Active Postlicensure Safety Surveillance for Recombinant Zoster Vaccine Using Electronic Health Record Data.

Recombinant zoster vaccine (RZV) (Shingrix; GlaxoSmithKline, Brentford, United Kingdom) is an adjuvanted glycoprotein vaccine that was licensed in 2017 to prevent herpes zoster (shingles) and its complications in older adults. In this prospective, postlicensure Vaccine Safety Datalink study using electronic health records, we sequentially monitored a real-world population of adults aged ≥50 years who received care in multiple US Vaccine Safety Datalink health systems to identify potentially increased risks of 10 prespecified health outcomes, including stroke, anaphylaxis, and Guillain-Barré syndrome (GBS). Among 647,833 RZV doses administered from January 2018 through December 2019, we did not detect a sustained increased risk of any monitored outcome for RZV recipients relative to either historical (2013-2017) recipients of zoster vaccine live, a live attenuated virus vaccine (Zostavax; Merck & Co., Inc., Kenilworth, New Jersey), or contemporary non-RZV vaccine recipients who had an annual well-person visit during the 2018-2019 study period. We confirmed prelicensure trial findings of increased risks of systemic and local reactions following RZV. Our study provides additional reassurance about the overall safety of RZV. Despite a large sample, uncertainty remains regarding potential associations with GBS due to the limited number of confirmed GBS cases that were observed.

A tale of two public dental benefit programs: Iowa dentist participation in traditional Medicaid versus a Medicaid expansion program.

BACKGROUND: In Iowa from 2014 to 2017, there were 2 separate public dental benefit programs for Medicaid-enrolled adults: one for the Medicaid expansion population called the Dental Wellness Plan (DWP), and one for the traditional, non-expansion adult Medicaid population. The programs differed with respect to reimbursement, administration, and benefit structure. This study explored differences in patterns and predictors of dentist participation in the two programs. METHODS: Authors sent a survey to all private practice dentists in Iowa (n = 1301) 2 years after DWP implementation. Descriptive, bivariate, and logistic regression analyses were used to examine patterns and predictors of dentist participation in Medicaid and DWP. RESULTS: Overall rates of dentists' acceptance of new Medicaid and DWP patients were 45 and 43%, respectively. However, Medicaid participants were much more likely than DWP participants to place limits on patient acceptance. Adjusting for other factors, practice busyness was the only significant predictor of DWP participation, and practice location was the only significant predictor of Medicaid participation. Dentists who were not busy enough were more than twice as likely to participate in DWP compared to others, and dentists in rural areas were almost twice as likely to participate in Medicaid compared to dentists in urban areas. CONCLUSIONS: Dentist participation in Medicaid is an ongoing concern for states aiming to ensure access to dental care for low-income populations. We found distinct participation patterns and predictors between a traditional Medicaid dental program and the DWP, suggesting different motivations for participation between the two programs.

As Health Care Landscape Shifts, Stakeholders Need To Shift as Well.

Change is happening on multiple fronts and at a faster pace than ever before. Stakeholders that ignore or minimize it will do so at their peril. To be clear, addressing organizational change or purpose internally, as well as external positioning today, is the more likely path to success.

Models of care for severe asthma: the role of primary care.

Severe asthma encompasses treatment-refractory asthma and difficult-to-treat asthma. There are a number of barriers in primary, secondary and tertiary settings which compromise optimal care for severe asthma in Australia. Guidelines recommend a multidimensional assessment of severe asthma, which includes confirming the diagnosis, severity and phenotype and identifying and treating comorbidities and risk factors. This approach has been found to improve severe asthma symptoms and quality of life and reduce exacerbations. Primary care providers can contribute significantly to the multidimensional approach for severe asthma by performing spirometry, optimising therapy and addressing risk factors such as non-adherence and smoking before referring the patient to a respiratory physician for review. Primary care practitioners are encouraged to remain engaged with the management of a patient with severe asthma following specialist review by assisting with community-based allied health referrals, managing general medical comorbidities and administering prescribed biological therapies. Specialists can support primary care by providing advice to individuals with indeterminate diagnosis, streamlining investigation and management of unrecognised risk factors and complex comorbidities, optimising treatment for severe or difficult asthma including assessment of suitability for and, if appropriate, initiating advanced therapies such as biological therapies. When discharging patients back to primary care, specialists should provide clear recommendations regarding ongoing management and should specify the indications requiring further specialist review, ideally offering a streamlined re-referral pathway.

Effects of post-discharge management on rates of early re-admission and death after hospitalisation for heart failure.

OBJECTIVES: To investigate whether enrolment of patients in management programs after hospitalisation for heart failure (HF) reduces the likelihood of post-hospital adverse outcomes. DESIGN: Cohort study in which associations between adverse outcomes at 30 and 90 days for people hospitalised for HF and baseline clinical, socio-demographic and blood pathology factors, and with post-discharge management strategies, were assessed. Setting, participants: 906 patients with HF were prospectively enrolled in five Australian states at cardiology departments with expertise in treating people with HF. MAIN OUTCOME MEASURES: All-cause re-admissions and deaths at 30 and 90 days after discharge from the index admission. RESULTS: 58% of patients were men; the mean age was 72.5 years (SD, 13.9 years). By hospital, 30-day re-admission rates ranged from 17% to 33%, and 90-day rates from 40% to 55%; 30-day mortality rates were 0-13%, 90-day rates 4-24%. Factors associated with increased odds of re-admission or death at 30 or 90 days included living alone, cognitive impairment, depression, NYHA classification, left atrial volume index, and Charlson index score. Nurse-led disease management programs and reviews within 7 days were associated with reduced odds of re-admission (but not of death) at 30 and 90 days; exercise programs were associated with reduced odds at 90 days. Significant between-hospital differences in re-admission rates were reduced after adjustment for post-discharge management programs, and abolished by further adjustment for echocardiography findings. Between-hospital differences in mortality were largely explained by differences in echocardiographic findings. CONCLUSIONS: Differences in early re-admission rates after hospitalisation for HF are primarily explained by differences in post-discharge management.

Internal validation of Medicaid Analytic eXtract (MAX) data capture for comprehensive managed care plan enrollees from 2007 to 2010.

PURPOSE: Because of concerns over incomplete medical encounter capture in Medicaid capitated comprehensive managed care (CMC) plans, researchers have traditionally confined analyses to fee-for-service (FFS) enrollees. We aimed to evaluate the usability of data for CMC enrollees in Medicaid Analytic eXtract (MAX) files for 29 states from 2007 to 2010. METHODS: We applied 7 measures to MAX inpatient, other therapy, and prescription drug files for each state and study year. Four measures were based on "connectivity" criteria where we expected use of a select essential service to be closely connected to another, resulting in "service pairs." Three measures were based on "continuity" criteria where we expected patients to continue chronically used services or treatments when they switched enrollment from FFS to CMC plans. High proportions of continuity and comparable proportions of patients with complete service pairs relative to FFS enrollees may suggest complete data capture for CMC enrollees. Data of states that met preset criteria were considered usable for research and policy analyses. RESULTS: The completeness of CMC enrollees' data in MAX varied by states. Among 22 states having at least 5% CMC plan enrollment, data of 12 states met our quality standard and were considered usable starting in 2007. Four states had usable data starting in 2008 and one in 2009. CONCLUSIONS: The completeness of CMC enrollees' data in MAX improved over the study period. In 17 out of 29 states, CMC enrollees' data in selected years were comparable with FFS enrollees and can be considered for use in analysis.

Interventions for improving management of chronic non-communicable diseases in Dikgale, a rural area in Limpopo Province, South Africa.

BACKGROUND: Chronic disease management (CDM) is an approach to health care that keeps people as healthy as possible through the prevention, early detection and management of chronic diseases. The aim of this study was to develop interventions to improve management of chronic diseases in the form of an integrated, evidence-based chronic disease management model in Dikgale, a rural area of Limpopo Province in South Africa. METHODS: A multifaceted intervention, called 'quality circles' (QCs) was developed to improve the quality and the management of chronic diseases in the Dikgale Health and Demographic Surveillance System (HDSS). These QCs used the findings from previous studies which formed part of the larger project in the study area, namely, the quantitative study using STEPwise survey and qualitative studies using focus group discussions and semi-structured interviews. RESULTS: The findings from previous studies in Dikgale HDSS revealed that an epidemiological transition is occurring. Again, the most widely reported barriers from previous studies in this rural area were: lack of knowledge of NCDs; shortages of medication and shortages of nurses in the clinics, which results in patients having long waiting-time at clinics. Lack of training of health care providers on the management of chronic diseases and the lack of supervision by the district and provincial health managers, together with poor dissemination of guidelines, were contributing factors to the lack of knowledge of non-communicable diseases (NCDs) management among nurses and community health care workers (CHWs). Consideration of all of these findings led to the development of model which focuses on integrating nursing services, CHWs and traditional health practitioners (THPs), including a well-established clinical information system for health care providers. A novel aspect of the model is the inclusion of community ambassadors who are on treatment for NCDs and are, thus, repositories of knowledge who can serve as a bridge between health care workers and community members. CONCLUSION: The model developed highlights the need for health interventions that aim to control risk factors at the population level, the need for availability of NCD-trained nurses, functional equipment and medication and a need to improve the link with traditional healers.

Bundled payments for joint replacement reduce expenditures, don't compromise quality.

Bundled payments work for hip and knee replacements for several reasons. The surgeries themselves are now fairly routine. For most patients, the recovery is usually predictable. There are also some golden opportunities for reducing expenditures that don't compromise care.

Health Care Needs the Real Triple Aim.

Price transparency, payment reform, and consumerism are needed to bring market forces to health care. Too many managed care organizations are comfortable with the status quo.

How Smart Use of Data Can Help To Manage Complex Medicaid Patients.

Care managers can quickly assess clinical complexity and monitor members climbing the cost and risk curve if they are armed with up-to-date information about a member's medical and behavioral diagnoses, prescription medications, physician office visits, emergency room visits, and hospitalizations.

The risk of unintentional out-of-network encounters with hospital-based physicians at in-network hospitals.

OBJECTIVE: When hospital-based specialists including emergency physicians, anesthesiologists, pathologists and radiologists are not included in the same insurance networks as their parent hospitals, it creates confusion and leads to unexpected costs for patients. This study explored the frequency with which hospital-based physicians at academic medical centers are not included in the network directories for the same insurance networks as their parent teaching hospitals. METHODS: We studied teaching hospitals with residency programs in all four hospital-based specialties. Using insurance plan provider directories, we determined whether each teaching hospital was in-network for randomly selected locally available insurance plans offered through the federal and state marketplace exchanges. For each established hospital-network relationship, we then determined whether hospital-based specialists were included in the provider network directory by searching for the name of each specialty's residency program director and the name of the physician practice group. RESULTS: We identified 79 teaching hospitals participating in 144 locally available insurance plan networks. Hospital-based specialist inclusion in these hospital-network relationships was: emergency physicians: 50.0% (CI: 40%-59%); anesthesiologists: 50.0% (CI: 42%-58%); pathologists: 45.4% (CI: 37%-54%); and radiologists: 55.1% (46%-64%). Inclusion of all four hospital-based specialties occurred in only 45.0% (CI: 36%-54%) of the hospital-network relationships. CONCLUSION: For insurance plans offered through the federal and state marketplace exchanges, hospital-based specialists frequently are not included in the directories for the insurance networks in which their parent teaching hospitals participate. Further research is needed to explore this issue at non-academic hospitals and for off-exchange insurance products, and to determine effective policy solutions.

Variation in dentist participation between dental medicaid managed care organizations.

OBJECTIVES: Dentists' Medicaid participation is a critical factor affecting dental care access for Medicaid beneficiaries. An important gap in existing literature is the variation in participation across Medicaid dental Managed Care Organizations (MCOs) in states with more than one. This study examined the variation in participation overall and in predictors of dentist participation between two MCOs in Iowa's Dental Medicaid program. METHODS: Data were obtained from a survey of Iowa private practice dentists (n = 1256). Responding general dentists (n = 497) were included in the final analytic sample. Univariate, bivariate, and multivariable logistic regression analyses were conducted to examine demographic and practice characteristics associated with dentist participation (acceptance of new Medicaid patients) between MCOs and by age category. RESULTS: Among respondents, the proportions accepting new adults with Medicaid were 26% (MCO 1) and 7% (MCO 2); for children, they were 40% (MCO 1) and 11% (MCO 2). For adults, dentists who were too busy (MCO1) and solo practice dentists (MCO2) were positively significantly associated with the acceptance of new patients. For children, group and rural practice dentists, as well as dentists who worked <32 h/week were positively significantly associated with acceptance of new patients with MCO1. CONCLUSIONS: There was considerable variation in dentist-reported acceptance of new adult and child Medicaid patients, and in the factors affecting acceptance of new patients between MCOs in Iowa dental Medicaid. Future studies of Medicaid participation should consider variations by MCO in states with more than one dental MCO so as not to miss important factors affecting Medicaid participation.

BENEFITS OF A CLINICAL PATHWAY IN TOTAL KNEE ARTHROPLASTY.

Objective: Demonstrate whether a multiprofessional Clinical Pathway Program in Total Knee Arthroplasty (CPPA) contributesto optimizing hospital care. Method: Retrospective study of medical data of care indicators in 310 patients divided into two groups: A- who underwent arthroplasty in the last biennium before the introduction of the CPPA (n=144) and group B- who underwent TKA in the biennium after the introduction of the CPPA (n=166). Results: Postoperative showed a significant difference in favor of group B over group A for hospitalization time in days 4.33 ± 2.79 and 5.4 ± 1.67 (p<0.001), time of prophylactic antibiotic in hours 28.13 ± 33.77 and 81.49 ± 40.91 (p<0.001), referral to the intensive care unit 40.9% and 73.4% (p<0.001), initiation of thromboprophylaxis within 24 hours 97.9% and 82.5% (p<0.001), use of elastic stockings and/or intermittent compression prescribed for thromboprophylaxis 89.5% and 31.2% (p<0.001), initiation of rehabilitation within 24 hours 90.1% and 66.1% (p<0.001), readmissions within 30 days 4.1% and 3% (p = 0.76), readmissions 90 days 2.7% and 6.6% (p = 0.183), transfusions 5.5% and 15.2% (p = 0.033). Conclusion: The implementation of a multiprofessional CPPA contributed to the implementation of care protocols, favoring greater patient safety. Level of Evidence III; Retrospective Comparative Study.

Objetivo: Demonstrar se um Programa de Cuidados Clínicos multiprofissional em Artroplastia Total de Joelho (PCCA) contribui para a otimização assistencial hospitalar. Método: Estudo retrospectivo em prontuários de indicadores assistenciais em 310 pacientes divididos em dois grupos: A- submetidos a artroplastia no último biênio antecessor a introdução do PCCA (n=144) e grupo B- submetidos a ATJ no biênio após a introdução do PCCA (n=166). Resultados: Indicadores pós-operatórios mostraram diferença significativa a favor do grupo B sobre o grupo A para tempo de hospitalização em dias 4,33 ± 2,79 e 5,4 ± 1,67 (p<0,001), tempo de antibiótico profilático em horas 28,13 ± 33,77 e 81,49 ± 40,91 (p<0,001), encaminhamento para unidade de terapia intensiva 40,9% e 73,4% (p<0,001), início da tromboprofilaxia dentro de 24h 97,9% e 82,5% (p<0,001), uso de meias elásticas e/ou compressão intermitente prescritos para tromboprofilaxia 89,5% e 31,2% (p<0,001), tempo para iniciação da reabilitação em 24h 90,1% e 66,1% (p<0,001), readmissões em 30 dias 4,1% e 3% (p = 0,76), readmissões 90 dias 2,7% e 6,6% (p = 0,183), transfusões 5,5% e 15,2% (p = 0,033). Conclusão: A implementação de um PCCA multiprofissional contribuiu para o cumprimento dos protocolos assistenciais favorecendo maior segurança para os pacientes. Nível de Evidência III; Estudo Retrospectivo Comparativo.

Rural-urban differences in out-of-network treatment initiation and engagement rates for substance use disorders.

OBJECTIVE: To examine rural-urban disparities in substance use disorder treatment access and continuation. DATA SOURCES AND STUDY SETTING: We analyzed a 2016-2018 U.S. national secondary dataset of commercial insurance claims. STUDY DESIGN: This cross-sectional study examined individuals with a new episode of opioid, alcohol, or other drug use disorders. Treatment initiation and engagement rates, and rates of using out-of-network providers for these services, were compared between rural and urban patients. DATA COLLECTION: We included individuals 18-64 years old with continuous employer-sponsored insurance. PRINCIPAL FINDINGS: Patients in rural settings experienced lower treatment initiation rates for alcohol (36.6% vs. 38.0%, p < 0.001), opioid (41.2% vs. 44.2%, p < 0.001), and other drug (37.7% vs. 40.1%, p < 0.001) use disorders, relative to those in urban areas. Similarly, rural patients had lower treatment engagement rates for alcohol (15.1% vs. 17.3%, p < 0.001), opioid (21.0% vs. 22.6%, p < 0.001), and other drug (15.5% vs. 17.5%, p < 0.001) use disorders. Rural patients had higher out-of-network rates for treatment initiation for other drug use disorders (20.4% vs. 17.2%, p < 0.001), and for treatment engagement for alcohol (27.6% vs. 25.2%, p = 0.006) and other drug (36.1% vs. 31.1%, p < 0.001) use disorders. CONCLUSIONS: These findings indicate that individuals with substance use disorders in rural areas have lower rates of initial and ongoing treatment, and are more likely to seek care out-of-network.

Physician patient sharing relationships within insurance plan networks.

OBJECTIVE: To quantify shared patient relationships between primary care physicians (PCPs) and cardiologists and oncologists and the degree to which those relationships were captured within insurance networks. DATA SOURCES: Secondary analysis of Vericred data on physician networks, CareSet data on physicians' shared Medicare patients, and insurance plan attributes from Health Insurance Compare. Data validation exercises used data from Physician Compare and IQVIA. STUDY DESIGN: Cross-sectional study of the PCP-to-specialist in-network shared patient percentage (primary outcome). We also categorized networks by insurance market segment (Medicare Advantage [MA], Medicaid managed care, small-group or individually purchased), insurance plan type, and network breadth. DATA EXTRACTION: We analyzed data on 219,982 PCPs, 29,400 cardiologists, and 22,745 oncologists who, in 2021, accepted MA (n = 941 networks), Medicaid managed care (n = 293), and individually-purchased (n = 332) and small-group (n = 501) plans. PRINCIPAL FINDINGS: Networks captured, on average, 64.6% of PCP-cardiology shared patient ties, and 61.8% of PCP-oncologist ties. Less than half of in-network ties (44.5% and 38.9%, respectively) were among physicians with a common organizational affiliation. After adjustment for network breadth, we found no evidence of differences in the shared patient percentage across insurance market segments or networks of different types (p-value >0.05 for all comparisons). An exception was among national versus local and regional networks, where we found that national plans captured fewer shared patient ties, particularly among the narrowest networks (58.4% for national networksvs. 64.7% for local and regional networks for PCP-cardiology). CONCLUSIONS: Given recent trends toward narrower networks, our findings underscore the importance of incorporating additional and nuanced measures of network composition to aid plan selection (for patients) and to guide regulatory oversight.

Near Two Decades of the Family Physician Program in Iran and the Structural Challenges: A Systematic Review.

The family physician program (FPP) is one of the most significant health care reforms in Iran; however, many studies showed that this program has not been able to achieve its intended objectives because of a variety of challenges. This program, despite the existing challenges, is going to be expanded across the country. To improve the likelihood of its success, identification of the structural and infrastructural challenges is necessary. This systematic review was conducted to assess the structural and infrastructural challenges of FPP in Iran. This systematic review of the literature was conducted in order to investigate the infrastructure and structure needs of the current program in Iran. All published articles related to the FPP in Iran were the subject of this study. The eligibility criteria included original articles, reviews, or case studies published in English or Persian during 2011-2021 related to the challenges in the referral system of FPP in Iran. Data were extracted based on Sample, Phenomenon of Interest, Design, Evaluation, Research type technique and were reported based on the structure of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. International credible scholarly databases were searched. The search strategy was defined based on keywords and the search syntax. This study identified different challenges of the referral system in the areas associated with legal structure, administration, and social structure. The identified challenges in this program should be addressed in order to ensure that this program will lead to improved quality of care and equity in Iran health care system.

Leaving No Stone Unturned: Factors Associated With Overturning Insurance Claim Denials for Urological Conditions in New York State.

INTRODUCTION: Denied health claims in New York State may be appealed by external review. After appeal, the denial can either be upheld or overturned. Regardless, an appeal process results in delays in care and can negatively impact patient health and practice efficiency. This study aimed to describe the epidemiology of New York State urological external appeals and assess factors associated with successful appeals. METHODS: The New York State External Appeals database was queried for 2019-2021 urological cases (N=408). Patient age, gender, decision year, appeal reason, diagnosis, treatment, and reference to American Urological Association were extracted. Annual appeal volume was analyzed by linear regression. Relationships between appeal outcomes and characteristics were analyzed by χ2 tests. Multivariate logistic regression analysis was used to identify factors related to overturns. RESULTS: Overall, 39.5% of denials in this data set were overturned. Appeal volume increased annually, with overturned cases increasing 244% (mean 29.5, P = .068). Of reviewers, 15.6% referenced American Urological Association guidelines in their decision. Appeals mostly involved ages 40-59 years (32.4%), inpatient stays (63.5%), and infections (32.4%). Female sex, age 80+, diagnosis of incontinence/lower urinary tract symptoms, treatment with home health care, medications, or surgical services, and not referencing American Urological Association guidelines were significantly associated with successful appeal. Referencing American Urological Association guidelines had 70% decreased odds of overturning denials. CONCLUSIONS: Our findings suggest that upon appeal of denied claims, practices may have a high chance of overturning an initial denial and this trend is rising. These findings will help serve as a reference for future external appeals research and urology policy and advocacy groups.

SWOT Analysis and Expert Assessment of the Effectiveness of the Introduction of Healthcare Information Systems in Polyclinics in Aktobe, Kazakhstan.

OBJECTIVES: The purpose of this study was to assess the organizational effectiveness of the introduction of a healthcare information system (electronic medical records and databases) in healthcare in Kazakhstan. METHODS: The authors used a combination of 2. METHODS: expert assessment and strengths, weaknesses, opportunities, and threats (SWOT) analysis. SWOT analysis is a necessary element of research, constituting a mandatory preliminary stage both when drawing up strategic plans and for taking corrective measures in the future. The expert survey was conducted using 2 questionnaires. RESULTS: The study involved 40 experts drawn from specialists in primary healthcare in Aktobe: 15 representatives of administrative and managerial personnel (chief doctors and their deputies, heads of medical statistics offices, organizational and methodological offices, and internal audit services) and 25 general practitioners. CONCLUSIONS: The following functional indicators of the medical and organizational effectiveness of the introduction of information systems in polyclinics were highlighted: first, improvement of administrative control, followed in descending order by registration and movement of medical documentation, statistical reporting and process results, and the cost of employees' working time. There has been no reduction in financial costs, namely in terms of the costs of copying, delivery of information in paper form, technical equipment, and paper.

Potentially inappropriate prescriptions: Associations with the health insurance contract and the quality of the patient-physician relationship?

CONTEXT: Potentially Inappropriate Prescriptions (PIP) are often used as an indicator of potential drug overuse or misuse to limit adverse drug events in older people. OBJECTIVE: To determine whether PIP exposure differs as a function of the patient's health insurance scheme and the patient-physician relationship. METHODS: Our dataset was collected from two surveys delivered to two cohorts of the Swiss Lc65+ study, together with a stratified random sample of older people in the Swiss canton of Vaud. The study sample consisted of 1,595 people aged 68 years and older living in the community and reporting at least one prescription drug. Logit regression models of PIP risk were run for various categories of variables: health related, socioeconomic, health insurance scheme and patient-physician relationship. RESULTS: 17% of our respondents had at least one PIP. Our results suggested that being enrolled in a health plan with restriction in the patient's choice of providers and having higher deductibles were associated with lower PIP risk. PIP risk did not differ as a function of the quality of the patient-physician relationship. CONCLUSION: Our study helps to raise awareness about the organizational risk factors of PIP and, more specifically, how health insurance contracts could play a role in improving the management of drug consumption among community-dwelling older people.