Objectives
Louisiana extended Medicaid coverage on July 1, 2016, to previously ineligible populations. We aimed to estimate the effect of Louisiana’s Medicaid expansion on self-reported affordability ...of health care.
Methods
We used 2011-2019 data from the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS measured affordability of health care by asking respondents 2 questions: (1) whether they could not see a doctor due to cost in the previous 12 months and (2) whether they could not get a prescribed medication due to cost in the previous 12 months. We estimated difference-in-differences and difference-in-difference-in-differences analytical models using multivariable linear regression that compared trends in Louisiana with trends in states that did not expand Medicaid during the study period.
Results
Compared with adults aged <65 with annual household income >138% of the federal poverty level (FPL) in nonexpansion states, Medicaid expansion in Louisiana decreased the percentage of adults aged <65 with annual household income ≤138% FPL who reported being unable to see a doctor due to cost by 5.1 percentage points (95% CI, −6.5 to −3.6; P < .001) and unable to afford prescribed medication by 7.9 percentage points (95% CI, −9.2 to −6.6; P < .001). We found similar estimates when we limited the comparison group to Southern nonexpansion states.
Conclusions
Louisiana’s Medicaid expansion lowered cost barriers to health care. Further research may find improvements in health care affordability in states that have not yet expanded Medicaid.
Full text
Available for:
NUK, OILJ, SAZU, UKNU, UL, UM, UPUK, VSZLJ
The COVID-19 pandemic led to an increased reliance on telemedicine. Whether this exacerbated existing disparities within vulnerable populations is not yet known.
Characterize changes in outpatient ...telemedicine evaluation and management (E&M) services for Louisiana Medicaid beneficiaries by race, ethnicity, and rurality during the COVID-19 pandemic.
Interrupted time series regression models estimated pre-COVID-19 trends and changes in E&M service use at the April and July 2020 peaks in COVID-19 infections in Louisiana and in December 2020 after those peaks had subsided.
Louisiana Medicaid beneficiaries continuously enrolled between January 2018 and December 2020 who were not also enrolled in Medicare.
Monthly outpatient E&M claims per 1000 beneficiaries.
Prepandemic differences in service use between non-Hispanic White and non-Hispanic Black beneficiaries narrowed by 34% through December 2020 (95% CI: 17.6%-50.6%), while differences between non-Hispanic White and Hispanic beneficiaries increased by 10.5% (95% CI: 0.1%-20.7%). Non-Hispanic White beneficiaries used telemedicine at higher rates than non-Hispanic Black (difference=24.9 claims per 1000 beneficiaries, 95% CI: 22.3-27.4) and Hispanic beneficiaries (difference=42.3 claims per 1000 beneficiaries, 95% CI: 39.1-45.5) during the first wave of COVID-19 infections in Louisiana. Telemedicine use increased slightly for rural beneficiaries compared with urban beneficiaries (difference=5.3 claims per 1000 beneficiaries, 95% CI: 4.0-6.6).
The COVID-19 pandemic narrowed gaps in outpatient E&M service use between non-Hispanic White and non-Hispanic Black Louisiana Medicaid beneficiaries, though gaps in telemedicine use emerged. Hispanic beneficiaries experienced large reductions in service use and relatively small increases in telemedicine use.
Limited availability of in-person health care services and fear of contracting COVID-19 during the pandemic promoted an increased reliance on telemedicine. However, long-standing inequities in ...telemedicine due to unequal levels of digital literacy and internet connectivity among different age groups raise concerns about whether the uptake of telemedicine has exacerbated or alleviated those inequities.
The aim of this study is to examine changes in telemedicine and in-person health service use during the COVID-19 pandemic across age groups for Medicaid beneficiaries in the state of Louisiana.
Interrupted time series models were used on Louisiana Medicaid claims data to estimate trends in total, in-person, and telemedicine monthly office visit claims per 1000 Medicaid beneficiaries between January 2018 and December 2020. Changes in care pattern trends and levels were estimated around the infection peaks (April 2020 and July 2020) and for an end-of-year infection leveling off period (December 2020). Four mutually exclusive age categories (0 to 17, 18 to 34, 35 to 49, and 50 to 64 years) were used to compare the differences.
Prior to the COVID-19 pandemic, telemedicine services accounted for less than 1% of total office visit claim volume across the age groups. Each age group followed similar patterns of sharp increases in April 2020, downward trends until sharp increases again in July 2020, followed by flat trends thereafter until December 2020. These sharp increases were most pronounced for older patients, with those aged 50 to 64 years seeing increases of 184.09 telemedicine claims per 1000 Medicaid beneficiaries in April 2020 (95% CI 172.19 to 195.99) and 120.81 in July 2020 (95% CI 101.32 to 140.31) compared with those aged 18 to 34 years, seeing increases of 84.47 (95% CI 78.64 to 90.31) and 57.00 (95% CI 48.21 to 65.79), respectively. This resulted in overall changes from baseline to December 2020 levels of 123.65 (95% CI 112.79 to 134.51) for those aged 50 to 64 years compared with 59.07 (95% CI 53.89 to 64.24) for those aged 18 to 34 years.
Older Medicaid beneficiaries in Louisiana had higher rates of telemedicine claim volume during the COVID-19 pandemic compared with younger beneficiaries.
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
This study aimed to estimate the impact of the Check It program, a novel community-based chlamydia seek, test, and treat program for young Black men who have sex with women, on test positivity rates ...for chlamydia in young Black women.
We used a synthetic control model to compare chlamydia test positivity rates in Orleans Parish (intervention site) with other similar parishes (control sites) in Louisiana. We estimated a model that used all other parishes as potential contributors to a synthetic control for Louisiana as well as a sample limited to the 40 parishes in Louisiana with the largest Black populations.
The Check It program was associated with a 1.69-percentage-point decline in chlamydia positivity in the first full year of operation and a 2.44-percentage-point decline in chlamydia positivity in the second full year of operation compared with control sites with the largest Black populations (P = 0.05). Results were similar when the treatment site was compared with all other sites in Louisiana.
The Check It program was associated with a significant decline in chlamydia testing positivity rates among women in Orleans Parish compared with control sites. Screening of young Black men who have sex with women can decrease rates in women living in the same community. Future recommendations for chlamydia screening of young men should be considered.
Harmonic ACE +7 Shears with Advanced Hemostasis is an upgraded ultrasonic device, an ultrasonic surgical and electrosurgical system (USES). The study aimed to evaluate the economic and clinical ...effectiveness of the USES compared with the conventional ultrasonic scalpel (CUS) in gastrectomy.
We conducted a single-center, retrospective cohort study using the electronic medical records in China. We collected intraoperative and postoperative data from gastric cancer patients who underwent the endoscope-assisted distal gastrectomy from 2018 to June 30, 2019. Procedure-related costs were estimated. We used linear regression by controlling a set of covariates to assess the effect of USES on outcomes.
Out of 87 eligible patients, the USES group (40 patients) and CUS group (47 patients) were comparable in terms of age, medical history and stages of cancer. Compared with the CUS, the USES saved 4.27 hemoclips per person (95% CI 0.57-7.97, p < 0.05) and 34.18 ml intraoperative blood per person (95% CI 8.74-59.62 ml, p < 0.05), respectively. Postoperative length of stay (LOS) was shorter in the USES group (7.90 ± 1.95 vs. 9.26 ± 2.81 days) but the difference was not statistically significant (p = 0.05).
The USES group was associated with fewer hemoclips use and intraoperative blood loss in patients undergoing laparoscopic gastrectomy at comparable costs.
Full text
Available for:
CEKLJ, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
This systematic review aims to provide a critical summary of economic evaluations of pneumococcal vaccines for adults aged 50 years or older in low- and middle-income countries (LMICs): a 23-valent ...polysaccharide vaccine (PPSV23), and a 13-valent conjugated vaccine (PCV13).
We systematically searched for studies published until October2020 in PubMed and Web of Science. Searching strategies in this literature review were done using various combinations of terms related to 'economic evaluation or cost-effectiveness or cost-benefit or cost-utility,' 'pneumococcal or PPSV or PCV or PPV,' and 'vaccine or vaccination or immunization' in all fields. To be included, each study had to meet our inclusion criteria. Two authors reviewed and extracted studies. From 1,711 records, we included 18 studies for this review. All 18 studies were cost-effectiveness analysis. Compared with no vaccination, either PPSV23 or PCV13 was economically favorable, highly cost-effective, and in many cases, cost-saving for older adults. Studies compared one vaccination (PPSV23 or PCV13) over another and had different findings.
While all studies recommended either PPSV23 or PCV13 for older adults in LMICs, substantial questions about potential bias in studies and whether conclusions hold after including the impact of indirect protection.
We developed an individual-level discrete-time microsimulation model, namely the Building, Relating, Assessing, and Validating Outcomes (BRAVO) diabetes model. The BRAVO model was externally ...validated using cohort-level data in people with type 2 diabetes (T2D) . This study further externally validated the BRAVO diabetes model using patient-level data from the Exenatide Study of Cardiovascular Event Lowering Trial (EXSCEL) . Baseline characteristics and trajectories of key biomarkers, including A1c, LDL, SBP, and BMI, were retrospectively extracted from the EXSCEL study database. To protect patients’ private information, variables of age and BMI were masked in ranges from the EXSCEL study (e.g., BMI 35 coded as BMI>30) . To convert the ranges back into specific values to support the simulation, we used the National Health and Nutrition Examination Survey (NHANES) data for the data imputations. We used the median value for each population subgroup from NHANES to replace the ranges. The BRAVO diabetes model was applied to the EXSCEL baseline data to predict the 7-year EXSCEL study outcomes. We assessed the BRAVO model’s discrimination power using C-statistics and calibration using the Brier score. The model demonstrated good discrimination and calibration in predicting the first occurrence of non-fatal myocardial infarction (C-index 0.620 95% CI 0.590-0.650 and Brier Score (BS) 0.080 0.074-0.085) , non-fatal stroke (C-index 0.696 0.634-0.758 and BS 0.031 0.028-0.034) , heart failure (C-index 0.700 0.666-0.733 and BS 0.037 0.034-0.041) , revascularization (C-index 0.664 0.590-0.738 and BS 0.036 0.033-0.039) , and all-cause mortality (C-index 0.746 0.711-0.781 and BS 0.102 0.098-0.106) , respectively. Although the majority of the data obtained from EXSCEL trial was obtained in range instead of specific values, the BRAVO model remained robust in prediction performance in diabetes complications and mortality.
Disclosure
Y.Shao: None. S.Niu: None. L.Shi: None. V.Fonseca: Consultant; Abbott, Asahi Kasei Corporation, Bayer AG, Novo Nordisk, Sanofi, Research Support; Fractyl Health, Inc., Jaguar Gene Therapy, Stock/Shareholder; Abbott, Amgen Inc., BRAVO4Health, Mellitus Health. H.Shao: Board Member; BRAVO4HEALTH, LLC.
Funding
Astrazeneca
Background: Recent studies found elevated serum uric acid (SUA) level were associated with type 2 diabetes mellitus (T2DM) progression. However, whether SUA level was relevant to the development of ...cardiovascular events was inconclusive.
Objective: To explore the association between SUA level and risk of cardiovascular events and all-cause mortality among patients with T2DM.
Method: A systematic literature search was conducted using the Web of Science and PubMed database (1980-2017). Search terms and strategies for PubMed were as follows: using Title/Abstract or MeSH Terms to search “diabetes”, “serum uric acid”, “cardiovascular disease”, and “all-cause mortality.” Studies that reported associations between SUA and cardiovascular events (i.e., coronary heart disease (CHD) and stroke), and all-cause mortality in patients with T2DM were identified, and these associations were extracted and converted into hazard ratio (HR) of cardiovascular events per 59μmol/l SUA increase. Meta-analysis was conducted to synthesize the associations between SUA level and risk of cardiovascular events, using random effect model to account for possible study heterogeneity. Heterogeneity was assessed using I2, and the meta-analysis was performed using Stata 12.0. This study was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline.
Results: 6 (n=11,750 patients), 4 (n=3034 patients) and 2 studies (n=7792 patients) were identified reporting associations between SUA level and all-cause mortality, CHD and stroke respectively. HR for all-cause mortality, CHD, and stroke per 59 μmol/l increase was 1.150 (95% CI: 1.134, 1.165), 1.002 (95% CI: 0.983, 1.021) and 1.177 (95% CI: 1.070, 1.284), respectively. Heterogeneity bias was found in the analyses.
Conclusion: Overall, SUA were associated with higher risk of all-cause mortality and stroke. However, we found no significant association between SUA level and CHD among T2DM population.
Disclosure
Y. Shao: None. H. Shao: None. L. Shi: None.
At the onset of the COVID-19 pandemic, the Centers for Medicare and Medicaid Services broadened access to telehealth. This provided an opportunity to test whether diabetes, a risk factor for COVID-19 ...severity, can be managed with telehealth services.
The objective of this study was to examine the impacts of telehealth on diabetes control.
A doubly robust estimator combined a propensity score-weighting strategy with regression controls for baseline characteristics using electronic medical records data to compare outcomes in patients with and without telehealth care. Matching on preperiod trajectories in outpatient visits and weighting by odds were used to ensure comparability between comparators.
Medicare patients with type 2 diabetes in Louisiana between March 2018 and February 2021 (9530 patients with a COVID-19 era telehealth visit and 20,666 patients without one).
Primary outcomes were glycemic levels and control ie, hemoglobin A1c (HbA1c) under 7%. Secondary outcomes included alternative HbA1c measures, emergency department visits, and inpatient admissions.
Telehealth was associated with lower pandemic era mean A1c values estimate=-0.080%, 95% confidence interval (CI): -0.111% to -0.048%, which translated to an increased likelihood of having HbA1c in control (estimate=0.013; 95% CI: 0.002-0.024; P<0.023). Hispanic telehealth users had relatively higher COVID-19 era HbA1c levels (estimate=0.125; 95% CI: 0.044-0.205; P<0.003). Telehealth was not associated with differences in the likelihood of having an emergency department visits (estimate=-0.003; 95% CI: -0.011 to 0.004; P<0.351) but was associated with more the likelihood of having an inpatient admission (estimate=0.024; 95% CI: 0.018-0.031; P<0.001).
Telehealth use among Medicare patients with type 2 diabetes in Louisiana stemming from the COVID-19 pandemic was associated with relatively improved glycemic control.
Preventing type 2 diabetes (T2D) involves reducing T2D risk factors at the population level (PL) and lowering the risk of developing T2D in groups at higher risk (GHR). We used the 2013-2018 National ...Health and Nutrition Examination Survey data to generate a nationally representative population of adults without diabetes. Using the CDC-RTI T2D Cost-Effectiveness simulation model, we estimated the number of T2D cases and their complications prevented by two hypothetical combined PL and high-risk strategies compared with no intervention over 10 years: a moderate strategy (MS) consisting of an annual T2D risk reduction (RR) of 4% at the PL and a RR of 35%, 17.5%, and 10.5% in years 1, 2, and 3 in GHR using a moderate lifestyle intervention program (LIP); an intensive strategy (IS) consisting of an annual RR of 6% at the PL and a RR of 40%, 20%, and 12% over 3 years in GHR using an intensive LIP. We assumed a 50% LIP participation rate. We also assessed % of T2D prevented by the PL strategy alone under MS or IS. The MS and IS would prevent 667,317 and 926,265 T2D cases over 10 years. Of the total cases prevented, 68.3% and 73.9% were due to PL strategy with MS and IS. The prevented complication cases increased with the number of prevented T2D cases. Curbing the national T2D epidemic, implementing both the cost-effective LIP in GHR and PL strategies is needed.
Disclosure
Y.Shao: Employee; Biogen. H.Shao: Consultant; Lilly Diabetes. G.Imperatore: None. C.S.Holliday: None. P.Zhang: None.
