Evaluating the accessibility and value of U.S. ambulatory care among Medicaid expansion states and non-expansion states, 2012-2015.

BACKGROUND: While the Affordable Care Act's Medicaid expansion improved healthcare coverage and access for millions of uninsured Americans, less is known about its effects on the overall accessibility and quality of care across all payers. Rapid volume increases of newly enrolled Medicaid patients might have unintentionally strained accessibility or quality of care. We assessed changes in physician office visits and high- and low-value care associated with Medicaid expansion across all payers. METHODS: Prespecified, quasi-experimental, difference-in-differences analysis pre and post Medicaid expansion (2012-2015) in 8 states that did and 5 that did not choose to expand Medicaid. Physician office visits sampled from the National Ambulatory Medical Care Survey, standardized with U.S. Census population estimates. Outcomes included visit rates per state population and rates of high or low-value service composites of 10 high-value measures and 7 low-value care measures respectively, stratified by year and insurance. RESULTS: We identified approximately 143 million adults utilizing 1.9 billion visits (mean age 56; 60% female) during 2012-2015. Medicaid visits increased in expansion states post-expansion compared to non-expansion states by 16.2 per 100 adults (p = 0.031 95% CI 1.5-31.0). New Medicaid visits increased by 3.1 per 100 adults (95% CI 0.9-5.3, p = 0.007). No changes were observed in Medicare or commercially-insured visit rates. High or low-value care did not change for any insurance type, except high-value care during new Medicaid visits, which increased by 4.3 services per 100 adults (95% CI 1.1-7.5, p = 0.009). CONCLUSIONS: Following Medicaid expansion, the U.S. healthcare system increased access to care and use of high-value services for millions of Medicaid enrollees, without observable reductions in access or quality for those enrolled in other insurance types. Provision of low-value care continued at similar rates post-expansion, informing future federal policies designed to improve the value of care.

Health Equity: The Only Path Forward for Primary Care.

The 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report on Implementing High-Quality Primary Care identifies 5 high-level objectives regarding payment, access, workforce development, information technology, and implementation. Nine junior primary care leaders (3 internal medicine, 3 family medicine, 3 pediatrics) invited from broad geographies, practice settings, and academic backgrounds used appreciative inquiry to identify priorities for the future of primary care. Highlighting the voices of these early career clinicians, we propose a response to the report from the perspective of early career primary care physicians. Health equity must be the foundation of the future of primary care. Because Barbara Starfield's original 4 Cs (first contact, coordination, comprehensiveness, and continuity) may not be inclusive of the needs of under-resourced communities, we promote an extension to include 5 additional Cs: convenience, cultural humility, structural competency, community engagement, and collaboration. We support the NASEM report's priorities and its focus on achieving health equity. We recommend investing in local communities and preparatory programs to stimulate diverse individuals to serve in health care. Finally, we support a blended value-based care model with risk adjustment for the social complexity of our patients.Appeared as Annals "Online First" article.

The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007-2016.

BACKGROUND: Low-value care, or patient care that offers no net benefit in specific clinical scenarios, is costly and often associated with patient harm. The US Preventive Services Task Force (USPSTF) Grade D recommendations represent one of the most scientifically sound and frequently delivered groups of low-value services, but a more contemporary measurement of the utilization and spending for Grade D services beyond the small number of previously studied measures is needed. OBJECTIVE: To estimate utilization and costs of seven USPSTF Grade D services among US Medicare beneficiaries. DESIGN: We conducted a cross-sectional study of data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016 to identify instances of Grade D services. SETTING/PARTICIPANTS: NAMCS is a nationally representative survey of US ambulatory visits at non-federal and non-hospital-based offices that uses a multistage probability sampling design. We included all visits by Medicare enrollees, which included traditional fee-for-service, Medicare Advantage, supplemental coverage, and dual-eligible Medicare-Medicaid enrollees. MAIN MEASURES: We measured annual utilization of seven Grade D services among adult Medicare patients, using inclusion and exclusion criteria from prior studies and the USPSTF recommendations. We calculated annual costs by multiplying annual utilization counts by mean per-unit costs of services using publicly available sources. KEY RESULTS: During the study period, we identified 95,121 unweighted Medicare patient visits, representing approximately 2.4 billion visits. Each year, these seven Grade D services were utilized 31.1 million times for Medicare beneficiaries and cost $477,891,886. Three services-screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years-comprised $322,382,772, or two-thirds of the annual costs of the Grade D services measured in this study. CONCLUSIONS: US Medicare beneficiaries frequently received a group of rigorously defined and costly low-value preventive services. Spending on low-value preventive care concentrated among a small subset of measures, representing important opportunities to safely lower US health care spending while improving the quality of care.

Differences in Rates of High-Value and Low-Value Care Between Community Health Centers and Private Practices.

BACKGROUND: Community health centers (CHCs) are an integral part of the health care safety net. As health systems seek to improve value, it is important to understand the quality of care provided by CHCs. OBJECTIVE: To evaluate the performance of CHCs compared with private practices on a comprehensive set of high-value and low-value care measures. DESIGN: This cross-sectional study used data from the National Ambulatory Medical Care Survey from 2010 through 2012. We compared CHCs with private practices using logistic regression models that adjusted for age, sex, race/ethnicity, insurance, number of chronic illnesses, rural versus urban location, region of country, and survey year. SETTING/PARTICIPANTS: We included outpatient visits to generalist physicians at either CHCs or private practices by patients 18 years and older. MAIN MEASURES: We examined 12 measures of high-value care and 7 measures of low-value care. RESULTS: A total of 29,155 physician visits, representing 584,208,173 weighted visits, from 2010 through 2012 were included. CHCs were more likely to provide high-value care by ordering beta-blockers in CHF (46.9% vs. 36.5%; aOR 2.56; 95%CI 1.18-5.56), statins in diabetes (37.0% vs 35.5%; aOR 1.35; 95%CI 1.02-1.79), and providing treatment for osteoporosis (35.7% vs 23.2%; aOR 1.77; 95%CI 1.05-3.00) compared with private practices. CHCs were more likely to avoid low-value screening EKGs (98.7% vs. 88.0%; aOR 11.03; 95%CI 2.67-45.52), CBCs (75.9% vs. 65.7%; aOR 1.72; 95%CI 1.18-2.53), or urinalyses (86.0% vs. 80.5%; aOR 1.87; 95%CI 1.11-3.14) during a general medical exam. CHCs were also less likely to prescribe antibiotics for a URI (48.3% vs. 63.1%; aOR 0.59; 95%CI 0.40-0.88). CONCLUSIONS: On a number of high-value and low-value measures of care, CHCs performed similar to or better than private practices. As healthcare delivery reforms continue to progress, CHCs are well positioned to provide high-value healthcare.

Identifying Subgroups of Adult Superutilizers in an Urban Safety-Net System Using Latent Class Analysis: Implications for Clinical Practice.

BACKGROUND: Patients with repeated hospitalizations represent a group with potentially avoidable utilization. Recent publications have begun to highlight the heterogeneity of this group. Latent class analysis provides a novel methodological approach to utilizing administrative data to identify clinically meaningful subgroups of patients to inform tailored intervention efforts. OBJECTIVE: The objective of the study was to identify clinically distinct subgroups of adult superutilizers. RESEARCH DESIGN: Retrospective cohort analysis. SUBJECTS: Adult patients who had an admission at an urban safety-net hospital in 2014 and 2 or more admissions within the preceding 12 months. MEASURES: Patient-level medical, mental health (MH) and substance use diagnoses, social characteristics, demographics, utilization and charges were obtained from administrative data. Latent class analyses were used to determine the number and characteristics of latent subgroups that best represented these data. RESULTS: In this cohort (N=1515), a 5-class model was preferred based on model fit indices, clinical interpretability and class size: class 1 (16%) characterized by alcohol use disorder and homelessness; class 2 (14%) characterized by medical conditions, MH/substance use disorders and homelessness; class 3 (25%) characterized primarily by medical conditions; class 4 (13%) characterized by more serious MH disorders, drug use disorder and homelessness; and class 5 (32%) characterized by medical conditions with some MH and substance use. Patient demographics, utilization, charges and mortality also varied by class. CONCLUSIONS: The overall cohort had high rates of multiple chronic medical conditions, MH, substance use disorders, and homelessness. However, the patterns of these conditions were different between subgroups, providing important information for tailoring interventions.

Monitoring Depression Rates in an Urban Community: Use of Electronic Health Records.

OBJECTIVES: Depression is the most common mental health disorder and mediates outcomes for many chronic diseases. Ability to accurately identify and monitor this condition, at the local level, is often limited to estimates from national surveys. This study sought to compare and validate electronic health record (EHR)-based depression surveillance with multiple data sources for more granular demographic subgroup and subcounty measurements. DESIGN/SETTING: A survey compared data sources for the ability to provide subcounty (eg, census tract [CT]) depression prevalence estimates. Using 2011-2012 EHR data from 2 large health care providers, and American Community Survey data, depression rates were estimated by CT for Denver County, Colorado. Sociodemographic and geographic (residence) attributes were analyzed and described. Spatial analysis assessed for clusters of higher or lower depression prevalence. MAIN OUTCOME MEASURE(S): Depression prevalence estimates by CT. RESULTS: National and local survey-based depression prevalence estimates ranged from 7% to 17% but were limited to county level. Electronic health record data provided subcounty depression prevalence estimates by sociodemographic and geographic groups (CT range: 5%-20%). Overall depression prevalence was 13%; rates were higher for women (16% vs men 9%), whites (16%), and increased with age and homeless patients (18%). Areas of higher and lower EHR-based, depression prevalence were identified. CONCLUSIONS: Electronic health record-based depression prevalence varied by CT, gender, race/ethnicity, age, and living status. Electronic health record-based surveillance complements traditional methods with greater timeliness and granularity. Validation through subcounty-level qualitative or survey approaches should assess accuracy and address concerns about EHR selection bias. Public health agencies should consider the opportunity and evaluate EHR system data as a surveillance tool to estimate subcounty chronic disease prevalence.

A Multilevel Analysis of Individual, Health System, and Neighborhood Factors Associated with Depression within a Large Metropolitan Area.

Depression prevalence is known to vary by individual factors (gender, age, race, medical comorbidities) and by neighborhood factors (neighborhood deprivation). However, the combination of individual- and neighborhood-level data is rarely available to assess their relative contribution to variation in depression across neighborhoods. We geocoded depression diagnosis and demographic data from electronic health records for 165,600 patients seen in two large health systems serving the Denver population (Kaiser Permanente and Denver Health) to Denver's 144 census tracts, and combined these data with indices of neighborhood deprivation obtained from the American Community Survey. Non-linear mixed models examined the relationships between depression rates and individual and census tract variables, stratified by health system. We found higher depression rates associated with greater age, female gender, white race, medical comorbidities, and with lower rates of home owner occupancy, residential stability, and higher educational attainment, but not with economic disadvantage. Among the Denver Health cohort, higher depression rates were associated with higher crime rates and a lower percent of foreign born residents and single mother households. Our findings suggest that individual factors had the strongest associations with depression. Neighborhood risk factors associated with depression point to low community cohesion, while the role of education is more complex. Among the Denver Health cohort, language and cultural barriers and competing priorities may attenuate the recognition and treatment of depression.

Disparities in 30-Day Readmissions After Total Hip Arthroplasty.

BACKGROUND: Policymakers have expanded readmissions penalties to include elective total hip arthroplasties (THA), but little is known whether disparities exist on the basis of race, socioeconomic status, or payer. OBJECTIVE: To identify disparities in elective primary THA readmissions based on race, socioeconomic status, and type of insurance. RESEARCH DESIGN: This analysis is a retrospective cohort study of patients discharged for an elective THA. The Healthcare Cost & Utilization Project's State Inpatient Database from California was used to identify index hospitalizations for elective primary THA and rehospitalizations within 30 days of discharge. We used multivariate logistic regression to examine differences in readmissions by race, socioeconomic status, and insurance. SUBJECTS: Subjects included patients discharged from California hospitals from 2009 through 2011 after THA. MEASURES: Risk-adjusted odds of all-cause 30-day readmission. RESULTS: The overall rate of unplanned 30-day all-cause readmissions was 4.6%. African American [odds ratio (OR)=1.38; 95% confidence interval (CI), 1.16-1.64] and Hispanic (OR=1.16; 95% CI, 1.00-1.34) patients had a higher risk of readmission than white patients after THA, when accounting for comorbidities and hospital factors. The observed difference for Hispanic patients, however, was null after adjusting for socioeconomic status and payer. Lower socioeconomic status was associated with higher odds of readmission (OR=1.24; 95% CI, 1.10-1.39). Compared with private insurance, Medicare (OR=1.26; 95% CI, 1.13-1.43), Medicaid (OR=1.86; 95% CI, 1.49-2.32), and uninsured status (OR=1.31; 95% CI, 1.01-1.69) were also associated with increased readmission risk. CONCLUSIONS: We found significant differences in the odds of 30-day readmissions on the basis of race, socioeconomic status, and payer. As readmissions penalties become widely adopted, payers need to be mindful of their effects on vulnerable populations.

Academic seminars as tool for clinical and translational science education and dissemination: Perceptions and priorities in the COVID-19 era.

Academic seminars are an important venue through which investigators in health services research (HSR) and other clinical and translational science disciplines can share their work, gather feedback, and connect with colleagues. However, the format and focus of these seminars shifted abruptly when the coronavirus disease 2019 (COVID-19) pandemic necessitated social distancing and underscored the salience of health equity. Little is known about how contemporary academic seminars are meeting the evolving needs of the HSR community. We surveyed 2021-2022 participants in a virtual HSR seminar series to understand experiences of and priorities for the seminars. We also compared results stratified by self-reported under-represented minority (URM) status. Of 45 respondents (including 26 faculty members, 8 trainees, 9 staff members, and 2 community partners), 38% self-identified as URM. Participants reported high satisfaction with seminar quality, diversity of topics, and audience participation (median ≥4 for all outcomes in Likert-scaled items where 5 = very satisfied). Knowledge acquisition, understanding of research methods, and collaboration were commonly cited as benefits of seminar attendance. Implementation science content and external collaboration were most often endorsed as priorities for future seminars. URM participants were over three times more likely than non-URM participants to cite learning about engaging community stakeholders and historically excluded populations as a benefit of seminar participation. Virtual academic seminars can be an effective modality for knowledge sharing and collaboration worth continuing after COVID-19 restrictions are lifted. Emphasizing equity, diversity, and inclusion (EDI) values in these seminars may hold potential for advancing academic departments' own EDI goals.

Inability to Access Needed Medical Care Among Asian American, Native Hawaiian, and Pacific Islander Medicaid Enrollees.

We examined self-reported inability to access to needed medical care and reasons for not accessing medical care among US-representative adult Medicaid enrollees, disaggregated across 10 Asian American, Native Hawaiian, and Pacific Islander ethnic groups. Chinese (-4.54 percentage points [PP], P < .001), Other Asian (-4.42 PP, P < .001), and Native Hawaiian (-4.36 PP, P < .001) enrollees were significantly less likely to report being unable to access needed medical care compared with non-Hispanic White enrollees. The most common reason reported was that a health plan would not approve, cover, or pay for care. Mitigating inequities may require different interventions specific to certain ethnic groups.

Addressing The Interlocking Impact Of Colonialism And Racism On Filipinx/a/o American Health Inequities.

Within the monolithic racial category of "Asian American," health determinants are often hidden within each subgroup's complex histories of indigeneity, colonialism, migration, culture, and socio-political systems. Although racism is typically framed to underscore the ways in which various institutions (for example, employment and education) disproportionately disadvantage Black/Latinx communities over White people, what does structural racism look like among Filipinx/a/o Americans (FilAms), the third-largest Asian American group in the US? We argue that racism defines who is visible. We discuss pathways through which colonialism and racism preserve inequities for FilAms, a large and overlooked Asian American subgroup. We bring to light historical and modern practices inhibiting progress toward dismantling systemic racial barriers that impinge on FilAm health. We encourage multilevel strategies that focus on and invest in FilAms, such as robust accounting of demographic data in heterogeneous populations, explicitly naming neocolonial forces that devalue and neglect FilAms, and structurally supporting community approaches to promote better self- and community care.

Learning to love ourselves again: Organizing Filipinx/a/o scholar-activists as antiracist public health praxis.

A critical component for health equity lies in the inclusion of structurally excluded voices, such as Filipina/x/o Americans (FilAms). Because filam invisibility is normalized, denaturalizing these conditions requires reimagining power relations regarding whose experiences are documented, whose perspectives are legitimized, and whose strategies are supported. in this community case study, we describe our efforts to organize a multidisciplinary, multigenerational, community-driven collaboration for FilAm community wellness. Catalyzed by the disproportionate burden of deaths among FilAm healthcare workers at the onset of the COVID-19 pandemic and the accompanying silence from mainstream public health leaders, we formed the Filipinx/a/o Community Health Association (FilCHA). FilCHA is a counterspace where students, faculty, clinicians, and community leaders across the nation could collectively organize to resist our erasure. By building a virtual, intellectual community that centers our voices, FilCHA shifts power through partnerships in which people who directly experience the conditions that cause inequities have leadership roles and avenues to share their perspectives. We used Pinayism to guide our study of FilCHA, not just for the current crisis State-side, but through a multigenerational, transnational understanding of what knowledges have been taken from us and our ancestors. By naming our collective pain, building a counterspace for love of the community, and generating reflections for our communities, we work toward shared liberation. Harnessing the collective power of researchers as truth seekers and organizers as community builders in affirming spaces for holistic community wellbeing is love in action. This moment demands that we explicitly name love as essential to antiracist public health praxis.

Interventions to Address Food Insecurity Among Adults in Canada and the US: A Systematic Review and Meta-analysis.

Importance: Inadequate access to food is a risk factor for poor health and the effectiveness of federal programs targeting food insecurity, such as the Supplemental Nutrition Assistance Program (SNAP), are well-documented. The associations between other types of interventions to provide adequate food access and food insecurity status, health outcomes, and health care utilization, however, are unclear. Objective: To review evidence on the association between food insecurity interventions and food insecurity status, clinically-relevant health outcomes, and health care utilization among adults, excluding SNAP. Data Sources: A systematic search for English-language literature was performed in PubMed Central and Cochrane Trials databases (inception to January 23, 2020), the Social Interventions Research and Evaluation Network database (December 10, 2019); and the gray literature using Google (February 1, 2021). Study Selection: Studies of any design that assessed the association between food insecurity interventions for adult participants and food insecurity status, health outcomes, and health care utilization were screened for inclusion. Studies of interventions that described addressing participants' food needs or reporting food insecurity as an outcome were included. Interventions were categorized as home-delivered food, food offered at a secondary site, monetary assistance in the form of subsidies or income supplements, food desert interventions, and miscellaneous. Data Extraction and Synthesis: Data extraction was performed independently by 3 reviewers. Study quality was assessed using the Cochrane Risk of Bias Tool, the ROBINS-I (Risk of Bias in Non-Randomized Studies of Interventions) tool, and a modified version of the National Institutes of Health's Quality Assessment Tool for Before-After Studies With No Control. The certainty of evidence was based on GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria and supplemented with mechanistic and parallel evidence. For outcomes within intervention categories with at least 3 studies, random effects meta-analysis was performed. Main Outcomes and Measures: Food insecurity (measured through surveys; eg, the 2-item Hunger Vital Sign), health outcomes (eg, hemoglobin A1c), and health care utilization (eg, hospitalizations, costs). Results: A total of 39 studies comprising 170 605 participants were included (8 randomized clinical trials and 31 observational studies). Of these, 14 studies provided high-certainty evidence of an association between offering food and reduced food insecurity (pooled random effects; adjusted odds ratio, 0.53; 95% CI, 0.33-0.67). Ten studies provided moderate-certainty evidence of an association between offering monetary assistance and reduced food insecurity (pooled random effects; adjusted odds ratio, 0.64; 95% CI, 0.49-0.84). There were fewer studies of the associations between interventions and health outcomes or health care utilization, and the evidence in these areas was of low or very low certainty that any food insecurity interventions were associated with changes in either. Conclusions and Relevance: This systematic review with meta-analysis found that providing food and monetary assistance was associated with improved food insecurity measures; however, whether it translated to better health outcomes or reduced health care utilization was unclear.

The impact of tailored intervention services on charges and mortality for adult super-utilizers.

BACKGROUND: Interventions designed to improve care and reduce costs for patients with the highest rates of hospital utilization (super-utilizers) continue to proliferate, despite conflicting evidence of cost savings. METHODS: We evaluated a practice transformation intervention that implemented team-based care and risk-stratification to match specific primary care resources based on need. This included an intensive outpatient clinic for super-utilizers. We used multivariate regression and a difference-in-differences approach to compare changes in mortality, utilization, and charges between the intervention group and a historical control. Sensitivity analyses tested the robustness of findings and revealed the inherent challenges associated with quasi-experimental designs. RESULTS: Observed charges for the intervention group were significantly lower than expected charges as derived by the trend of the historical control (p<0.04) resulting in total charge avoidance of approximately $26 million. While inpatient admissions were significantly higher (p<0.01), charges associated with total inpatient (p=0.01), intensive-care unit (p<0.05, not robust to sensitivity analyses), and surgery (p<0.01) were significantly lower than expected in the intervention group. One year mortality was significantly less in the intervention group (12.6% vs 11.5%, p<0.01). CONCLUSIONS: The use of tailored services, including a dedicated intensive outpatient clinic, for super-utilizers within a larger primary care practice transformation reduced mortality and provided significant savings, even while total hospitalizations increased. These savings were achieved through a reduction in the intensity of inpatient services. The unexpected finding of a reduction in ICU charges deserves further exploration. IMPLICATIONS: These findings suggest that intensity of inpatient service, and not merely volume of services, should be considered a focus for future intervention design and evaluated as an outcome. LEVEL OF EVIDENCE: Level III (Quasi-Experimental Design).