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OBJECTIVE - To evaluate the impact of health insurance expansion on racial disparities in severity of peripheral arterial disease.
BACKGROUND - Lack of insurance and non-white race are associated with increased severity, increased amputation rates, and decreased revascularization rates in patients with peripheral artery disease (PAD). Little is known about how expanded insurance coverage affects disparities in presentation with and management of PAD. The 2006 Massachusetts health reform expanded coverage to 98% of residents and provided the framework for the Affordable Care Act.
METHODS - We conducted a retrospective cohort study of nonelderly, white and non-white patients admitted with PAD in Massachusetts (MA) and 4 control states. Risk-adjusted difference-in-differences models were used to evaluate changes in probability of presenting with severe disease. Multivariable linear regression models were used to evaluate disparities in disease severity before and after the 2006 health insurance expansion.
RESULTS - Before the 2006 MA insurance expansion, non-white patients in both MA and control states had a 12 to 13 percentage-point higher probability of presenting with severe disease (P < 0.001) than white patients. After the expansion, measured disparities in disease severity by patient race were no longer statistically significant in Massachusetts (+3.0 percentage-point difference, P = 0.385) whereas disparities persisted in control states (+10.0 percentage-point difference, P < 0.001). Overall, non-white patients in MA had an 11.2 percentage-point decreased probability of severe PAD (P = 0.042) relative to concurrent trends in control states.
CONCLUSIONS - The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe PAD and resolution of measured racial disparities in severe PAD in MA.
This investigation describes the relationship between TBI patient demographics, quality of life outcome, and functional status outcome among clinic attendees and non-attendees. Of adult TBI survivors with intracranial hemorrhage, 63 attended our TBI clinic and 167 did not attend. All were telephone surveyed using the Extended-Glasgow Outcome Scale (GOSE), the Quality of Life after Brain Injury (QOLIBRI) scale, and a post-discharge therapy questionnaire. To determine risk factors for GOSE and QOLIBRI outcomes, we created multivariable regression models employing covariates of age, injury characteristics, clinic attendance, insurance status, post-discharge rehabilitation, and time from injury. Compared with those with severe TBI, higher GOSE scores were identified in individuals with both mild (odds ratio [OR]=2.0; 95% confidence interval [CI]: 1.1-3.6) and moderate (OR=4.7; 95% CI: 1.6-14.1) TBIs. In addition, survivors with private insurance had higher GOSE scores, compared with those with public insurance (OR=2.0; 95% CI: 1.1-3.6), workers' compensation (OR=8.4; 95% CI: 2.6-26.9), and no insurance (OR=3.1; 95% CI: 1.6-6.2). Compared with those with severe TBI, QOLIBRI scores were 11.7 points (95% CI: 3.7-19.7) higher in survivors with mild TBI and 17.3 points (95% CI: 3.2-31.5) higher in survivors with moderate TBI. In addition, survivors who received post-discharge rehabilitation had higher QOLIBRI scores by 11.4 points (95% CI: 3.7-19.1) than those who did not. Survivors with private insurance had QOLIBRI scores that were 25.5 points higher (95% CI: 11.3-39.7) than those with workers' compensation and 16.8 points higher (95% CI: 7.4-26.2) than those without insurance. Because neurologic injury severity, insurance status, and receipt of rehabilitation or therapy are independent risk factors for functional and quality of life outcomes, future directions will include improving earlier access to post-TBI rehabilitation, social work services, affordable insurance, and community resources.
OBJECTIVE - The general equivalence mappings (GEMs) and reimbursement mappings (RMs) facilitate translation between ICD-9-CM and ICD-10-CM. This study compared prospectively dual-encoded diagnoses assigned by professional coders with the GEMs/RMs in a clinical setting.
MATERIALS AND METHODS - Professional coders manually encoded diagnoses from 100 primary care notes into both ICD-9-CM and ICD-10-CM. The investigators evaluated whether manual mappings were reproducible using the GEMs/RMs. Reproducible mappings with one ICD-9-CM and one ICD-10-CM code ("one-to-one") were classified as exact or approximate using GEMs flags. Mismatches were characterized manually.
RESULTS - Manual encodings were reproducible from the forward GEMs, backward GEMs, and RMs in 85.2%, 90.4%, and 88.1% of diagnoses, respectively. For one-to-one, reproducible mappings, 61% (forward) and 63% (backward) were approximate mappings compared to 85% and 95% in the GEMs as a whole. Mismatches between manual and GEMs encodings were due to differences in coder interpretation (11%-13%), subtle hierarchical differences (52%-55%), or unknown reasons (32%-35%).
DISCUSSION - This study highlights inconsistencies between manual encoding and using the GEMs/RMs. The number of approximate mappings in our population compared to all one-to-one GEMs entries supports the notion that statistics describing the GEMs as a whole might not represent the most important mappings for each organization. The mismatch characteristics highlight the subtle differences between manual encoding and using the GEMs/RMs.
CONCLUSION - These results support the need for organizations to assess the GEMs and RMs in their own environment to avoid changes in reimbursement and longitudinal statistics.
© The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
BACKGROUND - Therapy for certain medical conditions occurs in a stepwise fashion, where one medication is recommended as initial therapy and other medications follow. Sequential pattern mining is a data mining technique used to identify patterns of ordered events.
OBJECTIVE - To determine whether sequential pattern mining is effective for identifying temporal relationships between medications and accurately predicting the next medication likely to be prescribed for a patient.
DESIGN - We obtained claims data from Blue Cross Blue Shield of Texas for patients prescribed at least one diabetes medication between 2008 and 2011, and divided these into a training set (90% of patients) and test set (10% of patients). We applied the CSPADE algorithm to mine sequential patterns of diabetes medication prescriptions both at the drug class and generic drug level and ranked them by the support statistic. We then evaluated the accuracy of predictions made for which diabetes medication a patient was likely to be prescribed next.
RESULTS - We identified 161,497 patients who had been prescribed at least one diabetes medication. We were able to mine stepwise patterns of pharmacological therapy that were consistent with guidelines. Within three attempts, we were able to predict the medication prescribed for 90.0% of patients when making predictions by drug class, and for 64.1% when making predictions at the generic drug level. These results were stable under 10-fold cross validation, ranging from 89.1%-90.5% at the drug class level and 63.5-64.9% at the generic drug level. Using 1 or 2 items in the patient's medication history led to more accurate predictions than not using any history, but using the entire history was sometimes worse.
CONCLUSION - Sequential pattern mining is an effective technique to identify temporal relationships between medications and can be used to predict next steps in a patient's medication regimen. Accurate predictions can be made without using the patient's entire medication history.
Copyright © 2014 Elsevier Inc. All rights reserved.
The next open enrollment period for plans offered in the Affordable Care Act's (ACA's) insurance Marketplaces is set to occur between November 15, 2014, and February 15, 2015--just when many lower-income people are financially stressed by demands of the holiday season. Recent research by experimental psychologists and behavioral economists strongly suggests that when people's decision-making capacity (bandwidth) is stretched thin, either they cannot make decisions or they make poor choices. Using data from nearly a decade of US-based Internet search queries to measure population behavior, we found considerable seasonality in measures of financial stress and in when people seek out information on health insurance plans. A more opportune time for scheduling open enrollment for the ACA Marketplaces may be between February 15 and April 15--weeks when low-income people typically receive income tax refunds and Earned Income Tax Credit payments. Such lump-sum payments could be applied to pay individuals' share of premiums.
Project HOPE—The People-to-People Health Foundation, Inc.
OBJECTIVES - The goal of this study was to examine 2006 to 2010 emergency department (ED) admission rates, hospital procedures, lengths of stay, and costs for acute heart failure (AHF).
BACKGROUND - Patients with AHF are often admitted and are associated with high readmissions and cost.
METHODS - We utilized Nationwide Emergency Department Sample AHF data from 2006 to 2010 to describe admission proportion, hospital length of stay (LOS), and ED charges as a surrogate for resource utilization. Results were compared across U.S. regions, patient insurance status, and hospital characteristics.
RESULTS - There were 958,167 mean yearly ED visits for AHF in the United States. Fifty-one percent of the patients were female, and the median age was 75.1 years (interquartile range [IQR]: 62.5 to 83.7 years). Overall, 83.7% (95% confidence interval: 83.1% to 84.2%) were admitted; the median LOS was 3.4 days (IQR: 1.9 to 5.8 days). Comparing 2006 with 2010, there was a small decrease in median LOS (0.09 days), but the proportion admitted did not change. Odds of admission, adjusting for age, sex, hospital characteristic (academic and safety net status), and insurance (Medicare, Medicaid, private, self-pay/no charge) were highest in the Northeast. Median ED charges were $1,075 (IQR: $679 to $1,665) in 2006 and $1,558 (IQR: $1,018 to $2,335) in 2010. Patients without insurance were more likely to be discharged from the ED, but when admitted, were more likely to receive a major diagnostic or therapeutic procedure.
CONCLUSIONS - A very high proportion of ED patients with AHF are admitted nationally, with significant variation in disposition and procedural decisions based on region of the country and type of insurance, even after adjusting for potential confounding.
Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
BACKGROUND AND OBJECTIVES - Uninsured and underinsured cancer patients often have delayed diagnosis and inferior outcomes. As healthcare reform proceeds in the US, this disparity may gain increasing importance. Our objective was to investigate the impact of health insurance status on the presentation, treatment, and survival among colorectal cancer (CRC) patients.
METHODS - A total of 10,692 patients diagnosed with CRC between 2004 and 2008 identified from the Tennessee Cancer Registry were stratified into five groups: Private, Medicare, Military, Medicaid, and uninsured. Multivariable regression models were constructed to test the association of insurance with receipt of recommended adjuvant therapy and overall survival (OS).
RESULTS - Uninsured and Medicaid patients were more often African American (AA) and presented with higher stage tumors (P < 0.001). Medicare patients were less likely to receive recommended adjuvant therapy (OR 0.54). Lack of insurance, Medicaid, and failure to receive recommended adjuvant therapy were independently associated with worse OS.
CONCLUSIONS - Although uninsured and Medicaid patients receive recommended adjuvant therapy comparable to other patients, they present with later stage disease and have a worse OS. Future studies are needed to better explain these disparities especially in the light of changing healthcare climate in the US.
© 2014 Wiley Periodicals, Inc.
BACKGROUND - Despite the documented survival benefit conferred by neoadjuvant (NAC) and adjuvant chemotherapy (AC), there has been a slow adoption of guideline recommendations for the use of perioperative chemotherapy (POC) in patients with muscle-invasive bladder cancer (MIBC).
OBJECTIVE - To evaluate temporal trends in POC utilization and identify factors influencing POC delivery in a representative cohort of patients with MIBC.
DESIGN, SETTING, AND PARTICIPANTS - Retrospective cohort study identifying factors associated with receipt of POC and evaluating temporal changes in NAC and AC utilization. We included patients from the National Cancer Data Base (NCDB) with no prior malignancy who ultimately underwent radical cystectomy for ≥ cT2/cN0/cM0 MIBC between 2006 and 2010.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS - Relationships between demographic and hospital factors and the likelihood of receiving POC were evaluated using Pearson chi-square and Wilcoxon rank-sum tests, and multivariable logistic regression. Temporal changes in NAC and AC use were detected using a linear test of trend.
RESULTS AND LIMITATIONS - A total of 5692 patients met our inclusion criteria. POC use increased from 29.5% in 2006 to 39.8% in 2010 (p < 0.001). NAC use increased from 10.1% in 2006 to 20.8% in 2010 (p = 0.005); AC remained stable between 18.1% and 21.3% (p = 0.68). Multivariable modeling revealed advanced age, increasing comorbidity, lack of insurance, increased travel distance, geographic location outside the northeastern United States, and lower income as negatively associated with POC receipt (all p < 0.05). Limitations include retrospective design and potential sampling bias, excluding patients treated at non-NCDB facilities.
CONCLUSIONS - POC use for MIBC increased from 2006 to 2010, with this increase disproportionately due to rising NAC utilization. Nonetheless, there is persistent variation in the likelihood of receiving POC secondary to nonclinical factors.
PATIENT SUMMARY - When retrospectively analyzing a representative cohort of patients undergoing radical cystectomy for muscle-invasive bladder cancer between 2006 and 2010, we noted that preoperative chemotherapy rates increased steadily while use of chemotherapy after surgery remained stable. Factors related to access to care significantly influenced receipt of chemotherapy.
Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
The number and types of people who become eligible for and enroll in the Affordable Care Act's (ACA's) health insurance expansions will depend in part on the factors that cause people to become uninsured for different lengths of time. We used a small-area estimation approach to estimate differences across states in percentages of adults losing health insurance and in lengths of their uninsured spells. We found that nearly 50 percent of the nonelderly adult population in Florida, Nevada, New Mexico, and Texas--but only 18 percent in Massachusetts and 22 percent in Vermont--experienced an uninsured spell between 2009 and 2012. Compared to people who lost private coverage, those with public insurance were more likely to experience an uninsured spell, but their spells of uninsurance were shorter. We categorized states based on estimated incidence of uninsured spells and the spells' duration. States should tailor their enrollment outreach and retention efforts for the ACA's coverage expansions to address their own mix of types of coverage lost and durations of uninsured spells.
BACKGROUND - Soft tissue sarcomas (STS) continue to be excised inappropriately without proper preoperative planning. The reasons for this remain elusive. The role of insurance status and patient distance from sarcoma center in influencing such inappropriate excisions were examined in this study.
METHODS - This retrospective review of a single institution prospective database evaluated 400 patients treated for STS of the extremities between January 2000 and December 2008. Two hundred fifty three patients had a primary excision while 147 patients underwent re-excision. Wilcoxon rank sum test and either χ(2) or Fisher's exact were used to compare variables. Multivariable regression analyses were used to take into account potential confounders and identify variables that affected excision status.
RESULTS - Tumor size, site, depth, stage, margins, and histology were significantly different between the primary excision and re-excision groups; P < 0.05. Insurance status and patient distance from the treatment center were not statistically different between the two groups. Large and deep tumors and certain histology types predicted appropriate referral.
CONCLUSIONS - Inappropriate excision of STS is not influenced by patient distance from a sarcoma center or by a patient's insurance status. In this study, tumor size, depth, and certain histology types predicted the appropriate referral of a STS to a sarcoma center.
© 2013 Wiley Periodicals, Inc.