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1.
Stomatologiia (Mosk) ; 100(1): 67-72, 2021.
Artigo em Russo | MEDLINE | ID: mdl-33528959

RESUMO

THE AIM OF THE STUDY: Was to analyze financial feasibility of obligatory medical insurance programs in dentistry based on the cost of relative unit of labor intensity. MATERIAL AND METHODS: The study is based on statistical analysis of service types and costs dynamics in dental obligatory medical insurance programs in Russia in 2013-2018. RESULTS: The study identified trends in financing health care, government guarantee programs and financial costs per 1 unit of labor intensity, which should be taken into account when making a medical and economic feasibility study of basic and territorial government guarantee programs to provide citizens of the Russian Federation with free medical care and planning the dental section of the compulsory medical insurance program. CONCLUSION: The financial possibilities of implementing the compulsory medical insurance program in the field of dentistry in the Russian Federation are limited by reducing the cost of dental services from the total amount of healthcare financing, not proportional to the increase in inflation and the level of expenses for the compulsory medical insurance program, aggravation of the pathology of patients and untimely treatment for dental services. The provision of planned dental services and preventive measures will reduce the financial costs of these services.


Assuntos
Financiamento da Assistência à Saúde , Seguro , Odontologia , Humanos , Seguro Saúde , Federação Russa
3.
Int Dent J ; 71(1): 67-75, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33616055

RESUMO

INTRODUCTION: Dental care is mostly excluded from healthcare coverage in China. This study examines disparities in dental care and in the costs of such care, according to insurance type and socio-economic status, among Chinese older adults. METHODS: The data were obtained from the 2015 China Health and Retirement Longitudinal Study (CHARLS). A final sample of 5,230 respondents was included, with a mean age of 72 years. Edentulousness, any dental visit and per-patient dental care expenditure were used as outcome variables. Both unweighted and weighted logistic regression analyses were used to examine the association of socio-economic status (education, insurance type and income) associated with edentulousness and use of dental care. RESULTS: We found that 28% of Chinese older adults have no remaining teeth and that only 19% had used dental care in the past year. The uninsured and those with rural resident insurance had edentulousness rates of 31%, while the edentulousness rate in those with urban employee insurance was 19%. About 13% of the uninsured study respondents and 15% of those with rural resident insurance had used dental care compared with 30% of those with urban employee insurance. Those in the highest income and education groups and those enrolled in a plan with a lower coinsurance rate had a higher likelihood of using dental care services and spending more on dental care than did those in the lowest socio-economic groups. CONCLUSIONS: Dental care disparities in China may be reduced through increasing the proportion of the population with insurance and expanding the range of dental treatments covered by all three major insurance schemes.


Assuntos
Gastos em Saúde , Seguro Saúde , Idoso , China/epidemiologia , Assistência Odontológica , Disparidades em Assistência à Saúde , Humanos , Cobertura do Seguro , Estudos Longitudinais
4.
BMC Infect Dis ; 21(1): 52, 2021 Jan 11.
Artigo em Inglês | MEDLINE | ID: mdl-33430793

RESUMO

BACKGROUND: Workplace absenteeism increases significantly during influenza epidemics. Sick leave records may facilitate more timely detection of influenza outbreaks, as trends in increased sick leave may precede alerts issued by sentinel surveillance systems by days or weeks. Sick leave data have not been comprehensively evaluated in comparison to traditional surveillance methods. The aim of this paper is to study the performance and the feasibility of using a detection system based on sick leave data to detect influenza outbreaks. METHODS: Sick leave records were extracted from private French health insurance data, covering on average 209,932 companies per year across a wide range of sizes and sectors. We used linear regression to estimate the weekly number of new sick leave spells between 2016 and 2017 in 12 French regions, adjusting for trend, seasonality and worker leaves on historical data from 2010 to 2015. Outbreaks were detected using a 95%-prediction interval. This method was compared to results from the French Sentinelles network, a gold-standard primary care surveillance system currently in place. RESULTS: Using sick leave data, we detected 92% of reported influenza outbreaks between 2016 and 2017, on average 5.88 weeks prior to outbreak peaks. Compared to the existing Sentinelles model, our method had high sensitivity (89%) and positive predictive value (86%), and detected outbreaks on average 2.5 weeks earlier. CONCLUSION: Sick leave surveillance could be a sensitive, specific and timely tool for detection of influenza outbreaks.


Assuntos
Absenteísmo , Epidemias , Influenza Humana/epidemiologia , Vigilância em Saúde Pública/métodos , Vigilância de Evento Sentinela , Licença Médica , França/epidemiologia , Humanos , Incidência , Influenza Humana/virologia , Seguro Saúde , Pessoa de Meia-Idade , Modelos Estatísticos , Estudos Retrospectivos , Sensibilidade e Especificidade , Local de Trabalho
6.
J Am Dent Assoc ; 152(1): 55-64, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33413851

RESUMO

BACKGROUND: National data indicate that working-aged adults (20-64 years) are more likely to report financial barriers to receiving needed oral health care relative to other age groups. The aim of this study was to examine the burden of untreated caries (UC) and its association with reporting an unmet oral health care need among working-aged adults. METHODS: The authors used National Health and Nutrition Examination Survey data from 2011 through 2016 for 10,286 dentate adults to examine the prevalence of mild to moderate (1-3 affected teeth) and severe (≥ 4 affected teeth) UC. The authors used multivariable logistic regression to identify factors that were associated with reporting an unmet oral health care need. RESULTS: Low-income adults had mild to moderate UC (26.2%) 2 times more frequently and severe UC (13.2%) 3 times more frequently than higher-income adults. After controlling for covariates, the variables most strongly associated with reporting an unmet oral health care need were UC, low income, fair or poor general health, smoking, and no private health insurance. The model-adjusted prevalence of reporting an unmet oral health care need among low-income adults with mild to moderate and severe UC were 35.7% and 45.1%, respectively. CONCLUSIONS: The burden of UC among low-income adults is high; prevalence was approximately 40% with approximately 3 affected teeth per person on average. Reporting an unmet oral health care need appears to be capturing primarily differences in UC, health, and financial access to oral health care. PRACTICAL IMPLICATIONS: Data on self-reported unmet oral health care need can have utility as a surveillance tool for monitoring UC and targeting resources to decrease UC among low-income adults.


Assuntos
Cárie Dentária , Inquéritos Nutricionais , Adulto , Idoso , Assistência à Saúde , Cárie Dentária/epidemiologia , Humanos , Seguro Saúde , Pessoa de Meia-Idade , Saúde Bucal , Adulto Jovem
7.
Epidemiol Infect ; 149: e25, 2021 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-33455608

RESUMO

Hispanic/Latino populations are disproportionately impacted by coronavirus disease 2019 (COVID-19) in the United States. The impact of state reopening on COVID-19 in this population after stay-at-home orders is unknown. We evaluated the incidence, prevalence and trends during reopening of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) at a major federally qualified health centre in Providence, Rhode Island. A total of 14 505 patients were tested for SARS-CoV-2 from 19 March to 18 August 2020, of which, data on 13 318 (91.8%) patients were available; 70.0% were Hispanic/Latino, and 2905 were positive for SARS-CoV-2 infection. The urban Hispanic/Latino population was almost five times more likely to test positive for SARS-CoV-2 (risk ratio 4.97, 95% CI 2.59-9.53, P < 0.001) compared to non-Hispanic White. The positivity rates among the urban Hispanic/Latino population remained >10% during all phases of reopening. The trends of the incidence rates showed similar associations to those we observed for positivity rates. Public health interventions to address SARS-CoV-2 in Hispanic/Latino communities are urgently needed, even in latter phases of state reopening.


Assuntos
/etnologia , Hispano-Americanos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde/etnologia , Habitação/classificação , Humanos , Incidência , Lactente , Seguro Saúde , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , População Urbana , Adulto Jovem
8.
Fam Med ; 53(1): 48-53, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33471922

RESUMO

The COVID-19 pandemic, together with its resultant economic downturn, has unmasked serious problems of access, costs, quality of care, inequities, and disparities of US health care. It has exposed a serious primary care shortage, the unreliability of employer-sponsored health insurance, systemic racism, and other dysfunctions of a system turned on its head without a primary care base. Fundamental reform is urgently needed to bring affordable health care that is accessible to all Americans. Over the last 40-plus years, our supposed system has been taken over by corporate stakeholders with the presumption that a competitive unfettered marketplace will achieve the needed goal of affordable, accessible care. That theory has been thoroughly disproven by experience as the ranks of more than 30 million uninsured and 87 million underinsured demonstrates. Three main reform alternatives before us are: (1) to build on the Affordable Care Act; (2) to implement some kind of a public option; and (3) to enact single-payer Medicare for All. It is only the third option that can make affordable, comprehensive health care accessible for our entire population. As the debate goes forward over these alternatives during this election season, the likelihood of major change through a new system of national health insurance is becoming increasingly realistic. Rebuilding primary care and public health is a high priority as we face a new normal in US health care that places the public interest above that of corporate stakeholders and Wall Street investors. Primary care, and especially family medicine, should become the foundation of a reformed health care system.


Assuntos
Medicina de Família e Comunidade , Reforma dos Serviços de Saúde , Setor de Assistência à Saúde , Disparidades em Assistência à Saúde/etnologia , Atenção Primária à Saúde , Qualidade da Assistência à Saúde , Cobertura Universal do Seguro de Saúde , Recessão Econômica , Emprego , Tabela de Remuneração de Serviços , Instituições Privadas de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Seguro Saúde , Medicare , National Health Insurance, United States , Médicos de Família/provisão & distribução , Médicos de Atenção Primária/provisão & distribução , Desemprego , Estados Unidos
9.
Epidemiol Health ; 43: e2021007, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33445821

RESUMO

OBJECTIVES: This study explored socioeconomic disparities in Korea using health insurance type as a proxy during the ongoing coronavirus disease 2019 (COVID-19) pandemic. METHODS: We conducted a retrospective cohort study using Korea's nationwide healthcare database, which contained all individuals who received a diagnostic test for COVID-19 (n=232,390) as of May 15, 2020. We classified our cohort by health insurance type into beneficiaries of the National Health Insurance (NHI) or Medicaid programs. Our study outcomes were infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and COVID-19-related outcomes, a composite of all-cause death, intensive care unit admission, and mechanical ventilation use. We estimated age-, sex-, and Charlson comorbidity index score-adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using a multivariable logistic regression analysis. RESULTS: Of the 218,070 NHI and 14,320 Medicaid beneficiaries who received COVID-19 tests, 7,777 and 738 tested positive, respectively. The Medicaid beneficiaries were older (mean age, 57.5 vs. 47.8 years), more likely to be males (47.2 vs. 40.2%), and had a higher comorbidity burden (mean CCI, 2.0 vs. 1.7) than NHI beneficiaries. Compared to NHI beneficiaries, Medicaid beneficiaries had a 22% increased risk of SARS-CoV-2 infection (aOR, 1.22; 95% CI, 1.09 to 1.38), but had no significantly elevated risk of COVID-19-related outcomes (aOR 1.10, 95% CI 0.77 to 1.57); the individual events of the composite outcome yielded similar findings. CONCLUSIONS: As socioeconomic factors, with health insurance as a proxy, could serve as determinants during the current pandemic, pre-emptive support is needed for high-risk groups to slow its spread.


Assuntos
/estatística & dados numéricos , Disparidades em Assistência à Saúde/economia , Seguro Saúde/estatística & dados numéricos , Pandemias , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores Socioeconômicos , Adulto Jovem
11.
Arch Gerontol Geriatr ; 92: 104227, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32979552

RESUMO

OBJECTIVES: Little is known about the magnitude of catastrophic health expenditure (CHE) attributable to critical disease, especially in the middle-aged and elderly population. This research aimed to exploring the key aspects of how the health insurance fails to protect the middle-aged and elderly against CHE in the past five years. And propose corresponding measures to improve. METHODS: Data were obtained from the 2011 to 2015 China Health and Retirement Longitudinal Study. The method was adapted from WHO to calculate the catastrophic health expenditure (CHE) and impoverishment by medical expense (IME), and use Generalized Linear Mixed Models (GLMMs) to comprehensively analyze the risk factors that cause middle-aged and elderly people to fall into CHE. RESULTS: The incidence of CHE of China's middle-aged and elderly population has been rose in the five years from 2011 (10.5 %) to 2013 (17.5 %) to 2015 (19.7 %). The CHE of richest families was almost 6 times from 2011 to 2015. Urban Employee Medical Insurance Scheme, the incidence of CHE was up 10 percentage from 2011 to 2015. According to the GLMMs, families have inpatient cares as the most important factor to CHE. The incidence of CHE increased by 2.25 times compared with those who did not use inpatient services. CONCLUSIONS: The health system needs to control the irrational growth of health expenses and reduce residents' overuse of health services. Government should take supplementary measures to comprehensively strengthen the advantages of health insurance. Raise residents' awareness of health care, enhance citizens' physical fitness, and avoid unnecessary waste of health resources.


Assuntos
Gastos em Saúde , Seguro Saúde , Idoso , China/epidemiologia , Serviços de Saúde , Humanos , Estudos Longitudinais , Pessoa de Meia-Idade
12.
J Urol ; 205(1): 298-300, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33164627
13.
Neurology ; 96(3): e322-e332, 2021 01 19.
Artigo em Inglês | MEDLINE | ID: mdl-33361253

RESUMO

OBJECTIVE: To measure the out-of-pocket (OOP) costs of evaluation and management (E/M) services and common diagnostic testing for neurology patients. METHODS: Using a large, privately insured health care claims database, we identified patients with a neurologic visit or diagnostic test from 2001 to 2016 and assessed inflation-adjusted OOP costs for E/M visits, neuroimaging, and neurophysiologic testing. For each diagnostic service each year, we estimated the proportion of patients with OOP costs, the mean OOP cost, and the proportion of the total service cost paid OOP. We modeled OOP cost as a function of patient and insurance factors. RESULTS: We identified 3,724,342 patients. The most frequent neurologic services were E/M visits (78.5%), EMG/nerve conduction studies (NCS) (7.7%), MRIs (5.3%), and EEGs (4.5%). Annually, 86.5%-95.2% of patients paid OOP costs for E/M visits and 23.1%-69.5% for diagnostic tests. For patients paying any OOP cost, the mean OOP cost increased over time, most substantially for EEG, MRI, and E/M. OOP costs varied considerably; for an MRI in 2016, the 50th percentile paid $103.10 and the 95th percentile paid $875.40. The proportion of total service cost paid OOP increased. High deductible health plan (HDHP) enrollment was associated with higher OOP costs for MRI, EMG/NCS, and EEG. CONCLUSION: An increasing number of patients pay OOP for neurologic diagnostic services. These costs are rising and vary greatly across patients and tests. The cost sharing burden is particularly high for the growing population with HDHPs. In this setting, neurologic evaluation might result in financial hardship for patients.


Assuntos
Gastos em Saúde , Seguro Saúde/economia , Doenças do Sistema Nervoso/diagnóstico , Neuroimagem/economia , Exame Neurológico/economia , Neurologia/economia , Humanos , Doenças do Sistema Nervoso/economia
15.
J Urol ; 205(1): 115-121, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32658588

RESUMO

PURPOSE: Optimal treatment of intermediate risk prostate cancer remains unclear. National Comprehensive Cancer Network® guidelines recommend active surveillance, prostatectomy or radiotherapy. Recent trials demonstrated no difference in prostate cancer specific mortality for men undergoing active surveillance for low risk prostate cancer compared to prostatectomy or radiotherapy. The use of active surveillance for intermediate risk prostate cancer is less clear. In this study we characterize U.S. national trends for demographic, clinical and socioeconomic factors associated with active surveillance for men with intermediate risk prostate cancer. MATERIALS AND METHODS: This retrospective cohort study examined 176,122 men diagnosed with intermediate risk prostate cancer from 2010 to 2016 in the National Cancer Database. Temporal trends in demographic, clinical and socioeconomic factors among men with intermediate risk prostate cancer and association with the use of active surveillance were characterized. The analysis was performed in April 2020. RESULTS: In total, 176,122 men were identified with intermediate risk prostate cancer from 2010 to 2016. Of these men 57.3% underwent prostatectomy, 36.4% underwent radiotherapy and 3.2% underwent active surveillance. Active surveillance nearly tripled from 1.6% in 2010 to 4.6% in 2016 (p <0.001). On multivariate analysis use of active surveillance was associated with older age, diagnosis in recent years, lower Gleason score and tumor stage, type of insurance, treatment at an academic center and proximity to facility, and attaining higher education (p <0.05). Race and comorbidities were not associated with active surveillance. CONCLUSIONS: Our findings highlight increasing active surveillance use for men with intermediate risk prostate cancer demonstrating clinical and socioeconomic disparities. Prospective data and improved risk stratification are needed to guide optimal treatment for men with intermediate risk prostate cancer.


Assuntos
Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Neoplasias da Próstata/terapia , Conduta Expectante/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Disparidades em Assistência à Saúde/economia , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Calicreínas/sangue , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Próstata/patologia , Antígeno Prostático Específico/sangue , Prostatectomia/economia , Prostatectomia/estatística & dados numéricos , Neoplasias da Próstata/sangue , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/patologia , Radioterapia/economia , Radioterapia/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Conduta Expectante/economia
16.
J Urol ; 205(1): 257-263, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32716676

RESUMO

PURPOSE: Among some populations access to neonatal circumcision has become increasingly limited despite evidence of its benefits. This study examines national neonatal circumcision trends before and after the 2012 American Academy of Pediatrics recommendation for neonatal circumcision reimbursement. MATERIALS AND METHODS: A retrospective cohort study of boys aged 28 days or less was conducted using data from the Kids' Inpatient Database (2003 to 2016). Boys who underwent neonatal circumcision prior to discharge were compared to boys who did not. Boys with coagulopathies, penile anomalies or a history of prematurity were excluded. RESULTS: An estimated 8,038,289 boys comprised the final cohort. Boys were primarily White (53.7%), privately insured (49.1%) and cared for at large (60.8%) teaching (49.4%) hospitals in metropolitan areas (84.1%). While 55.0% underwent circumcision prior to discharge, neonatal circumcision rates decreased significantly over time (p <0.0001). Black (68.0%) or White (66.0%) boys, boys in the highest income quartile (60.7%) and Midwestern boys (75.0%) were most likely to be circumcised. Neonatal circumcision was significantly more common among privately (64.9%) than publicly (44.6%) insured boys after controlling for demographics, region, hospital characteristics and year (p <0.0001). The odds of circumcision over time were not significantly different in the years before vs after 2012 (p=0.28). CONCLUSIONS: Among approximately 8 million boys sampled over a 13-year period 55.0% underwent neonatal circumcision. The rate of neonatal circumcision varied widely by region, race and socioeconomic status. The finding that boys with public insurance have lower circumcision rates in all years may be related to lack of circumcision access for boys with public insurance.


Assuntos
Circuncisão Masculina/tendências , Acesso aos Serviços de Saúde/economia , Disparidades em Assistência à Saúde/economia , Afro-Americanos/estatística & dados numéricos , Circuncisão Masculina/economia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Geografia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/tendências , Humanos , Recém-Nascido , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Classe Social , Estados Unidos
17.
J Urol ; 205(1): 213-218, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32856985

RESUMO

PURPOSE: Neurogenic lower urinary tract dysfunction is a significant source of morbidity for individuals with spinal cord injury and is managed with a range of treatment options that differ in efficacy, tolerability and cost. The effect of insurance coverage on bladder management, symptoms and quality of life is not known. We hypothesized that private insurance is associated with fewer bladder symptoms and better quality of life. MATERIALS AND METHODS: This is a cross-sectional, retrospective analysis of 1,226 surveys collected as part of the prospective Neurogenic Bladder Research Group SCI Registry. We included patients with complete insurance information, which was classified as private or public insurance. The relationship between insurance and bladder management, bladder symptoms and quality of life was modeled using multinomial logistic regression analysis. Spinal cord injury quality of life was measured by the Neurogenic Bladder Symptom Score. RESULTS: We identified 654 privately insured and 572 publicly insured individuals. The demographics of these groups differed by race, education, prevalence of chronic pain and bladder management. Publicly insured patients were more likely to be treated with indwelling catheters or spontaneous voiding and less likely to take bladder medication compared to those with private insurance. On multivariate analysis insurance type was not associated with differences in bladder symptoms (total Neurogenic Bladder Symptom Score) or in urinary quality of life. CONCLUSIONS: There is an association between insurance coverage and the type of bladder management used following spinal cord injury, as publicly insured patients are more likely to be treated with indwelling catheters. However, insurance status, controlling for bladder management, did not impact bladder symptoms or quality of life.


Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Traumatismos da Medula Espinal/complicações , Bexiga Urinaria Neurogênica/terapia , Adulto , Cateteres de Demora/economia , Cateteres de Demora/estatística & dados numéricos , Estudos Transversais , Feminino , Disparidades em Assistência à Saúde/economia , Humanos , Cobertura do Seguro/economia , Seguro Saúde/economia , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente/economia , Estudos Prospectivos , Qualidade de Vida , Estudos Retrospectivos , Traumatismos da Medula Espinal/economia , Traumatismos da Medula Espinal/terapia , Resultado do Tratamento , Bexiga Urinária/inervação , Bexiga Urinária/fisiopatologia , Bexiga Urinaria Neurogênica/diagnóstico , Bexiga Urinaria Neurogênica/economia , Bexiga Urinaria Neurogênica/etiologia , Cateterismo Urinário/economia , Cateterismo Urinário/estatística & dados numéricos
18.
Lancet Child Adolesc Health ; 5(2): 103-112, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33333071

RESUMO

BACKGROUND: Disparities in outcomes of adult sepsis are well described by insurance status and race and ethnicity. There is a paucity of data looking at disparities in sepsis outcomes in children. We aimed to determine whether hospital outcomes in childhood severe sepsis were influenced by race or ethnicity and insurance status, a proxy for socioeconomic position. METHODS: This population-based, retrospective cohort study used data from the 2016 database release from the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The 2016 KID included 3 117 413 discharges, accounting for 80% of national paediatric discharges from 4200 US hospitals across 47 states. Using multilevel logistic regression, clustered by hospital, we tested the association between race or ethnicity and insurance status and hospital mortality, adjusting for individual-level and hospital-level characteristics, in children with severe sepsis. The secondary outcome of length of hospital stay was examined through multilevel time to event (hospital discharge) regression, with death as a competing risk. FINDINGS: 12 297 children (aged 0-21 years) with severe sepsis with or without shock were admitted to 1253 hospitals in the 2016 KID dataset. 1265 (10·3%) of 12 297 patients did not have race or ethnicity data recorded, 15 (0·1%) were missing data on insurance, and 1324 (10·8%) were transferred out of hospital, resulting in a final cohort of 9816 children. Black children had higher odds of death than did White children (adjusted odds ratio [OR] 1·19, 95 % CI 1·02-1·38; p=0·028), driven by higher Black mortality in the south (1·30, 1·04-1·62; p=0·019) and west (1·58, 1·05-2·38; p=0·027) of the USA. We found evidence of longer hospital stays for Hispanic children (adjusted hazard ratio 0·94, 95% CI 0·88-1·00; p=0·049) and Black children (0·88, 0·82-0·94; p=0·0002), particularly Black neonates (0·53, 95% CI 0·36-0·77; p=0·0011). We observed no difference in survival between publicly and privately insured children; however, other insurance status (self-pay, no charge, and other) was associated with increased mortality (adjusted OR 1·30, 95% CI 1·04-1·61; p=0·021). INTERPRETATION: In this large, representative analysis of paediatric severe sepsis in the USA, we found evidence of outcome disparities by race or ethnicity and insurance status. Our findings suggest that there might be differential sepsis recognition, approaches to treatment, access to health-care services, and provider bias that contribute to poorer sepsis outcomes for racial and ethnic minority patients and those of lower socioeconomic position. Studies are warranted to investigate the mechanisms of poorer sepsis outcomes in Black and Hispanic children. FUNDING: None.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Sepse/etnologia , Sepse/mortalidade , Adolescente , Adulto , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Disparidades em Assistência à Saúde , Mortalidade Hospitalar/etnologia , Humanos , Lactente , Recém-Nascido , Masculino , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
19.
PLoS One ; 15(12): e0243810, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33338071

RESUMO

BACKGROUND: There are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI). OBJECTIVE: To assess the influence of insurance status on STEMI outcomes. METHODS: Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample database (2000-2017). Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes of interest included in-hospital mortality, use of coronary angiography and percutaneous coronary intervention (PCI), hospitalization costs, hospital length of stay and discharge disposition. RESULTS: Of the 4,310,703 STEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively. Compared to the others, the Medicare cohort was older (75 vs. 53-57 years), more often female (46% vs. 20-36%), of white race, and with higher comorbidity (all p<0.001). The Medicare and Medicaid population had higher rates of cardiogenic shock and cardiac arrest. The Medicare cohort had higher in-hospital mortality (14.2%) compared to the other groups (4.1-6.7%), p<0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in uninsured (adjusted odds ratio (aOR) 1.14 [95% confidence interval {CI} 1.11-1.16]), and lower in Medicaid (aOR 0.96 [95% CI 0.94-0.99]; p = 0.002), privately insured (aOR 0.73 [95% CI 0.72-0.75]) and other insurance (aOR 0.91 [95% CI 0.88-0.94]); all p<0.001. Coronary angiography (60% vs. 77-82%) and PCI (45% vs. 63-70%) were used less frequently in the Medicare population compared to others. The Medicare and Medicaid populations had longer lengths of hospital stay, and the Medicare population had the lowest hospitalization costs and fewer discharges to home. CONCLUSIONS: Compared to other types of primary payers, STEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.


Assuntos
Seguro Saúde/estatística & dados numéricos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/economia , Idoso , Feminino , Humanos , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Prognóstico , Estados Unidos
20.
JAMA Netw Open ; 3(12): e2029419, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33331918

RESUMO

Importance: Little is known about the breadth of health care networks or the degree to which different insurers' networks overlap. Objective: To quantify network breadth and exclusivity (ie, overlap) among primary care physician (PCP), cardiology, and general acute care hospital networks for employer-based (large group and small group), individually purchased (marketplace), Medicare Advantage (MA), and Medicaid managed care (MMC) plans. Design, Setting, and Participants: This cross-sectional study included 1192 networks from Vericred. The analytic unit was the network-zip code-clinician type-market, which captured attributes of networks from the perspective of a hypothetical patient seeking access to in-network clinicians or hospitals within a 60-minute drive. Exposures: Enrollment in a private insurance plan. Main Outcomes and Measures: Percentage of in-network physicians and/or hospitals within a 60-minute drive from a hypothetical patient in a given zip code (breadth). Number of physicians and/or hospitals within each network that overlapped with other insurers' networks, expressed as a percentage of the total possible number of shared connections (exclusivity). Descriptive statistics (mean, quantiles) were produced overall and by network breadth category, as follows: extra-small (<10%), small (10%-25%), medium (25%-40%), large (40%-60%), and extra-large (>60%). Networks were analyzed by insurance type, state, and insurance, physician, and/or hospital market concentration level, as measured by the Hirschman-Herfindahl index. Results: Across all US zip code-network observations, 415 549 of 511 143 large-group PCP networks (81%) were large or extra-large compared with 138 485 of 202 702 MA (68%), 191 918 of 318 082 small-group (60%), 60 425 of 149 841 marketplace (40%), and 21 781 of 66 370 MMC (40%) networks. Large-group employer networks had broader coverage than all other network plans (mean [SD] PCP breadth: large-group employer-based plans, 57.3% [20.1]; small-group employer-based plans, 45.7% [21.4]; marketplace, 36,4% [21.2]; MMC, 32.3% [19.3]; MA, 47.4% [18.3]). MMC networks were the least exclusive (a mean [SD] overlap of 61.3% [10.5] for PCPs, 66.5% [9.8] for cardiology, and 60.2% [12.3] for hospitals). Networks were narrowest (mean [SD] breadth 42.4% [16.9]) and most exclusive (mean [SD] overlap 47.7% [23.0]) in California and broadest (79.9% [16.6]) and least exclusive (71.1% [14.6]) in Nebraska. Rising levels of insurer and market concentration were associated with broader and less exclusive networks. Markets with concentrated primary care and insurance markets had the broadest (median [interquartile range {IQR}], 75.0% [60.0%-83.1%]) and least exclusive (median [IQR], 63.7% [52.4%-73.7%]) primary care networks among large-group commercial plans, while markets with least concentration had the narrowest (median [IQR], 54.6% [46.8%-67.6%]) and most exclusive (median [IQR], 49.4% [41.9%-56.9%]) networks. Conclusions and Relevance: In this study, narrower health care networks had a relatively large degree of overlap with other networks in the same geographic area, while broader networks were associated with physician, hospital, and insurance market concentration. These results suggest that many patients could switch to a lower-cost, narrow network plan without losing in-network access to their PCP, although future research is needed to assess the implications for care quality and clinical integration across in-network health care professionals and facilities in narrow network plans.


Assuntos
Redes Comunitárias , Prestação Integrada de Cuidados de Saúde/organização & administração , Setor de Assistência à Saúde/organização & administração , Instituições Privadas de Saúde/normas , Seguro Saúde/organização & administração , Redes Comunitárias/estatística & dados numéricos , Redes Comunitárias/provisão & distribução , Estudos Transversais , Sistemas de Informação em Saúde , Humanos , Atenção Primária à Saúde/organização & administração , Garantia da Qualidade dos Cuidados de Saúde , Estados Unidos
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