bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Impact of Medicaid Expansion for Adults Under the Affordable Care Act on Preventive Care for Children
Authors: Roy Shreya , Wilson Fernando A. , Chen Li-Wu , Kim Jungyoon , Yu Fang 
Published: September 2020

Introduction:
The Affordable Care Act of 2010 expanded Medicaid to low-income adults at or below 138% of the Federal Poverty Level (FPL). The aim of this study was to examine if expanding Medicaid to adults had an impact on preventive health care utilization of children from low-income families (focusing on families with annual incomes 0%–99% and 100%–199% of the FPL).

Methods:
This study used data from the 2016 and 2017 National Survey of Children’s Health and a quasi-experimental difference-in-differences method. The dependent variable was the number of preventive care visits in the past year and the primary independent variable was the Medicaid expansion status of the state. Louisiana expanded Medicaid in 2016 (treatment group) and neighboring nonexpansion states of Texas and Mississippi constituted the control group. Differences in dependent variable were calculated between survey years 2016 and 2017.

Results:
In Louisiana, the change in the predicted probability of at least 1 preventive care visit among children of ages 0–17 years, from 0% to 99% FPL families, was higher by 26 percentage points after Medicaid was expanded (2017 vs. 2016), as compared with the change in the predicted probability (2017 vs. 2016) of at least 1 preventive care visit among children of ages 0–17 years, from 0% to 99% FPL families in the nonexpansion states, Texas and Mississippi.

Conclusions:
Children in poverty residing in a Medicaid expansion state, Louisiana, had increased likelihood of having an annual preventive care visit after expansion of Medicaid eligibility under the Affordable Care Act, as compared with children in nonexpansion states. Thus, this study showed that the implications of the public health insurance expansion for adults were not limited to adult health outcomes, but extended to children’s health care utilization.
Can Continuity of Care Reduce Hospitalization Among Community-dwelling Older Adult Veterans Living With Dementia?
Authors: Lei Lianlian , Cai Shubing , Conwell Yeates , Fortinsky Richard H. , Intrator Orna 
Published: September 2020

Background:
Hospitalization is a difficult experience, especially for patients with dementia. Understanding whether better continuity of care (COC) reduces hospitalizations can indicate interventions that might help curb hospitalizations.

Objective:
To estimate the causal impact of COC on hospitalizations and different reasons for hospitalization among community-dwelling older veterans with dementia.

Research Design:
Population-based observational study using nationwide Veterans Health Administration data linked to Medicare claims in Fiscal Years (FYs) 2014–2015. To account for unobserved confounders we used an instrumental variable for COC—whether veteran changed residence by more than 10 miles.

Subjects:
Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (n=105,528).

Measures:
Bice-Boxerman Continuity of Care (BBC) index (0—worst to 1—best COC); binary indicators of any hospitalization for all causes, for ambulatory care sensitive conditions (ACSCs) and for reasons grouped by major diagnostic category.

Results:
The mean BBC in FY 2014 was 0.32 (SD, 0.23). In FY 2015 43.3% of the cohort veterans were hospitalized. A 0.1 higher BBC resulted in 2.4% (95% confidence interval, 0.5%–4.4%) lower probability of hospitalization for all causes. BBC was not associated with hospitalization for ACSCs. Grouped by major diagnostic category, a 0.1 higher BBC resulted in 3.8% (95% confidence interval, 2.1%–5.4%) lower probability of hospitalization for neuropsychiatric diseases/disorders, with no impact on hospitalizations for circulatory, respiratory, infectious, kidney and urinary, digestive, musculoskeletal, and endocrine-metabolic diseases/disorders.

Conclusions:
Among community-dwelling older veterans with dementia, better COC resulted in less hospitalizations, and this effect was primarily due to less hospitalization for neuropsychiatric diseases/disorders but not hospitalization for ACSCs, or other hospitalization reasons.
The Impact of Various Risk Assessment Time Frames on the Performance of Opioid Overdose Forecasting Models
Authors: Chang Hsien-Yen , Ferris Lindsey , Eisenberg Matthew , Krawczyk Noa , Schneider Kristin E. , Lemke Klaus , Richards Thomas M. , Jackson Kate , Murthy Vijay D. , Weiner Jonathan P. , Saloner Brendan 
Published: September 2020

Background:
An individual’s risk for future opioid overdoses is usually assessed using a 12-month “lookback” period. Given the potential urgency of acting rapidly, we compared the performance of alternative predictive models with risk information from the past 3, 6, 9, and 12 months.

Methods:
We included 1,014,033 Maryland residents aged 18–80 with at least 1 opioid prescription and no recorded death in 2015. We used 2015 Maryland prescription drug monitoring data to identify risk factors for nonfatal opioid overdoses from hospital discharge records and investigated fatal opioid overdose from medical examiner data in 2016. Prescription drug monitoring program–derived predictors included demographics, payment sources for opioid prescriptions, count of unique opioid prescribers and pharmacies, and quantity and types of opioids and benzodiazepines filled. We estimated a series of logistic regression models that included 3, 6, 9, and 12 months of prescription drug monitoring program data and compared model performance, using bootstrapped C-statistics and associated 95% confidence intervals.

Results:
For hospital-treated nonfatal overdose, the C-statistic increased from 0.73 for a model including only the fourth quarter to 0.77 for a model with 4 quarters of data. For fatal overdose, the area under the curve increased from 0.80 to 0.83 over the same models. The strongest predictors of overdose were prescription fills for buprenorphine and Medicaid and Medicare as sources of payment.

Conclusions:
Models predicting opioid overdose using 1 quarter of data were nearly as accurate as models using all 4 quarters. Models with a single quarter may be more timely and easier to identify persons at risk of an opioid overdose.
Differences in Health Care Utilization, Process of Diabetes Care, Care Satisfaction, and Health Status in Patients With Diabetes in Medicare Advantage Versus Traditional Medicare
Authors: Park Sungchul , Larson Eric B. , Fishman Paul , White Lindsay , Coe Norma B. 
Published: September 2020

Objective:
The objective of this study was to determine differences in health care utilization, process of diabetes care, care satisfaction, and health status for Medicare Advantage (MA) and traditional Medicare (TM) beneficiaries with and without diabetes.

Methods:
Using the 2010–2016 Medicare Current Beneficiary Survey, we identified MA and TM beneficiaries with and without diabetes. To address the endogenous plan choice between MA and TM, we used an instrumental variable approach. Using marginal effects, we estimated differences in the outcomes between MA and TM beneficiaries with and without diabetes.

Results:
Our instrumental variable analysis showed that compared with TM beneficiaries with diabetes, MA beneficiaries with diabetes had less annual health care utilization, including −22.4 medical provider visits [95% confidence interval (CI): −23.6 to −21.1] and −3.4 outpatient hospital visits (95% CI: −3.8 to −3.0). A significant difference between MA and TM beneficiaries without diabetes was only observed in medical provider visits and the difference was greater among beneficiaries with diabetes than beneficiaries without diabetes (−12.5 medical provider visits; 95% CI: −15.9 to −9.2). While we did not detect significant differences in 5 measures of the process of diabetes care between MA and TM beneficiaries with diabetes, there were inconsistent results in the other 3 measures. There were no or marginal differences in care satisfaction and health status between MA and TM beneficiaries with and without diabetes.

Conclusions:
MA enrollment was associated with lower health care utilization without compromising care satisfaction and health status, particularly for beneficiaries with diabetes. MA may have a more efficient care delivery system for beneficiaries with diabetes.
Patient Coded Severity and Payment Penalties Under the Hospital Readmissions Reduction Program
Authors: Li Jun , Sukul Devraj , Nuliyalu Ushapoorna , Ryan Andrew M. 
Published: September 2020

Objective:
The objective of this study was to examine variation in hospital responses to the Centers for Medicare and Medicaid’s expansion of allowable secondary diagnoses in January 2011 and its association with financial penalties under the Hospital Readmission Reduction Program (HRRP).

Data Sources/Study Setting:
Medicare administrative claims for discharges between July 2008 and June 2011 (N=3102 hospitals).

Research Design:
We examined hospital variation in response to the expansion of secondary diagnoses by describing changes in comorbidity coding before and after the policy change. We used random forest machine learning regression to examine hospital characteristics associated with coded severity. We then used a 2-part model to assess whether variation in coded severity was associated with readmission penalties.

Results:
Changes in severity coding varied considerably across hospitals. Random forest models indicated that greater baseline levels of condition categories, case-mix index, and hospital size were associated with larger changes in condition categories. Hospital coding of an additional condition category was associated with a nonsignificant 3.8 percentage point increase in the probability for penalties under the HRRP (SE=2.2) and a nonsignificant 0.016 percentage point increase in penalty amount (SE=0.016).

Conclusion:
Changes in patient coded severity did not affect readmission penalties.
Single-arm Trials With External Comparators and Confounder Misclassification
Authors: Webster-Clark Michael , Jonsson Funk Michele , Stürmer Til 
Published: September 2020

Background:
“Single-arm trials” with external comparators that contrast outcomes in those on experimental therapy to real-world patients have been used to evaluate efficacy and safety of experimental drugs in rare and severe diseases. Regulatory agencies are considering expanding the role these studies can play; guidance thus far has explicitly considered outcome misclassification with little discussion of misclassification of confounding variables.

Objectives:
This work uses causal diagrams to illustrate how adjustment for a misclassified confounder can result in estimates farther from the truth than ignoring it completely. This theory is augmented with quantitative examples using plausible values for misclassification of smoking in real-world pharmaceutical claims data. A tool is also provided for calculating bias of adjusted estimates with specific input parameters.

Results:
When confounder misclassification is similar in both data sources, adjustment generally brings estimates closer to the truth. When it is not, adjustment can generate estimates that are considerably farther from the truth than the crude. While all nonrandomized studies are subject to this potential bias, single-arm studies are particularly vulnerable due to perfect alignment of confounder measurement and treatment group. This is most problematic when the prevalence of the confounder does not differ between data sources and misclassification does, but can occur even with strong confounder-data source associations.

Discussion:
Researchers should consider differential confounder misclassification when designing protocols for these types of studies. Subsample validation of confounders, followed by imputation or other bias correction methods, may be a key tool for combining trial and real-world data going forward.
Use of the Veterans’ Choice Program and Attrition From Veterans Health Administration Primary Care
Authors: Yoon Jean , Leung Lucinda B. , Rubenstein Lisa V. , Rose Danielle E. , Stockdale Susan E. , Kaboli Peter J. , Chow Adam 
Published: September 2020

Background:
Concerns over timely access and waiting times for appointments in the Veterans Health Administration (VHA) spurred the push towards greater privatization. In 2014, VHA increased the provision of care from community providers through the Veterans’ Choice Program (Choice).

Objectives:
We examined the characteristics of patients and practices more likely to use Choice care and whether using Choice care affected patients’ attrition from VHA primary care.

Study Design:
We conducted a longitudinal study of VHA primary care users in the fiscal year 2015 and their attrition 2 years later. In the multivariate analysis, we examined whether attrition from VHA primary care was related to prior use of Choice care.

Subjects:
A total of 1.4 million nonelderly patients diagnosed with chronic conditions.

Measures:
Choice outpatient care utilization was measured in the baseline year. Attrition was measured as not receiving any VHA primary care in 2 subsequent years.

Results:
In our cohort, 93,710 (7%) patients used some Choice outpatient care, and these patients were more likely to be female, White or Hispanic, to have more primary care utilization at baseline, and to have long driving distances to VHA care. Practices which sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation and longer mean waiting times for appointments. In the adjusted analysis, the probability of attrition was significantly lower (−0.009) among patients who used Choice outpatient care (0.036) versus patients who did not (0.044) (P<0.001).

Conclusion:
The use of community outpatient providers in the Choice program was associated with less attrition from VHA primary care.
Coordination of Care as Experienced by the Specialist
Authors: Vimalananda Varsha G. , Meterko Mark , Solch Amanda K. , Qian Shirley , Wormwood Jolie B. , Greenlee Carol M. , Smith Cynthia D. , Fincke Benjamin G. 
Published: September 2020

Background:
We previously developed 2 complementary surveys to measure coordination of care as experienced by the specialist and the primary care provider (PCP). These Coordination of Specialty Care (CSC) surveys were developed in the Veterans Health Administration (VA), under an integrated organizational umbrella that includes a shared electronic health record (EHR).

Objective:
To develop an augmented version of the CSC-Specialist in the private sector and use that version (CSC-Specialist 2.0) to examine the effect of a shared EHR on coordination.

Research Design:
We administered the survey online to a national sample of clinicians from 10 internal medicine subspecialties. We used multitrait analysis and confirmatory factor analysis to evaluate the psychometric properties of the original VA-based survey and develop an augmented private sector survey (CSC-Specialist 2.0). We tested construct validity by regressing a single-item measure of overall coordination onto the 4 scales. We used analysis of variance to examine the relationship of a shared EHR to coordination.

Results:
Psychometric assessment supported the 13-item, 4-scale structure of the original VA measure and the augmented 18-item, 4-scale structure of the CSC-Specialist 2.0. The CSC-Specialist 2.0 scales together explained 45% of the variance in overall coordination. A shared EHR was associated with significantly better scores for the Roles and Responsibilities and Data Transfer scales, and for overall coordination.

Conclusions:
The CSC-Specialist 2.0 is a unique survey that demonstrates adequate psychometric performance and is sensitive to use of a shared EHR. It can be used alone or with the CSC-PCP to identify coordination problems, guide interventions, and measure improvements.
Incident Musculoskeletal Conditions Among Men and Women Veterans Returning From Deployment
Authors: Haskell Sally G. , Brandt Cynthia , Bastian Lori , Driscoll Mary , Bathulapalli Harini , Dziura James 
Published: September 2020

Background:
Military service confers an increased risk for musculoskeletal (MSK) injury among women and men Veterans.

Objective:
The objective of this study was to determine the prevalence of MSK conditions at first visit to Veterans Affairs (VA), and the incidence rates of new MSK conditions in women and men Veterans with and without a baseline MSK condition.

Design:
A cohort study including Veterans whose end of last deployment was between October 1, 2001 and October 1, 2015.

Subjects:
A total of 765,465 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans.

Main Outcome Measures:
Prevalent and incident MSK conditions identified through the International Classification of Diseases, ninth Revision, Clinical Modification diagnostic codes.

Results:
Twenty-six percent of women and 29% of men present to the VA with a MSK condition. In those without an MSK diagnosis at baseline, the unadjusted rate of developing at least 1 MSK condition was 168 and 180 per 1000 person-year [hazard ratio (HR)=0.94; 95% confidence interval (CI)=0.92–0.95] in women and men. Women were more likely to develop newly diagnosed MSK conditions of the hip (HR=1.9; 95% CI=1.83–1.98) or the ankle/foot (HR=1.17; 95% CI=1.15–1.20) and less likely to develop MSK conditions of the upper extremity (HR=0.75; 95% CI=0.73–0.78), knee (HR=0.87; 95% CI=0.86–0.89), and spine (HR=0.94; 95% CI=0.93–0.96). In those with prevalent MSK conditions at baseline, the rate of developing a second MSK condition was higher in women than men (151 and 133/1000 person-year; HR=1.13; 95% CI=1.11–1.15).

Conclusions:
A high proportion of Veterans present to the VA with MSK conditions. Women are less likely to develop conditions related to the upper extremities, spine or knee, and more likely to have conditions of the hip or ankle/foot.
BRCA1/2 Testing in Massachusetts Among Women With Private Insurance or Medicaid, 2011–2015
Authors: Pace Lydia E. , Baum Christopher F. , Horvath Krisztina , Raja Sahitya C. , Cohen Jessica , Hawkins Summer S. 
Published: September 2020

Purpose:
Testing for BRCA1/2 mutations has increased among privately insured women in the United States. However, little is known about testing rates or trends among women with Medicaid. We sought to determine whether BRCA1/2 testing rates differed between women with private insurance compared with women with Medicaid in a state where both insurance types cover the test, and to compare testing trends from 2011 to 2015.

Methods:
We conducted a retrospective cohort study of medical claims from January 2011 through June 2015. We included Massachusetts women aged 18–64 with private insurance or Medicaid and at least 12 months of continuous enrollment. We used multivariable linear regression to examine the association of insurance type, age, and time with testing rates.

Results:
Mean monthly BRCA1/2 testing rates were lower among women with Medicaid compared with those with private insurance. Among privately insured women, mean monthly rates rose from 9.3 per 100,000 in 2011 to 18.4 per 100,000 in 2015, while among Medicaid-insured women, rates increased from 3.7 to 14.7. There was no difference in the monthly rate of increase in both groups (P=0.07). In adjusted analyses, rates were lower among Medicaid-insured women (7 fewer tests per month than privately insured women, P<0.001), and differed by age, with women aged 44–54 most likely to receive testing and women 18–34 the least likely.

Conclusion:
BRCA1/2 testing rates were lower among women insured by Medicaid compared with those with private insurance, though rates increased from 2011 to 2015 among both groups of women at a similar rate.
Telehealth Benefits Offered by Medicare Advantage Plans in 2020
Authors: Park Sungchul , Langellier Brent A. , Burke Robert E. 
Published: September 2020

Objective:
The objective of this study was to analyze new telehealth benefits offered by Medicare Advantage (MA) plans in 2020 and examine plan characteristics associated with the provision of the new telehealth benefits.

Research Design:
Using publicly available data from the Centers for Medicare and Medicaid Services, we identified unique MA plans with at least 1 enrollee in January 2020. We examined whether plans offered any new telehealth benefits in 2020, the 20 most common types of telehealth services covered, and cost-sharing. Next, we used multivariable logistic regression to identify associations between offering any telehealth benefits and plan characteristics. We conducted a similar analysis for each of the 3 most commonly covered telehealth services.

Results:
Of 2992 unique MA plans, 58.1% offered new telehealth benefits in 2020. The most frequently covered services were primary care, mental health, and urgent care. Coverage for other types of services was limited. Our multivariable logistic regression showed that offering any new telehealth benefits was not more common among plans in rural areas, but was more likely among national plans, those with a monthly premium, those with >3540 enrollees, and those with a star rating of 4.0–4.5. The new telehealth benefits were less likely to be provided by for-profit plans. Overall, findings remained similar when analyzed according to the type of services.

Conclusions:
MA plans are embracing new telehealth benefits, but there is room for improvement. Policymakers should consider how to accelerate the adoption curve of telehealth in MA plans.
State Opioid Limits and Volume of Opioid Prescriptions Received by Medicaid Patients
Authors: Zhang Hao , Tallavajhala Srikar , Kapadia Shashi N. , Jeng Philip J. , Shi Yuyan , Wen Hefei , Bao Yuhua 
Published: September 2020

Background:
Since early 2016, an increasing number of states passed legislations that limit the duration and/or dosage of initial opioid prescriptions or opioids for acute pain.

Objective:
The objective of this study was to assess changes in the number of opioid prescriptions covered by Medicaid and received by Medicaid patients associated with state implementation of legislative limits on initial opioid prescriptions.

Research Design:
We explored the natural experiment resulting from the staggered implementation of state legislative limits. The analysis adopted a Difference-in-Differences framework and controlled for other major state policies bearing implications for prescription opioid use. The main analysis included 26 states that implemented limits from early 2016 to late 2018. A secondary analysis included all 50 states and the District of Columbia.

Measures:
Population-adjusted state-quarter level counts of Schedule II and III opioid prescriptions received by Medicaid patients, based on data from the Medicaid State Drug Utilization Data and state Medicaid enrollment reports for 2013–2018.

Results:
Implementation of legislative limits on initial opioid prescriptions was associated with a 7% reduction in the number of opioid prescriptions per 100 Medicaid enrollees. Such reduction was largely attributable to a reduction in Schedule II opioid prescriptions. Secondary analysis by including all jurisdictions and sensitivity checks supported the robustness of results.

Conclusion:
The recent implementation of state legislative limits on initial opioid prescriptions was associated with meaningful reductions in the volume of Schedule II opioid prescriptions received by Medicaid patients.