Extending Postpartum Medicaid Beyond 60 Days Improves Care Access and Uncovers Unmet Needs in a Texas Medicaid Health Maintenance Organization.

Under longstanding federal law, pregnancy-related Medicaid coverage is only guaranteed through 60-days postpartum, at which point many women become uninsured. Barriers to care, including lack of insurance, contribute to maternal mortality and morbidity. Leveraging the Families First Coronavirus Response Act, a federal law requiring that states provide continuous coverage to Medicaid enrollees during the COVID-19 pandemic as a condition of receiving enhanced federal financial support, we examine whether postpartum women seek additional care, and what types of care they use, with extended coverage. We analyze claims from the Parkland Community Health Plan (a Texas Medicaid Health Maintenance Organization) before and after implementation of the pandemic-related Medicaid extension. We find that after implementation of the coverage extension, women used twice as many postpartum services, 2 × to 10 × as many preventive, contraceptive, and mental/behavioral health services, and 37% fewer services related to short interval pregnancies within the first-year postpartum. Our findings provide timely insights for state legislators, Medicaid agencies, and members of Congress working to improve maternal health outcomes. We add empirical evidence to support broad extension of Medicaid coverage throughout the first-year postpartum.

Geographic barriers to prenatal care access and their consequences.

BACKGROUND: Although prenatal care has long been viewed as an important strategy toward improving maternal morbidity and mortality, limited data exist that support the premise that access to prenatal care impacts perinatal outcomes. Furthermore, little is known about geographic barriers that impact access to care in an underserved population and how this may influence perinatal outcomes. OBJECTIVE: This study aimed to (1) evaluate perinatal outcomes among women with and without prenatal care and (2) examine barriers to receiving prenatal care according to block-level data of residence. We hypothesized that women without prenatal care would have worse outcomes and more barriers to receiving prenatal care services. STUDY DESIGN: This was a retrospective cohort study of pregnant women delivering at ≥24 weeks' gestation in a large inner-city public hospital system. Maternal and neonatal data were abstracted from the electronic health record and a community-wide data initiative data set, which included socioeconomic and local geographic data from diverse sources. Maternal characteristics and perinatal outcomes were examined among women with and without prenatal care. Prenatal care was defined as at least 1 visit before delivery. Outcomes of interest were (1) preterm delivery at <37 weeks' gestation, (2) preeclampsia or eclampsia, and (3) days in the neonatal intensive care unit after delivery. Barriers to care were analyzed, including public transportation access and location of the nearest county-sponsored prenatal clinic according to block-level location of residence. Statistical analysis included chi-square test and analysis of variance with logistic regression performed for adjustment of demographic features. RESULTS: Between January 1, 2019, and October 31, 2019, 9488 women received prenatal care and 326 women did not. Women without prenatal care differed by race and were noted to have higher rates of substance use (P=.004), preterm birth (P<.001), and longer lengths of newborn admission (P<.001). After adjustment for demographic features, higher rates of preterm birth in women without prenatal care persisted (adjusted odds ratio, 2.65; 95% confidence interval, 1.95-3.55). Women without prenatal care resided in areas that relied more on public transportation and required longer transit times (42 minutes vs 30 minutes; P=.005) with more bus stops (29 vs 17; P<.001) to the nearest county-sponsored prenatal clinic. CONCLUSION: Women without prenatal care were at a significantly increased risk of adverse pregnancy outcomes. In a large inner city, women without prenatal care resided in areas with significantly higher demands for public transportation. Alternative resources, including telemedicine and ridesharing, should be explored to reduce barriers to prenatal care access.

Timely preterm-birth prediction among pregnant women in Medicaid without preterm-birth history.

OBJECTIVES: To develop and prospectively validate a novel model incorporating claims and community-level socioeconomic data to predict preterm birth at scale among pregnant Medicaid women with no history of preterm birth (PTB). STUDY DESIGN: A longitudinal Texas Medicaid cohort study, with 2-year retrospective model building (October 2015-October 2017) and a 1-year prospective model validation phase (January 2018-December 2018). METHODS: Inclusion criteria were females aged 11 to 55 years with at least 1 live singleton birth and no history of PTB. The primary outcome was live singleton birth earlier than 35 weeks. Covariates were medical/mental/behavioral comorbidities, obstetric history, sociodemographic characteristics, and health services utilization. Of multiple models built, the most parsimonious was selected to classify pregnancies as very high, high, medium, and low risk. Model performance was evaluated using positive predictive value (PPV), sensitivity, case identification ratio (1 / PPV), and timing of prediction. RESULTS: The model was built on 6689 pregnancies and validated on 7855 pregnancies. PTB rate earlier than 35 weeks was approximately 3.3%. Significant risk predictors included prenatal visit attendance, insurance gap days, and medical/obstetrical comorbidities. Model PPV was approximately 4-fold higher for very high-risk women (14.7%) vs cohort (3.3%) and so was the case identification ratio (1:7 vs 1:30, respectively). Sensitivity was good, with 57% of PTBs classified as medium risk or higher. Timing of prediction was clinically relevant, with more than 80% of PTBs risk stratified before 24 weeks. CONCLUSIONS: We report a novel PTB prediction model among pregnant Medicaid women without PTB history, which is timely, accurate, practical, and scalable. We leverage Medicaid and community data readily accessible by Medicaid plans to support population-level interventions to prevent PTBs.

From Cultural Competency to Cultural Immersion: Lessons from A Community Advocate in Guatemala.

The article introduces the novel concept of "Cultural Immersion", going beyond cultural competency to immerse oneself into the local culture for sustainable community impact.

Predicting asthma-related emergency department visits using big data.

Asthma is one of the most prevalent and costly chronic conditions in the United States, which cannot be cured. However, accurate and timely surveillance data could allow for timely and targeted interventions at the community or individual level. Current national asthma disease surveillance systems can have data availability lags of up to two weeks. Rapid progress has been made in gathering nontraditional, digital information to perform disease surveillance. We introduce a novel method of using multiple data sources for predicting the number of asthma-related emergency department (ED) visits in a specific area. Twitter data, Google search interests, and environmental sensor data were collected for this purpose. Our preliminary findings show that our model can predict the number of asthma ED visits based on near-real-time environmental and social media data with approximately 70% precision. The results can be helpful for public health surveillance, ED preparedness, and targeted patient interventions.

Dynamics and unexpected localization of the plakin binding protein, kazrin, in mouse eggs and early embryos.

The cell uses the cytoskeleton in virtually every aspect of cell survival and function. One primary function of the cytoskeleton is to connect to and stabilize intercellular junctions. To accomplish this task, microtubules, actin filaments, and intermediate filaments utilize cytolinker proteins, which physically bind the cytoskeletal filament to the core proteins of the adhesion junction. The plakin family of linker proteins have been in the spotlight recently as critical components for embryo survival and, when mutated, the cause of diseases such as muscular dystrophy and cardiomyopathies. Here, we reveal the dynamics of a recently discovered plakin binding protein, kazrin (kaz), during early mouse development. Kaz was originally found in adult tissues, primarily epidermis, linking periplakin to the plasma membrane and colocalizing with desmoplakin in desmosomes. Using reverse transcriptase-polymerase chain reaction, Western blots, and confocal microscopy, we found kaz in unfertilized eggs associated with the spindle apparatus and cytoskeletal sheets. As quickly as 5 min after egg activation, kaz relocates to a diffuse peri-spindle position, followed 20-30 min later by clear localization to the presumptive cytokinetic ring. Before the blastocyst stage of development, kaz associates with the nuclear matrix in a cell cycle-dependent manner, and also associates with the cytoplasmic actin cytoskeleton. After blastocyst formation, kaz localization and potential function(s) become highly complex as it is found associating with cell-cell junctions, the cytoskeleton, and nucleus. Postimplantation stages of development reveal that kaz retains a multifunctional, tissue-specific role as it is detected at diverse locations in various embryonic tissue types.

Src inhibition enhances paclitaxel cytotoxicity in ovarian cancer cells by caspase-9-independent activation of caspase-3.

Src tyrosine kinase has been found to be overexpressed and activated in a high proportion of ovarian cancers and ovarian cancer cell lines. Furthermore, Src activation is associated with activation of growth and survival signaling pathways. The present study was conducted in order to determine the effects of Src inhibition on ovarian cancer cell survival in response to chemotherapeutic agents. Inhibition of Src, either pharmacologically or through expression of a Src dominant-negative fusion construct, enhanced the cytotoxicity of two different classes of chemotherapeutics: paclitaxel and cisplatinum, in both mouse and human ovarian cancer cells. Interestingly, Src inhibition also restored sensitivity to drug-resistant ovarian cancer cells. The increased cytotoxicity in response to Src inhibition was associated with a large increase in processing and activation of caspase-3. The activation of caspase-3 seems to be independent of cytochrome c release and caspase-9 activation. The present study indicates that Src tyrosine kinase may provide an important target for small molecule inhibition in ovarian cancer.

Src tyrosine kinase promotes survival and resistance to chemotherapeutics in a mouse ovarian cancer cell line.

The vast majority of ovarian cancers originate in the ovarian surface epithelium. Unfortunately, there is a lack of appropriate animal models for ovarian cancer research. Spontaneously transformed mouse ovarian surface epithelial cells may provide a faithful animal model for human ovarian cancer. One such cell line (ID8) has been partially characterized. ID8 cells demonstrate constitutive Src tyrosine kinase activation with resulting phosphatidylinositol-3-kinase activation and Akt and forkhead phosphorylation. In addition, focal adhesion kinase is constitutively phosphorylated at tyrosine 925, a Src phosphorylation site, resulting in increased Ras activation. These features are common to human ovarian cancer cell lines. Inhibition of Src enhances the cell killing effects of both paclitaxel and cisplatinum. Finally, Src inhibition restores sensitivity of a drug resistant ID8 cell line. The ID8 mouse ovarian cancer cell line presents new opportunities to study ovarian cancer progression and pre-therapeutic trials in an immune competent background.