Rethinking the Digital Divide: Using an Internet Survey in a Flint Water Crisis Medicaid Population.

This project examined the preferred mode of response (internet, phone, mail) to a health services survey. Data were collected via survey responses from a subsample of Flint Water Crisis Medicaid Expansion Waiver enrollees (N=2,584). Analyses were stratified by age, residency, race, and income. Chi-square tests were used to detect categorical differences. The majority of participants responded by internet (55.5%), followed by mail (39.4%), and phone (5.2%). Of those responding by internet, 75% used smartphones for connectivity. Black and White respondents used the internet at a greater rate than Hispanic respondents (p<.01). Respondents at 200% federal poverty level (FPL) or higher used the internet mode at greater rates than those below 200% FPL (p<.01). Our findings suggest greater internet use in a vulnerable population than expected, but the digital divide persists. In the advent of COVID-19, this finding can inform future health programming using digital communication and telehealth.

New Composite Measure for ADL Limitations: Application to Predicting Nursing Home Placement for Michigan MI Choice Clients.

Functional status measured by activities of daily living (ADL) may be used to predict nursing home placement. Scoring of ADL measures is summarized for convenience, yet this is accompanied by losing detail regarding deficits. We sought to determine whether a revised composite measure tailored to Michigan Medicaid beneficiaries would better identify those at risk for nursing home admission. We compared composite ADL measures created by exploratory factor analysis and additive modeling to Medicaid Enrollment, MI Choice Waiver program, and Nursing Facility claims data from 2013 to 2017. There were moderate to high levels of correlation between ADLs (.4-.82). Exploratory factor analysis extracted two factors, corresponding to domains of mobility or self-care tasks. Application of the self-care-based ADL limitations composite measure provided prediction power equivalent to an additive measure incorporating all ADL limitations for nursing home admission. This approach demonstrated improved interpretability with the need for just five measures.

Meaningful Use: Does Physician Participation Move the Needle on Quality Metrics?

INTRODUCTION: To determine the association between pattern of participation in the Meaningful Use (MU) initiative and self-reported clinical quality metrics. METHODS: We used state-level Medicaid electronic health record (EHR) incentive program data to categorize physicians based on receipt of MU payments (single year vs. multiple years) and self-reported quality metrics from 2011 to 2016. RESULTS: Among 4,198 participating physicians, only 36% received more than one EHR incentive payment. Physicians participating for a single year had better cancer-screening metrics. By comparison, physicians who participated for multiple years reported better medication-related metrics and chronic disease management metrics. CONCLUSIONS: Nature of participation may have varying degrees of influence on types of clinical quality metrics. Sustained participation may support management of chronic conditions. Administrative claims data will help to elucidate our findings.

Factors Associated With Medical School Entrants' Interest in Military Financial Assistance in Exchange for a Service Obligation: The Michigan State University College of Human Medicine Cohort.

INTRODUCTION: The U.S. military offers comprehensive scholarships to medical students to help offset costs in exchange for either reserve or active duty service commitments. Our goal was to describe to what degree newly admitted students to Michigan State University's College of Human Medicine were aware of and interested in these opportunities. MATERIALS AND METHODS: We surveyed 176 newly admitted students at the beginning and immediately following a presentation on military medicine opportunities. We collected anonymous paper surveys from program attendees and entered the data into Stata v13.1. The project was submitted for institutional review board review and deemed to not involve human subjects. Tests of association were performed using Chi-square test of independence and Fisher's exact test where needed. RESULTS: Our cohort was 49% female, 51% male, and over 90% were less than 30 years of age. Only 14% reported having family involved in the military. Our results indicated that over 90% of students were aware of these programs but less than 3% took advantage of the offerings. Despite 65% reporting somewhat or significant concerns over debt, financial concerns were not statistically associated with scholarship interest level. Instead, having a family member in the military was the most significant positive predictor of interest (47% compared with 17%, p < 0.01). Among those expressing disinterest, 66% cited apprehension over control of their lives as their primary concern. CONCLUSION: Recruiters may wish to emphasize benefits of military service aside from financial support. Career vignettes and summaries may offer better insight into the service experience for those lacking familiarity thereby potentially increasing interest and applications. Focus groups with current scholarship awardees may inform recruitment strategies.

Predicting long-term nursing home transfer from MI choice waiver program.

This study aimed to identify characteristics of elderly participants in the Michigan Home and Community-Based Waiver Program that are associated with high risk of long-term nursing home (LT-NH) placement. We identified 8172 waiver clients aged 65 and older during 10/1/2010-9/30/2014. A proportional cause-specific hazards regression model was used to analyze risk factors of waiver elderly for LT-NH placement. Waiver elderly participants who were white (HR (white vs. black): 2.76, with 95% CI (1.91, 4.00); HR (white vs. other races): 1.77, with 95% CI (1.05, 2.97)), had a history of long-term care use (HR: 1.42, 95% CI (1.14, 1.76)), mental disorders (HR: 1.51, 95% CI (1.23, 1.86)), bathing dependency (HR: 1.43, 95% CI (1.07, 1.89)), and finance management dependency (HR: 1.73, 95% CI (1.15, 2.60)) had greater hazards of LT-NH placement. Our study can be useful for policy makers to develop relevant support to reduce LT-NH placement.

Work task disability in employed breast and prostate cancer patients.

INTRODUCTION: Nearly 60% of cancer survivors are of working age, making inquiries into work-related disabilities particularly relevant. This paper describes work-related physical and cognitive disability estimates 12 and 18 months after diagnosis and treatment in a sample of employed breast and prostate cancer patients. METHODS: We recruited employed, newly diagnosed patients (n=447 breast, n=267 prostate) from the Metropolitan Detroit Cancer Surveillance System for telephone interviews 12 and 18 months after diagnosis. We defined disability by work task activity limitation. Disability estimates and employment were compared using Pearson chi-square tests. Duration of hours worked was compared by disability status using t-tests. RESULTS: Approximately 60% of women reported physical disability at 12 months which decreased to 36% at 18 months. Cognitive disability was reported by 34% and 22% of women at 12 and 18 months, respectively. Fewer men reported physical disability, only 29% at 12 months, decreasing to 17% at 18 months. Cognitive disability was reported by 12% and 7% of men at 12 and 18 months, respectively. More individuals with disability left the workforce at each timeframe than those without disability. CONCLUSIONS: A significant proportion of breast and prostate cancer patients experienced work-related disabilities 1 year or more following treatment. Physical disability was more problematic than cognitive disability.

Breast and prostate cancer patient's reliability of treatment reporting.

PURPOSE: To compare patient reported cancer treatments with data obtained by trained abstractors in the Metropolitan Detroit Cancer Surveillance System (MDCSS) to assess the reliability of patient interviews as a source for cancer treatments. METHODS: Patients (n=492 breast patients and n=291 prostate patients) were identified from the MDCSS and interviewed approximately 6 months after initial diagnosis for receipt of cancer treatment. Kappa statistics compared agreement between patient's report of their treatments and the MDCSS. RESULTS: Breast cancer patients had moderate levels of agreement regarding receipt of chemotherapy and radiation and excellent agreement for surgery. In contrast, prostate cancer patients and registry reports achieved excellent concordance for radiation therapy, very good agreement for surgery, and moderate levels of agreement for hormone therapy. Sensitivity of chemotherapy, surgery, and radiation reporting exceeded 90% for both patient cohorts. Overall, patients reported more treatment than was recorded i n M DCSS. CONCLUSION: Patients can be reliabledata sources for medical information pertaining to cancer therapies, although recall may vary by treatment type and time since treatment. Protocols involving patient interviews may wish to consider these encounters as timely, reliable data source options.

Absenteeism from work: the experience of employed breast and prostate cancer patients in the months following diagnosis.

BACKGROUND: A better understanding of how cancer treatments affect patient's employment may help patients and physicians make more informed choices between treatment alternatives. This study examined the number of days employed patients undergoing treatment for either breast or prostate cancer were absent from their jobs. METHOD: Using the Detroit Surveillance, Epidemiology, End-Results registry, all potentially eligible women diagnosed with breast cancer and men diagnosed with prostate cancer were selected. Subjects who were employed full-time were included in this analysis. RESULTS: Women treated for breast cancer missed an average of 44.5 days from work; the median days missed was 22. The median days missed by women treated with surgery and chemotherapy was 40. Men diagnosed with prostate cancer missed an average of 27 days (median days = 20) from work. The median days missed for men treated surgically without hormone or radiation therapy was 25. In multivariable analyses, taking a leave of absence and greater elapsed time from diagnosis to interview were associated with the greatest number of days absent from work for all patients. Men treated with hormone and/or radiation therapy or who were not treated missed fewer days from work relative to men undergoing surgery. CONCLUSION: Research and interventions are needed to minimize work loss for cancer patients. Vocational rehabilitation programs may minimize the impact of treatment on work. Information on how treatments may infringe the ability for patients to earn a living may influence treatment decisions.

Rapid assessment of the needs and health status in Santa Rosa and Escambia counties, Florida, after Hurricane Ivan, September 2004.

BACKGROUND: Hurricane Ivan, a Category 3 storm, devastated the Florida panhandle on September 16, 2004, causing extensive property damage and 24 deaths. The Florida Department of Health requested assistance from the Centers for Disease Control and Prevention to conduct a rapid assessment in Santa Rosa and Escambia counties to determine the health impact of the hurricane and needs of the affected population. METHODS: A questionnaire was administered 6 days after the hurricane made landfall. The survey instrument elicited information about house damage, illness/injury, and access to utilities. A modified cluster sampling method was used to select 30 clusters in each county. Seven households were interviewed in each cluster and reported weighted frequencies. RESULTS: Three quarters of houses in each county were damaged. Households in Santa Rosa and Escambia lacked basic utilities, including regular garbage pick-up, telephone service, and electricity. Fifty-four percent of households in Santa Rosa and 27% in Escambia reported using a generator. The most commonly self-reported health conditions were sleep disturbances in Santa Rosa (54%) and upper respiratory problems in Escambia (46%). Injuries were reported in fewer than 15% of households in each county. CONCLUSION: Rapid restoration of power, telephone services, and debris pick-up remained a priority 1 week after the event. Findings demonstrated the need for (1) mental health and primary care services, (2) information about safe generator use, and (3) ways to access medical care and medications.

Impact of Hurricane Ivan on pharmacies in Baldwin County, Alabama.

OBJECTIVE: To evaluate the impact of Hurricane Ivan, which made landfall east of Mobile, Alabama, on September 16, 2004, on pharmacies in the affected areas. DESIGN: Retrospective cross-sectional analysis. SETTING: Baldwin County, Alabama. INTERVENTIONS: Pharmacy community rapid-needs-assessment survey. PARTICIPANTS: 41 hospital and community (chain and independent) pharmacies. MAIN OUTCOME MEASURES: Posthurricane pharmacy hours of operations, prescription volumes, infrastructure damage, and prehurricane disaster planning. RESULTS: During the week of the hurricane, both chain and independent community pharmacies within the evacuation zone worked significantly fewer hours (46% and 49%, respectively) and dispensed significantly fewer prescriptions (37% and 52%) compared with the same week of the prior year. Overall, 40% of pharmacies depleted their supplies of certain medications (e.g., anxiolytics, antihypertensives). A total of 60% of the chain and independent pharmacies outside the evacuation zone closed because of loss of electricity, but pharmacies with a generator were significantly less likely to report having turned away patients. The proportion of pharmacies that had a disaster plan but turned away patients or rationed or ran out of medications was similar to that of pharmacies without a disaster plan. CONCLUSION: Although Hurricane Ivan primarily affected the operation of pharmacies within the evacuation zone, pharmacies in the surrounding area were also affected because of loss of power. Emergency management officials should evaluate the efficacy of specific guidelines outlined in disaster plans and identify ways to deliver essential medications to people in disaster-affected areas.

Combining registry, primary, and secondary data sources to identify the impact of cancer on labor market outcomes.

Some cancers are rapidly becoming chronic conditions that are more and more often diagnosed in working-age individuals. The authors developed a research agenda to study the labor market outcomes attributable to detection and treatment for cancer, and research design and data collection strategies to improve upon other research on these questions. In this article, they describe their approach to combining secondary data sources, primary data collection, and cancer registry data to evaluate the impact cancer has on labor market outcomes such as employment, hours worked, wages, and health insurance. They then critically assess how well their study design and data collection strategy accomplished its objectives. The intention is to offer guidance on how researchers, who are interested in the economic consequences of cancer, as well as of other chronic conditions, might develop and execute studies that examine labor market outcomes. As more attention is placed on the economic aspects of disease, the methods used to estimate productivity loss and other economic outcomes attributable to these conditions require careful scrutiny so that reliable findings can be used to shape health care decisions and policy.

Increasing generic prescribing: a resident educational intervention.

BACKGROUND AND OBJECTIVES: Future physicians are urged to balance effectiveness and cost in their prescribing of medications. This study determined whether educational sessions for residents together with a "Resident Report Card" changed residents' prescribing of generic medications in both commercial and Medicaid patient panels, compared with regional performance of physicians in practice in the community. METHODS: Twenty-four family medicine residents providing care for 1,038 (600 Medicaid and 438 commercial) members (or 31,140 total member months) received biannual profiles of their prescribing patterns and participated in four training sessions related to prescription profiling within a regional health plan. We monitored prescribing during two time periods and compared rates of generic prescribing to a baseline rate. RESULTS: Resident generic prescribing increased significantly for commercial members, from a base period (July 1, 2000-June 30, 2001) rate of 38.4% to a period 1 (July 1, 2001-June 30, 2002) rate of 38.0% and a period 2 (July 1, 2002-December 31, 2002) rate of 47.9%. It also increased for Medicaid members, from a base period rate of 47.8% to a period 1 rate of 49.1% and a period 2 rate of 52.6%. There was no similar change in regional prescribing performance during the same periods for physicians in practice in the community. CONCLUSIONS: Feedback systems and training based on actual health plan data can be developed for residency training on prescribing performance, resulting in improved cost-efficient prescribing patterns.