Predicting opioid use disorder and associated risk factors in a Medicaid managed care population.

OBJECTIVES: Medicaid managed care organizations are developing comprehensive strategies to reduce the impact of opioid use disorder (OUD) among their members. The goals of this study were to develop and validate a predictive model of OUD and to predict future OUD diagnosis, resulting in proactive, person-centered outreach. STUDY DESIGN: We utilized machine learning methodology to select a multivariate logistic regression and identify predictors. METHODS: Using 2016-2018 data, we used a staged approach to test and validate the predictive accuracy of our model. We identified OUD, the dependent variable, using an industry-standard definition. We included a series of patient demographic, chronic condition, social determinants of health (SDOH), opioid-related, and health utilization indicators captured in administrative data. RESULTS: Caucasian (odds ratio [OR], 1.65), male (OR, 1.57), and younger (aged 40-64 years compared with 18-39 years: OR, 0.75) members had greater odds of being diagnosed with an OUD. Members with an SDOH vulnerability had 26% higher odds than those without a documented issue. From a prescribing perspective, we found that having an opioid dose of 120 morphine milligram equivalents and contiguous 5-day supply increased odds of OUD by 1.87 times, and an opioid supply of 30 days or longer increased the odds of OUD by 1.56 times. CONCLUSIONS: We built the necessary machine learning infrastructure to identify members with greater than 50% probability of developing OUD. The generated list strategically informs and guides person-centered care and interventions. Through application of these results, we strive to proactively reduce OUD-related structural barriers and prevent OUD from occurring.

Multifaceted interventions improve medication adherence and reduce acute hospitalization rates in medicaid patients prescribed asthma controllers.

OBJECTIVE: To measure the effectiveness of managed care-led interventions in Medicaid subjects with asthma on medication adherence and acute hospitalization in Pennsylvania. METHODS: A total of 3589 members (age range, 5-64 years) served by two Pennsylvania-based Medicaid managed care plans (southeastern Pennsylvania [SEPA] and Lehigh-Capital/New West Pennsylvania [LCNWPA]) with low adherence rates (proportion of days covered [PDC]; 20%-67%) for asthma controller prescription fills in 2012 were guided through a care continuum by a comprehensive asthma strategy, consisting of adherence-improvement interventions (grouped as general intervention [GI] or personalized intervention [PI] for higher-risk subjects). Medication adherence and acute hospitalization rates (emergency department [ED] and inpatient [IP]) were compared at baseline versus one-year post-intervention using paired t-test or signed-rank tests. Repeated measures analysis of variances detected the interaction effect of time by intervention group after controlling for sociodemographic covariates. RESULTS: Member profiles in SEPA (n = 2 796) and LCNWPA (n = 793) were racially and ethnically distinct. Both cohorts experienced statistically significant improvements in mean PDC rate (+4.9% and +7.2%; p = 0.01 and p = 0.03, respectively), accompanied by significant reductions in ED visits (asthma-related: -23.0% and -17.5%, respectively; p < 0.01), and IP admissions (asthma-related: -37.1% and -40.0%, respectively; p < 0.01). The PI subcohorts showed significantly greater improvements in mean PDC versus GI subcohorts (p ≤ 0.04), whereas acute hospitalization rates were statistically comparable in the SEPA cohort, despite its greater asthma burden. CONCLUSIONS: Managed care-led interventions can effectively improve medication adherence and reduce acute hospitalizations in high-risk Medicaid populations.

Postdischarge engagement decreased hospital readmissions in Medicaid populations.

OBJECTIVES: To investigate the effect of managed care organization (MCO)-implemented postdischarge engagement, supported by other broadly focused interventions, on 30-day hospital readmissions in 6 at-risk Medicaid populations. STUDY DESIGN: Prospective cohort study. METHODS: One-year follow-up analysis of member claims data was performed following an intervention period from January 1, 2014, to December 31, 2014. Postdischarge engagement, supported by additional MCO-initiated interventions, was implemented to reduce 30-day hospital readmissions in Medicaid members having 1 or more dominant chronic conditions. Hospital readmission rates were calculated at baseline and at 1 year post intervention. Bivariable and multivariable generalized estimating equation analysis was used to quantify the likelihood of hospital readmissions. RESULTS: Following implementation, postdischarge engagement rates increased significantly, whereas provider follow-up rates remained unchanged. Increased member engagement resulted in statistically significant reductions in weighted readmission rates enterprise-wide (-10.1%; P <.01) and in 3 of 6 MCOs (-3.9% to -15.8%; P ≤.05) in 2014. Compared with nonparticipants, members who were successfully reached for postdischarge engagement displayed a 33% decrease in 30-day readmissions enterprise-wide (adjusted odds ratio, 0.67; 95% CI, 0.62-0.73) and a comparable decrease (-23% to -39%) in 5 of the 6 MCOs. In this context, greater frequency of postdischarge engagement was associated with proportionally decreased likelihood of readmissions. CONCLUSIONS: Postdischarge engagement, against the backdrop of multifaceted MCO-implemented interventions, was associated with significantly reduced hospital readmissions in at-risk Medicaid subjects. Reduced likelihood of readmissions was observed at both the enterprise-wide and plan levels in a manner proportional to the frequency of engagement, a novel reported outcome for this population.

Factors associated with willingness to participate in biospecimen research among Chinese Americans.

A paucity of information exists on the recruitment of Asian Americans for biospecimen research. Although studies show that Chinese Americans are at high risk for hepatitis B virus (HBV) infection, little is known about their willingness to participate in HBV-related biospecimen research and how knowledge, attitudes, and cultural factors impact their willingness to participate. The study was guided by Community-Based Participatory Research principles. Data were derived from an assessment study on HBV-related biospecimen research participation among Chinese Americans in the Philadelphia region. The assessment was conducted with 415 Chinese Americans recruited from eight Chinese community-based organizations. Cultural beliefs, knowledge, and attitudes toward biospecimen research were examined for associations with their willingness to participate in biospecimen banking research. Overall, 192 (46.3%) of 415 participants who completed the assessment indicated they were willing to participate if they were invited to donate blood to be frozen and stored for future HBV biospecimen studies. Cultural variables significant in bivariate analysis included collectivism, knowledge about biospecimen research, and Yin-Yang beliefs. Fatalism and individualism were not associated with participation willingness. In multivariate analysis, age, health care attitudes, and trust were significantly associated with willingness to participate in biospecimen banking research. Asian American communities have little knowledge of biospecimen banking and will benefit from educational campaigns that emphasize collective benefits and attitudes towards and trust in the health care system. Understanding cultural factors is important for improving Chinese Americans' knowledge, awareness, and intentions of participation in biospecimen research. Similar efforts need to be undertaken to develop culturally appropriate educational intervention programs to increase participation in biospecimen research among other Asian American groups.

Culturally appropriate education intervention on biospecimen research participation among Chinese Americans.

BACKGROUND: Chinese Americans are at increased risk for hepatitis B virus (HBV) infection. To reduce or eliminate disparities in HBV-related infection rates, participation in scientific investigations of HBV risk and treatment, including biospecimen sampling, is important. However, Asian Americans have low rates of participation in biospecimen research, and little is known about how educational interventions affect knowledge and participation in HBV-related biospecimen research. METHODS: Eight Chinese community-based organizations participated in a quasi-experimental, two-group design with education assessments at pre- and postworkshop and a 3-month follow-up. Four sites were randomly assigned to receive the intervention (n = 175) and four sites to receive general health education (control; n = 240). RESULTS: Participant knowledge about biospecimen research increased from pre- to posteducation in the intervention but not in the control condition. Of intervention participants, 83.4% (146/175) donated one tube of blood for future HBV biospecimen research, and 50.9% (89/175) donated another tube of blood for HBV testing. In contrast, only 1.1% of participants in the control condition reported donating a blood sample at follow-up assessment. CONCLUSION: The intervention program significantly increased knowledge of and participation in HBV biospecimen research among Chinese Americans. Community-based participatory research (CBPR) methods featured active support by community leaders, a culturally specific curriculum, and convenient, immediate access to blood sampling, which resulted in high donation rates. IMPACT: HBV-related morbidity and mortality is an urgent problem faced by Chinese Americans. CBPR provides a model for engaging communities in early detection, vaccination, and treatment that can reduce this health threat.

Health beliefs associated with cervical cancer screening among Vietnamese Americans.

BACKGROUND: Vietnamese American women represent one of the ethnic subgroups at great risk for cervical cancer in the United States. The underutilization of cervical cancer screening and the vulnerability of Vietnamese American women to cervical cancer may be compounded by their health beliefs. OBJECTIVE: The objective of this study was to explore the associations between factors of the Health Belief Model (HBM) and cervical cancer screening among Vietnamese American women. METHODS: Vietnamese American women (n=1,450) were enrolled into the randomized controlled trial (RCT) study who were recruited from 30 Vietnamese community-based organizations located in Pennsylvania and New Jersey. Participants completed baseline assessments of demographic and acculturation variables, health care access factors, and constructs of the HBM, as well as health behaviors in either English or Vietnamese. RESULTS: The rate of those who had ever undergone cervical cancer screening was 53% (769/1450) among the participants. After adjusting for sociodemographic variables, the significant associated factors from HBM included: believing themselves at risk and more likely than average women to get cervical cancer; believing that cervical cancer changes life; believing a Pap test is important for staying healthy, not understanding what is done during a Pap test, being scared to know having cervical cancer; taking a Pap test is embarrassing; not being available by doctors at convenient times; having too much time for a test; believing no need for a Pap test when feeling well; and being confident in getting a test. CONCLUSION: Understanding how health beliefs may be associated with cervical cancer screening among underserved Vietnamese American women is essential for identifying the subgroup of women who are most at risk for cervical cancer and would benefit from intervention programs to increase screening rates.

Correlates of cervical cancer screening among Vietnamese American women.

OBJECTIVE: Vietnamese American women are at the greatest risk for cervical cancer but have the lowest cervical cancer screening rates. This study was to determine whether demographic and acculturation, healthcare access, and knowledge and beliefs are associated with a prior history of cervical cancer screening among Vietnamese women. METHODS: Vietnamese women (n = 1450) from 30 Vietnamese community-based organizations located in Pennsylvania and New Jersey participated in the study and completed baseline assessments. Logistic regression analyses were performed. RESULTS: Overall levels of knowledge about cervical cancer screening and human papillomavirus (HPV) are low. Factors in knowledge, attitude, and beliefs domains were significantly associated with Pap test behavior. In multivariate analyses, physician recommendation for screening and having health insurance were positively associated with prior screening. CONCLUSION: Understanding the factors that are associated with cervical cancer screening will inform the development of culturally appropriate intervention strategies that would potentially lead to increasing cervical cancer screening rates among Vietnamese women.

Health seeking behavioral analysis associated with breast cancer screening among Asian American women.

OBJECTIVE: The purpose of this community-based study was to apply a Sociocultural Health Behavior Model to determine the association of factors proposed in the model with breast cancer screening behaviors among Asian American women. METHODS: A cross-sectional design included a sample of 682 Chinese, Korean, and Vietnamese women aged 40 years and older. The frequency distribution analysis and Chi-square analysis were used for the initial screening of the following variables: sociodemographic, cultural, enabling, environmental, and social support. Univariate and multivariate analyses were conducted on factors for breast cancer screening using multinomial logistic regression analysis. RESULTS: Correlates to positive breast cancer screening included demographics (ethnicity), cultural factors (living in the United States for 15 years or more, speaking English well), enabling factors (having a regular physician to visit, health insurance covering the screening), and family/social support factors (those who had a family/friend receiving a mammogram). CONCLUSIONS: The results of this study suggest that breast cancer screening programs will be more effective if they include the cultural and health beliefs, enabling, and social support factors associated with breast cancer screening. The use of community organizations may play a role in helping to increase breast cancer screening rates among Asian American women.

A community-based participatory approach to a hepatitis B intervention for Korean Americans.

BACKGROUND: Hepatitis B virus (HBV) infection and liver cancer are severe health problems among Korean Americans. Most Korean Americans are neither screened nor vaccinated against HBV owing to substantial access barriers. OBJECTIVES: The primary objective of this article is to highlight how our team of academic researchers and community partners worked together to apply a community-based participatory research (CBPR) approach to developing, implementing, and evaluating a culturally appropriate, church-based HBV screening and vaccination intervention program for Korean Americans. METHODS: Guided by CBPR, multiple strategies were used to form academic-community partnerships in the development and implementation of the culturally appropriate HBV intervention program in the Korean-American community. These include the formation of a community advisory board (CAB) and adoption of CBPR principles, community needs assessment, development and evaluation of the pilot intervention program, and the full-scale community controlled trial. RESULTS: The pilot intervention results indicated significant increases in screening and vaccination rates in the intervention group compared with the control group. With the success of the partnership and pilot study, Korean church leaders, CAB members, and researchers are currently co-leading a full-scale intervention study to further evaluate the effectiveness of the intervention program. CONCLUSION: The current study highlights the role and contributions of multiple partners through five phases and discusses the challenges and lessons learned for how to sustain intervention programs by emphasizing common vision, trust development, shared recognition, capacity building, long-term commitments to partnership building, and balance between science and community needs.

Prostate cancer screening among chinese american men: a structural model.

OBJECTIVE: To test the Sociocultural Health Behavior Model in relation to the health behavior of prostate cancer (PCa) screening among Chinese American men. METHODS: Confirmatory factor analysis and structural equation model analyses were conducted among Chinese American men. RESULTS: The path analysis supported the components of the sociocultural model and indicated a positive and significant relationship between PCa screening and the enabling factors; between cultural factors and predisposing, enabling, and access/satisfaction with health care factors; and between enabling factors and access/satisfaction with health care. CONCLUSIONS: The model highlights the significance that sociocultural factors play in relation to PCa screening.

The prognostic meaning of the full spectrum of aVR ST-segment changes in acute myocardial infarction.

AIMS: ST-elevation in lead aVR is known to be associated with a worse prognosis in patients with acute ST elevation myocardial infarction (MI) but the significance of ST depression in lead aVR has been unclear. Infarction of the inferior apex of the left ventricle may not be appreciated on the standard 12-lead electrocardiogram (ECG) except by observing ST depression in lead aVR which is reciprocal to lead V(7). We therefore determined the prognostic value of the full spectrum of aVR ST changes in patients presenting with acute ST elevation MI. METHODS AND RESULTS: Lead aVR ST level was measured on randomization and 60 min ECGs in 15 315 patients with normal conduction from the HERO-2 trial. The outcome measure was 30-day mortality. aVR ST elevation ≥1 mm was associated with higher 30-day mortality for both inferior (22.5% for ≥1.5 mm and 13.2% for 1 mm) and anterior (23.5% for ≥1.5 mm and 11.5% for 1 mm) infarction. In contrast, deeper aVR ST depression (0, 0.5, 1, and ≥1.5 mm) was associated with higher mortality for anterior infarction (9.8, 13.2, 12.8, and 16.8%, respectively, trend P-value <0.0001) but not for inferior infarction. The resolution of aVR ST depression and ST elevation 60 min after fibrinolysis was associated with lower mortality. CONCLUSION: There is a U-shaped relationship between 30-day mortality and aVR ST level in patients presenting with anterior but not inferior ST elevation MI.

New ST-depression: an under-recognized high-risk category of 'complete' ST-resolution after reperfusion therapy.

AIM: It is not known if there is an association between resolution of ST-elevation to ST-depression following fibrinolysis and 30-day mortality. METHODS: In an ECG substudy of HERO-2, which compared bivalirudin to unfractionated heparin following streptokinase in 12,556 patients with ST-elevation myocardial infarction ECGs were recorded at baseline and at 60 minutes after commencing fibrinolysis. The main outcome measure was 30-day mortality. RESULTS: Using summed ST-segment elevation and five categories of changes in the infarct leads, further ST-elevation, 0-30% ST-resolution, >30-70% (partial) ST-resolution, >70% (complete) ST-resolution, and new ST-depression occurred in 21.7, 24.9, 36.8, 14.8, and 1.8% of patients, with 30-day mortality of 12.3, 11.7, 8.0, 4.2, and 8.1%, respectively. For the comparison of new ST-depression with complete ST-resolution and no ST-depression, p<0.01 with 24-hour mortality 4.5 vs. 1.3%, respectively (p=0.0003). Patients with new ST-depression had similar peak cardiac enzyme elevations as patients with complete ST-resolution without ST-depression. On multivariate analysis including summed ST-elevation at baseline, age, sex, and infarct location, new ST-depression was a significant predictor of 30-day mortality (OR 1.82, 95% CI 1.42-4.29). CONCLUSIONS: In patients with complete ST-resolution following fibrinolysis, new ST-depression at 60 minutes developed in 10.8% of patients. These patients had higher mortality than patients with complete ST-resolution without ST-depression and represent a high-risk group which could benefit from rapid triage to early angiography and revascularization as appropriate.

Workplace-based breast cancer screening intervention in china.

BACKGROUND: Breast cancer continues to be the primary cause of death among East and Southeast Asian women. Although China, the most populous country in the world, is experiencing unprecedented economic growth, its health care system has yet to benefit from the current economic prosperity. Indeed, studies have shown a consistent increase in breast cancer rates among Chinese women over the past two decades in the absence of breast cancer screening guidelines. METHODS: The primary objective of this study was to examine the impact of a workplace intervention on increasing breast cancer screening rates. The study was implemented at eight worksites in Nanjing, four of which were assigned to the intervention group (n = 232) and four to the control group (n = 221). The intervention group received breast cancer education and screening navigation. The control group was provided with general cancer education and received a delayed intervention after completion of the study. Study measures were completed at pre- and postprogram and at 6-month follow-up to assess uptake of mammography. RESULTS: Baseline mammography use was low among both intervention and control groups. However, exposure to the workplace intervention dramatically increased the uptake of mammography from 10.3% at baseline to 72.6% at 6-month follow-up in the intervention group (P < 0.001). CONCLUSIONS: Findings provide preliminary evidence that the implementation of a comprehensive workplace breast cancer screening intervention program in China can lead to increased uptake of mammography. These data may help facilitate the development of theory-based workplace cancer prevention programs and screening guidelines in China. IMPACT: A workplace-based multifaceted intervention could have a strong impact in breast cancer prevention and early detection among women in China.

Role of sociocultural factors in hepatitis B screening among Asian Americans.

OBJECTIVE: To apply the proposed Sociocultural Health Behavior Model to determine association of factors related to hepatitis B virus (HBV) screening among Asian Americans. METHODS: A cross-sectional design of 1312 Asian men and women 18 years and older. The frequency distribution analysis and chi square analysis were used for the initial screening of the following variables: access/satisfaction with health care, enabling, predisposing, cultural, and health belief factors. Univariate and multivariate analyses were conducted on factors for HBV screening using logistic regression analysis. RESULTS: Correlates to HBV screening included demographics, cultural factors, enabling factors, and family/social support factors. Enabling factors were more likely to be associated with HBV screening. CONCLUSION: The model highlights the role sociocultural factors play in HBV screening. Findings reinforce the need for HBV screening programs and indicate programs could be more effective if they included these components and were sensitive to ethnic and cultural factors.

Maternal self-report of oral health in six-year-old Pacific children from South Auckland, New Zealand.

OBJECTIVE: To examine maternal and socio-demographic factors associated with oral health practices and experiences in six-year-old Pacific children. METHODS: The longitudinal Pacific Islands Families (PIF) study is following a cohort of Pacific children born in Auckland, New Zealand in 2000. At approximately six years postpartum maternal reports (n = 1001) on child oral health practices and experiences of fillings and extractions were gathered. RESULTS: Forty-five per cent of mothers reported that their child had experienced fillings or extractions. After adjusting for confounding factors, we found that Tongan children were almost twice as likely to have their teeth filled or extracted than Samoan children (OR, 1.93; 95%, 1.34-2.77). Differences between Samoan children and children of other ethnic groups were not significant. Children of mothers who had secondary qualifications were significantly less likely to have their teeth filled or extracted compared to children of mothers who had postsecondary qualifications (OR, 0.634; 95%, 0.44-0.90). Prolonged duration of breastfeeding was associated with an increased likelihood of filling or extraction experience. In terms of maternal oral hygiene, maternal tooth brushing frequency of less that once a day was significantly associated with increased odds of fillings and/or extractions in their children (OR, 1.35; 95% CI, 1.02-1.79). Children who were sometimes supervised for tooth brushing were significantly more likely to have fillings or extractions than children who were not provided supervision. CONCLUSIONS: These findings highlight the role of cultural factors and maternal hygiene in child oral health outcomes and suggest that health promotion efforts should encompass the whole family and embrace a culturally appropriate approach.

Child developmental assessment at two-years of age: data from the Pacific Islands Families Study.

AIMS: To describe the developmental profile of Pacific children living in New Zealand at two years of age in personal/social, language, cognitive, fine motor, and gross motor domains, and to examine how sociodemographic, maternal, and cultural factors influence children's development. METHODS: A cohort of Pacific infants born during 2000 in Auckland, New Zealand, was followed up at two-years postpartum. Maternal interviews were administered and the developmental status of the child was measured using the Australian Developmental Screening Test. RESULTS: Maternal child development reports are presented for 1,018 two-year-old children. The majority of children were identified as having no developmental delay. The prevalence of no delay in any of these five domains was 64.8%. For those children (35%) who were identified with possible overall delay the significant risk factors were child ethnicity, low birth weight, being breastfed for less than six weeks, and single parenthood. DISCUSSION: The powerful associations of these factors and developmental outcome suggest that interventions need to have the flexibility to address such issues within individual Pacific families and communities.

Agreement and discordance of parents' and teachers' reports of behavioural problems among Pacific children living in New Zealand.

Research suggests that ratings of child psychopathology by parents and teachers are generally not highly correlated. We examined the agreement and discordance between the child behaviour ratings of parents and teachers of a cohort of 6-year-old Pacific children living in New Zealand, based on scores from the Child Behaviour Checklist and the Teacher Report Form. Mother's reports were obtained for 1019 children, of whom, 602 also had father's reports and 559 had teacher's reports. Rater agreement was low between all pairs of informants. Fathers and teachers had higher agreement than mothers and fathers, the latter in turn had higher agreement than mothers and teachers, and agreement was generally higher for Externalizing problems than Internalizing problems. In terms of discordance, mothers reported more aggressive behaviour than fathers, while fathers reported more Internalizing and Total problems than mothers. Mothers and fathers generally reported more behaviour problems than teachers. The higher agreement found between informants from different settings (fathers and teachers) than between informants from similar settings (mothers and fathers) is in contrast with some of the literature. Further research is needed to investigate how child, informant, and setting characteristics affect ratings of children's behaviour.

Traditional gift-giving and gambling amongst Pacific mothers living in New Zealand.

Cultural variables are implicated in gambling literature as playing an important role in the initiation and maintenance of gambling activity, however there remains a paucity of research that defines and investigates the association between cultural factors, gambling and problem gambling amongst different cultural groups. The first data collection point for a cohort of mothers within the longitudinal Pacific Islands Families study identified that the Pacific cultural practice of traditional gift-giving was associated with gambling activity and expenditure. In this paper, data about traditional gift-giving and gambling are presented from the third collection point within this study. The results support an association between gambling (rather than problem gambling) and traditional gift-giving. This paper contends the need to contextualise Pacific peoples gambling within Pacific cultures. Also a need is identified to examine and address the psycho-social and cultural impacts of gambling for Pacific peoples.