Decomposition analysis of racial and ethnic differences in receipt of immediate postpartum, long-acting, reversible, and permanent contraception.

OBJECTIVES: This study aimed to determine the factors contributing to racial and ethnic disparities in the use of immediate postpartum, long-acting reversible contraception (IPP LARC) and permanent contraception among Medicaid recipients. STUDY DESIGN: We conducted a cross-sectional study using 3 years of national Medicaid claims data to examine the rates of IPP LARC use alone and a composite measure of postpartum permanent contraception and IPP LARC within 7 days of delivery by race and ethnicity. We used a Blinder-Oaxaca model to quantify the extent to which medical complexity, age, rurality, mode of delivery, and year explained differences in outcomes among different minoritized groups in comparison to non-Hispanic White women. RESULTS: Our study sample contained 1,729,663 deliveries occurring from 2016 through 2018 among 1,605,199 people living in 16 states. IPP LARC use rates were highest among Black (2.2%), followed by American Indian and Alaska Native at 2.1% and Hawaiian/Pacific Islander beneficiaries at 1.9%, Hispanic (all races) at 1.2%, and Asian at 1.0%. IPP LARC was lowest among White beneficiaries (0.8%). Medical complexity, age, rurality, year, and mode of delivery explained only 12.3% of the difference in IPP LARC rates between Black and White beneficiaries. Postpartum permanent contraception was highest among White (7.6%), Hispanic (7.2%), and American Indian and Alaska Native (6.8%), followed by Black (6.3%), Hawaiian/Pacific Islander (5.1%) and lowest among Asian women (4.1%). When we examined the use of IPP LARC or postpartum permanent contraception together, these same factors explained 94.4% of the differences between Black and White beneficiaries. CONCLUSIONS: While differences in the use of IPP LARC by race and ethnicity were identified, our findings suggest that overall use of inpatient highly effective contraception are similar across racial and ethnic groups. IMPLICATIONS: When IPP LARC and postpartum permanent contraception are examined jointly, their use is similar across racial and ethnic groups.

Medicaid Policy Change and Immediate Postpartum Long-Acting Reversible Contraception.

Importance: Improving access to the choice of postpartum contraceptive methods is a national public health priority, and the need is particularly acute within the Medicaid population. One strategy to ensure individuals have access to the full range of contraceptive methods is the provision of a method prior to hospital discharge following a birth episode. Beginning in 2016, some states changed their Medicaid billing policy, allowing separate reimbursement for intrauterine devices and contraceptive implants to increase the provision of long-acting reversible contraceptive (LARC) methods immediately postpartum (IPP). Objective: To assess the association of a change in Medicaid billing policy with use of IPP LARC. Design, Setting, and Participants: The cohort study of postpartum Medicaid recipients in 9 treatment and 6 comparison states was conducted from January 2016 to October 2019. Data were analyzed from August 2023 to January 2024. Main Outcomes and Measures: The primary outcome was use of IPP LARC. Results: The final sample included 1 378 885 delivery encounters for 1 197 287 Medicaid enrollees occurring in 15 states. Mean age of beneficiaries at delivery was 27 years. The IPP LARC billing policy was associated with a mean increase of 0.74 percentage points (95% CI, 0.30-1.18 percentage points) in the immediate receipt of IPP LARC, with a prepolicy baseline rate of 0.54%. The IPP LARC billing policy was also associated with an overall increase of 1.48 percentage points (95% CI, 0.43-2.73 percentage points) in LARC use by 60 days post partum. Conclusions and Relevance: In this cohort study, changing Medicaid billing policy to allow for separate reimbursement of LARC devices from the global fee was associated with increased use of IPP LARC, suggesting that this may be a strategy to improve access to the full range of postpartum contraceptive methods.

The association of federal Medicaid abortion funding restrictions with adverse obstetric outcomes among United States Medicaid recipients.

OBJECTIVE: We examine the association of the Hyde Amendment with obstetrical outcomes in a national Medicaid population. STUDY DESIGN: We conducted a national study of Medicaid-funded abortions to determine the association of restrictions on adolescent, preterm, low-birth weight, and short interpregnancy interval births using administrative data. RESULTS: States that restricted coverage for abortion had a higher median rate of adolescent (10.2%; vs 7.4%; p-value < 0.001), preterm (11.4%; vs 10.1%; p < 0.001), short interpregnancy interval, (13.0% vs 9.6%; p < 0.001), and low birth weight births (10.2% vs 8.7%; p = 0.003) than states where Medicaid provided comprehensive coverage. CONCLUSIONS: Restricting federal funds for abortion is associated with adverse outcomes. IMPLICATIONS: When Medicaid does not provide comprehensive coverage for abortion care, few abortions are provided and higher rates of adverse obstetrical outcomes are noted.

Geographic Variation In Effective Contraceptive Use Among Medicaid Recipients In 2018.

Medicaid is the largest payer for publicly funded contraception, serving millions of women across the United States. However, relatively little is known about the extent to which effective contraceptive services vary geographically for Medicaid recipients. This study used national Medicaid claims to assess county-level variation in rates of provision of the most or moderately effective methods of contraception and provision of long-acting reversible contraception (LARC) across forty states and Washington, D.C., in 2018. County-level rates of most or moderately effective contraceptive use varied almost fourfold across states, from a low of 10.8 percent to a high of 44.4 percent. Rates of LARC provision varied almost tenfold, from a low of 1.0 percent to a high of 9.6 percent. Despite the fact that contraception is a core benefit within Medicaid, access and use vary substantially across and within states. Medicaid agencies have a variety of options to ensure that people have access to a choice of the full range of contraceptive methods, including removing or loosening utilization controls, incorporating quality metrics or value-based payments into contraceptive services, and adjusting reimbursement to remove barriers to the clinical provision of LARC.

Catholic sole community hospitals are associated with decreased receipt of postpartum permanent contraception among Medicaid recipients.

OBJECTIVES: To examine the association of Catholic hospitals with receipt of postpartum tubal ligation and long acting, reversible contraception among Medicaid recipients. STUDY DESIGN: We conducted a retrospective cohort study of live births from January 1, 2016 to October 31, 2016 to female Medicaid beneficiaries in the United States between ages 21 and 44. Our main exposure was the presence of a Catholic-affiliated sole community hospital, and our primary outcome was highly effective postpartum contraception. We examined rates of postpartum permanent contraception, along with the use of a long acting, reversible form of contraception (LARC) at 3 and 60 days are postpartum. We compared counties that had only a Catholic-affiliated hospital with counties with only a non-Catholic hospital. RESULTS: Our study population included 14,545 postpartum Medicaid beneficiaries. Study participants came from 88 counties across 10 United States states. Only 7.7% of women in counties with Catholic sole community hospitals received permanent contraception by 3 days postpartum, compared to 11.3% in counties with non-Catholic sole community hospitals (RD: -3.92%; 95% CI: -6.01%, -1.83%). This difference was not mitigated by receipt of outpatient procedures or long-acting, reversible contraception. Importantly, women residing in counties with Catholic sole community hospitals were much less likely to return postpartum for an outpatient visit between 8 and 60 days postpartum than women in counties with non-Catholic sole community hospitals (35.4% vs 45.4%, RD: -9.29%; 95% CI: -16.71%, -1.86%). CONCLUSIONS: In counties where the only hospital was Catholic, Medicaid recipients giving birth were significantly less likely to receive permanent contraception and to return for postpartum care. IMPLICATIONS: Catholic hospitals are increasing in the United States, which may restrict access to postpartum contraception, particularly in rural areas. We found that Medicaid recipients giving birth at a Catholic sole community hospital were less likely to receive permanent contraception and to return for care.

Variation in Care and Clinical Outcomes Among Infants Hospitalized With Hyperbilirubinemia.

OBJECTIVES: To assess hospital-level variation in laboratory testing and intravenous fluid (IVF) use and examine the association between these interventions and hospitalization outcomes among infants admitted with neonatal hyperbilirubinemia. METHODS: We performed a retrospective multicenter study of infants aged 2 to 7 days hospitalized with a primary diagnosis of hyperbilirubinemia from December 1, 2016, to June 30, 2018, using the Pediatric Health Information System. Hospital-level variation in laboratory and IVF use was evaluated after adjusting for clinical and demographic factors and associated with hospital-level outcomes by using Pearson correlation. RESULTS: We identified 4396 infants hospitalized with hyperbilirubinemia. In addition to bilirubin level, the most frequently ordered laboratories were direct antiglobulin testing (45.7%), reticulocyte count (39.7%), complete blood cell counts (43.7%), ABO blood type (33.4%), and electrolyte panels (12.9%). IVFs were given to 26.3% of children. Extensive variation in laboratory testing and IVF administration was observed across hospitals (all P < .001). Increased use of laboratory testing but not IVFs was associated with a longer length of stay (P = .007 and .162, respectively). Neither supplementary laboratory use nor IVF use was associated with either readmissions or emergency department revisits. CONCLUSIONS: Substantial variation exists among hospitals in the management of infants with hyperbilirubinemia. With our results, we suggest that additional testing outside of bilirubin measurement may unnecessarily increase resource use for infants hospitalized with hyperbilirubinemia.

Opioid Use to Treat Migraine Headaches in Hospitalized Children and Adolescents.

OBJECTIVES: Prescription of opioids to treat pediatric migraine is explicitly discouraged by treatment guidelines but persists in some clinical settings. We sought to describe rates of opioid administration in pediatric migraine hospitalizations. METHODS: Using data from the Pediatric Health Information System, we performed a cross-sectional study to investigate the prevalence and predictors of opioid administration for children aged 7 to 21 years who were hospitalized for migraine between January 1, 2016, and December 31, 2018. RESULTS: There were 6632 pediatric migraine hospitalizations at 50 hospitals during the study period, of which 448 (7%) had an opioid administered during the hospitalization. There were higher adjusted odds of opioid administration in hospitalizations for non-Hispanic black (adjusted odds ratio [aOR], 1.68; P < .001) and Hispanic (aOR, 1.54; P = .005) (reference white) race and ethnicity, among older age groups (18-21 years: aOR, 2.74; P < .001; reference, 7-10 years), and among patients with higher illness severity (aOR, 2.58; P < .001). Hospitalizations during which an opioid was administered had a longer length of stay (adjusted rate ratio, 1.48; P < .001) and higher 30-day readmission rate (aOR, 1.96; P < .001). By pediatric hospital, opioid administration ranged from 0% to 23.5% of migraine hospitalizations. Hospitals with higher opioid administration rates demonstrated higher adjusted readmission rates (P < .001) and higher adjusted rates of return emergency department visits (P = .026). CONCLUSIONS: Opioids continue to be used during pediatric migraine hospitalizations and are associated with longer lengths of stay and readmissions. These findings reveal important opportunities to improve adherence to migraine treatment guidelines and minimize unnecessary opioid exposure, with the potential to improve hospital discharge outcomes.

Racial and ethnic disparities in a state-wide registry of patients with pancreatic cancer and an exploratory investigation of cancer cachexia as a contributor to observed inequities.

Pancreatic cancer (PC) is characterized by racial/ethnic disparities and the debilitating muscle-wasting condition, cancer cachexia. Florida ranks second in the number of PC deaths and has a large and understudied minority population. We examined the primary hypothesis that PC incidence and mortality rates may be highest among Black Floridians and the secondary hypothesis that biological correlates of cancer cachexia may underlie disparities. PC incidence and mortality rates were estimated by race/ethnicity, gender, and county using publicly available state-wide cancer registry data that included approximately 2700 Black, 25 200 Non-Hispanic White (NHW), and 3300 Hispanic/Latino (H/L) Floridians diagnosed between 2004 and 2014. Blacks within Florida experienced a significantly (P < 0.05) higher incidence (12.5/100 000) and mortality (10.97/100 000) compared to NHW (incidence = 11.2/100 000; mortality = 10.3/100 000) and H/L (incidence = 9.6/100 000; mortality = 8.7/100 000), especially in rural counties. To investigate radiologic and blood-based correlates of cachexia, we leveraged data from a subset of patients evaluated at two geographically distinct Florida Cancer Centers. In Blacks compared to NHW matched on stage, markers of PC-induced cachexia were more frequent and included greater decreases in core musculature compared to corresponding healthy control patients (25.0% vs 10.1% lower), greater decreases in psoas musculature over time (10.5% vs 4.8% loss), lower baseline serum albumin levels (3.8 vs 4.0 gm/dL), and higher platelet counts (332.8 vs 268.7 k/UL). Together, these findings suggest for the first time that PC and cachexia may affect Blacks disproportionately. Given its nearly universal contribution to illness and PC-related deaths, the early diagnosis and treatment of cachexia may represent an avenue to improve health equity, quality of life, and survival.

Survivor clinic attendance among pediatric- and adolescent-aged survivors of childhood cancer.

PURPOSE: Childhood cancer survivors need regular, risk-adapted, long-term survivor care. This retrospective study describes the proportion of survivors seen for an initial survivor clinic visit within a large pediatric oncology program. METHODS: Patients diagnosed with non-central nervous system childhood malignancies from 2007 to 2012 were followed from the time of survivor clinic eligibility (2 years following completion of therapy) through their initial survivor clinic visit or end of study. Demographic, cancer-related, and logistical factors related to clinic attendance were examined using Kaplan-Meier curves and Cox proportional regressions. RESULTS: Eligible survivors were 53.0% male, 51.5% non-Hispanic white, and 30.9% survivors of leukemia. Among the 866 eligible survivors for this study, 610 (70.4%) completed their initial visit. After controlling for sex and time eligible, survivors who received surgery only (aHR 0.04 (0.02, 0.08)) or radiation only (0.24 (0.15, 0.39)) and who had Medicaid (0.77 (0.64, 0.92)) were significantly less likely to have an initial visit as were those of black or other/mixed race and those who lived > 25 mi from the clinic (p < 0.01). Survivors aged 6-11 years or 12-17 years at eligibility were significantly more likely to complete an initial visit as compared to those aged 2-5 years (1.55 (1.24, 1.93) and 1.44 (1.14, 1.83), respectively). CONCLUSIONS: Nearly a third of survivors were not seen in a pediatric survivor clinic despite the importance of survivor care. These results identify populations at risk for not pursuing long-term survivorship care. IMPLICATIONS FOR CANCER SURVIVORS: Failure to transition to pediatric survivor care may lead to lifelong non-engagement and incorrect perceptions about future health.

Childhood obesity and in-hospital asthma resource utilization.

OBJECTIVE: To examine the relationship between pediatric obesity and inpatient length of stay (LOS), resource utilization, readmission rates, and total billed charges for in-hospital status asthmaticus. DESIGN/METHODS: We conducted a cross-sectional study of patients 5 to 17 years old hospitalized with status asthmaticus to 1 free-standing children's hospital system over 12 months. Only hospitalized patients initially treated in the hospital's emergency department were included to ensure all therapies/charges were examined. Patients with complex chronic conditions, pneumonia, or lacking recorded body mass index (BMI) were excluded. The primary exposure was BMI percentile for age. The primary outcome was LOS (in hours). Secondary outcomes were 90-day readmission rate, billed charges, and resource utilization: number of albuterol treatments, chest radiographs, intravenous fluids, intravenous or intramuscular steroids, and intensive care unit admission. Bivariate, adjusted Poisson and logistic regression model analyses were performed. RESULTS: Five hundred eighteen patients met inclusion criteria. Most had a normal BMI (59.7%); 36.7% were overweight or obese. LOS, readmissions, and resource utilization outcomes were not associated with BMI category on bivariate analyses. After adjustment for demographic/clinical characteristics, LOS decreased by 2% for each decile increase in BMI percentile for age. BMI percentile for age was not associated with billed charges, readmissions, or other measures of resource utilization. CONCLUSIONS: Although BMI decile for age is inversely associated with LOS for in-hospital pediatric status asthmaticus, the effect likely is not clinically meaningful.