Updated Bivalent COVID-19 Vaccines Reduce Risk of Hospitalization and Severe Outcomes in Adults: An Observational Cohort Study.

Background: This study evaluates the real-world effectiveness of updated bivalent coronavirus disease 2019 (COVID-19) vaccines in adults, as the virus evolves and the need for new vaccinations increases. Methods: In this observational, retrospective, multi-center, cohort analysis, we examined emergency care encounters with COVID-19 in metro Detroit, Michigan, from January 1, 2022, to March 9, 2023. Patients were categorized by vaccination status: unvaccinated, fully vaccinated, fully vaccinated and boosted (FV&B), or fully vaccinated and bivalent boosted (FV&BB). The primary outcome was to assess the impact of bivalent COVID-19 vaccinations on the risk of composite severe outcomes (intensive care unit (ICU) admission, mechanical ventilation, or death) among patients presenting to a hospital with a primary diagnosis of COVID-19. Results: A total of 21,439 encounters met inclusion criteria: 9,630 (44.9%) unvaccinated, 9,223 (43.0%) vaccinated, 2,180 (10.2%) FV&B, and 406 (1.9%) FV&BB. The average age was 48.8, with 59.6% female; 61.1% were White, 32.8% Black, and 6.0% other races. Severe disease affected 5.5% overall: 5.0% unvaccinated, 5.7% vaccinated, 7.0% FV&B, and 4.7% FV&BB (P = 0.001). Severe disease rates among admitted patients were 13.3% unvaccinated, 11.9% vaccinated, 12.2% boosted, and 8.1% FV&BB (P = 0.052). The FV&BB group showed a 4.0% (P = 0.0369) lower risk of severe disease compared to FV&B and a 5.1% (P = 0.0203) lower probability of hospitalization. Conclusions: As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to mutate and evolve, updated vaccines are necessary to better combat COVID-19. In a real-world hospital-based population, this investigation demonstrates the incremental benefit of the bivalent booster vaccine in reducing the risk of hospitalization and severe outcomes in those diagnosed with COVID-19 compared to all other forms of vaccination.

Nasopharyngeal rapid diagnostic testing to reduce unnecessary antibiotic use and individualize management of acute otitis media.

Background: Acute otitis media (AOM) is the most common indication for antibiotics in children. The associated organism can influence the likelihood of antibiotic benefit and optimal treatment. Nasopharyngeal polymerase chain reaction can effectively exclude the presence of organisms in middle-ear fluid. We explored the potential cost-effectiveness and reduction in antibiotics with nasopharyngeal rapid diagnostic testing (RDT) to direct AOM management. Methods: We developed 2 algorithms for AOM management based on nasopharyngeal bacterial otopathogens. The algorithms provide recommendations on prescribing strategy (ie, immediate, delayed, or observation) and antimicrobial agent. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed as cost per quality-adjusted life day (QALD) gained. We used a decision-analytic model to evaluate the cost-effectiveness of the RDT algorithms compared to usual care from a societal perspective and the potential reduction in annual antibiotics used. Results: An RDT algorithm that used immediate prescribing, delayed prescribing, and observation based on pathogen (RDT-DP) had an ICER of $1,336.15 per QALD compared with usual care. At an RDT cost of $278.56, the ICER for RDT-DP exceeded the willingness to pay threshold; however, if the RDT cost was <$212.10, the ICER was below the threshold. The use of RDT was estimated to reduced annual antibiotic use, including broad-spectrum antimicrobial use, by 55.7% ($4.7 million for RDT vs $10.5 million for usual care). Conclusion: The use of a nasopharyngeal RDT for AOM could be cost-effective and substantially reduce unnecessary antibiotic use. These iterative algorithms could be modified to guide management of AOM as pathogen epidemiology and resistance evolve.

Total cost of care associated with opioid use disorder treatment.

The opioid epidemic in the United States disproportionately affects Medicaid beneficiaries than other groups. This results in a significant financial burden on state Medicaid programs. In this analysis, we investigate the association of medication for opioid use disorder (MOUD) treatment initiation and linkage to ongoing care on overall healthcare costs of Medicaid Fee-for-Service patients. We conducted a retrospective study among adult patients diagnosed with opioid use disorder (OUD) and who had a clinical encounter at a safety-net institution in Denver Colorado in 2020. Three categories of MOUD status of patients were defined: 1) identified with OUD but did not receive MOUD; 2) initiated MOUD but not linked to ongoing treatment and 3) received MOUD and linked to ongoing treatment. Our outcome variable was per-member per-month total healthcare cost. We estimated a multivariable model to test the association between healthcare cost and MOUD status, while controlling for demographic and risk classification variables. We found that in individuals with OUD who initiated MOUD treatment but were not linked to ongoing care had the highest healthcare cost, while those who were linked to ongoing MOUD treatment had the lowest healthcare cost. MOUD treatment is not only effective at addressing the significant morbidity and mortality burden of OUD but also associated with decreased financial cost, which is disproportionately incurred by Medicaid. Additional policy and care delivery changes are needed to focus efforts to improve linkage to ongoing treatment.

Missed appointments during COVID-19: The impact of telehealth for persons experiencing homelessness with substance use disorders.

We examined the impact of telehealth on appointment retention among individuals with substance use disorder (SUD) by housing status. We evaluated appointment status using multivariate logistic regression with primary predictor variables of visit modality, patient's housing status and interaction between these two variables. Between March 1 and September 30, 2020, there were 18,206 encounters among 1,626 clients with SUD. For telehealth encounters, the probability of an appointment no-show was significantly higher for persons experiencing homelessness compared to stably housed (37% versus 25%, p < 0.001). Housing status influences the effectiveness of telehealth as a modality of healthcare delivery for individuals with SUD.

Associations Between Midlife Functional Limitations and Self-Reported Health and Cognitive Status: Results from the 1998-2016 Health and Retirement Study.

BACKGROUND: Life-course approaches to identify and help improve modifiable risk factors, particularly in midlife, may mitigate cognitive aging. OBJECTIVE: We examined how midlife self-rated physical functioning and health may predict cognitive health in older age. METHODS: We used data from the Health and Retirement Study (1998-2016; unweighted-N = 4,685). We used survey multinomial logistic regression and latent growth curve models to examine how midlife (age 50-64 years) activities of daily living (ADL), physical function, and self-reported health affect cognitive trajectories and cognitive impairment not dementia (CIND) and dementia status 18 years later. Then, we tested for sex and racial/ethnic modifications. RESULTS: After covariates-adjustment, worse instrumental ADL (IADL) functioning, mobility, and self-reported health were associated with both CIND and dementia. Hispanics were more likely to meet criteria for dementia than non-Hispanic Whites given increasing IADL impairment. CONCLUSION: Midlife health, activities limitations, and difficulties with mobility are predictive of dementia in later life. Hispanics may be more susceptible to dementia in the presence of midlife IADLs. Assessing midlife physical function and general health with brief questionnaires may be useful for predicting cognitive impairment and dementia in later life.

Gains in insurance coverage following the affordable care act and change in preventive services use among non-elderly US immigrants.

Immigrants have lower and disproportionate use of preventive care. We use longitudinal panel data to examine how the 2014 full implementation of the ACA mandates affected change in preventive services (PS) use among immigrants that gained insurance. We used data on Foreign-Born (FB) and US-Born (USB) adults, ages 26-64 years, from the 2013/16 Medical Expenditures Panel Survey longitudinal files to examine within-person change in yearly utilization of age/sex specific United States Preventive Services Task Force (USPSTF) recommended services. We included five primary care (e.g., influenza immunization), three behavioral (e.g., diet), and seven cancer screening (e.g., mammography) measures. We used generalized estimating equations and difference-in-differences tests to assess the effects of insurance gain on: (1) change in PS utilization, and (2) reduction in utilization disparities between USB and FB adults, adjusting for predisposing, health enabling, and health needs factors. Our results showed that newly-insured FB adults substantially increased their use of all primary care checks, and exercise and diet advice. We also found improvements in use of endoscopies, two modalities of colon cancer screening, and prostate cancer screening, but not in receipt of mammography and clinical breast exams. Newly-insured FB PS use remained lower than use among continuously-insured USB adults, but some of the differences were explained by adjustment to enabling and health needs factors. Briefly, health insurance gains among immigrants translated into substantial improvements in use of recommended PS. Still, notable disparities persist among the newly-insured FB, and more so among the 1 in 5 that remain continuously uninsured.

Changes in Insurance Coverage and Healthcare Use Among Immigrants and US-Born Adults Following the Affordable Care Act.

OBJECTIVES: Immigrants to the USA have disparate access to health insurance coverage and healthcare services. We evaluate the effects of gaining insurance following the January 2014 Affordable Care Act's (ACA) key provisions implementation on health services use among foreign- (FB) and US-born (USB) adults. METHODS: Longitudinal data from two panels (2013/2014 and 2014/2015) of the Medical Expenditure Panel Survey on FB and USB adults, ages 26-64 (unweighted n = 15,232), and difference-in-differences analysis using generalized estimating equations were used to estimate the effects of insurance gain. The primary outcomes were five measures of healthcare utilization including yearly routine care appointment, annual number of physician office visits, annual number of prescription medications filled or refilled, use of the emergency department (ED) during the year, and having an inpatient hospital stay during the year. RESULTS: Immigrants were more likely to gain health insurance between 2013 and 2015 relative to USB adults (6.3% vs. 4.4%) but remained much more likely to be continuously uninsured by 2015 (20.8% vs. 6.4%). Controlling for sociodemographic and health characteristics, FB and USB adults who gained insurance increased their use of health services, including routine care (absolute change ΔFB = 15.7%; p < 0.001 and ΔUSB = 11.7%; p < 0.001), office-based doctor visits (ΔFB = 1.3; p < 0.001 and ΔUSB = 0.6; p < 0.001), prescribed medications (ΔFB = 2.5; p < 0.001 and ΔUSB = 1.6; p = 0.016), and inpatient hospitalizations (ΔFB = 3.6%; p = 0.017 and ΔUSB = 3%; p < 0.001). ED use increased only among the FB (ΔFB = 4.8%; p < 0.001). Gaining insurance eliminated the differences in health services use for all considered outcomes among the FB relative to the continuously insured USB. CONCLUSIONS: US immigrants had notable gains in health insurance after the ACA provisions took full effect, but major disparities in coverage persist. If insurance continues to expand among immigrants, then the gains may reduce longstanding disparities in health services use and enhance primary and preventive healthcare.

Medicaid managed care and preventable emergency department visits in the United States.

OBJECTIVES: In the United States the percentage of Medicaid enrollees in some form of Medicaid managed care has increased more than seven-fold since 1990, e.g., up from 11% in 1991 to 82% in 2017. Yet little is known about whether and how this major change in Medicaid insurance affects how recipients use hospital emergency rooms. This study compares the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the occurrence of potentially preventable emergency department (ED) use. METHODS: Using data from the 2003-2015 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the non-institutionalized US population, we estimated multivariable logistic regression models to examine the relationship between Medicaid HMO status and potentially preventable ED use. To accommodate the composition of the Medicaid population, we conducted separate repeated cross-sectional analyses for recipients insured through both Medicaid and Medicare (dual eligibles) and for those insured through Medicaid only (non-duals). We explicitly addressed the possibility of selection bias into HMOs in our models using propensity score weighting. RESULTS: We found that the type of Medicaid held by a recipient, i.e., whether an HMO or FFS coverage, was unrelated to the probability that an ED visit was potentially preventable. This finding emerged both among dual eligibles and among non-duals, and it occurred irrespective of the adopted analytical strategy. CONCLUSIONS: Within the U.S. Medicaid program, Medicaid HMO and FFS enrollees are indistinguishable in terms of the occurrence of potentially preventable ED use. Policymakers should consider this finding when evaluating the pros and cons of adopting Medicaid managed care.

Effects of the Affordable Care Act's enhancement of Medicare benefits on preventive services utilization among older adults in the U.S.

Since 2011, the Affordable Care Act (ACA) requires the provision of certain recommended clinical preventive services without cost-sharing for individuals in Medicare. We re-visited the effects of the ACA on preventive services utilization under Medicare, using data from the Medical Expenditure Panel Survey (MEPS) and examined the ACA's longer-term effects on preventive services utilization among Medicare beneficiaries. We analyzed nationally representative data on non-institutionalized Medicare beneficiaries (n = 27,124) from the 2006-2010 and 2012-2016 Medical Expenditure Panel Survey. Preventive services of interest were cholesterol test, blood pressure test, flu shot, endoscopy, blood stool test, clinical breast exam, mammography and prostate exam. We estimated propensity score weighted difference-in-difference (DID) models to test for differences in preventive services utilization based on Medicare insurance status. Nationwide, among beneficiaries with traditional Medicare only, who stood to gain the most from eliminating cost-sharing for preventive services, the percentage of women receiving clinical breast exams rose post-reform (Δ = 8.1%; p < 0.015) as compared to Medicare beneficiaries with supplemental private coverage, while at the same time the percentage receiving other preventive services did not change post-reform (all p > 0.05). Based on this analysis of MEPS data spanning 2006-2016, the ACA's enhancement of Medicare coverage had only modest effects on the percentage of beneficiaries receiving a range of preventive services. Medicare beneficiaries should be better informed of the availability of these services and encouraged by their physicians to avail the no cost-sharing incentive of these reforms.

Is enrollment in a Medicaid health maintenance organization associated with less preventable hospitalizations?

INTRODUCTION: The objective of this study is to compare the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the prevalence of potentially preventable hospitalizations, a recognized measure of outpatient care quality. METHODS: This study used nationally representative data on non-institutionalized Medicaid recipients, ages 18-64, from the 2003-2012 Medical Expenditure Panel Survey. Separate analyses are conducted for recipients insured through both Medicaid and Medicare ("dual eligibles") and recipients whose only health insurance is Medicaid ("non-duals"). In each group the occurrence of potentially preventable hospitalizations is measured, and then survey-weighted multivariable logistic regression models are fit to quantify the relationship between Medicaid HMO status and the occurrence of such stays. The possibility of selection bias into HMOs is considered and explicitly addressed in model estimation using propensity score methods. RESULTS: Adjusting for covariates and confounders dual eligible enrolled in Medicaid managed care are more likely to have a potentially preventable hospitalization relative to those covered under FFS Medicaid (survey weighted logit model OR = 1.72, 95% CI = 0.98-3.03; propensity score weighted logit model OR = 1.87, 95% CI = 1.06-3.28). In contrast, the odds ratios did not differ among non-duals in Medicaid HMOs versus FFS Medicaid. CONCLUSION: These findings suggest that, at least for dual eligibles, the quality of outpatient care in Medicaid HMOs may be worse than under FFS Medicaid. Better and more streamlined clinical preventive approaches for this high risk and vulnerable population might be required in Medicaid HMOs.