暂无摘要。

OBJECTIVE: To identify factors associated with clinicians\' likelihood and intensity of applying fluoride varnish (FV) overall and for visits paid by Medicaid and private insurers.
METHODS: Observational study using claims data.
METHODS: Using the Massachusetts All-Payer Claims Database (2016-2018), we conducted a repeated cross-sectional study of 2911 clinicians (7277 clinician-year observations) providing well-child visits to children aged 1 to 5 years. Zero-inflated negative binomial models estimated the probability of a clinician applying FV and the number of visits with FV applications, overall and separately for visits paid by Medicaid and private insurers.
RESULTS: A total of 30.9% of clinician-years applied FV at least once, and overall, an average of 8.4% of a clinician\'s well-child visits included FV annually. Controlling for all covariates, having a higher percentage of patients insured by Medicaid was associated with applying FV (OR, 1.35; 95% CI, 1.23-1.45) and a higher expected number of applications (OR, 1.05; 95% CI, 1.02-1.09). Additionally, having a higher percentage of patients aged 1 to 5 years was associated with applying FV (OR, 1.20; 95% CI, 1.01-1.43), but not the number of applications. Similar associations were observed among visits paid by private insurers.
CONCLUSIONS: Despite clinical recommendations and mandated insurance reimbursements, the likelihood and intensity of FV applications was low for most pediatric primary care clinicians. Clinician behavior was associated with patient-panel characteristics, suggesting the need for interventions that account for these differences.

This cohort study examines patterns of Medicaid coverage in the first 3 years of life among children with sickle cell disease across 5 states.

暂无摘要。

OBJECTIVE: To determine the differential impact of Medicaid expansion on all-cause mortality between Black, Latino/a, and White populations in rural and urban areas, and assess how expansion impacted mortality disparities between these groups.
METHODS: We employ a county-level time-varying heterogenous treatment effects difference-in-difference analysis of Medicaid expansion on all-cause age-adjusted mortality for those 64 years of age or younger from 2009 to 2019. For all counties within the 50 US States and the District of Columbia, we use restricted-access vital statistics data to estimate Average Treatment Effect on the Treated (ATET) for all combinations of racial and ethnic group (Black, Latino/a, White), rurality (rural, urban), and sex. We then assess aggregate ATET, as well as how the ATET changed as time from expansion increased.
RESULTS: Medicaid expansion led to a reduction in all-cause age-adjusted mortality for urban Black populations, but not rural Black populations. Urban White populations experienced mixed effects dependent on years after expansion. Latino/a populations saw no appreciable impact. While no effect was observed for rural Black and Latino/a populations, rural White all-cause age-adjusted mortality unexpectedly increased due to Medicaid expansion. These effects reduced rural- and urban-specific Black-White mortality disparities but did not shrink the rural-urban mortality gap.
CONCLUSIONS: The mortality-reducing impact of Medicaid expansion has been uneven across racial and ethnic groups and rural-urban status; suggesting that many populations-particularly rural individuals-are not seeing the same benefits as others. It is imperative that states work to ensure Medicaid expansion is being appropriately implemented in rural areas.

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

Pre-exposure prophylaxis (PrEP) has the potential to prevent new HIV infections, but it is unclear how state policies governing sexual and reproductive health services (SRH) impact access for cisgender women. The objective of this review is to identify barriers to PrEP access for cisgender women in the United States. Using the CDC Atlas Program, 20 states with the highest HIV incidence among cisgender women were included in this analysis. Through a search conducted in May-July 2022 of CDC, PrEPWatch.org, and other State Department and Insurance websites, Medicaid expansion status, pharmacist PrEP prescribing laws, financial support programs, and Traditional Medicaid coverage of PrEP, HIV testing, and emergency contraception were reviewed. Of the included states, nearly half did not expand Medicaid at the state level. Emergency contraception and HIV testing was covered under Traditional Medicaid for almost all included states, but insurance stipulations and eligibility requirements remain. Although PrEP is covered under all Traditional Medicaid plans, six states require pre-authorization. Three states have HIV testing mandates, four allow pharmacists to prescribe PrEP and six have financial support programs to cover the cost of PrEP. Medicaid expansion, pre-authorization requirements for PrEP prescriptions and emergency contraception, and limitations on pharmacist prescribing abilities were identified as barriers to SRH access for cisgender women. Medicaid expansion should be prioritized as an approach to expanding access to HIV prevention services at the state level.

BACKGROUND: Birthing people in the United States face numerous challenges when accessing adequate prenatal care (PNC), with transportation being a significant obstacle. Nevertheless, previous studies that relied solely on the distance to the nearest provider cannot differentiate the effects of travel burden on provider selection and care utilization. These may exaggerate the degree of inequality in access and fail to capture perceived travel burden. This study investigated whether travel distances to the initially visited provider, to the predominant PNC provider, and perceived travel burden (measured by the travel disadvantage index (TDI)) are associated with PNC utilization.
METHODS: A retrospective cohort of people with live births were identified from South Carolina Medicaid claims files in 2015-2018. Travel distances were calculated using Google Maps. The estimated TDI was derived from local pilot survey data. PNC utilization was measured by PNC initiation and frequency. Repeated measure logistic regression test was utilized for categorical variables and one-way repeated measures ANOVA for continuous variables. Unadjusted and adjusted ordinal logistic regressions with repeated measure were utilized to examine the association of travel burdens with PNC usage.
RESULTS: For 25,801 pregnancies among those continuously enrolled in Medicaid, birthing people traveled an average of 24.9 and 24.2 miles to their initial and predominant provider, respectively, with an average TDI of -11.4 (SD, 8.5). Of these pregnancies, 60% initiated PNC in the first trimester, with an average of 8 total visits. Compared to the specialties of initial providers, predominant providers were more likely to be OBGYN-related specialists (81.6% vs. 87.9%, p < .001) and midwives (3.5% vs. 4.3%, p < .001). Multiple regression analysis revealed that every doubling of travel distance was associated with less likelihood to initiate timely PNC (OR: 0.95, p < .001) and a lower visit frequency (OR: 0.85, p < .001), and every doubling of TDI was associated with less likelihood to initiate timely PNC (OR: 0.94, p = .04).
CONCLUSIONS: Findings suggest that the association between travel burden and PNC utilization was statistically significant but of limited practical significance.

This cross-sectional study provides a multistate description of utilization of Medicaid-covered peer support services in 2019 by enrollees with opioid use disorder (OUD).

UNASSIGNED: Untreated tooth decay is disproportionately present among low-income young children. While American Academy of Pediatrics (AAP) guidelines require pediatric clinicians to implement oral health care, the effectiveness of these oral health interventions has been inconclusive.
UNASSIGNED: To test the effectiveness of multilevel interventions in increasing dental attendance and reducing untreated decay among young children attending well-child visits (WCVs).
UNASSIGNED: The Pediatric Providers Against Cavities in Children\'s Teeth study is a cluster randomized clinical trial that was conducted at 18 pediatric primary care practices in northeast Ohio. The trial data were collected between November 2017 and July 2022, with data analyses conducted from August 2022 to March 2023. Eligible participants included Medicaid-enrolled preschoolers aged 3 to 6 years attending WCVs at participating practices who were enrolled at baseline (WCV 1) and followed-up for 2 consecutive examinations (WCV 2 and WCV 3).
UNASSIGNED: Clinicians in the intervention group received both the practice-level (electronic medical record changes to document oral health) and clinician-level (common-sense model of self-regulation theory-based oral health education and skills training) interventions. Control group clinicians received AAP-based standard oral health education alone.
UNASSIGNED: Dental attendance was determined through clinical dental examinations conducted by hygienists utilizing International Caries Detection and Assessment System criteria and also from Medicaid claims data. Untreated decay was determined through clinical examinations. A generalized estimating equations (GEE) approach was used for both clinical examinations and Medicaid claims data.
UNASSIGNED: Eighteen practices were randomized to either intervention or control. Participants included 63 clinicians (mean [SD] age, 47.0 [11.3] years; 48 female [76.2%] and 15 male [23.8%]; 28 in the intervention group [44.4%]; 35 in the control group [55.6%]) and 1023 parent-child dyads (mean [SD] child age, 56.1 [14.0] months; 555 male children [54.4%] and 466 female children [45.6%]; 517 in the intervention group [50.5%]; 506 in the control group [49.5%]). Dental attendance from clinical examinations was significantly higher in the intervention group (170 children [52.0%]) vs control group (150 children [43.1%]) with a difference of 8.9% (95% CI, 1.4% to 16.4%; P = .02). The GEE model using clinical examinations showed a significant increase in dental attendance in the intervention group vs control group (adjusted odds ratio, 1.34; 95% CI, 1.07 to 1.69). From Medicaid claims, the control group had significantly higher dental attendance than the intervention group at 2 years (332 children [79.6%] vs 330 children [73.7%]; P = .04) but not at 3 years. A clinically but not statistically significant reduction in mean number of untreated decay was found in the intervention group compared with controls (B = -0.27; 95% CI, -0.56 to 0.02).
UNASSIGNED: In this cluster randomized clinical trial, children in the intervention group had better dental outcomes as was evidenced by increased dental attendance and lower untreated decay. These findings suggest that intervention group clinicians comprehensively integrated oral health services into WCVs.
UNASSIGNED: ClinicalTrials.gov Identifier: NCT03385629.