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Value-based payment programs adjust payments to providers based on spending, quality, or health outcomes. Concern that these programs penalize providers disproportionately serving vulnerable patients prompted calls to adjust performance measures for social risk factors. We reviewed fourteen studies of social risk adjustment in Medicare's Hospital Readmissions Reduction Program (HRRP), a value-based payment model that initially did not adjust for social risk factors but subsequently began to do so. Seven studies found that adding social risk factors to the program's base risk-adjustment model (which adjusts only for age, sex, and comorbidities) reduced differences in risk-adjusted readmissions and penalties between safety-net hospitals and other hospitals. Three studies found that peer grouping, the HRRP's current approach to social risk adjustment, reduced penalties among safety-net hospitals. Two studies found that differences in risk-adjusted readmissions and penalties were further narrowed when augmentation of the base model was combined with peer grouping. Two studies showed that it is possible to adjust for social risk factors without obscuring quality differences between hospitals. These findings support the use of social risk adjustment to improve provider payment equity and highlight opportunities to enhance social risk adjustment in value-based payment programs.

Policy makers are pursuing strategies to integrate Medicare and Medicaid coverage for people enrolled in both programs, who are known as dual eligibles. Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans that exclusively serve this population, with several features intended to enhance care and facilitate integration with Medicaid. This study compared access to, use of, and satisfaction with care among dual eligibles enrolled in D-SNPs versus those enrolled in two other forms of Medicare coverage: other Medicare Advantage (MA) plans not exclusively serving dual eligibles and traditional Medicare. Compared with those in traditional Medicare, dual eligibles generally reported greater access to care, preventive service use, and satisfaction with care in D-SNPs. However, we found fewer differences in these outcomes among dual eligibles in D-SNPs versus other MA plans. Compared with non-Hispanic White dual eligibles, dual eligibles of color (for example, those identifying as Black or Hispanic) were less likely to report receiving better care in D-SNPs versus other Medicare coverage. These findings suggest that D-SNPs altogether have not provided consistently superior or more equitable care, and they highlight areas where federal and state policy could strengthen incentives for D-SNPs to improve care.

ImportanceMedicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program’s income eligibility threshold (100% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries’ ability to afford care.ObjectiveTo examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care.Design, Setting, and ParticipantsThis cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0% to 200% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022.Main outcome measuresPatient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data.ResultsThis cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1% of beneficiaries were women, 14.8% were non-Hispanic Black, 13.6% were Hispanic, and 71.6% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95% CI, 2.0-9.4), lower outpatient use (−6.3 services per person-year; 95% CI, −10.4 to −2.2), and fewer medication fills (−6.9 fills per person-year; 95% CI, −11.4 to −2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: −6.2 services per person-year; 95% CI, −11.7 to −0.6; P = .03) and medication fills (disparity: −7.2 fills per person-year; 95% CI, −13.4 to −1.0; P = .02) among Black and Hispanic vs White beneficiaries.Conclusions and RelevanceThis cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.

BACKGROUND AND OBJECTIVES Permanent supportive housing (PSH) integrates long-term housing and supports for families and individuals experiencing homelessness. Although PSH is frequently provided to families with children, little is known about the impacts of PSH among children. We examined changes in health care visits among children receiving PSH compared with similar children who did not receive PSH. METHODS We analyzed Pennsylvania Medicaid administrative data for children entering PSH between 2011 and 2016, matching to a comparison cohort with similar demographic and clinical characteristics who received non-PSH housing services. We conducted propensity score-weighted difference-in-differences (DID) analyses to compare changes in health care visits 3 years before and after children entered PSH versus changes in the comparison cohort. RESULTS We matched 705 children receiving PSH to 3141 in the comparison cohort. Over 3 years following PSH entry, dental visits among children entering PSH increased differentially relative to the comparison cohort (DID: 12.70 visits per 1000 person-months, 95% confidence interval: 3.72 to 21.67). We did not find differential changes in preventive medicine visits, hospitalizations, or emergency department (ED) visits overall. When stratified by age, children ≤5 years old at PSH entry experienced a greater decrease in ED visits relative to the comparison cohort (DID: −13.16 visits per 1000 person-months, 95% confidence interval: −26.23 to −0.10). However, emergency visit trends before PSH entry differed between the cohorts. CONCLUSIONS Children in PSH had relatively greater increases in dental visits, and younger children entering PSH may have experienced relative reductions in ED visits. Policymakers should consider benefits to children when evaluating the overall value of PSH.

Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100 percent but less than 200 percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8 percentage points just above the eligibility threshold for Medicaid (100 percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55 percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.

OBJECTIVE: To assess changes in physicians’ provision of care to duals (low‐income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully pay Medicare's cost sharing for office visits with these patients. This policy—a provision of the Affordable Care Act—effectively increased payments for office visits with duals by 0%‐20%, depending on the state, in 2013 and 2014. DATA SOURCES: Fee‐for‐service claims for a 5% random sample of Medicare beneficiaries in 2010‐2016. STUDY DESIGN: We conducted a difference‐in‐differences analysis to compare changes in office visits among Qualified Medicare Beneficiaries (QMBs)—the largest subpopulation of duals for whom payment rates were affected by this policy—to changes among other low‐income Medicare beneficiaries for whom payment rates were unaffected (pooled across all states). Next, we conducted a triple‐differences analysis that compared changes between QMBs and other low‐income beneficiaries in 33 states with payment rate increases of approximately 20% to analogous changes in 14 states without payment increases. DATA COLLECTION: The study included administrative Medicare enrollment and claims data for QMBs and a comparison group of other low‐income Medicare beneficiaries (1 914 073 beneficiary‐years from 2010 to 2016). PRINCIPAL FINDINGS: Nationally, we did not find a differential increase in office visits among QMBs versus other low‐income beneficiaries that coincided with this payment change. In the triple‐differences analysis, we did not observe a greater increase in visits among QMBs vs other low‐income beneficiaries in states where the policy resulted in large (approximately 20%) increases in payment rates vs states where payment rates were unaffected (triple‐differences estimate: −0.12 annual visits, 95% CI: −0.28, 0.04; P = 0.15). CONCLUSIONS: Physicians’ provision of care to low‐income Medicare beneficiaries may not be responsive to short‐run payment changes.

To examine the limitations of peer grouping and associated challenges measuring social risk in Medicare's Hospital Readmission Reduction Program (HRRP). Under peer grouping, hospitals are divided into quintiles based on the proportion of a hospital's Medicare inpatients with Medicaid ("dual share"). This approach was implemented to address concerns that the HRRP unfairly penalized hospitals that disproportionately serve disadvantaged patients.Public data on hospitals in the HRRP.We examined the relationship between hospital dual share and readmission rates within peer groups; changes in hospitals' peer group assignments, readmission rates, and penalties; and the relationship between state Medicaid eligibility rules and peer groups.Public data on hospital characteristics and readmission rates for 3119 hospitals from 2019 to 2020.The proportion of dual inpatients among hospitals of the same peer group varied by as much as 69 percentage points (ppt). Within peer groups, a one ppt increase in dual share was associated with a 0.01 ppt increase in the difference from the median readmission rate (p 0.001). From 2019 to 2020, 8.8% of hospitals switched peer groups. Compared to hospitals that did not switch, those moving to a lower peer group had a higher mean penalty in 2020 (0.096 ppt; p = 0.006); those moving to a higher group had a lower mean penalty (-0.06 ppt; p = 0.079). However, changes in penalties did not correspond to changes in readmission rates. Hospitals in states with higher Medicaid income eligibility limits were more likely to be in higher peer groups.Peer grouping is limited in the extent to which it accounts for differences in hospitals' patient populations, and it may not fully insulate hospitals from penalties linked to changes in patient mix. These problems arise from the construction of peer groups and the measure of social risk used to define them.

Objective To develop the first longitudinal database of state Medicaid policies for paying the cost sharing in Medicare Part B for services provided to dual Medicare-Medicaid enrollees ("duals") and an index summarizing the impact of these policies on payments for physician office services. Data sources Medicaid policy data collected from electronic sources and inquiries with states. Study design We constructed a national database of Medicaid payment policies for the period 2004-2018, consolidating information from online Medicaid policy documents, state laws, and policy data reported to us by state Medicaid programs. Using this database and state Medicaid fee schedules, we constructed a Medicaid payment index for duals. This index represented the proportion of the Medicare allowed amount that physicians would expect to be paid from Medicare and Medicaid for a subset of physician office services (evaluation and management services) based on annual state payment policies and Medicaid fee schedules. Principal findings In 2018, 42 states had policies to limit Medicaid payments of Medicare cost sharing when Medicaid's fee schedule was lower than Medicare's-an increase from 36 such states in 2004. In the preponderance of states with these policies, combined Medicare and Medicaid payments for evaluation and management services provided to duals averaged 78 percent of the Medicare allowed amount for these services, reflecting relatively low Medicaid fee schedules in these states. In 2013 and 2014, physicians who qualified for the Affordable Care Act's Medicaid "fee bump" were paid 100 percent of the Medicare allowed amount for these services. Conclusions Medicaid programs vary across states and over time in their payments of cost sharing for physician office services provided to duals. Our database and index can facilitate monitoring of these policies and research on the consequences of policy changes for duals.

Objective To examine whether low-income children's use of preventive dental services is linked to variation in state Medicaid policies that affect parents' access to dental care in Medicaid. Data sources Medical Expenditure Panel Survey (2011-2016), Area Health Resources File, and Medicaid adult dental coverage policies. Study design We conducted a quasi-experimental analysis using linked parent-child dyads in low-income families (≤125 percent of the Federal Poverty Level). We assessed whether expansions of Medicaid to low-income adults under the Affordable Care Act were associated with increases in the use of preventive dental services among low-income children when state Medicaid programs did vs did not cover these services for adults. Principal findings Over the study period, 37.8 percent of low-income children received at least one annual preventive dental visit. We found no change in children's receipt of preventive dental care associated with Medicaid expansions in states that covered (1.26 percentage points; 95% CI: -3.74 to 6.27) vs did not cover preventive dental services for adults (3.03 percentage points; 95% CI: -2.76 to 8.81). (differential change: -1.76 percentage points; 95% CI: -8.09, 4.56). However, our estimates are imprecise, with wide confidential intervals that are unable to rule out sizable effects in either direction. Conclusion We did not find an association between Medicaid expansions with concurrent coverage of preventive dental services for adults and children's use of these services. Factors other than parental access to dental benefits through Medicaid may be more salient determinants of preventive dental care use among low-income children.

Objective To examine the association between non-adherence to clinical practice guidelines (CPGs) and medical and indemnity spending among back and shoulder injury patients. Methods Workers compensation claims data was used from a large, US insurer (1999 to 2010). Least square regression models were created to examine the association between spending and guideline-discordant care. Results Non-adherence to CPGs was associated with higher medical and indemnity spending for 11 of the 28 CPG indicators. Failure to adhere to the other CPGs did not increase medical or total spending. After covariate adjustment, non-adherence to these 11 CPGs was associated with spending increases that ranged from $16,000 for physical therapy (PT) to $114,000 for surgery. Conclusions Our results demonstrate that failure to adhere to a subset of CPG indicators significantly predicts increased medical and indemnity spending for two important occupational injuries.

Recent reductions in readmission rates have been attributed to public reporting and pay-for-performance initiatives focused on readmissions. However, admission rates also declined during the same period. We demonstrate that, because the probability of an admission occurring soon after another is lower when there are fewer admissions per patient, the reduction in admission rates may have explained much of the reduction in readmission rates.

Importance Medicare’s Merit-Based Incentive Payment System (MIPS), a public reporting and pay-for-performance program, adjusts clinician payments based on publicly reported measures that are chosen primarily by clinicians or their practices. However, measure selection raises concerns that practices could earn bonuses or avoid penalties by selecting measures on which they already perform well, rather than by improving care—a form of gaming. This has prompted calls for mandatory reporting on a smaller set of measures including patient experiences. Objective To examine (1) practices’ selection of Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience measures for quality scoring under the pay-for-performance program and (2) the association between mandated public reporting on CAHPS measures and performance on those measures within precursor programs of the MIPS. Design, Setting, and Participants This cross-sectional study included 2 analyses. The first analysis examined the association between the baseline CAHPS scores of large practices (≥100 clinicians) and practices’ selection of these measures for quality scoring under a pay-for-performance program up to 2 years later. The second analysis examined changes in patient experiences associated with a requirement that large practices publicly report CAHPS measures starting in 2014. A difference-in-differences analysis of 2012 to 2017 fee-for-service Medicare CAHPS data was conducted to compare changes in patient experiences between large practices (111-150 clinicians) that became subject to this reporting mandate and smaller unaffected practices (50-89 clinicians). Analyses were conducted between October 1, 2020, and July 30, 2021. Main Outcomes and Measures The primary outcomes of the 2 analyses were (1) the association of baseline CAHPS scores of large practices with those practices’ selection of those measures for quality scoring under a pay-for-performance program; and (2) changes in patient experiences associated with a requirement that large practices publicly report CAHPS measures starting in 2014. Results Among 301 large practices that publicly reported patient experience measures, the mean (IQR) age of patients at baseline was 71.6 (70.4-73.2 ) years, and 55.8% of patients were women (IQR, 54.3%-57.7%). Large practices in the top vs bottom quintile of patient experience scores at baseline were more likely to voluntarily include these scores in the pay-for-performance program 2 years later (96.3% vs 67.9%), a difference of 28.4 percentage points (95% CI, 9.4-47.5 percentage points;P = .004). After 2 to 3 years of the reporting mandate, patient experiences did not differentially improve in affected vs unaffected practices (difference-in-differences estimate: −0.03 practice-level standard deviations of the composite score; 95% CI, −0.64 to 0.58;P = .92). Conclusions and Relevance In this cross-sectional study of US physician practices that participated in precursors of the MIPS, large practices were found to select measures on which they were already performing well for a pay-for-performance program, consistent with gaming. However, mandating public reporting was not associated with improved patient experiences. These findings support recommendations to end optional measures in the MIPS but also suggest that public reporting on mandated measures may not improve care.

RESEARCH OBJECTIVE: To estimate take‐up of the Part D Low‐Income Subsidy (LIS) among Medicare beneficiaries with diabetes, and to examine differences in out‐of‐pocket costs and prescription drug use between enrollees and LIS‐eligible non‐enrollees. The LIS lowers prescription drug costs for Medicare beneficiaries with incomes ≤150% of the Federal Poverty Level (FPL), and caps out‐of‐pocket costs for beneficiaries with incomes ≤135% of FPL. Although a number of recent policy proposals seek to address rising drug costs, the LIS itself remains underutilized. The value of forgoing this benefit among chronically ill beneficiaries has not previously been studied. STUDY DESIGN: We used data from the Health and Retirement Study (HRS) to estimate take‐up of the LIS among Medicare beneficiaries with diabetes. Using propensity score‐weighted analyses, we compared out‐of‐pocket costs, prescription drug use, and cost‐related drug non‐adherence among LIS enrollees and eligible non‐enrollees. We stratified the analyses according to whether respondents' income was ≤100% vs. >100% to ≤150% of FPL because of differences in the generosity and take‐up of Medicaid benefits above vs. below 100% of FPL, and because individuals with Medicaid automatically receive the LIS. POPULATION STUDIED: Community‐dwelling HRS respondents surveyed biennially between 2008–2016 who were enrolled in Medicare Part D, had an established diagnosis of diabetes, and were eligible for the LIS (income ≤150% FPL and assets below LIS limit). PRINCIPAL FINDINGS: Among Medicare beneficiaries with diabetes, 56.9% of those with incomes >100% to ≤150% of FPL received the LIS, while 90.3% of those with incomes ≤100% received the LIS, reflecting automatic enrollment from Medicaid. Based on these take‐up rates, we estimate that 322,746 LIS‐eligible individuals with diabetes do not enroll in the LIS annually. For those with incomes >100% to ≤150% of FPL, compared to LIS enrollees, eligible non‐enrollees incurred higher annual out‐of‐pocket drug spending ($518, p 100% to ≤150% of FPL. Forgoing the LIS was associated with higher out‐of‐pocket costs and cost‐related non‐adherence, and lower use of medications used to treat chronic conditions. Our findings demonstrate the extent to which out‐of‐pocket costs may be reduced, and use of chronic disease medications increased, if a higher proportion of LIS‐eligible Medicare beneficiaries receive this benefit. IMPLICATIONS FOR POLICY OR PRACTICE: Proposals to lower out‐of‐pocket drug costs for Medicare beneficiaries often overlook the fact that existing prescription drug subsidy programs are underutilized. Because the LIS reduces cost sharing for all Part D covered drugs and caps annual out‐of‐pocket costs for most recipients, increasing LIS take‐up would likely provide better financial protection for seniors with chronic conditions than a flat subsidy or price caps limited to certain drugs. Policies to streamline or automate LIS enrollment for low‐income Medicare beneficiaries could help to mitigate the impact of rising drug costs in this vulnerable population. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Objective To examine whether the correlation between a provider's effect on one population of patients and the same provider's effect on another population is under-estimated if the effects for each population are estimated separately as opposed to being jointly modeled as random-effects, and to characterize how the impact of the estimation procedure varies with sample-size. Data sources Medicare claims and enrollment data on emergency department (ED) visits, including patient characteristics, the patient's hospitalization status, and identification of the doctor responsible for the decision to hospitalize the patient. Study design We used a three-pronged investigation consisting of analytical derivation, simulation experiments, and analysis of administrative data to demonstrate the fallibility of stratified estimation. Under each investigation method, results are compared between the joint modeling approach to those based on stratified analyses. Data collection/extraction methods We used data on ED visits from administrative claims from traditional (fee-for-service) Medicare from January 2012 through September 2015. Principal findings The simulation analysis demonstrates that the joint modeling approach is generally close to unbiased whereas the stratified approach can be severely biased in small samples, a consequence of joint modeling benefitting from bivariate shrinkage and the stratified approach being compromised by measurement error. In the administrative data analyses, the estimated correlation of doctor admission tendencies between female and male patients was estimated to be 0.98 under the joint model but only 0.38 using stratified estimation. The analogous correlations for white and non-white patients are 0.99 and 0.28 and for Medicaid dual-eligible and non-dual-eligible patients are 0.99 and 0.31, respectively. These results are consistent with the analytical derivations. Conclusions Joint modeling targets the parameter of primary interest. In the case of population correlations, it yields estimates that are substantially less biased and higher in magnitude than naive estimators that post-process the estimates obtained from stratified models. This article is protected by copyright. All rights reserved.

This cross-sectional study uses Medicare Advantage benefit package data for 2021 to examine differences in the coverage of nonmedical supplemental benefits—such as transportation services and food and meal assistance—for dual-eligible enrollees with health-related social needs.

ImportanceMedicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending.ObjectiveTo describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity.Evidence ReviewAnalyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included.FindingsMedicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity.Conclusions and RelevanceMedicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.

Health Care Budgets for Rural Providers Policymakers are moving forward with payment models that establish budgets for rural health care organizations. Such programs reflect an attempt to help reme...

Objective To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. Data source 2010-2013 Medicare Current Beneficiary Survey. Study design Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. Principal findings Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. Conclusions Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.

Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100 percent but less than 200 percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8 percentage points just above the eligibility threshold for Medicaid (100 percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55 percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.

Background: The risk of recurrence of stroke has been found to be modifiable through changes in health behavior and reducing key risk factors such as hypertension. Evidence suggests social networks can influence health behaviors and health outcomes; however, there is a lack of literature on the relationship between stroke survivor’s social network and secondary prevention efforts. In this study, we assessed the association between social network structure and systolic blood pressure (SBP) reduction at one-year post stroke. Methods: Using data from the DESERVE (Discharge Educational Strategies for Reduction of Vascular Events) trial, we assessed the social networks of 552 participants who have had a mild/moderate stroke or transient ischemic attack (TIA). At baseline enrollment, participants were asked to identify up to 5 persons, or “alters,” with whom they discuss important matters, such as health. The data on the alters were then classified into structural and functional characteristics. The combination of the number of alters and the amount of alters that met the “optimal” level for each characteristic were used to determine the characteristics of the social network. We used linear regression models to quantify the SBP change on social network characteristics adjusting for age, gender, race-ethnicity, education, marital status, and prior stroke history. Results: Stronger social networks were associated with greater SBP reduction. The overall mean SBP reduction at 12-month follow-up was 5.6 (±24.5) mmHg. On fully adjusted models having 3-5 alters compared to none (mean SBP reduction of 11.4 mmHg, p = 0.01) and having a family and friend network compared to a family-only network (mean SBP reduction of 7.6 mmHg, p = 0.01) were significantly associated with a larger SBP reduction. Conclusion: Social networks may play an important role in blood pressure reduction in patients post stroke. Future interventions should involve social networks to help reduce vascular risk and enhance secondary prevention efforts.

This cross-sectional study examines the association between cognition and Medicare Savings Program enrollment among qualified elderly Medicare beneficiaries.

RESEARCH OBJECTIVE: Cost sharing is intended to mitigate the effects of moral hazard in health insurance but can have unintended consequences if patients underuse medically beneficial care that is subject to out‐of‐pocket costs. The Medicare program requires substantial cost sharing, including deductibles and coinsurance for outpatient care and prescription drugs. However, little is known about the consequences of this benefit design for low‐income Medicare beneficiaries who do not qualify for Medicaid or Part D Low‐Income Subsidies (LIS), which defray these costs. In this study, we harnessed quasi‐random variation in exposure to Medicare cost sharing, resulting from “cliffs” in cost sharing subsidies above vs. below income eligibility thresholds for Medicaid and the LIS, to assess the effects of cost sharing on low‐income beneficiaries’ out‐of‐pocket spending and use of care. STUDY DESIGN: We conducted regression discontinuity analyses using detailed household income data from the Health and Retirement Study (HRS) linked to Medicare claims. Our study design compared Medicare beneficiaries with incomes above vs. below eligibility thresholds for the Qualified Medicare Beneficiary (QMB) program, a Medicaid benefit that eliminates cost sharing in Medicare Parts A and B for beneficiaries $2,000) out‐of‐pocket medical costs, relative to beneficiaries whose income was below this threshold. Beneficiaries whose income exceeded the LIS threshold had 17% fewer prescription drug claims and were 16% more likely to have high out‐of‐pocket costs. We found no discernable differences in inpatient utilization above vs. below either threshold. CONCLUSIONS: Our findings show how cost sharing obligations in the Medicare program affect low‐income beneficiaries’ use of care: beneficiaries whose income just exceeds thresholds at which these cost sharing obligations are eliminated or appreciably reduced use substantially fewer prescription drugs and, in some cases, outpatient care. IMPLICATIONS FOR POLICY OR PRACTICE: Medicare beneficiaries with minimally different incomes can face substantially different out‐of‐pocket costs that affect their use of care. Extending Medicaid and LIS cost sharing subsidies to additional near‐poor beneficiaries, and gradually tapering assistance for individuals with modestly higher incomes, could alleviate the impacts of Medicare’s cost sharing obligations on near poor beneficiaries’ use of care. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

BACKGROUND: There is growing interest in financing housing and supportive services for homeless individuals through Medicaid. Permanent Supportive Housing (PSH), which integrates non-time-limited housing with supportive services for people who are disabled and chronically homeless, has seen rapid growth in the last decade, but clear evidence on the long-term impacts of PSH, needed to guide state efforts to finance some PSH services through Medicaid, is lacking. OBJECTIVE: Assess changes in Medicaid expenditures and utilization associated with receiving PSH. DESIGN: Cohort study using a difference-in-differences approach. PARTICIPANTS: A total of 1226 PA Medicaid enrollees who entered PSH 2011–2016 and remained in PSH for 180 days or more, and a matched comparison cohort of 970 enrollees experiencing housing instability who did not receive PSH. MAIN MEASURES: Medicaid spending in aggregate, and on behavioral and physical health services; emergency department (ED) visits and inpatient hospital stays. KEY RESULTS: Three years after PSH entry, spending decreased by an average of $145/month in the PSH cohort relative to changes in the comparison cohort (p = 0.046), with the greatest relative spending reductions occurring for residential behavioral health ($64, p < 0.001) and inpatient non-behavioral health services ($89, p = 0.001). We also found relative reductions in ED use (4.7 visits/100 person-months, p = 0.010) and inpatient hospital stays (1.6 visits/100 person-months, p < 0.001). CONCLUSIONS: These results can inform emerging state efforts to finance PSH services through Medicaid. Additional state expenditures to expand financing for PSH services could be partially offset by reductions in Medicaid spending, in part by facilitating a shift in treatment to outpatient from acute care settings. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06465-y.

Background There is growing recognition that positive health beliefs may promote blood pressure (BP) reduction, which is critical to stroke prevention but remains a persistent challenge. Yet, studies that examine the association between positive health beliefs and BP among stroke survivors are lacking. Methods and Results Data came from the DESERVE (Discharge Educational Strategies for Reduction of Vascular Events) study, a randomized controlled trial of a skills‐based behavioral intervention to reduce vascular risk in a multiethnic cohort of 552 transient ischemic attack and mild/moderate stroke patients in New York City. The exposure was perception that people can protect themselves from having a stroke (ie, prevention self‐efficacy) at baseline. The association between systolic BP ( SBP ) reduction at 12‐month follow‐up and self‐efficacy was examined using linear regression adjusted for key confounders, overall and stratified by age, sex, race/ethnicity, and intervention trial arm. Approximately three quarters endorsed self‐efficacy. These participants had, on average, 5.6 mm Hg greater SBP reduction compared with those who did not endorse it (95% CI , 0.5–10.7 mm Hg; P =0.032). Self‐efficacy was significantly associated with greater SBP reduction, particularly among female versus male, younger versus older, and Hispanic versus non‐Hispanic white patients. Sensitivity analysis adjusting for baseline SBP instead of elevated BP yielded no association between self‐efficacy and SBP reduction, but showed sex differences in this association (women: β=5.3; 95% CI , −0.2 to 10.8; P =0.057; men: β=−3.3; 95% CI , −9.4 to 2.9; P =0.300; interaction P =0.064). Conclusions Self‐efficacy was linked with greater SBP reduction among female stroke survivors. Targeted strategies to improve health beliefs after stroke may be important for risk factor management. REGISTRATION URL : https://www.clini​caltr​ials.gov ; Unique identifier: NCT 01836354.

BACKGROUND: Patients with serious mental illness (i.e., SMI; bipolar disorder, major depressive disorder, and schizophrenia) are at increased risk of readmission, yet little is known about the extent to which readmission rates among these patients vary across hospitals. The purpose of this study was to examine the variation across hospitals in readmissions for patients with SMI and differences in the characteristics of hospitals with the highest and lowest adjusted readmission rates. METHODS: We conducted a cross-sectional analysis of pooled inpatient claims from 2013–2016. Mixed logit models with hospital random effects were used to estimate the hospital-level variance. The sample included patients with SMI from a 5% sample of fee-for-service Medicare beneficiaries. RESULTS: We identified 2,066 hospitals with at least 30 index admissions for Medicare beneficiaries with SMI. In multivariate analyses, factors most strongly associated with increased risk of readmission included substance use disorder (OR 2.311; p

Successful payment reform requires strong incentives for provider organizations to limit health care spending. Often overlooked in the debate over how to strengthen global budget models is that inc...

Health systems are increasingly testing interventions to reduce costs and improve patient care.1 By leveraging their ability to deploy interventions across a network of providers and their data infrastructure, health systems have capacity to test new models of care delivery and to assess their effects. What differentiates health systems from learning health systems, however, is how systems combine this infrastructure with rigorous research methods to generate evidence that can inform decision-making.1 2 Critical to this is isolating the causal effects of interventions from potential sources of bias (internal validity) and providing evidence that generalises to broader, real-world settings (external validity). As Walkey et al demonstrate in this issue of BMJ Quality and Safety , natural experiments that arise in the design and implementation of health system interventions can provide valuable opportunities to learn about the effectiveness of interventions, yielding findings that may offer both high internal and external validity.3 Natural experiments arise when the design or implementation of a programme generates variation in exposure to an intervention that is ‘as good as random’, conditional on observed confounders. For example, patients may be allocated to different treatments based on an arbitrary eligibility threshold (Walkey et al exploit this variation); health systems may stagger the roll-out of interventions across sites4; or patients may be entered into a lottery to allocate a number of intervention slots.5 When well conceived and thoroughly vetted, natural experiments retain many of the appealing statistical features of …

OBJECTIVE: To assess the effect of Maryland's 2010 Total Patient Revenue (TPR) global budget reform in eight rural hospitals on population‐level hospital rates of utilization three years after implementation. DATA SOURCES/STUDY SETTING: Data on all inpatient discharges and outpatient department visits from the Health Services Cost Review Commission, population data from Claritas Demographic Reports, and county‐level data from the Area Health Resource File. STUDY DESIGN: We use a difference‐in‐differences approach to compare changes in utilization rates over time in the reform areas comprising 125 Zip Code Tabulation Areas (ZCTAs) and in two control hospital areas (66 ZCTAs and 327 ZCTAs, respectively). We examine several inpatient and outpatient measures and distinguish between relatively discretionary and nondiscretionary utilization. DATA COLLECTION: Admissions data are hospital‐reported discharge abstracts of all encounters in Maryland during 2008‐2013. Population data are derived from the US Census. PRINCIPAL FINDINGS: We find no statistically significant changes in admissions, either overall or discretionary. We find a statistically significant 8.9 percent (95%CI = [1.8, 16.0]) reduction in outpatient visits, with a statistically significant reduction of 14.8 percent (95%CI = [5.3, 24.3]) visits not to the Emergency Department. CONCLUSIONS: We find that the TPR reform decreased outpatient utilization but did not affect inpatient utilization.

Background and Purpose The study aimed to investigate the effect of gender on the association between social networks and stroke preparedness as measured by emergency department (ED) arrival within 3 hours of symptom onset. Methods As part of the Stroke Warning Information and Faster Treatment study, baseline data on demographics, social networks, and time to ED arrival were collected from 1193 prospectively enrolled stroke/transient ischemic attack (TIA) patients at Columbia University Medical Center. Logistic regression was conducted with arrival to the ED ≤3 hours as the outcome, social network characteristics as explanatory variables, and gender as a potential effect modifier. Results Men who lived alone or were divorced were significantly less likely to arrive ≤3 hours than men who lived with a spouse (adjusted odds ratio [aOR]: .31, 95% confidence interval [CI]: .15-0.64) or were married (aOR: .45, 95% CI: .23-0.86). Among women, those who lived alone or were divorced had similar odds of arriving ≤3 hours compared with those who lived with a spouse (aOR: 1.25, 95% CI: .63-2.49) or were married (aOR: .73, 95% CI: .4-1.35). Conclusions In patients with stroke/TIA, living with someone or being married improved time to arrival in men only. Behavioral interventions to improve stroke preparedness should incorporate gender differences in how social networks affect arrival times.

Pesticides have adverse impacts on the environment and public health. In response to growing public concern over these impacts, California implemented the Pesticide Use Reporting (PUR) program in 1990. The PUR program is widely recognized as the world's most comprehensive pesticide reporting system, and its pesticide application records are highly detailed. However, the complexity and volume of PUR data require a level of data skills and resources beyond many government agencies, public health professionals, and community stakeholders. Over the past decade, the California Environmental Health Tracking Program has undertaken multiple strategies to make PUR data more accessible, understandable, and useful to a diversity of data users. Three specific efforts are described in detail-the Pesticide Linkage Service, the Pesticide Mapping Tool, and a policy-relevant analysis on pesticide use near schools-as are their impacts on environmental and public health research, community outreach and education, and policy change.

A nucleophile crossover experiment was used to monitor the reversibility of nucleophilic addition of benzylamine to π-allylpalladium complexes. Dppe, dppp, dppb, and PHOX showed more crossover than PPh 3 and dppm in both DMF and dichloromethane. Crossover was inhibited by the addition of DBU or Cs 2 CO 3 , but much less elimination to diene side products was observed with Cs 2 CO 3 . Analysis of percent crossover vs. percent reaction completion using the PHOX ligand revealed that with added DBU or Cs 2 CO 3 crossover only began occurring after 100% completion had been reached.

BACKGROUND:Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. OBJECTIVE:We evaluated the cost-effectiveness of a stroke preparedness behavioral intervention study (Stroke Warning Information and Faster Treatment [SWIFT]), a stroke intervention demonstrating capacity to decrease race-ethnic disparities in ED arrival times. METHODS:Using the literature and SWIFT outcomes for 2 interventions, enhanced educational (EE) materials, and interactive intervention (II), we assess the cost-effectiveness of SWIFT in 2 ways: (1) Markov model, and (2) cost-to-outcome ratio. The Markov model primary outcome was the cost per quality-adjusted life-year (QALY) gained using the cost-effectiveness threshold of $100 000/QALY. The primary cost-to-outcome endpoint was cost per additional patient with ED arrival

For some low-income Medicare beneficiaries, Medicaid provides financial protection against Medicare's out-of-pocket costs, but many Medicare beneficiaries who qualify for Medicaid are not continuously enrolled. We examined Medicaid disenrollment among fee-for-service Medicare beneficiaries and the relationship between disenrollment and state policies. In the period 2012-16, 18.2 percent of Medicare beneficiaries who received full or partial Medicaid disenrolled for reasons other than death. More than 50 percent of Medicare beneficiaries who remained without Medicaid one year after disenrolling continued to receive low-income subsidies for Medicare Part D coverage with eligibility requirements similar to those of Medicaid. Among Medicare beneficiaries with continuous Part D subsidies, the rate of Medicaid disenrollment was 24 percent lower in states that automatically enrolled recipients of the federal Supplemental Security Income program in full Medicaid, 33 percent lower in states with more generous provider payment policies, and 37 percent lower in states with less restrictive asset limits for partial Medicaid. Policies that make it easier for people to maintain Medicaid eligibility and that enhance access to care in Medicaid via higher provider reimbursements may reduce disenrollment.

This study&rsquo, s purpose is to determine if neighborhood disadvantage, air quality, economic distress, and violent crime are associated with mortality among term life insurance policyholders, after adjusting for individual demographics, health, and socioeconomic characteristics. We used a sample of approximately 38,000 term life policyholders, from a large national life insurance company, who purchased a policy from 2002 to 2010. We linked this data to area-level data on neighborhood disadvantage, economic distress, violent crime, and air pollution. The hazard of dying for policyholders increased by 9.8% (CI: 6.0&ndash, 13.7%) as neighborhood disadvantage increased by one standard deviation. Area-level poverty and mortgage delinquency were important predictors of mortality, even after controlling for individual personal income and occupational status. County level pollution and violent crime rates were positively, but not statistically significantly, associated with the hazard of dying. Our study provides evidence that neighborhood disadvantage and economic stress impact individual mortality independently from individual socioeconomic characteristics. Future studies should investigate pathways by which these area-level factors influence mortality. Public policies that reduce poverty rates and address economic distress can benefit everyone&rsquo, s health.

Introduction: Hypertension is a leading risk factor for stroke recurrence. Previous studies have found that patients’ health attitudes and beliefs play a critical role in shaping health behaviors. The aim of this analysis is to investigate the relationship between specific health beliefs and blood pressure reduction following stroke. Methods: DESERVE is an RCT of a skills-based educational intervention vs. standard care in a multi-ethnic cohort of mild/moderate stroke and TIA survivors. The relationship between participants’ baseline health beliefs and systolic blood pressure (SBP) reduction from baseline to one-year follow-up was assessed. Health beliefs were measured by asking participants to agree or disagree with five health belief questions such as, ‘I worry about having a stroke,’ ‘I can protect myself against having a stroke,’ and ‘Some people are more likely to have a stroke than others.’ Multivariable linear regression models were used to assess the relationship between each health belief and SBP reduction. Results: A total of 434 patients were included in the analysis (50.2% female; mean age 64.2; 29.7% non-Hispanic white, 32.0% non-Hispanic black, 32.5% Hispanic, 5.8% other). Of those participants, 77.9% agreed with the statement, “I can protect myself against having a stroke” and had a significantly greater mean SBP reduction compared to those who disagreed (6.29 vs. 1.57 mmHg, p=0.02). No other health belief questions were found to be significantly associated with SBP reduction. In the multivariable model, adjusting for age, gender, race, education, intervention status, stroke history, and marital status, agreeing that you can protect yourself against having a stroke was associated with a 6.44 mmHg greater mean SBP reduction compared to disagreeing (p=0.02). Conclusion: In this cohort of stroke/TIA patients, participants who agreed that they could protect themselves against having a stroke had an average mean SBP reduction of more than two times that of participants who disagreed with that statement. Certain health beliefs, such as those related to patient empowerment, may play an important role in secondary stroke prevention.

Background: Stroke knowledge, which includes awareness of symptoms, risk factors and treatment options, is critical to preventing stroke and improving outcomes. In recent years there have been significant state, federal, and private initiatives to improve “door to needle time” including efforts towards lay education about acute stroke as an emergency; however, their impact is unknown. We assessed stroke knowledge over time among mild/moderate stroke/TIA patients in New York City in two large clinical trials, the Stroke Warning Information and Faster Treatment (SWIFT) study and the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) study. Methods: Basline data from SWIFT was collected between 2005-2009 and for DESERVE between 2012-2016. Before randomization, patients were asked closed-ended questions focused on stroke symptoms, risk factors and preparedness behaviors. Proportions of correct responses were calculated and logistic regression was used to assess the change in knowledge over time while controlling for education, age, gender, and race/ethnicity. We also assessed whether stroke knowledge changed differentially over time by race or gender using product terms. Results: A total of 1,190 participants from SWIFT and 552 from DESERVE were included in the analysis. The pooled sample was 50.1% female, 23.9% non-Hispanic black, 43.4% non-Hispanic white, and 48.4% Hispanic, mean age 64.3. The brain was correctly identified as the site where stroke occurs by 78.14%, all 5 symptoms of stroke were correctly identified by 40.64% (replying ‘yes’ to hemiparesis, hemisensory loss, difficulty speaking, blurred vision and ‘no’ to chest pain), and 6 or more risk factors were identified by 75.55% of participants in both cohorts. The odds of identifying the brain as the location of a stroke increased each year (OR=1.05, p. Correct responses to all 5 symptoms did not significantly change over time. Knowledge over time did not change differentially by race or gender. Conclusion: There was a small increase in stroke knowledge over time between 2005-2016 in our urban, multi-ethnic cohorts, though levels remain suboptimal.

Introduction: Prior research has shown that sleep duration is associated with risk of stroke and other cardiovascular events. However, evidence is sparse linking sleep duration with stroke severity. The aim of this study is to investigate the association between pre-stroke sleep duration and stroke severity at hospital admission in a cohort of mild/moderate stroke and TIA survivors. Methods: The present analysis used baseline data from the DESERVE study, a randomized controlled trial of a skills-based educational intervention. Sleep duration was measured using patients’ self-reported average hours of sleep per night during the past four weeks. Hours of sleep were then categorized into four groups with three non-normative groups, “Very Short Sleep” (1-4 hours), “Short Sleep” (5-6 hours), and “Long Sleep” (9-12 hours), and one normative sleep group (7-8 Hours). Stroke severity was assessed using the National Institute of Health Stroke Scale (NIHSS). The distribution of NIHSS was not normal; therefore the Kruskal Wallis test was used to assess bivariate associations. Multivariable analysis was conducted for sleep duration and stroke severity assuming a negative binomial distribution, due to overdispersion of variance. The final model was adjusted for gender, age, race/ethnicity, stroke history, hypertension, alcohol, and BMI. Results: A total of 453 patients were included in the analysis (51% Female; 28% Non-Hispanic white, 35% Non-Hispanic black, 31% Hispanic, and 6% Other; mean age 64.6). Median NIHSS was significantly different across the sleep categories, (Very Short Sleep=4; Short Sleep=2; Normative Sleep=2; Long Sleep=1; p=0.0024). The unadjusted model did not show significant differences in stroke severity between non-normative groups and the normative group (Very Short Sleep, p=0.068; Short Sleep, p=0.235; Long Sleep, p=0.203). Further adjustment for sociodemographic and clinical factors did not alter the pattern of results. Conclusions: We found no significant association between normative and non-normative sleep duration and stroke severity among mild/moderate stroke and TIA survivors. However, future studies may be needed to examine this relationship with a greater range of stroke severity.

Studies suggest that cognitive impairment is common, even following mild stroke. Yet, secondary prevention strategies typically do not take into account patients’ cognitive functioning. Data from DESERVE, a secondary stroke prevention trial, were used to investigate relationships between cognition 6 months post-stroke and changes in medication adherence (MA) and total cholesterol (TC) between baseline and 12-month follow-up among mild/moderate stroke and TIA patients. Patients with any documented history of cognitive impairment and those unable to provide informed consent were excluded from the study. At six months, cognition was measured using three cognitively focused variables from the Stroke Impact Scale: Concentration, Remember Things Told to You (‘Memory’) and Orientation in Time. Items were scored from 1 to 5, with 1-3 = severe impairment, 4 = mild impairment, and 5 = no impairment. MA was measured using the 8-item Morisky Medication Adherence Scale. ANCOVA models were used to analyze associations between cognition and changes in MA and TC, and association between MA and TC, adjusting for key socio-demographic and clinical characteristics and intervention status. The analytic sample (n=396) was 48% male, 27% white, 32% black, 35% Hispanic, with mean age 64. Impairment in Memory was 13.4% severe, 13.6% mild, 44.7% none. In fully adjusted models, patients who were severely impaired in Memory, showed less improvement in MA compared to mild and no impairment: 0.3 vs. 0.2 vs 1.3 points (p

Introduction: Studies have documented seasonal patterns in stroke outcomes. While results are equivocal most report increased rates of these outcomes in the winter-spring and hypothesize this is explained by ambient temperature. Sleep disturbance, which also varies by season, may also explain this pattern. In this analysis we leverage a unique cohort to test whether incident or recurrent strokes vary by season, and whether this co-varies with sleep disturbance. Methods: Data comes from SWIFT, a stroke preparedness RCT conducted in northern Manhattan. Season of stroke was classified as winter (W; Dec - Feb), spring (Sp; Mar - May), summer (Su; Jun - Aug), fall (F; Sept - Nov). We restricted our analysis to the period Feb 2005 - Jan 2009. Incident strokes were individuals enrolled at baseline without radiological or clinical evidence of prior stroke. Recurrent strokes were captured as part of follow-up protocol. Sleep was measured with the MOS sleep scale, a 12 item questionnaire that produces 8 validated scales. For brevity, we report results using the sleep problem index 2 (9 questions). We assessed seasonal variation in stroke incidence using a one-way goodness of fit chi-square test assuming a distribution based on the number of days per season. The relationship between seasonal variation in stroke and sleep was assessed using ANOVA. Results: A total of 835 incident strokes were enrolled (25% white, 15.5% black, 53.1% Hispanic, 6.4% other; 49.8% female; mean age 63.4±15.6). Incident stroke was not significantly different by season (24.3% W; 22.8% Sp; 28.6% Su; 24.3% F; p=0.09). Mean sleep problems did not vary by season (32.3 W; 30.8 Sp; 31.9 Su; 31.4 F; p=0.86) for incident strokes. A total of 120 first recurrent strokes were captured (20.8% white, 17.5% black, 5% Hispanic, 6.7% other; 49.2% female; mean age 66.0±15.0). Recurrent stroke was significantly different by season (21.7% W; 14.2% Sp; 36.7% Su; 27.5% F; p Conclusion: We find no variation in incident strokes but an increased proportion of first recurrent strokes in the summer. Neither incident nor recurrent strokes co-varied with sleep problems. Future studies in non-urban samples are warranted.