast cancer before and after ACA implementation or Ohio Medicaid expansion (P = 0.56). Statewide data similarly demonstrated no change (P = 0.88). Improved insurance access had a smaller-than-anticipated impact on the stage at which Ohioans presented with breast cancer. As significant morbidity and mortality can be avoided by earlier presentation, additional research is appropriate to identify factors affecting patients' decision to seek breast cancer screening and care.


Assuntos
Neoplasias da Mama/diagnóstico , Detecção Precoce de Câncer/economia , Custos de Cuidados de Saúde , Medicaid/economia , Avaliação de Resultados em Cuidados de Saúde , Adulto , Idoso , Neoplasias da Mama/economia , Neoplasias da Mama/mortalidade , Bases de Dados Factuais , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Cobertura do Seguro/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Ohio , Patient Protection and Affordable Care Act , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida , Estados Unidos
3.
Surgery ; 167(6): 985-990, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32305231

RESUMO

BACKGROUND: Gastrointestinal cancers contribute substantially to the cost of health care. We sought to quantify and compare the financial burden associated with treatment of gastrointestinal cancers versus other common nongastrointestinal cancers. METHODS: The Medical Expenditure Panel Survey from 2006 to 2015 was used to identify individuals with gastrointestinal cancer, other nongastrointestinal cancer (breast/prostate or lung), or no history of malignancy. Total and out-of-pocket medical expenditures were compared. Among each cohort, risk of high and catastrophic financial burden was determined. RESULTS: A total of 90,344 individuals were identified, which was extrapolated to a national representative sample of 95,449,062 individuals. Overall, an estimated 365,367 (0.4%) individuals had a gastrointestinal cancer while 2,015,724 (2.1%) had lung, breast, or prostate cancer. Mean adjusted total health expenditures was greater among patients with gastrointestinal cancer ($13,716; 95% confidence interval, $9,805-$17,628) versus patients with nongastrointestinal cancer ($8,665; 95% confidence interval, $8,222-$9,108) or individuals without cancer ($5,807; 95% confidence interval $5,740-$5,874). An estimated 15.8% (n = 57,898) and 7.1% (n = 25,956) of patients with gastrointestinal cancer experienced a high and catastrophic financial burden, respectively. Patients with gastrointestinal cancer had a 64% increased odds of experiencing catastrophic financial burden compared with patients without a history of cancer (odds ratio 1.64, 95% confidence interval, 1.17-2.31). Furthermore, patients with a gastrointestinal cancer had nearly 40% increased odds of high financial burden associated with their care compared with patients without cancer (odds ratio 1.37; 95% confidence interval, 1.00-1.88). CONCLUSION: The risk of experiencing catastrophic financial burden among patients with gastrointestinal cancer was considerable, as roughly 1 in 7 patients experienced high financial burden, and 1 in 13 had a catastrophic financial burden.


Assuntos
Neoplasias Gastrointestinais/economia , Gastos em Saúde/estatística & dados numéricos , Adulto , Idoso , Feminino , Neoplasias Gastrointestinais/epidemiologia , Inquéritos Epidemiológicos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Estados Unidos/epidemiologia
5.
Am J Surg ; 219(4): 571-577, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32147020

RESUMO

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.


Assuntos
Gastrectomia/tendências , Derivação Gástrica/tendências , Mortalidade Hospitalar , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Comorbidade , Grupos de Populações Continentais/estatística & dados numéricos , Conjuntos de Dados como Assunto , Feminino , Financiamento Pessoal/estatística & dados numéricos , Humanos , Renda/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Setor Privado , Fatores Raciais , Fatores Sexuais , Estados Unidos/epidemiologia , Adulto Jovem
6.
Med Care ; 58(5): 453-460, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32049877

RESUMO

OBJECTIVES: We describe payor for contraceptive visits 2013-2014, before and after Medicaid expansion under the Affordable Care Act (ACA), in a large network of safety-net clinics. We estimate changes in the proportion of uninsured contraceptive visits and the independent associations of the ACA, Title X, and state family planning programs. METHODS: Our sample included 237 safety net clinics in 11 states with a common electronic health record. We identified contraception-related visits among women aged 10-49 years using diagnosis and procedure codes. Our primary outcome was an indicator of an uninsured visit. We also assessed payor type (public/private). We included encounter, clinic, county, and state-level covariates. We used interrupted time series and logistic regression, and calculated multivariable absolute predicted probabilities. RESULTS: We identified 162,666 contraceptive visits in 219 clinics. There was a significant decline in uninsured contraception-related visits in both Medicaid expansion and nonexpansion states, with a slightly greater decline in expansion states (difference-in-difference: -1.29 percentage points; confidence interval: -1.39 to -1.19). The gap in uninsured visits between expansion and nonexpansion states widened after ACA implementation (from 2.17 to 4.1 percentage points). The Title X program continues to fill gaps in insurance in Medicaid expansion states. CONCLUSIONS: Uninsured contraceptive visits at safety net clinics decreased following Medicaid expansion under the ACA in both expansion and nonexpansion states. Overall, levels of uninsured visits are lower in expansion states. Title X continues to play an important role in access to care and coverage. In addition to protecting insurance gains under the ACA, Title X and state programs should continue to be a focus of research and advocacy.


Assuntos
Anticoncepção/economia , Pessoas sem Cobertura de Seguro de Saúde , Provedores de Redes de Segurança , Adolescente , Adulto , Criança , Estudos de Coortes , Serviços de Planejamento Familiar/legislação & jurisprudência , Feminino , Humanos , Medicaid , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act , Planos Governamentais de Saúde , Estados Unidos/epidemiologia , Adulto Jovem
7.
Recurso na Internet em Português | LIS - Localizador de Informação em Saúde | ID: lis-LISBR1.1-46969

RESUMO

Entrevista com a pesquisadora Ednilsa da Silva Ramos concedida ao informe ENSP sobre a assinatura da medida provisória que extingue o Seguro Obrigatório de Danos Pessoais (DPVAT) causados por veículos automotores tem levantado questões sobre o real impacto dessa decisão para as vítimas de acidente de trânsito. Com o estabelecimento da medida, que passará a vigorar em 2020, as indenizações às vítimas de trânsito serão encerradas a partir do ano que vem. Além disso, o SUS deixará de receber o valor de 45%, que atualmente arrecada com o seguro.


Assuntos
Acidentes de Trânsito , Pessoas sem Cobertura de Seguro de Saúde , Sistema Único de Saúde , Webcast , Entrevista
8.
PLoS One ; 15(1): e0222387, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31978141

RESUMO

In order to gain insights into how the effects of the uneven adoption of Medicaid expansion varies across the rural/urban spectrum and between racial/ethnic groups in the United States, this research used the fertility question in the 2011-2015 American Community Survey to link infants' records to their mothers' household health insurance status. This preliminary exploration of the Medicaid expansion used logistic regression to examine the probability that an infant will be born without health insurance coverage. Overall, the states that adopted Medicaid expansion improved the health insurance coverage for households with infants. However, rural households with infants report lower percentages of coverage than urban households with infants. Furthermore, the rural/urban gap in health insurance coverage is wider in states that adopted the Medicaid expansion. Additionally, Hispanic infants remain significantly less likely to have health insurance coverage compared to Non-Hispanic White infants. Understanding infant health insurance coverage across ethnic/racial groups and the rural/urban spectrum will become increasingly important as the U.S. population transitions to a minority-majority and also becomes more urban. Although not a perfect solution, our findings showed that the Medicaid expansion of health insurance coverage had a mainly overall positive effect on the percentage of U.S. households with infants who have health insurance coverage.


Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Adulto , Grupos de Populações Continentais/estatística & dados numéricos , Grupos Étnicos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu , Feminino , Serviços de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde , Hispano-Americanos , Humanos , Lactente , Cobertura do Seguro , Masculino , Pessoas sem Cobertura de Seguro de Saúde , Patient Protection and Affordable Care Act/estatística & dados numéricos , População Rural , Estados Unidos/epidemiologia
9.
BMC Health Serv Res ; 20(1): 45, 2020 Jan 17.
Artigo em Inglês | MEDLINE | ID: mdl-31952520

RESUMO

BACKGROUND: According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe. METHODS: We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 - October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income. RESULTS: Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05). CONCLUSION: This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care. TRIAL REGISTRATION: Registered at www.clinical trials.gov identifier NCT03604458.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Programas Nacionais de Saúde/economia , Procedimentos Cirúrgicos Operatórios/economia , Adulto , Feminino , Gana , Hospitais de Ensino , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade
10.
Am J Cardiol ; 125(5): 812-819, 2020 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-31902476

RESUMO

Improved treatment of congenital heart defects (CHDs) has resulted in women with CHDs living to childbearing age. However, no US population-based systems exist to estimate pregnancy frequency or complications among women with CHDs. Cases were identified in multiple data sources from 3 surveillance sites: Emory University (EU) whose catchment area included 5 metropolitan Atlanta counties; Massachusetts Department of Public Health (MA) whose catchment area was statewide; and New York State Department of Health (NY) whose catchment area included 11 counties. Cases were categorized into one of 5 mutually exclusive CHD severity groups collapsed to severe versus not severe; specific ICD-9-CM codes were used to capture pregnancy, gestational complications, and nongestational co-morbidities in women, age 11 to 50 years, with a CHD-related ICD-9-CM code. Pregnancy, CHD severity, demographics, gestational complications, co-morbidities, and insurance status were evaluated. ICD-9-CM codes identified 26,655 women with CHDs, of whom 5,672 (21.3%, range: 12.8% in NY to 22.5% in MA) had codes indicating a pregnancy. Over 3 years, age-adjusted proportion pregnancy rates among women with severe CHDs ranged from 10.0% to 24.6%, and 14.2% to 21.7% for women with nonsevere CHDs. Pregnant women with CHDs of any severity, compared with nonpregnant women with CHDs, reported more noncardiovascular co-morbidities. Insurance type varied by site and pregnancy status. These US population-based, multisite estimates of pregnancy among women with CHD indicate a substantial number of women with CHDs may be experiencing pregnancy and complications. In conclusion, given the growing adult population with CHDs, reproductive health of women with CHD is an important public health issue.


Assuntos
Cardiopatias Congênitas/epidemiologia , Complicações Cardiovasculares na Gravidez/epidemiologia , Complicações na Gravidez/epidemiologia , Taxa de Gravidez , Adolescente , Adulto , Anemia/epidemiologia , Arritmias Cardíacas/epidemiologia , Área Programática de Saúde , Criança , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Diabetes Gestacional/epidemiologia , Hipertensão Essencial/epidemiologia , Feminino , Georgia/epidemiologia , Humanos , Hiperêmese Gravídica/epidemiologia , Hiperlipidemias/epidemiologia , Hipertensão Induzida pela Gravidez/epidemiologia , Armazenamento e Recuperação da Informação , Cobertura do Seguro/estatística & dados numéricos , Classificação Internacional de Doenças , Massachusetts/epidemiologia , Medicaid , Pessoas sem Cobertura de Seguro de Saúde , Medicare , Pessoa de Meia-Idade , New York/epidemiologia , Obesidade Materna/epidemiologia , Trabalho de Parto Prematuro/epidemiologia , Gravidez , Complicações Hematológicas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Trombose/epidemiologia , Estados Unidos/epidemiologia , Adulto Jovem
11.
Ann Thorac Surg ; 109(5): 1512-1520, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31982443

RESUMO

BACKGROUND: Socioeconomic status (SES) disparities in the surgical management of patients with non-small cell lung cancer (NSCLC) are well described. Disparities in the receipt of adjuvant chemotherapy are poorly understood. We assessed the influence of SES on adjuvant chemotherapy after resection in patients with pN1 NSCLC. METHODS: The National Cancer Database was queried for cN0/N1 NSCLC patients who underwent surgical resection and had demonstrated pN1 disease. This cohort was further divided into those who received multiagent adjuvant chemotherapy (MAAC) vs surgery-only treatment. Factors associated with treatment assignment were examined, and long-term survival was compared. RESULTS: Of the 14,892 patients who underwent resection for pN1 disease, 8061 (54.1%) received MAAC. Patients were less likely to receive MAAC if they resided in rural areas (odds ratio, 1.23; 95% confidence interval [CI], 1.11-1.37; P < .001), or were uninsured or on Medicaid (odds ratio, 1.23; 95% CI, 1.07-1.41; P = .004). The propensity score-weighted 5-year survival was significantly higher for those receiving MAAC compared with surgery only (53.6% vs 39.5%, log-rank P < .001). Lower income (hazard ratio, 1.06; 95% CI, 1.00-1.12; P = .044) and uninsured or Medicaid insurance status (hazard ratio, 1.22; 95% CI, 1.13-1.31; P < .001) were independently associated with increased mortality by Cox regression in the propensity score-weighted cohort. CONCLUSIONS: pN1 NSCLC patients living in rural areas or who are uninsured or on Medicaid insurance are at increased risk of not receiving MAAC. Treatment with MAAC significantly improves long-term survival of pN1 patients. Efforts should be made to ensure these at-risk groups receive guideline-concordant care.


Assuntos
Antineoplásicos/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/terapia , Fidelidade a Diretrizes , Neoplasias Pulmonares/terapia , Estadiamento de Neoplasias , Pneumonectomia/métodos , Idoso , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Quimioterapia Adjuvante , Feminino , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/mortalidade , Masculino , Pessoas sem Cobertura de Seguro de Saúde , Pontuação de Propensão , Classe Social , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
12.
Am J Public Health ; 110(S1): S123-S129, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31967870

RESUMO

Objectives. To explore whether and how the Affordable Care Act (ACA) affects the relationship between employment and health insurance coverage, health care utilization, and health outcomes among recently incarcerated men aged 18 to 64 years in the United States.Methods. With data from the National Survey on Drug Use and Health (NSDUH), we used a difference-in-differences approach to compare changes in outcomes by employment status among recently incarcerated men.Results. Uninsurance declined significantly among recently incarcerated men after ACA implementation. As the uninsured rate of unemployed men fell below that of their employed counterparts, the ACA helped to fully eliminate the effect of employment on insurance coverage among recently incarcerated men. The employment gap in diabetes widened after ACA implementation as unemployed men saw significant increases in diagnosed diabetes. Employment disparities in hospital visits, diagnosed hypertension, and reported mental illness also declined in the period following ACA implementation, but these changes were not statistically significant.Conclusions. These findings highlight how the ACA, by providing a new route to health care, reduces the confounding forces associated with employment that are linked to both incarceration and health.


Assuntos
Emprego/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act , Prisioneiros/estatística & dados numéricos , Adolescente , Adulto , Doença Crônica/epidemiologia , Estudos Transversais , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
13.
Obstet Gynecol ; 135(2): 257-265, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31923060

RESUMO

OBJECTIVE: To estimate how implementation of the 2010 Affordable Care Act (ACA) might be associated with stage at diagnosis and time to treatment for women with ovarian cancer. METHODS: We conducted a retrospective cohort study using difference-in-differences analysis comparing stage at diagnosis and time to treatment before and after implementation of the ACA among women with ovarian cancer aged 21-64 years (exposure group) compared with women aged 65 years or older (control group). Using 2004-2015 data from the National Cancer Database, outcomes were analyzed overall and by insurance type and race, adjusting for urban-rural, income and education level, comorbidities, distance traveled for care, region, and care at an academic center. RESULTS: A total of 39,999 ovarian cancer cases prereform and 36,564 postreform were identified for women aged 21-64 years compared with 31,290 cases prereform and 29,807 postreform for women aged 65 years or older. The ACA was associated with increased early-stage diagnosis detection for women aged 21-64 years compared with women 65 and older (difference-in-differences 1.4%, 95% CI 0.4-2.4). The ACA was associated with more women receiving treatment within 30 days of ovarian cancer diagnosis (2.3%, 95% CI 1.7-3.0). Among women with public insurance, the ACA was associated with a significant improvement in early-stage diagnosis and receipt of treatment within 30 days of diagnosis (difference-in-differences 2.7%, 95% CI 1.0-4.5, difference-in-differences 2.5%, 95% CI 1.2-3.8). Improvements in time to treatment were seen across race and income groups. CONCLUSION: Implementation of the ACA was associated with earlier ovarian cancer stage at detection and treatment within 30 days of diagnosis.


Assuntos
Detecção Precoce de Câncer/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/epidemiologia , Patient Protection and Affordable Care Act/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Detecção Precoce de Câncer/economia , Feminino , Humanos , Renda/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Modelos Lineares , Medicaid/economia , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias , Neoplasias Ovarianas/economia , Patient Protection and Affordable Care Act/economia , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
14.
Med Care ; 58(2): 137-145, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31651740

RESUMO

BACKGROUND: Research on frequent emergency department (ED) use shows that a subgroup of patients visits multiple EDs. This study characterizes these individuals. OBJECTIVE: The objective of this study was to determine how many frequent ED users seek care at multiple EDs and to identify sociodemographic, clinical, and contextual factors associated with such behavior. RESEARCH DESIGN: We used the 2011-2014 Healthcare Cost and Utilization Project State Emergency Department Databases data on all outpatient ED visits in New York, Massachusetts, and Florida. We studied all adult ED users with ≥5 visits in a year and defined multisite use as visits to ≥3 different sites. We estimated predictors of multisite use with multivariate logistic regressions. RESULTS: Across all 3 states, 1,033,626 frequent users accounted for 7,613,077 ED visits. Of frequent users, 25% were multisite users, accounting for 30% of the visits studied. Frequent users with at least 1 visit for mental health or substance use-related diagnosis were more likely to use multiple sites. Uninsured frequent users and those with public insurance were associated with less use of multiple EDs than those with private coverage while lacking consistent coverage by the same insurance within each year were associated with using multiple sites. CONCLUSIONS: Health policy interventions to reduce duplicative or unnecessary ED use should apply a population health perspective and engage multiple hospitals. Community-level preventive approaches and a stronger infrastructure for mental health and substance use are essential to mitigate multisite ED use.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Adolescente , Adulto , Distribuição por Idade , Idoso , Grupos de Populações Continentais/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Serviços de Saúde Mental/estatística & dados numéricos , Pessoa de Meia-Idade , Distribuição por Sexo , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados Unidos , Adulto Jovem
15.
J Manag Care Spec Pharm ; 26(1): 42-47, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31880234

RESUMO

BACKGROUND: Influenza (also known as "flu") is estimated to cause between 12,000 and 79,000 deaths annually. Vaccinations are beneficial in preventing influenza cases and reducing the likelihood of severe outcomes. Unfortunately, vaccination coverage is low among uninsured populations. Removing the cost barrier can help increase vaccination coverage in this group, averting flu cases and related morbidity and costs. OBJECTIVE: To model the potential effect of providing no-cost flu vaccinations to uninsured individuals on influenza-related morbidity, mortality, and costs. METHODS: In collaboration with the Department of Health and Human Services and local agencies, Walgreens pharmacies provided free flu vaccinations through a nationwide voucher distribution program. We calculated the redemption rate, potentially averted cases, and estimated cost savings for the 2015-2016 and 2016-2017 flu seasons. Using incidence and vaccine effectiveness estimates from the Centers for Disease Control and Prevention, we calculated the rate of influenza in the general population and the estimated cases averted based on the number of redeemed vouchers. We applied patient age along with parameters from published studies to estimate averted ambulatory care visits, hospitalizations, mortality, productively losses, and overall related costs. RESULTS: During the 2015-2016 flu season, the pharmacy chain distributed 600,000 vouchers with a redemption rate of 52.3%, resulting in 314,033 flu vaccinations. Improvements were subsequently made to the distribution process to increase utilization rates. There were 400,000 vouchers distributed during the 2016-2017 season with a higher redemption rate of 87.2%, resulting in 348,924 flu vaccinations. The estimated number of potentially averted cases was higher during the 2016-2017 season (13,347) than the 2015-2016 season (11,537) due to a higher redemption rate and increased flu activity. Taken together, we estimated that 8,621 ambulatory care visits, 314 hospitalizations, and 15 deaths were averted due to the flu voucher program. Averted health care costs totaled $937,494 in ambulatory care visits and $3,510,055 in hospitalizations. Averted productivity losses ranged from $4,473,509 to $14,613,502. CONCLUSIONS: This study demonstrates the effectiveness of a pharmacy-led partnership with local community-based organizations to promote flu vaccinations among uninsured individuals. Our model found that a no-cost flu voucher program has the potential to reduce influenza-related morbidity, mortality, and costs. DISCLOSURES: This study was funded by Walgreen Co. All authors are employees of Walgreen Co. and affiliated with Walgreens Center for Health and Wellbeing Research. Findings from this study were presented as a podium presentation at the Academy of Managed Care Pharmacy Nexus 2018; October 22-25, 2018; Orlando, FL.


Assuntos
Serviços Comunitários de Farmácia/economia , Custos de Medicamentos , Acesso aos Serviços de Saúde/economia , Vacinas contra Influenza/administração & dosagem , Vacinas contra Influenza/economia , Influenza Humana/economia , Influenza Humana/prevenção & controle , Vacinação em Massa/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Serviços Comunitários de Farmácia/organização & administração , Redução de Custos , Análise Custo-Benefício , Feminino , Acesso aos Serviços de Saúde/organização & administração , Humanos , Vacinas contra Influenza/efeitos adversos , Influenza Humana/mortalidade , Masculino , Vacinação em Massa/efeitos adversos , Vacinação em Massa/mortalidade , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
16.
Tex Med ; 115(12): 26-28, 2019 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-31800091

RESUMO

Data compiled by the Texas Medical Association and other organizations, as well as physicians' own anecdotal experiences, show how 5 million uninsured patients in Texas become 5 million dominoes. As they fall, so do countless others representing the health of Texas: The economy and well-being of entire communities. The classmates and friends of uninsured children. And yes, the physicians who deal with the burdens of treating uninsured patients in emergency rooms and providing uncompensated care.


Assuntos
Seguro Saúde , Medicaid , Pessoas sem Cobertura de Seguro de Saúde , Saúde Pública , Problemas Sociais , Absenteísmo , Adolescente , Adulto , Criança , Saúde da Criança , Comércio , Serviço Hospitalar de Emergência , Pesquisas sobre Serviços de Saúde , Hospitais , Humanos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act , Médicos , Saúde Pública/estatística & dados numéricos , Texas , Cuidados de Saúde não Remunerados , Estados Unidos , Adulto Jovem
17.
Biomedica ; 39(4): 737-747, 2019 12 01.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31860184

RESUMO

Introduction: Inequalities in the health field are caused by the differences in the social and economic conditions, that influence the disease risk and the measures taken to treat the disease. Objective: We aimed to estimate the social inequalities in health in Colombia, according to the type of affiliation to the health system as a proxy of socioeconomic status. Materials and methods: We conducted a retrospective descriptive analysis calculating incidence rates age and sex adjusted for all mandatory reporting events using the affiliation regime (subsidized and contributory) as a socioeconomic proxy. Estimates were made at departmental level for 2015. Social inequalities were calculated in terms of absolute and relative gaps. Results: We found social inequalities in the occurrence of mandatory reporting events in population affiliated to the Colombian subsidized regime (poor population). In this population, 82.31 cases of Plasmodium falciparum malaria per 100,000 affiliates were reported more than those reported in the contributory regime. Regarding the relative gap, belonging to the subsidized regime increased by 31.74 times the risk of dying from malnutrition in children under 5 years of age. Other events such as those related to sexual and reproductive health (maternal mortality, gestational syphilis and congenital syphilis); neglected diseases and communicable diseases related to poverty (leprosy and tuberculosis), also showed profound inequalities. Conclusion: In Colombia there are inequalities by regime of affiliation to the health system. Measured socioeconomic status was a predictor of increased morbidity and premature mortality.


Assuntos
Notificação de Doenças/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Planos de Sistemas de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Programas Nacionais de Saúde/estatística & dados numéricos , Fatores Etários , Causas de Morte , Colômbia/epidemiologia , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Notificação de Abuso , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos
18.
Med Care ; 57(12): 996-1001, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31730569

RESUMO

BACKGROUND: Evidence indicates the unmet need for primary care services including medical, mental health, and dental care is greater among uninsured and Medicaid beneficiaries than privately insured individuals, many of whom use Health Resources and Services Administration-funded health centers (HRSA HCs). OBJECTIVE: We examined differences in rates of unmet need between low-income uninsured and Medicaid patients of HRSA HCs and safety-net clinics in general or private physicians. RESEARCH DESIGN: We used logistic regression models to compare the predicted probabilities of unmet need for uninsured and Medicaid individuals whose usual source of care is HRSA HCs versus clinics in general or private physicians. SAMPLE: We used a nationally representative survey of low income, adult patients who identified HRSA HCs as their usual source of care. We used the National Health Interview Survey to independently identify low-income individuals whose usual source of care was clinics (National Health Interview Survey clinics) or physicians (National Health Interview Survey physicians) in the general population. MEASURES: Dependent variables were unmet need and delay in medical care, and unmet need for prescription medications, mental health, and dental care. The primary independent variable of interest was the usual source of care. We controlled for potential confounders. RESULTS: We found the probability of unmet need for medical and dental care to be lower among HRSA HC patients than individuals whose usual source of care were not HRSA HCs. CONCLUSIONS: HRSA HC patients have lower probabilities of unmet need for medical and dental care. This is likely because HRSA HCs provide accessible, affordable, and comprehensive primary care services. Expanding capacity of these organizations will help reduce unmet need and its consequences.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Provedores de Redes de Segurança/estatística & dados numéricos , United States Health Resources and Services Administration/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Assistência Odontológica/estatística & dados numéricos , Feminino , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Medicaid/estatística & dados numéricos , Serviços de Saúde Mental/estatística & dados numéricos , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Fatores Sexuais , Fatores Socioeconômicos , Tempo para o Tratamento , Estados Unidos , Adulto Jovem
19.
Int J Health Policy Manag ; 8(11): 636-645, 2019 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-31779289

RESUMO

BACKGROUND: Nepal has made remarkable efforts towards social health protection over the past several years. In 2016, the Government of Nepal introduced a National Health Insurance Program (NHIP) with an aim to ensure equitable and universal access to healthcare by all Nepalese citizens. Following the first year of operation, the scheme has covered 5 percent of its target population. There are wider concerns regarding the capacity of NHIP to achieve adequate population coverage and remain viable. In this context, this study aimed to identify the factors associated with enrolment of households in the NHIP. METHODS: A cross-sectional household survey using face to face interview was carried out in 2 Palikas (municipalities) of Ilam district. 570 households were studied by recruiting equal number of NHIP enrolled and non-enrolled households. We used Pearson's chi-square test and binary logistic regression to identify the factors associated with household's enrolment in NHIP. All statistical analyses were performed using IBM SPSS version 23 software. RESULTS: Enrolment of households in NHIP was found to be associated with ethnicity, socio-economic status, past experience of acute illness in family and presence of chronic illness. The households that belonged to higher socio-economic status were about 4 times more likely to enrol in the scheme. It was also observed that households from privileged ethnic groups such as Brahmin, Chhetri, Gurung, and Newar were 1.7 times more likely to enrol in NHIP compared to those from underprivileged ethnic groups such as janajatis (indigenous people) and dalits (the oppressed). The households with illness experience in 3 months preceding the survey were about 1.5 times more likely to enrol in NHIP compared to households that did not have such experience. Similarly, households in which at least one of the members was chronically ill were 1.8 times more likely to enrol compared to households with no chronic illness. CONCLUSION: Belonging to the privileged ethnic group, having a higher socio-economic status, experiencing an acute illness and presence of chronically ill member in the family are the factors associated with enrolment of households in NHIP. This study revealed gaps in enrolment between rich-poor households and privileged-underprivileged ethnic groups. Extension of health insurance coverage to poor and marginalized households is therefore needed to increase equity and accelerate the pace towards achieving universal health coverage.


Assuntos
Acesso aos Serviços de Saúde , Seguro Saúde/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Programas Nacionais de Saúde , Adulto , Idoso , Estudos Transversais , Feminino , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/estatística & dados numéricos , Nepal , Fatores Socioeconômicos , Cobertura Universal do Seguro de Saúde , Adulto Jovem
20.
S Afr Med J ; 109(10): 771-783, 2019 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-31635576

RESUMO

BACKGROUND: The proposed National Health Insurance (NHI) system aims to re-engineer primary healthcare (PHC) provision in South Africa, with strategic purchasing of services from both private and public sector providers by the NHI Fund. Currently, while access to the private sector is primarily restricted to high-income insured earners, an important proportion of the low-income segment is choosing to utilise private PHC providers over public sector clinics. In recent years, a number of private providers in SA have established innovative models of PHC delivery that aim to expand access beyond the insured population and provide affordable access to good-quality PHC services. OBJECTIVES: To describe the current landscape of private PHC clinic models targeting low-income, uninsured earners and the role they might play during the transition to NHI. METHODS: Key informant interviews were conducted with representatives of a sample of private PHC provider organisations providing services to low-income, uninsured earners with clinics - beyond the traditional private sector general practitioner model. Organisations were asked to describe their service delivery model, the population it serves, the PHC services offered and the financing model. Written responses were captured in Excel and coded manually, and the results were thematically analysed. RESULTS: Of the eight organisations identified, most have actively engaged strategies to ensure the provision of affordable quality care. Within these strategies, scale is an important pivot in spreading fixed costs across more paying patients as well as task shifting to lower cadres of healthcare workers. Access to government medicines and laboratory tests is an important factor in achieving lower costs per patient. Together, these strategies support the sustainability of these models. CONCLUSIONS: We have provided an exploratory analysis of private PHC service delivery models serving the low-income, uninsured patient population, establishing factors that increase the efficiency of such service delivery, and delineating combinations of strategies that could make these models successful both during the transition to NHI and during full-scale NHI implementation. A clear regulatory framework would act as a catalyst for further innovation and facilitate contracting. These existing models can enhance and complement government provision and could be scaled up to meet the needs of expanding PHC under NHI. Understanding these models and the space and parameters in which they operate is important.


Assuntos
Assistência à Saúde/organização & administração , Pessoas sem Cobertura de Seguro de Saúde , Programas Nacionais de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Assistência à Saúde/economia , Assistência à Saúde/normas , Clínicos Gerais/organização & administração , Acesso aos Serviços de Saúde , Humanos , Renda , Programas Nacionais de Saúde/economia , Pobreza , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/normas , Setor Privado/economia , Setor Público/economia , Qualidade da Assistência à Saúde , África do Sul
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