Comparative effectiveness of alternative intervals between first and second doses of the mRNA COVID-19 vaccines.

The optimal interval between the first and second doses of COVID-19 mRNA vaccines has not been thoroughly evaluated. Employing a target trial emulation approach, we compared the effectiveness of different interdose intervals among >6 million mRNA vaccine recipients in Georgia, USA, from December 2020 to March 2022. We compared three protocols defined by interdose interval: recommended by the Food and Drug Administration (FDA) (17-25 days for Pfizer-BioNTech; 24-32 days for Moderna), late-but-allowable (26-42 days for Pfizer-BioNTech; 33-49 days for Moderna), and late ( ≥ 43 days for Pfizer-BioNTech; ≥50 days for Moderna). In the short-term, the risk of SARS-CoV-2 infection was lowest under the FDA-recommended protocol. Longer-term, the late-but-allowable protocol resulted in the lowest risk (risk ratio on Day 120 after the first dose administration compared to the FDA-recommended protocol: 0.83 [95% confidence interval: 0.82-0.84]). Here, we showed that delaying the second dose by 1-2 weeks may provide stronger long-term protection.

Provider-Level Caseload of Psychosocial Services for Medicaid-Insured Children.

OBJECTIVE: We estimated the caseload of providers, practices, and clinics for psychosocial services (including psychotherapy) to Medicaid-insured children to improve the understanding of the current supply of such services and to inform opportunities to increase their accessibility. METHODS: We used 2012-2013 Medicaid claims data and data from the 2013 National Plan and Provider Enumeration System to identify and locate therapists, psychiatrists, and mental health centers along with primary, rehabilitative, and developmental care providers in the United States who provided psychosocial services to Medicaid-insured children. We estimated the per-provider, per-location, and state-level caseloads of providers offering these services to Medicaid-insured children in 34 states with sufficiently complete data to perform this analysis, by using the most recent year of Medicaid claims data available for each state. We measured caseload by calculating the number of psychosocial visits delivered by each provider in the selected year. We compared caseloads across states, urbanicity, provider specialty (eg, psychiatry, psychology, primary care), and practice setting (eg, mental health center, single practitioner). RESULTS: We identified 63 314 providers, practices, or centers in the Medicaid claims data that provided psychosocial services to Medicaid-insured children in either 2012 or 2013. The median provider-level per-year caseload was <25 children and <250 visits across all provider types. Providers with a mental health center-related taxonomy accounted for >40% of visits for >30% of patients. Fewer than 10% of providers and locations accounted for >50% of patients and visits. CONCLUSIONS: Psychosocial services are concentrated in a few locations, thereby reducing geographic accessibility of providers. Providers should be incentivized to offer care in more locations and to accept more Medicaid-insured patients.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders.

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs' perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010-2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

Quantifying Disparities in Accessibility and Availability of Pediatric Primary Care across Multiple States with Implications for Targeted Interventions.

OBJECTIVE: To quantify disparities in accessibility and availability of pediatric primary care by modeling interventions across multiple states that compare publicly insured versus privately insured children, and urban versus rural communities. DATA SOURCES: Secondary data sources include 2013 National Plan and Provider Enumeration System, 2009 MAX Medicaid claims, 2012 American Community Survey. STUDY DESIGN: The study models accessibility and availability of care for all children in seven states. METHODS: Optimization modeling with access constraints is used to estimate access. Statistical hypothesis testing is used to quantify systematic disparities. PRINCIPAL FINDINGS: California has the best accessibility for privately insured children and Minnesota for publicly insured children. Mississippi has the lowest availability for both populations. Overall, the disparities in availability for pediatric primary care are not as significant as in accessibility. Both rural and urban communities are in need of improvement in accessibility to primary care for publicly insured children, although at varying levels across states. CONCLUSIONS: Disparities in availability are not as significant as disparities in accessibility. Opportunities to improve access to pediatric primary care vary by state. Generating specific recommendations for small areas is critical to enabling health policy decision makers to improvement access.

Estimating Demand for and Supply of Pediatric Preventive Dental Care for Children and Identifying Dental Care Shortage Areas, Georgia, 2015.

OBJECTIVES: Demand for dental care is expected to outpace supply through 2025. The objectives of this study were to determine the extent of pediatric dental care shortages in Georgia and to develop a general method for estimation that can be applied to other states. METHODS: We estimated supply and demand for pediatric preventive dental care for the 159 counties in Georgia in 2015. We compared pediatric preventive dental care shortage areas (where demand exceeded twice the supply) designated by our methods with dental health professional shortage areas designated by the Health Resources & Services Administration. We estimated caries risk from a multivariate analysis of National Health and Nutrition Examination Survey data and national census data. We estimated county-level demand based on the time needed to perform preventive dental care services and the proportion of time that dentists spend on pediatric preventive dental care services from the Medical Expenditure Panel Survey. RESULTS: Pediatric preventive dental care supply exceeded demand in Georgia in 75 counties: the average annual county-level pediatric preventive dental care demand was 16 866 hours, and the supply was 32 969 hours. We identified 41 counties as pediatric dental care shortage areas, 14 of which had not been designated by the Health Resources & Services Administration. CONCLUSIONS: Age- and service-specific information on dental care shortage areas could result in more efficient provider staffing and geographic targeting.

Projecting the Impact of the Affordable Care Act Provisions on Accessibility and Availability of Primary Care Providers for the Adult Population in Georgia.

OBJECTIVES: To evaluate how met need for accessibility and availability of primary care among nonelderly individuals in Georgia will be affected by the Patient Protection and Affordable Care Act (ACA) over the next 10 years. METHODS: We used a stock-and-flow model to predict the number of available visits from 2013 to 2025, regression models to project needed visits, and an optimization model to estimate met need. The outputs of these models were used to estimate unmet need and the availability and accessibility of primary care. RESULTS: Our findings showed that the number of primary care providers will increase by 9.2% to 11.7% by 2025 and that the number of needed visits will increase by 20%. Under Medicaid expansion, the percentage of met need will increase from 67% to 80%. Accessibility will improve by 20% under expansion, and availability will decrease by 13% to 19% under expansion. CONCLUSIONS: The ACAs' provisions will reduce unmet need and positively affect accessibility while reducing availability in some communities. Increased need because of a larger Medicaid population under Medicaid expansion will not be a significant burden on the privately insured population.