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2.
PLoS One ; 15(8): e0237995, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32841267

RESUMO

BACKGROUND: Ocular inflammation causes significant visual morbidity in the United States, yet little is known about the epidemiology of infectious uveitis and scleritis. This study aims to evaluate the epidemiology of infectious uveitis/scleritis employing a large national medical claims database. METHODS: This was a retrospective, case-control study, employing Optum's de-identified Clinformatics® Data Mart Database, containing data from 21.5 million privately insured individuals with enrollment for at least 15 months within 2007-2015. Inclusion in the uveitis/scleritis sample required an index uveitis/scleritis diagnosis based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Exclusion criteria included index date within 3 months after intraocular surgery. Rates for uveitis/scleritis were determined by anatomic site. Multivariable logistic regression analyses were performed to determine odds ratios for the incidence and prevalence of uveitis/scleritis by anatomic category. FINDINGS: Infectious etiologies accounted for less than 20% of uveitis/scleritis, with mean rates of 18.9 (incidence) and 60.6 (prevalence) per 100,000 persons. The mean prevalences of infectious anterior, intermediate, posterior, panuveitis, and scleritis were 27.7, 0.17, 23.4, 4.4, and 4.6, per 100,000, respectively. Overall risk of prevalent infectious uveitis/scleritis increased with age (OR>3.3 for each decade over age 18, p<0.01), female sex (OR = 1.2, p<0.01), non-Hispanic white race (OR<1 for all other races, p<0.01), as well as the East South Central census division (OR = 1.2, p<0.01), comprising Alabama, Kentucky, Missouri, and Tennessee. Medical comorbidities, including HIV infection (OR = 6.4, p<0.01) and rheumatologic disease (OR = 1.9, p<0.01), were common in the infectious uveitis/scleritis cohort. CONCLUSIONS: The incidence and prevalence of infectious uveitis/scleritis in the United States were higher than previously reported estimates but remained lower than in developing countries. Rates varied by age, sex, race, and medical comorbidities, and may reflect differential susceptibility to various infectious agents with disparate geographic distributions within the United States.


Assuntos
Infecções/complicações , Seguro Saúde/estatística & dados numéricos , Esclerite/complicações , Esclerite/epidemiologia , Uveíte/complicações , Uveíte/epidemiologia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Esclerite/economia , Estados Unidos/epidemiologia , Uveíte/economia , Adulto Jovem
3.
Int J Health Serv ; 50(4): 408-414, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32605414

RESUMO

Four decades of neoliberal health policies have left the United States with a health care system that prioritizes the profits of large corporate actors, denies needed care to tens of millions, is extraordinarily fragmented and inefficient, and was ill prepared to address the COVID-19 pandemic. The payment system has long rewarded hospitals for providing elective surgical procedures to well-insured patients while penalizing those providing the most essential and urgent services, causing hospital revenues to plummet as elective procedures were cancelled during the pandemic. Before the recession caused by the pandemic, tens of millions of Americans were unable to afford care, compromising their physical and financial health; deep-pocketed corporate interests were increasingly dominating the hospital industry and taking over physicians' practices; and insurers' profits hit record levels. Meanwhile, yawning class-based and racial inequities in care and health outcomes remain and have even widened. Recent data highlight the failure of policy strategies based on market models and the need to shift to a nonprofit social insurance model.


Assuntos
Infecções por Coronavirus/epidemiologia , Assistência à Saúde/organização & administração , Pneumonia Viral/epidemiologia , Betacoronavirus , Custos e Análise de Custo , Assistência à Saúde/economia , Acesso aos Serviços de Saúde/organização & administração , Disparidades nos Níveis de Saúde , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Medicare/economia , Pandemias , Política , Fatores Socioeconômicos , Estados Unidos/epidemiologia
4.
PLoS One ; 15(7): e0235599, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32649662

RESUMO

BACKGROUND: As percutaneous transthoracic needle biopsy (PTNB) of the lung is a well-established diagnostic method for the evaluating pulmonary lesions, evidence of safety based on representative data is limited. This study investigated the practice patterns of PTNB of the lung and assessed the incidence and risk factors of PTNB-related severe pneumothorax in Korea. METHODS: We used a national-level health insurance database between January 1, 2007 and December 31, 2015. Patients who underwent PTNB of the lung were identified using procedure codes for organ biopsy, fluoroscopy, computed tomography, chest radiography, and lung-related diagnosis codes. The annual age-/sex-standardized rate of PTNB and the incidence of PTNB-related severe pneumothorax were calculated. We defined severe pneumothorax as the pneumothorax requiring intervention. The odds ratios of risk factors were assessed by a generalized estimating equation model with exchangeable working correlation matrix to address clustering effect within institution. RESULTS: A total of 66,754 patients were identified between 2007 and 2015. The annual age-/sex-standardized rate of PTNB per 100,000 population was 19.6 in 2007 and 22.4 in 2015, and it showed an increasing trend. The incidence of severe pneumothorax was 2.4% overall: 2.5% in men and 1.2% in women, and 2.6%, 2.7%, 2.1%, 2.1%, 1.9%, 2.4%, and 2.4% from 2009 to 2015. Older age (≥60), male sex, presence of chronic obstructive pulmonary disease, receiving treatment in an urban or rural area versus a metropolitan area, and receiving treatment at a general hospital were significantly associated with the risk of severe pneumothorax. CONCLUSIONS: Considering the increasing trend of PTNB, more attention needs to be paid to patients with risk factors for severe pneumothorax.


Assuntos
Biópsia por Agulha/efeitos adversos , Pulmão/patologia , Pneumotórax/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Risco , Fatores de Risco , Adulto Jovem
5.
Matern Child Health J ; 24(9): 1151-1160, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32613334

RESUMO

BACKGROUND: Women experiencing unintended and short-interval pregnancies are at increased risk for adverse outcomes. Nationally, researchers report disparities in women's use of effective contraceptive methods based on demographic, cultural, financial and system-level factors. Despite 58% of Louisiana births being unplanned, researchers have not reported on these relationships in Louisiana. METHODS: We used Louisiana Pregnancy Risk Assessment Monitoring System data from 2015 to 2018. Among postpartum women who were not abstinent, pregnant, or trying to become pregnant, we estimated use of five categories of effective contraception versus no effective method. We used multivariable multinomial logistic regression to investigate the association between effective contraceptive use and race/ethnicity, postpartum insurance and education. RESULTS: Among Louisiana postpartum women who were not abstinent, pregnant, or trying to become pregnant, 35.4% were not using effective contraception. Women with public insurance had greater odds of using long-acting reversible contraception than women with private insurance (adjusted odds ratio [AOR] 1.55; 95% confidence interval [CI] 1.11-2.16). Compared to women with a bachelor's or higher, women with less than high school (AOR 2.09; CI 1.22-3.56), high school (AOR 3.11; CI 2.01-4.82) or some college education (AOR 2.48; CI 1.64-3.75) had greater odds of using permanent contraception. Black (AOR 3.83; CI 2.66-5.54) and Hispanic (AOR 3.85; CI 2.09-7.11) women, women with less than high school (AOR 6.79; CI 2.72-16.94), high school (AOR 7.26; CI 3.06-17.21) and some college (AOR 7.22; CI 3.14-16.60), and women with public insurance (AOR 1.91; CI 1.28-2.87) had greater odds of using injectable contraception. DISCUSSION: Results showed variation in effective contraceptive method use by race/ethnicity, insurance and education. These findings highlight the need for state-level research into the individual, provider, and policy-level factors that influence women's contraceptive choices.


Assuntos
Comportamento Contraceptivo/estatística & dados numéricos , Anticoncepção/métodos , Grupos Étnicos/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Cuidado Pós-Natal/estatística & dados numéricos , Período Pós-Parto , Adolescente , Adulto , Afro-Americanos , Escolaridade , Grupo com Ancestrais do Continente Europeu , Feminino , Disparidades em Assistência à Saúde , Hispano-Americanos , Humanos , Louisiana , Gravidez , Características de Residência , Adulto Jovem
6.
Public Health ; 185: 130-138, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32622220

RESUMO

OBJECTIVES: Health insurance availability and affordability are vital elements in diagnosis and treatment of patients with cancer and thus constitute clinical significance as well. Although past studies have explored the disparity in mortality figures for patients with different insurance statuses, this population-based study is pioneering in analyzing the changes in cancer mortality risks over time amid macroeconomic shifts. STUDY DESIGN: The study uses Surveillance Epidemiology and End Results (SEER) data of 424,889 non-elderly patients with breast, cervical, ovarian, and uterine cancer diagnosed during 2007-2010 and 2011-2015. METHODS: In addition to discussing incidence figures and insurance patterns, the study uses Kaplan-Meier and Cox's proportional hazard models to examine the changes in survival probability and mortality risks for insurance-stratified patients with female-specific cancer across the two time periods. RESULTS: Patients without insurance have an increased risk of mortality over time relative to insured patients. Moreover, uninsured patients face this heightened risk more than Medicaid patients. DISCUSSION: Despite public policy measures as well as advancements in diagnostic facilities and treatment technology, the increased relative mortality of patients without insurance limits the long-term affordability of cancer treatment for economically vulnerable patients in comparison with insured patients.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Neoplasias/mortalidade , Adolescente , Adulto , Neoplasias da Mama/mortalidade , Feminino , Humanos , Incidência , Cobertura do Seguro/economia , Seguro Saúde/economia , Medicaid/economia , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Neoplasias/economia , Neoplasias/epidemiologia , Neoplasias Ovarianas/mortalidade , Fatores de Risco , Programa de SEER , Estados Unidos , Neoplasias do Colo do Útero/mortalidade , Neoplasias Uterinas/mortalidade , Adulto Jovem
7.
Niger Postgrad Med J ; 27(3): 196-201, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32687119

RESUMO

Background: Waning donor funding and poor country ownership of HIV care programmes are challenges for the sustainability of care for people living with HIV (PLHIV) in Nigeria. Health insurance presents a viable alternative for funding of HIV care services. This study assessed the determinants of willingness to participate in health insurance amongst PLHIV in a tertiary hospital in South-East Nigeria. Methods: Across-sectional survey was conducted amongst 371 PLHIV on treatment at Federal Teaching Hospital, Abakaliki, Nigeria, using a semi-structured, interviewer-administered questionnaire. Chi-square test and logistic regression were conducted with SPSS version 20 at 5% level of significance. Results: Respondents were mostly males (51.8%) with a mean age and monthly income of 45.4 ± 10.3 years and $74.1 ± 42, respectively. Majority were willing to participate (82.5%) and to finance health insurance (65.2%). The major reasons cited by those unwilling to participate were poor understanding of how the system works and lack of regular source of income. The predictors of willingness to participate were female gender (adjusted odds ratio [AOR] = 2.9; 95% confidence interval [CI]: 1.6-5.7), being currently unmarried (AOR = 4.3; 95% CI: 2.3-7.8), being self-employed (AOR = 2.2; 95% CI: 1.2-3.9), having family size >5 (AOR = 3.1; 95% CI: 1.7-5.9) and having less than secondary school education (AOR = 4.3; 95% CI: 2.3-7.8). Conclusion: Majority of the respondents surveyed were willing to participate in, and finance health insurance. Willingness to participate was more amongst vulnerable subgroups (females, unmarried, self-employed, poorly educated and those with large family size). We recommend the inclusion of health insurance in the care package of PLHIV.


Assuntos
Infecções por HIV/tratamento farmacológico , Seguro Saúde/estatística & dados numéricos , Participação do Paciente/estatística & dados numéricos , Adulto , Estudos Transversais , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Nigéria , Aceitação pelo Paciente de Cuidados de Saúde , Participação do Paciente/psicologia , Inquéritos e Questionários , Centros de Atenção Terciária
8.
Am J Public Health ; 110(8): 1208-1210, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32552024

RESUMO

Objectives. To identify risk factors for Medicaid disenrollment after the implementation of Arkansas's work requirements.Methods. Using a 2018 telephone survey of 1208 low-income adults aged 30 to 49 years in Arkansas (expansion state with work requirements implemented in June 2018), Kentucky (expansion state with proposed work requirements blocked by courts), Louisiana (expansion state without work requirements), and Texas (nonexpansion state), we assessed Medicaid disenrollment rates among the age group targeted by Arkansas's policy.Results. The Medicaid disenrollment rate was highest in Texas (12.8%), followed by Arkansas (10.5%), Kentucky (5.8%), and Louisiana (2.8%). Over half of those who disenrolled in Texas and Arkansas became uninsured, compared with less than a quarter in Kentucky and Louisiana. In multivariate models, Arkansas had significantly higher disenrollment compared with the 3 comparison states; men and non-Hispanic Whites experienced higher disenrollment than women and racial minorities. In Arkansas, having a chronic condition was associated with higher disenrollment.Conclusions. As states debate work requirements and Medicaid reforms, our findings provide insights for policymakers about which populations may be most vulnerable to losing Medicaid coverage.


Assuntos
Emprego , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/etnologia , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/legislação & jurisprudência , Políticas , Pobreza/estatística & dados numéricos , Fatores Sexuais , Inquéritos e Questionários , Estados Unidos
10.
Medicine (Baltimore) ; 99(18): e19871, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32358355

RESUMO

The presence of comorbid conditions along with heterogeneity in terms of healthcare practices and service delivery could have a significant impact on the patient's outcomes. With a strong interest in social epidemiology to examine the impact of health services and variations on health outcomes, the current study was conducted to analyse the incidence of hemodialysis-associated infection (HAI) as well as its associated factors, and to quantify the extent to which the contextual effects of the care facility and regional variations influence the risk of HAI.A total of 6111 patients with end-stage renal disease who received hemodialysis treatment between 1 October 2015 and 31 March 2016 were identified from the insurance claim database as a population-based, close-cohort retrospective study. Patients were followed for one year from April 1, 2016 to March 31, 2017. A total of 200 HAI cases were observed during the follow-up and 12 patients died within 90 days of the onset of HAI. Increased risks for HAI were associated with moderate (HR 1.73, 95% confidence interval [CI] 1.00-2.98) and severe (HR 1.87, 95% CI 1.11-3.14) comorbid conditions as well as malignancy (HR 1.36, 95% CI 1.00-1.85). Increased risk was also seen among patients who received hemodialysis treatment from clinics (HR 2.49, 95% CI 1.1-5.33). However, these statistics were no longer significant when variations at the level of care facilities were statistically controlled. In univariate analyses, no statistically significant association was observed between 90-day mortality and baseline patients, and the characteristics of the care facility.The results of the multivariate, multilevel analyses indicated that HAI variations were only significant at the care facility level (σ 2.07, 95% CI 1.3-3.2) and were largely explained by the heterogeneity between care facilities. The results of this study highlight the need to look beyond the influence of patient-level characteristics when developing policies that aim at improving the quality of hemodialysis healthcare and service delivery in Japan.


Assuntos
Infecções/epidemiologia , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Infecções/etiologia , Seguro Saúde/estatística & dados numéricos , Japão/epidemiologia , Falência Renal Crônica/microbiologia , Masculino , Pessoa de Meia-Idade , Análise Multinível , Estudos Retrospectivos
11.
Med Care ; 58(6): 497-503, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32412941

RESUMO

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


Assuntos
Grupos de Populações Continentais/estatística & dados numéricos , Recém-Nascido de Baixo Peso , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/legislação & jurisprudência , Nascimento Prematuro/etnologia , Afro-Americanos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Inquéritos Epidemiológicos , Hispano-Americanos/estatística & dados numéricos , Humanos , Recém-Nascido , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Análise Espacial , Estados Unidos/epidemiologia
12.
BMC Public Health ; 20(1): 608, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32357871

RESUMO

BACKGROUND: Risk adjustment models are employed to prevent adverse selection, anticipate budgetary reserve needs, and offer care management services to high-risk individuals. We aimed to address two unknowns about risk adjustment: whether machine learning (ML) and inclusion of social determinants of health (SDH) indicators improve prospective risk adjustment for health plan payments. METHODS: We employed a 2-by-2 factorial design comparing: (i) linear regression versus ML (gradient boosting) and (ii) demographics and diagnostic codes alone, versus additional ZIP code-level SDH indicators. Healthcare claims from privately-insured US adults (2016-2017), and Census data were used for analysis. Data from 1.02 million adults were used for derivation, and data from 0.26 million to assess performance. Model performance was measured using coefficient of determination (R2), discrimination (C-statistic), and mean absolute error (MAE) for the overall population, and predictive ratio and net compensation for vulnerable subgroups. We provide 95% confidence intervals (CI) around each performance measure. RESULTS: Linear regression without SDH indicators achieved moderate determination (R2 0.327, 95% CI: 0.300, 0.353), error ($6992; 95% CI: $6889, $7094), and discrimination (C-statistic 0.703; 95% CI: 0.701, 0.705). ML without SDH indicators improved all metrics (R2 0.388; 95% CI: 0.357, 0.420; error $6637; 95% CI: $6539, $6735; C-statistic 0.717; 95% CI: 0.715, 0.718), reducing misestimation of cost by $3.5 M per 10,000 members. Among people living in areas with high poverty, high wealth inequality, or high prevalence of uninsured, SDH indicators reduced underestimation of cost, improving the predictive ratio by 3% (~$200/person/year). CONCLUSIONS: ML improved risk adjustment models and the incorporation of SDH indicators reduced underpayment in several vulnerable populations.


Assuntos
Promoção da Saúde/economia , Promoção da Saúde/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Aprendizado de Máquina/economia , Aprendizado de Máquina/estatística & dados numéricos , Determinantes Sociais da Saúde/economia , Determinantes Sociais da Saúde/estatística & dados numéricos , Adulto , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Risco Ajustado
13.
BMC Public Health ; 20(1): 614, 2020 May 04.
Artigo em Inglês | MEDLINE | ID: mdl-32366310

RESUMO

BACKGROUND: Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa. METHODS: This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018. RESULTS: Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately. CONCLUSIONS: Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.


Assuntos
Assistência à Saúde/economia , Assistência à Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Previdência Social/estatística & dados numéricos , Cobertura Universal do Seguro de Saúde/estatística & dados numéricos , Adolescente , Adulto , Idoso , Estudos Transversais , Feminino , Gana , Humanos , Quênia , Masculino , Pessoa de Meia-Idade , Adulto Jovem
14.
JAMA Netw Open ; 3(5): e205852, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32459355

RESUMO

Importance: Timely initiation and referral to treatment for patients with opioid use disorder seen in the emergency department is associated with reduced mortality. It is not known how often commercially insured adults obtain follow-up treatment after nonfatal opioid overdose. Objective: To investigate the incidence of follow-up treatment following emergency department discharge after nonfatal opioid overdose and patient characteristics associated with receipt of follow-up treatment. Design, Setting, and Participants: A retrospective cohort study was conducted using an administrative claims database for a large US commercial insurer, from October 1, 2011, to September 30, 2016. Data analysis was performed from May 1, 2019, to September 26, 2019. Adult patients discharged from the emergency department after an index opioid overdose (no overdose in the preceding 90 days) were included. Patients with cancer and without continuous insurance enrollment were excluded. Main Outcomes and Measures: The primary outcome was follow-up treatment in the 90 days following overdose, defined as a combined outcome of claims for treatment encounters or medications for opioid use disorder (buprenorphine and naltrexone). Analysis was stratified by whether patients received treatment for opioid use disorder in the 90 days before the overdose. Logistic regression models were used to identify patient characteristics associated with receipt of follow-up treatment. Marginal effects were used to report the average adjusted probability and absolute risk differences (ARDs) in follow-up for different patient characteristics. Results: A total of 6451 patients were identified with nonfatal opioid overdose; the mean (SD) age was 45.0 (19.3) years, 3267 were women (50.6%), and 4676 patients (72.5%) reported their race as non-Hispanic white. A total of 1069 patients (16.6%; 95% CI, 15.7%-17.5%) obtained follow-up treatment within 90 days after the overdose. In adjusted analysis of patients who did not receive treatment before the overdose, black patients were half as likely to obtain follow-up compared with non-Hispanic white patients (ARD, -5.9%; 95% CI, -8.6% to -3.6%). Women (ARD, -1.7%; 95% CI, -3.3% to -0.5%) and Hispanic patients (ARD, -3.5%; 95% CI, -6.1% to -0.9%) were also less likely to obtain follow-up. For each additional year of age, patients were 0.2% less likely to obtain follow-up (95% CI, -0.3% to -0.1%). Conclusions and Relevance: Efforts to improve the low rate of timely follow-up treatment following opioid overdose may seek to address sex, race/ethnicity, and age disparities.


Assuntos
Assistência ao Convalescente/estatística & dados numéricos , Analgésicos Opioides/envenenamento , Overdose de Drogas/epidemiologia , Seguro Saúde/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/terapia , Adulto , Overdose de Drogas/terapia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia
16.
BMC Public Health ; 20(1): 509, 2020 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-32299421

RESUMO

BACKGROUND: Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type. METHODS: We compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011 and 2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring (> 2 lab measures/year, > 30 days apart) and durable viral suppression (VS; HIV RNA < 50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors. RESULTS: Among 3908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p = 0.03; ART-experienced: private 80.2% vs public 69.4%, p < 0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR = 1.59, 95% CI: 1.20, 2.12; p = 0.001). CONCLUSIONS: Paradoxical differences between HIV monitoring and durable VS exist among publicly and privately-insured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.


Assuntos
Infecções por HIV/epidemiologia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Pacientes Ambulatoriais/estatística & dados numéricos , Adulto , Terapia Antirretroviral de Alta Atividade , Contagem de Linfócito CD4 , Estudos de Coortes , District of Columbia , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Modelos Logísticos , Masculino , Medicaid , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
17.
PLoS One ; 15(4): e0231417, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32271845

RESUMO

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


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Adulto , Arkansas , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act , Pobreza , Estados Unidos , Adulto Jovem
19.
BMC Health Serv Res ; 20(1): 334, 2020 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-32316952

RESUMO

BACKGROUND: There is a rich literature on insurance coverage and its impacts on health care. Many recent studies have examined the impacts of the Affordable Care Act (ACA) and found that it had positive effects on health insurance coverage and health care usage. Most of the literature, however, has focused on insurance coverage at a single point in time, while research on insurance instability is underrepresented, even though it could significantly impact health outcomes. The aim of this study is to examine changes and implications of insurance instability among nonelderly adults from 2006 to 2016, covering the Great Recession and post-ACA periods. METHODS: Using 2006-to-2016 Medical Expenditure Panel Survey data, we identify seven insurance patterns and analyze them by race/ethnicity, age, geography, income, and medical conditions. We then use multivariable linear models to analyze the relationship between insurance instability and health care status, access, and utilization. Logistic, Poisson and nonlinear models test the robustness of our results. RESULTS: The post-ACA period 2015-2016 saw the lowest ever-uninsured rate (25.68% or 67.91 million). The largest decrease in insurance instability was among adults aged 19-25, low-income families, Hispanics, the western population, and the healthy population. Like the always-uninsured, those with other insurance gaps experienced a lack of access to care and decreased preventive care and other services. CONCLUSIONS: Despite the post-ACA instability reduction, over 25% of the U.S. population continued to have insurance gaps over a two-year period. Disparities continued to exist between income groups, race/ethnicities, and regions. Repealing ACA could exacerbate insurance instability and disparities between different groups, which in turn could lead to adverse health outcomes.


Assuntos
Cobertura do Seguro , Pessoas sem Cobertura de Seguro de Saúde , Adolescente , Adulto , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Entrevistas como Assunto , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act , Pesquisa Qualitativa , Inquéritos e Questionários , Estados Unidos , Adulto Jovem
20.
Am J Gastroenterol ; 115(6): 895-905, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32324606

RESUMO

OBJECTIVES: Chronic idiopathic constipation (CIC) is characterized by unsatisfactory defecation and difficult or infrequent stools. CIC affects 9%-20% of adults in the United States, and although prevalent, gaps in knowledge remain regarding CIC healthcare seeking and medication use in the community. We recruited a population-based sample to determine the prevalence and predictors of (i) individuals having discussed their constipation symptoms with a healthcare provider and (ii) the use of constipation therapies. METHODS: We recruited a representative sample of Americans aged 18 years or older who had experienced constipation. Those who met the Rome IV criteria for irritable bowel syndrome and opioid-induced constipation were excluded. The survey included questions on constipation severity, healthcare seeking, and the use of constipation medications. We used multivariable regression methods to adjust for confounders. RESULTS: Overall, 4,702 participants had experienced constipation (24.0% met the Rome IV CIC criteria). Among all respondents with previous constipation, 37.6% discussed their symptoms with a clinician (primary care provider 87.6%, gastroenterologist 26.0%, and urgent care/emergency room physician 7.7%). Age, sex, race/ethnicity, marital status, employment status, having a source of usual care, insurance status, comorbidities, locus of control, and constipation severity were associated with seeking care (P < 0.05). Overall, 47.8% of respondents were taking medication to manage their constipation: over-the-counter medication(s) only, 93.5%; prescription medication(s) only, 1.3%; and both over-the-counter medication(s) and prescription medication(s), 5.2%. DISCUSSION: We found that 3 of 5 Americans with constipation have never discussed their symptoms with a healthcare provider. Furthermore, the use of prescription medications for managing constipation symptoms is low because individuals mainly rely on over-the-counter therapies.


Assuntos
Constipação Intestinal/tratamento farmacológico , Laxantes/uso terapêutico , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Fatores Etários , Bisacodil/uso terapêutico , Doença Crônica , Colonoscopia/estatística & dados numéricos , Constipação Intestinal/fisiopatologia , Fibras na Dieta/uso terapêutico , Ácido Dioctil Sulfossuccínico/uso terapêutico , Serviço Hospitalar de Emergência , Emprego , Grupos Étnicos/estatística & dados numéricos , Feminino , Gastroenterologistas , Fármacos Gastrointestinais/uso terapêutico , Agonistas da Guanilil Ciclase C/uso terapêutico , Humanos , Seguro Saúde/estatística & dados numéricos , Controle Interno-Externo , Lactulose/uso terapêutico , Masculino , Estado Civil/estatística & dados numéricos , Pessoa de Meia-Idade , Medicamentos sem Prescrição/uso terapêutico , Peptídeos/uso terapêutico , Médicos de Atenção Primária , Polietilenoglicóis/uso terapêutico , Senosídeos/uso terapêutico , Índice de Gravidade de Doença , Fatores Sexuais , Tensoativos/uso terapêutico , Inquéritos e Questionários , Estados Unidos
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