Characteristics and co-morbidities associated with hospital discharges for opioid and methamphetamine co-use, United States 2016-2019.

Introduction: The US overdose crisis is increasingly characterized by opioid and methamphetamine co-use. Hospitalization is an important opportunity to engage patients in substance use treatment. Understanding characteristics of co-use-related hospital stays can inform the development of services to better support this growing patient population. Methods: We used 2016-2019 National Inpatient Sample data to conduct a cross sectional analysis of hospitalizations involving use of opioids, methamphetamine, or both. We used bivariate analysis to compare patient demographics. We then used multinomial logistic regressions to compare the proportion of hospital stays which indicated co-morbid diagnosis. To account for correlated data, we used generalized linear models to compare outcomes in hospital mortality, patient-directed discharge, and length of stay. Results: Co-use-related stays had a higher proportion of co-morbid mental health (60.7%; 95% CI: 59.9-61.4%) and infectious diseases (41.5%; 95% CI: 40.8-42.2%), than opioid- or methamphetamine-related stays. Co-use-related stays increased between 2016 and 2019 and were associated with a higher proportion of patient directed discharge (10.7%; 95% CI: 10.4-11.0%) and longer length of stay (6.3 days; 95% CI: 6.2-6.4 days) compared to opioid (8.1%; 95% CI: 7.9-8.3% and 5.8 days; 95% CI: 5.8-5.9 days) and methamphetamine-related stays (6.5%; 95% CI: 6.3-6.6% and 5.5 days; 95% CI: 5.4-5.5 days). Conclusion: Patients discharged with co-use differ from patients with opioid or methamphetamine use alone, representing a range of challenges and opportunities. In addition to offering treatment for both substance use disorders, hospital-based services that address co-occurring conditions may better support patients with co-use through targeted and tailored approaches.

Providers' Experiences and Perspectives in Treating Patients With Co-Occurring Opioid and Stimulant Use Disorders in the Hospital.

BACKGROUND: The overdose crisis is increasingly characterized by opioid and stimulant co-use. Despite effective pharmacologic treatment for both opioid use disorder (OUD) and contingency management for stimulant use disorders, most individuals with these co-occurring conditions are not engaged in treatment. Hospitalization is an important opportunity to engage patients and initiate treatment, however existing hospital addiction care is not tailored for patients with co-use and may not meet the needs of this population. METHODS: Semi-structured interviews were conducted with hospital providers about their experiences and perspectives treating patients with opioid and stimulant co-use. We used directed content analysis to identify common experiences and opportunities to improve hospital-based treatment for patients with co-use. RESULTS: From qualitative interviews with 20 providers, we identified 4 themes describing how co-use complicated hospital-based substance use treatment: (1) patients' unstable circumstances impacting the treatment plan, (2) co-occurring withdrawals are difficult to identify and treat, (3) providers holding more stigmatizing views of patients with co-use, and (4) stimulant use is often "ignored" in the treatment plans. Participants also described a range of potential opportunities to improve hospital-based treatment of co-use that fall into 3 categories: (1) provider practice changes, (2) healthcare system changes, and (3) development and validation of clinical tools and treatment approaches. CONCLUSIONS: We identified unique challenges providing hospital addiction medicine care to patients who use both opioids and stimulants. These findings inform the development, implementation, and testing of hospital-based interventions for patients with co-use.

Development and use of a novel tool for assessing and improving researcher embeddedness in learning health systems and applied system improvements.

This paper outlines the development, deployment and use, and testing of a tool for measuring and improving healthcare researcher embeddedness - i.e., being connected to and engaged with key leverage points and stakeholders in a health system. Despite the widely acknowledged importance of embeddedness for learning health systems and late-stage translational research, we were not aware of useful tools for addressing and improving embeddedness in scholar training programs. We developed the MN-LHS Embeddedness Tool covering connections to committees, working groups, leadership, and other points of contact across four domains: patients and caregivers; local practice (e.g., operations and workflows); local institutional research (e.g., research committees and agenda- or initiative-setting groups); and national (strategic connections within professional groups, conferences, etc.). We used qualitative patterns and narrative findings from 11 learning health system training program scholars to explore variation in scholar trajectories and the embeddedness tool's usefulness in scholar professional development. Tool characteristics showed moderate evidence of construct validity; secondarily, we found significant differences in embeddedness, as a score, from baseline through program completion. The tool has demonstrated simple, practical utility in making embeddedness an explicit (rather than hidden) part of applied and learning health system researcher training, alongside emerging evidence for validity.

A longitudinal cross-sectional analysis of substance use treatment trends for individuals experiencing homelessness, criminal justice involvement, both, or neither - United States, 2006-2018.

Background: Individuals experiencing homelessness or criminal justice involvement (CJI) have higher rates of substance use than the general public. Despite documented barriers to accessing treatment, few studies have compared substance use treatment patterns between these groups. Methods: This paper uses data from the Treatment Episode Dataset-Admissions between 2006 to 2018 to describe characteristics and trends in substance use treatment admissions indicating homelessness (n=2,524,413), CJI (4,764,750), both (509,902), or neither (8,950,797) in the United States. We used multivariable logistic regression to examine trends independent of demographic differences between groups. Findings: Between 2006 and 2018, the proportion of treatment admissions related to heroin increased across all groups. Methamphetamine-related admissions rose substantially for individuals experiencing homelessness, CJI, or both. By 2018, 27·8% (95% CI: 27·4-28·2%) of admissions for individuals experiencing both were methamphetamine-related and 16·7% (95% CI: 16·3-17·0%) were heroin-related. Conversely, among individuals experiencing neither, 7·5% (95% CI: 7·4-7·5%) of admissions were methamphetamine-related and 33·6% (95% CI: 33·4-33·7%) were heroin-related. Individuals experiencing both homelessness and CJI received lower rates of medications for opioid use disorder (OUD) (8·3%; 95% CI: 8·2-8·3%) compared to individuals experiencing neither (36·4%; 95% CI: 36·4-36·4%). Interpretation: Community treatment facilities should be supported to provide medications for OUD and accommodate rising rates of methamphetamine and polysubstance-related treatment admissions in populations experiencing complex social drivers of health such as homelessness, CJI, or both. Funding: National Institute of General Medical Sciences and National Institute of Diabetes and Digestive and Kidney Diseases.

Direct Oral Anticoagulants and Warfarin for Atrial Fibrillation Treatment: Rural and Urban Trends in Medicare Beneficiaries.

BACKGROUND: Data are needed on the use of oral anticoagulation in patients with atrial fibrillation (AF) in rural versus urban areas, including the initiation of direct oral anticoagulants (DOACs). OBJECTIVE: We used Medicare data to examine rural/urban differences in anticoagulation use in patients with AF. METHODS: We identified incident AF in a 20% sample of fee-for-service Medicare beneficiaries (aged ≥ 65 years) from 2011 to 2016 and collected ZIP code and covariates at the time of AF. We identified the first anticoagulant prescription filled, if any, following AF diagnosis. We categorized beneficiaries into four rural/urban areas using rural-urban commuting area codes and used Poisson regression models to compare anticoagulant use. RESULTS: We included 447,252 patients with AF (mean age 79 ± 8 years), of which 82% were urban, 9% large rural, 5% small rural, and 4% isolated. The percentage who initiated an anticoagulant rose from 34% in 2011 to 53% in 2016, paralleling the uptake of DOACs. In a multivariable-adjusted analysis, those in rural areas (vs. urban) were more likely to initiate an anticoagulant. However, rural beneficiaries (vs. urban) were less likely to initiate a DOAC; those in isolated areas were 17% less likely (95% confidence interval [CI] 13-20), those in small rural areas were 12% less likely (95% CI 9-15), and those in large rural areas were 10% less likely (95% CI 8-12). CONCLUSION: Among Medicare beneficiaries with AF, anticoagulation use was low but increased over time with the introduction of DOACs. Rural beneficiaries were less likely to receive a DOAC.

Trends in fall-related encounters and predictors of non-transport at a US Emergency Medical Services Agency.

Non-transport to a hospital after emergency medical services (EMS) encounters for falls is common. However, incident factors associated with non-transport have not been well studied, especially beyond older adults. The objectives of this study are to (1) describe trends in fall-related EMS utilisation among adult patients from 2010 to 2018; (2) describe incident characteristics by age; and (3) identify incident factors associated with non-transport following a fall. This retrospective observational study includes prehospital clinical records data on falls from a large ambulance service in Minnesota, USA. Multivariable logistic regression was used to assess the independent association between non-transport and the following factors: sex, age, race, previous fall-related EMS encounter, incident location and primary impression. Of 62,835 fall-related encounters studied, 14.7% (9,245) did not result in transport by EMS. Fall calls were less common among younger people and the location and medical conditions primarily treated by an EMS provider during a 9-1-1 call differed greatly from those occurring among patients 65 and older. Factors most strongly associated with an increased risk of non-transport in the multivariable model were a primary impression of 'No apparent illness/injury' (OR = 34.5, 95% CI = 30.7-38.7), falling in a public location (OR = 2.09, CI = 1.96-2.22) and having had a fall-related EMS encounter during the prior year (OR = 1.15, CI = 1.1-1.2). Falls that occur in public locations, in patients with a previous fall, or result in no clinical detection of apparent illness or injury have a significantly increased odds of non-transport. Non-transport fall incidents in the United States require significant agency resources. Knowledge about the incident factors associated with non-transport calls is informative for development of alternative models for prehospital care delivery and initiatives to better serve patients.

Proteomics and Risk of Atrial Fibrillation in Older Adults (From the Atherosclerosis Risk in Communities [ARIC] Study).

Plasma proteomic profiling may aid in the discovery of novel biomarkers upstream of the development of atrial fibrillation (AF). We used data from the Atherosclerosis Risk in Communities study to examine the relation between large-scale proteomics and incident AF in a cohort of older-aged adults in the United States. We quantified 4,877 plasma proteins in Atherosclerosis Risk in Communities participants at visit 5 (2011-2013) using an aptamer-based proteomic profiling platform. We used Cox proportional hazards models to assess the association between protein levels and incident AF, and explored relation of selected protein biomarkers using annotated pathway analysis. Our study included 4,668 AF-free participants (mean age 75 ± 5 years; 59% female; 20% Black race) with proteomic measures. A total of 585 participants developed AF over a mean follow-up of 5.7 ± 1.7 years. After adjustment for clinical factors associated with AF, N-terminal pro-B-type natriuretic peptide (NT-proBNP) was associated with the risk of incident AF (hazard ratio, 1.82; 95% CI, 1.68 to 1.98; p, 2.91 × 10-45 per doubling of NT-proBNP). In addition, 36 other proteins were also significantly associated with incident AF after Bonferroni correction. We further adjusted for medication use and estimated glomerular filtration rate and found 17 proteins, including angiopoietin-2 and transgelin, that remained significantly associated with incident AF. Pathway analyses implicated the inhibition of matrix metalloproteases as the top canonical pathway in AF pathogenesis. In conclusion, using a large-scale proteomic platform, we identified both novel and established proteins associated with incident AF and explored mechanistic pathways of AF development.

Implementation of an Anticoagulation Practice Guideline for COVID-19 via a Clinical Decision Support System in a Large Academic Health System and Its Evaluation: Observational Study.

BACKGROUND: Studies evaluating strategies for the rapid development, implementation, and evaluation of clinical decision support (CDS) systems supporting guidelines for diseases with a poor knowledge base, such as COVID-19, are limited. OBJECTIVE: We developed an anticoagulation clinical practice guideline (CPG) for COVID-19, which was delivered and scaled via CDS across a 12-hospital Midwest health care system. This study represents a preplanned 6-month postimplementation evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. METHODS: The implementation outcomes evaluated were reach, adoption, implementation, and maintenance. To evaluate effectiveness, the association of CPG adherence on hospital admission with clinical outcomes was assessed via multivariable logistic regression and nearest neighbor propensity score matching. A time-to-event analysis was conducted. Sensitivity analyses were also conducted to evaluate the competing risk of death prior to intensive care unit (ICU) admission. The models were risk adjusted to account for age, gender, race/ethnicity, non-English speaking status, area deprivation index, month of admission, remdesivir treatment, tocilizumab treatment, steroid treatment, BMI, Elixhauser comorbidity index, oxygen saturation/fraction of inspired oxygen ratio, systolic blood pressure, respiratory rate, treating hospital, and source of admission. A preplanned subgroup analysis was also conducted in patients who had laboratory values (D-dimer, C-reactive protein, creatinine, and absolute neutrophil to absolute lymphocyte ratio) present. The primary effectiveness endpoint was the need for ICU admission within 48 hours of hospital admission. RESULTS: A total of 2503 patients were included in this study. CDS reach approached 95% during implementation. Adherence achieved a peak of 72% during implementation. Variation was noted in adoption across sites and nursing units. Adoption was the highest at hospitals that were specifically transformed to only provide care to patients with COVID-19 (COVID-19 cohorted hospitals; 74%-82%) and the lowest in academic settings (47%-55%). CPG delivery via the CDS system was associated with improved adherence (odds ratio [OR] 1.43, 95% CI 1.2-1.7; P<.001). Adherence with the anticoagulation CPG was associated with a significant reduction in the need for ICU admission within 48 hours (OR 0.39, 95% CI 0.30-0.51; P<.001) on multivariable logistic regression analysis. Similar findings were noted following 1:1 propensity score matching for patients who received adherent versus nonadherent care (21.5% vs 34.3% incidence of ICU admission within 48 hours; log-rank test P<.001). CONCLUSIONS: Our institutional experience demonstrated that adherence with the institutional CPG delivered via the CDS system resulted in improved clinical outcomes for patients with COVID-19. CDS systems are an effective means to rapidly scale a CPG across a heterogeneous health care system. Further research is needed to investigate factors associated with adherence at low and high adopting sites and nursing units.

Characterizing trends in methamphetamine-related health care use when there is no ICD code for "methamphetamine use disorder".

BACKGROUND AND AIMS: The recent surge in methamphetamine use highlights the need for timely data on its health effects and healthcare service use impact. However, there is no ICD code for methamphetamine use. This study quantifies the positive predictive value of ICD-9-CM and ICD-10-CM psychostimulant codes for methamphetamine use. METHODS: A retrospective chart review of 220 adults aged 18 and older who had an inpatient admission with a psychostimulant-associated billing diagnosis at an urban safety-net hospital. Diagnoses were categorized as either methamphetamine-related or involving another specific psychostimulant. The positive predictive value of both ICD-9-CM or ICD-10-CM psychostimulant diagnosis codes for methamphetamine use was calculated. RESULTS: ICD-9-CM and ICD-10-CM psychostimulant codes had high positive predictive values of 78.2% (95% CI 70.3%-86.0%) and 85.5% (95% CI 78.8%-92.1%), respectively, for methamphetamine use. The most common non-methamphetamine psychostimulant in our cohort was khat, a cathinone-containing plant native to East Africa, accounting for psychostimulant-related diagnosis in 16 of the 220 hospitalizations. CONCLUSIONS: The high predictive values of psychostimulant codes for methamphetamine use support the application of administrative data in measuring methamphetamine-related healthcare use, as well as co-morbid health conditions and treatment patterns.

The Learning Health System Competency Appraisal Inventory (LHS-CAI): A novel tool for assessing LHS-focused education needs.

There is increasing interest in health care organizations functioning as learning health systems (LHSs) to improve the quality and efficiency of health care delivery while generating new knowledge. Individuals must be trained in associated concepts and competencies and subsequently positioned (or embedded) within the delivery system for maximum effect as they perform their scholarship. Potential researchers within LHSs come from many different training backgrounds; therefore, each LHS scholar requires a goal-directed plan tailored to his or her needs. There are few tools available to guide development, training, or evaluation of individuals interested in becoming leaders of research in LHSs. In this paper, we present a newly developed tool for guiding the training of such researchers, the Learning Health Systems Competency Appraisal Inventory (LHS-CAI). The LHS-CAI is modeled after the Clinical Research Appraisal Index (CRAI) used within Clinical and Translational Science Award sites across the United States. The LHS-CAI is a tool for trainees at all levels to use with their mentors in an interactive manner. The tool can then identify areas in which more training is needed and at what level to ensure success as a researcher within LHSs. We further modified the CRAI format to better leverage the LHS-CAI as a key part of an LHS scholar's individual development plan. To implement the LHS-CAI, we have identified key points within the Minnesota Learning Health System Mentored Career Development Program (MN-LHS) at which assessment of expertise for each competency would be useful to LHS scholars, mentors, and program leaders. Scholars in this program come from various clinical and academic backgrounds but are all targeting their career trajectories toward leading embedded LHS research. They will reevaluate their expertise upon completion of the program, with comparison to baseline serving as a key program evaluation tool. The LHS-CAI is currently being implemented with the first cohort of scholars in the MN-LHS program.

Travel, Treatment Choice, and Survival Among Breast Cancer Patients: A Population-Based Analysis.

Background: Travel distance to care facilities may shape urban-rural cancer survival disparities by creating barriers to specific treatments. Guideline-supported treatment options for women with early stage breast cancer involves considerations of breast conservation and travel burden: Mastectomy requires travel for surgery, whereas breast-conserving surgery (BCS) with adjuvant radiation therapy (RT) requires travel for both surgery and RT. This provides a unique opportunity to evaluate the impact of travel distance on surgical decisions and receipt of guideline-concordant treatment. Materials and Methods: We included 61,169 women diagnosed with early stage breast cancer between 2004 and 2013 from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Driving distances to the nearest radiation facility were calculated by using Google Maps. We used multivariable regression to model treatment choice as a function of distance to radiation and Cox regression to model survival. Results: Women living farthest from radiation facilities (>50 miles vs. <10 miles) were more likely to undergo mastectomy versus BCS (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.22-1.79). Among only those who underwent BCS, women living farther from radiation facilities were less likely to receive guideline-concordant RT (OR: 1.72, 95% CI: 1.32-2.23). These guideline-discordant women had worse overall (hazards ratio [HR]: 1.50, 95% CI: 1.42-1.57) and breast-cancer specific survival (HR: 1.44, 95% CI: 1.29-1.60). Conclusions: We report two breast cancer treatments with different clinical and travel implications to show the association between travel distance, treatment decisions, and receipt of guideline-concordant treatment. Differential access to guideline-concordant treatment resulting from excess travel burden among rural patients may contribute to rural-urban survival disparities among cancer patients.

Experiences with Work and Participation in Public Programs by Low-Income Medicaid Enrollees Using Qualitative Interviews.

BACKGROUND: Centers for Medicare & Medicaid Services (CMS) began encouraging governors to implement work requirements for Medicaid enrollees using section 1115 waivers in 2018. Significant controversy surrounds such attempts, but we know little about the perceptions and experiences of enrollees. OBJECTIVE: To characterize experiences of work and its relationship to participation in Medicaid and other public programs among potential targets of Medicaid work requirements. DESIGN: In-depth, semi-structured, one-time qualitative interviews. PARTICIPANTS: 35 very low-income, non-disabled Medicaid expansion enrollees participating in a county-sponsored Medicaid managed care plan as a part of a larger study. APPROACH: We used a biographical narrative interpretive method during interviews including questions about the use of employment and income support and other public programs including from state and federal disability programs. Our team iteratively coded verbatim transcripts allowing for emergent themes. KEY RESULTS: Interview data revealed high motivation for, and broad participation in, formal and informal paid work. Eight themes emerged: (1) critical poverty (for example, "I'm not content, but what choices do I have?"); (2) behavioral and physical health barriers to work; (3) social barriers: unstable housing, low education, criminal justice involvement; (4) work, pride, and shame; (5) inflexible, unstable work (for example, "Can I have a job that will accommodate my doctor appointments?…Will my therapy have to suffer? You know? So it's a double edged sword."); (6) Medicaid supports the ability to work; (7) lack of transparency and misalignment of program eligibility (for example, "It's not like I don't want to work because I would like to work. It's just that I don't want to be homeless again, right?"); and (8) barriers, confusion, and contradictions about federal disability. CONCLUSIONS: We conclude that bipartisan solutions prioritizing the availability of well-paying jobs and planful transitions off of public programs would best serve very low-income, work-capable Medicaid enrollees.

Informing Medication Discontinuation Decisions among Older Adults with Relapsing-Onset Multiple Sclerosis.

BACKGROUND: For older adults with relapsing-onset multiple sclerosis (MS), limited information is available to inform if, or when, disease-modifying drugs (DMDs) may be safely discontinued. OBJECTIVE: The aim of this study was to project the outcomes of DMD discontinuation among older adults with relapsing-onset MS. METHODS: We projected the 10-year outcomes of discontinuation of a DMD (interferon-ß, fingolimod, or natalizumab) among older adults (aged 55 or 70 years) who were relapse-free for 5 or more years and had not reached an Expanded Disability Status Scale (EDSS) score of 6. Outcomes included the percentage of people who had at least one relapse or reached EDSS 6, and quality-adjusted life-years (QALYs), which incorporated both relapses and disability. We used a simulation modeling approach. With increased age, relapses decreased and the effectiveness of DMDs for disability outcomes also decreased. RESULTS: We found lower projected benefits for DMD continuation at 70 years of age than at 55 years of age. Compared with discontinuation, the projected benefit of DMD continuation ranged from 0.007 to 0.017 QALYs at 55 years of age and dropped to 0.002-0.006 at 70 years of age. The annual projected benefits of DMD continuation (0.1-3.0 quality-adjusted life-days) were very low compared with typical patient preferences regarding treatment burden. CONCLUSION: The benefits of DMDs may not be substantial among older adults with relapsing-onset MS. Direct clinical evidence remains limited and the decision of whether to discontinue a DMD should also take into account patient preferences. It is important to gain a better understanding of how age-related changes in the trajectory of relapsing-onset MS affect treatment effectiveness among older adults.

Development and Implementation of an Interdisciplinary Intensive Primary Care Clinic for High-Need High-Cost Patients in a Safety Net Hospital.

In 2010, payment for some of Hennepin County Medical Center's highest need patients changed from fee for service to a per capita formula. This financial stress led the institution to employ a population health lens that revealed a significant concentration of spending on a small segment of the population. Finding high rates of potentially avoidable inpatient and emergency care, an organizational effort was initiated to attempt to manage this high-need, high-cost population more effectively. A freestanding interdisciplinary intensive primary care clinic was developed. Nurses led a risk stratification process to identify eligible patients for co-located medical, care coordination, and social services from multidisciplinary care teams. Workflows to engage the population were designed to reduce readmissions and inappropriate use of emergency services. Soon after opening, the clinic added mental health and substance use professionals. For people entering the clinic between January 2010 and July 2017, utilization and financial data were collected for the year before (pre) and after (post) enrollment (n = 487). Bivariate statistics and outlier analyses facilitated comparisons between pre/post enrollment. Patients visited the new clinic twice per month on average and outpatient costs almost doubled. Overall costs were 16% lower, with the largest decrease seen in inpatient costs. This experience has led to ongoing investment, replication, and expansion of the model. An interdisciplinary intensive primary care clinic for high-utilizing, underserved patients is a promising intervention. Multidisciplinary teams and ongoing institutional support are critical to program success. Payment reform is essential to the development of such programs.

Age-related decreases in relapses among adults with relapsing-onset multiple sclerosis.

BACKGROUND: Relapsing-onset multiple sclerosis (MS) typically starts in early- to mid-adulthood, yet the trajectory of disease activity over the subsequent lifetime remains poorly defined. Previous studies have not quantified the age-specific portion of decreases in annualized relapse rates (ARR). OBJECTIVE: The aim of this article is to determine, under a range of disease-related assumptions, the age-specific component of decreases in ARR over time among adults with relapsing-onset MS. METHODS: We used a simulation modeling approach to examine a range of assumptions about changes in ARR due to age versus disability status. Scenarios included variations in initial ARR and rate of worsening on the Expanded Disability Status Scale. Model parameters were developed through analysis of MS patients in British Columbia, Canada, and literature review. RESULTS: We found a substantial age-specific decrease in ARR in all simulated scenarios, independent of disability worsening. Under a range of clinically plausible assumptions, 88%-97% of the decrease was attributed to age and 3%-13% to disability. The age-specific decrease ranged from 22% to 37% per 5 years for a wide range of initial ARR (0.33-1.0). CONCLUSION: Decreases in ARR were due mostly to age rather than disability status. To facilitate informed decision making in MS, it is important to quantify the dynamic relationship between relapses and age.

Evaluating Travel Distance to Radiation Facilities Among Rural and Urban Breast Cancer Patients in the Medicare Population.

PURPOSE: The distance patients travel for specialty care is an important barrier to health care access, particularly for those living in rural areas. This study characterizes the actual distance older breast cancer patients traveled to radiation treatment and the minimum distance necessary to reach radiation care, and examines whether any patient demographic or clinical factors are associated with greater travel distance. METHODS: We used data from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Our cohort included 52,317 women diagnosed with breast cancer between 2004 and 2013. Driving distances were calculated using Google Maps. We used generalized estimating equations to estimate associations between patient demographic and disease variables and travel distance. FINDINGS: Patients living in rural areas traveled on average nearly 3 times as far as those from urban areas (40.8 miles vs 15.4 miles), and their nearest facility was more than 4 times farther away (21.9 miles vs 4.8 miles). Older age, being single or widowed, and lower household income were significantly associated with shorter actual travel distance, while increasing rurality was significantly associated with greater actual and minimum travel distance to radiation treatment. Disease severity (stage, grade, etc) was not significantly associated with actual or minimum travel distance. CONCLUSIONS: In this insured population, travel distance to radiation facilities may pose a significant burden for breast cancer patients, particularly among those living in rural areas. Policymakers and patient advocates should explore service delivery models, reimbursement models, and social supports aimed at reducing the impact of travel to radiation treatment for breast cancer patients.

Changes in Quality of Life Among Enrollees in Hennepin Health: A Medicaid Expansion ACO.

Despite limited program evaluations of Medicaid accountable care organizations (ACOs), no studies have examined if cost-saving goals negatively affect quality of life and health care experiences of low-income enrollees. The Hennepin Health ACO uses an integrated care model to address the physical, behavioral, and social needs of Medicaid expansion enrollees. As part of a larger evaluation, we conducted semistructured interviews with 35 primary care using Hennepin Health members enrolled for 2 or more years. Using fuzzy set qualitative comparative analysis, we assessed enrollee complexity and use of the care model and improvements in quality of life. We found improved quality of life was consistently associated with strong bonds to primary care, consistent mental health care, and support from extended care team members. Comprehensive, integrated care models within ACOs may improve quality of life for low-income Medicaid enrollees through coordinated primary and mental health care.

Integrated, Accountable Care For Medicaid Expansion Enrollees: A Comparative Evaluation of Hennepin Health.

Hennepin Health, a Medicaid accountable care organization, began serving early expansion enrollees (very low-income childless adults) in 2012. It uses an integrated care model to address social and behavioral needs. We compared health care utilization in Hennepin Health with other Medicaid managed care in the same area from 2012 to 2014, controlling for demographics, chronic conditions, and enrollment patterns. Homelessness and substance use were higher in Hennepin Health. Overall adjusted results showed Hennepin Health had 52% more emergency department visits and 11% more primary care visits than comparators. Over time, modeling a 6-month exposure to Hennepin Health, emergency department and primary care visits decreased and dental visits increased; hospitalizations decreased nonsignificantly but increased among comparators. Subgroup analysis of high utilizers showed lower hospitalizations in Hennepin Health. Integrated, accountable care under Medicaid expansion showed some desirable trends and subgroup benefits, but overall did not reduce acute health care utilization versus other managed care.

Long-Term Effects of Age Discrimination on Mental Health: The Role of Perceived Financial Strain.

OBJECTIVES: This study examines the role of work-related perceived age discrimination on women's mental health over the life course and tests whether financial strain mediates this relationship. METHODS: Using the National Longitudinal Survey of Mature Women (1967-2003), we employ nested growth curve models to evaluate whether perceived age discrimination at work influences women's depressive symptoms and life satisfaction and whether perceived financial strain mediates this relationship. RESULTS: Women who experienced age discrimination had greater overall depressive symptoms but not after controlling for financial strain. We found evidence that age discrimination affected financial strain, which, in turn, increased women's depressive symptoms. Women who reported age discrimination had lower odds of being in higher categories of overall life satisfaction; financial strain partially mediated the relationship but age discrimination remained a significant predictor. DISCUSSION: Despite legal protection, age discrimination at work is frequent and has significant effects on women's mental health over the life course. Financial strain partially mediates this relationship, pointing to financial implications of perceived age discrimination for women and their families. Our findings have important policy and workplace implications, calling attention to ageism as a potent stressor for working women's mental health beyond those tied to sex or race.