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BACKGROUND: Antiretroviral therapies (ART) are essential HIV care. As people living with HIV age and their presence in nursing homes (NH) increases, it is critical to evaluate the quality of HIV care. We determine the rate of ART use and examine individual and facility level characteristics associated with no ART use in a nationally representative long-stay NH residents with HIV. METHODS: This retrospective cohort study included all long-stay Medicare fee-for-service NH residents (2013–2016) with HIV who had a valid Minimum Data Set assessment. Residents were followed from long-stay qualification until death, Part D disenrollment, transfer from long-term care to another healthcare setting, or 12/31/2016. We identified individual and facility characteristics that associated with non-use of ART using generalized estimating equation logistic regression. RESULTS: 4,171 eligible HIV+ residents from 2,459 NHs were included in our study. Only 36% (1507/4171) received any ART regimen during an average of 11.6 months of observation. Older age, females, white race, receipt of Medicare skilled nursing benefits and some major cardiometabolic comorbidities and mental health conditions were associated with non-ART use. Rates of non-ART use did not vary significantly by residents’ end-of-life status (p=0.21). Residents in facilities with a higher HIV concentration [adjusted odds ratio (adjOR) 3.42; 95% confidence interval (CI) 2.13 – 5.48] and an AIDS unit (adjOR 2.51; 95% CI 1.92 – 3.30) had higher odds of using an ART. CONCLUSIONS AND IMPLICATIONS: The rate of ART use by HIV+ long-stay NH residents was low. Facilities’ experience with HIV played an important role in ART receipt. Interventions to improve rates of ART us in NHs are urgently needed to ensure optimal health outcomes.

Thoughtful, high-quality clinician–patient communication about starting antiretroviral therapy (ART) is a cornerstone of HIV care, and specific guidelines regarding exactly what ought to be discussed with patients considering ART have been in place since 2006. The extent to which the recommended topics are discussed and how these topics are addressed in observed dialogue in HIV care has not been studied. We conducted a content analysis to describe how these dialogues occur and, secondarily, assessed the frequency with which the recommended topics are discussed. Our study analyzed patient–clinician dialogue regarding ART initiation, comparing the content of 24 audio-recorded dialogues with the recommended guidelines, and describing how communication about the recommended topics takes place. While patient readiness to initiate therapy was discussed in the majority of visits (n = 18), the remaining topics (e.g. patient understanding of HIV and its treatment, motivation to adhere, barriers to and facilitators of adherence, social support, daily schedules, tolerance of pills) were discussed less often. Based on the findings, we suggest that systems be put in place (e.g. checklists) to guide providers in these discussions, and that providers utilize the teach-back method to ensure patient understanding.

Patient centered care (PCC) in human immunodeficiency virus (HIV) care systems in sub-Saharan Africa (SSA) may improve outcomes for persons with HIV (PWH). We review the progress the region has made in promoting PCC and highlight some of the implementation challenges and potential areas of research.Studies show growing interest in promoting PCC across HIV care programs in SSA. Effective implementation of PCC, however, is hampered by: (1) lack of consensus on the conceptualization of PCC, including definition, frameworks, measures, and implementation strategies; (2) limited regional studies on the adoption and sustainability of PCC interventions; and (3) healthcare structural challenges including limited capital and human resources, poor provider-patient dynamics, high provider turnover, and lack of continuity in care. Recent studies in the region have focused on identifying key PCC domains addressable in resource limited settings, understanding the PCC experiences and expectations of PWH and their providers, and testing innovative interventions. We highlight the need for additional studies to address the existing gaps.We discuss the progress and challenges of implementing PCC in HIV care settings in SSA as well as the need for additional research to ensure that proposed PCC interventions have optimal impact.

To examine changes in plan composition and enrollee experience associated with Medicaid expansion among Medicaid managed care organization (MCO) enrollees.Using 2012-2018 Adult Medicaid Consumer Assessment of Healthcare Providers and Systems surveys, we estimated changes in MCO enrollee characteristics and 4 outcomes: having access to needed care, having a personal doctor, having timely access to a checkup, and having timely access to specialty care.We estimated multivariable linear probability models comparing pre- vs postexpansion changes in expansion vs nonexpansion states. The postexpansion period was modeled as an event-study regression to account for changes over time. The coefficient of interest was a Medicaid expansion-by-year term.Medicaid expansion was associated with statistically significant decreases in the proportion of female enrollees (-8.4 percentage points [PP]; P .01) and increases in the proportion of enrollees who were aged 55 to 64 years (6.8 PP; P .01) and were non-Hispanic White (4.4 PP; P .01). Relative to enrollees in nonexpansion states, MCO enrollees in expansion states were significantly less likely to report access to a personal doctor (-1.6 PP; 95% CI, -3.0 to -0.1 PP) and less likely to report timely access to specialty care (-2.1 PP; 95% CI, -3.4 to -0.8 PP; P .01) in the first year after expansion. Differences were not statistically significant by the second year post expansion. There were not significant changes in the other 2 outcomes.State policy makers may need to account for the role that Medicaid expansion may have in changing Medicaid MCO enrollee composition to prevent unfair penalization on performance metrics.

U.S. nursing homes (NH) have a growing prevalence of individuals with severe mental illness (SMI) and substance use disorders (SUD), and an associated increasing proportion of people under 65. We explored how Directors of Nursing (DONs) perceive challenges and strategies in caring for these populations. We conducted semi-structured telephone interviews with 32 DONs from diverse facilities around the U.S. Participants reported that people with SUD and SMI often present behavioral challenges requiring resource intensive responses, while regulations constrain optimal medication treatment. Younger individuals are considered more demanding of staff and impatient with traditional NH activities designed for older people. Some NHs report they screen out people with behavioral health disorders; they tend to be concentrated in NHs in economically disadvantaged communities. Individuals may remain in NHs because suitable settings for discharge are unavailable. These developments constitute a back door “re-institutionalization” of people with behavioral health disorders, and a growing crisis.

BACKGROUND AND OBJECTIVES Rhetoric and policies aimed at restricting immigration to the United States, such as those proposed during the Trump administration, may lead to reduced enrollment in Medicaid for children of immigrants, even those who were legally eligible. This study assessed how children’s health insurance coverage changed before versus during the Trump administration by parental immigration status. METHODS Using American Community Survey data, we compared changes in rates of uninsurance and Medicaid enrollment for children in the United States before (2015 to 2016) versus during (2017 to 2019) the Trump administration. Children were categorized by parental immigration status: citizen children with US-born parents, citizen children with naturalized parents, children from mixed-status families, or noncitizen children. RESULTS The study population included 2 963 787 children between 2015 and 2019, representing approximately 64 million children annually. Throughout our study period, uninsurance rates for children from mixed-status families and noncitizen children were higher than citizen children with United States-born parents. Beginning in 2017, there were significant increases in uninsurance among children from mixed-status families (0.48 percentage points [PP], 95% confidence interval [CI]: 0.06 to 0.91) that increased to 1.48 PP (95% CI: 0.98 to 1.99) by 2019 when compared with concurrent trends among citizen children with US-born parents. Changes were accompanied by significant decreases in Medicaid enrollment by 2019 (−0.89 PP, 95% CI: −1.62 to −0.16). CONCLUSIONS There were substantial disparities in uninsurance rates by parental immigration status. Compared with citizen children with US-born parents, uninsurance rates among children from mixed-status families significantly increased between 2017 and 2019, with the magnitude of disparity widening over time.

BACKGROUND: In times of health resource reallocation, capacities must remain able to meet a continued demand for essential, nonambulatory neurosurgical acute care. This study sought to characterize the demand for and provision of neurosurgical acute care during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This single-center cross-sectional observational analysis compared nonambulatory neurosurgical consult encounters during the peri-surge period (March 9 to May 31, 2020) with those during an analogous period in 2019. Outcomes included consult volume, distribution of problem types, disease severity, and rate of acute operative intervention. RESULTS: A total of 1494 neurosurgical consults were analyzed. Amidst the pandemic surge, 583 consults were seen, which was 6.4 standard deviations below the mean among analogous 2016-2019 periods (mean 873; standard deviation 45, P = 0.001). Between 2019 and 2020, the proportion of degenerative spine consults decreased in favor of spinal trauma (25.6% vs. 34% and 51.9% vs. 41.4%, P = 0.088). Among aneurysmal subarachnoid hemorrhage cases, poor-grade (Hunt and Hess grades 4-5) presentations were more common (30% vs. 14.8%, P = 0.086). A greater proportion of pandemic era consults resulted in acute operative management, with an unchanged absolute frequency of acutely operative consults (123/583 [21.1%] vs. 120/911 [13.2%], P < 0.001). CONCLUSIONS: Neurosurgical consult volume during the pandemic surge hit a 5-year institutional low. Amidst vast reallocation of health care resources, demand for high-acuity nonambulatory neurosurgical care continued and proportionally increased for greater-acuity pathologies. In our continued current pandemic as well as any future situations of mass health resource reallocation, neurosurgical acute care capacities must be preserved.

BACKGROUND: Medicare Advantage plans, private managed care plans that enrolled 34% of Medicare beneficiaries in 2019, received $6 billion in annual bonus payments on the basis of their performance on a 5-star rating system. Little is known, however, as to the extent these ratings adequately capture enrollee experience. OBJECTIVES: To measure the effect of exposure to higher rated Medicare Advantage contracts on enrollee experience. DESIGN: An instrumental variables analysis using MA contract consolidation as an exogenous shock to the quality of plan enrollees are exposed to. PARTICIPANTS: A total of 345,897 MA enrollees enrolled in non-consolidated contracts and 21,405 enrollees who were consolidated. MAIN MEASURES: The primary exposure was enrollee star rating, instrumented using contract consolidation. The primary outcomes were enrollee self-reported experience measures. KEY RESULTS: There were no significant effects on increased star ratings on 23 of 27 outcomes. A one-star increase in contract star rating leads to a 5.4 percentage point increase in reporting that pain does not interfere with daily activities (95%CI 2.4, 8.4), and a 4.4 percentage reduction in the likelihood that a physician would talk to the enrollee about physical activity (95%CI: −7.8, −1.1, all p

Identifying patients at increased risk for HIV acquisition can be challenging. Primary care providers (PCPs) may benefit from tools that help them identify appropriate candidates for HIV pre-exposure prophylaxis (PrEP). We and others have previously developed and validated HIV risk prediction models to identify PrEP candidates using electronic health records data. In the current study, we convened focus groups with PCPs to elicit their perspectives on using prediction models to identify PrEP candidates in clinical practice. PCPs were receptive to using prediction models to identify PrEP candidates. PCPs believed that models could facilitate patient-provider communication about HIV risk, destigmatize and standardize HIV risk assessments, help patients accurately perceive their risk, and identify PrEP candidates who might otherwise be missed. However, PCPs had concerns about patients’ reactions to having their medical records searched, harms from potential breaches in confidentiality, and the accuracy of model predictions. Interest in clinical decision-support for PrEP was greatest among PrEP-inexperienced providers. Successful implementation of prediction models will require tailoring them to providers’ preferences and addressing concerns about their use.

Appropriate antiretroviral therapy use in children with Human Immunodeficiency Virus (HIV) is essential for optimizing clinical outcomes and preventing HIV transmission. To describe and determine correlates of HIV antiretroviral therapy (ART) persistence and implementation for children and adolescents in the United States. We studied Medicaid enrollees (ages 2–19 years) with HIV in 14 states in 2011 and 2012. We defined non-persistence as a discontinuation of an ART regimen for at least 90 days, and calculated implementation as the proportion of days on ART while persistent. We used Cox proportional regression and logistic regression to determine characteristics associated with ART non-persistence and poor (

Little is known about how well the Centers for Medicare and Medicaid Services' five-star rating system for the overall quality of Medicare Advantage (MA) contracts captures quality of care. Leveraging contract consolidation as a natural experiment to study the association between outcomes and insurer-initiated enrollee shifts to plans with higher-rated contracts, we found that enrollees experiencing a one-star MA rating increase were 20.8 percent less likely to voluntarily leave their plan to enroll in another plan or traditional Medicare. When hospitalized, they were 3.4 percent more likely to use a higher-quality hospital and 2.6 percent less likely to be readmitted within ninety days. Our findings suggest that MA star ratings may capture key domains of an MA plan's quality; however, the differences in outcomes that they capture might not all be clinically meaningful.

Measuring adherence to medication is complex due to the diversity of contexts in which medications are prescribed, dispensed and used. The Timelines-Events-Objectives-Sources (TEOS) framework outlined a process to operationalize adherence. We aimed to develop practical recommendations for quantification of medication adherence using self-report (SR), electronic monitoring (EM) and electronic healthcare databases (EHD) consistent with the TEOS framework for adherence operationalization.An adherence methodology working group of the International Society for Medication Adherence (ESPACOMP) analysed implications of the process of medication adherence for all data sources and discussed considerations specific to SR, EM and EHD regarding the information available on the prescribing, dispensing, recommended and actual use timelines, the four events relevant for distinguishing the adherence phases, the study objectives commonly addressed with each type of data, and the potential sources of measurement error and quality criteria applicable.Four key implications for medication adherence measurement are common to all data sources: adherence is a comparison between two series of events (recommended and actual use); it refers to one or more specific medication(s); it applies to regular repeated events coinciding with known recommended dosing; and it requires separate measurement of the three adherence phases for a complete picture of patients' adherence. We propose recommendations deriving from these statements, and aspects to be considered in study design when measuring adherence with SR, EM and EHD using the TEOS framework.The quality of medication adherence estimates is the result of several design choices that may optimize the data available.

Little is known about the mental health needs of adolescents living with HIV (ALWH) in Mozambique, including the potential relationship between mental health challenges and poor antiretroviral treatment (ART) adherence. We examined mental health problems (anxiety, depression, post-traumatic stress disorder [PTSD] symptoms and impairment) and their association with self-reported ART adherence among ALWH ages 15-19 in Nampula, Mozambique. The associations between each mental health problem area and sub-optimal adherence were estimated using logistic regression, controlling for age, education, and social support, with interaction by gender. Males had significantly higher anxiety (5.6 vs 4.3

The coronavirus disease 2019 (COVID-19) pandemic has been accompanied by an increase in depression in U.S. adults. Previous literature suggests that having assets may protect against depression. Using a nationally representative longitudinal panel survey of U.S. adults studied in March and April 2020 and in March and April 2021, we found that (i) 20.3% of U.S. adults reported symptoms of persistent depression in Spring 2020 and Spring 2021, (ii) having more assets was associated with lower symptoms of persistent depression, with financial assets—household income and savings—most strongly associated, and (iii) while having assets appeared to protect persons—in particular those without stressors—from symptoms of persistent depression over the COVID-19 pandemic, having assets did not appear to reduce the effects of job loss, financial difficulties, or relationship stress on symptoms of persistent depression. Efforts to reduce population depression should consider the role played by assets in shaping risk of symptoms of persistent depression.

The inverse relation between income and depression is well established. Less is understood about the relation between wealth and depression. We therefore conducted a scoping review to answer the question: What is known from the existing literature about the relation between wealth and depression?We searched for studies and articles in Medline (via PubMed), Embase, PsycINFO, PsycArticles, EconLit, and SocINDEX from inception through July 19, 2020. Ninety-six articles were included in our review. Key article characteristics were year of publication, sample size, country, study design, definition of depression, definition of wealth, and association between wealth and depression. Thirty-two longitudinal articles were included in a detailed charted review.Depression was defined in a relatively standard manner across articles. In contrast, definitions and measurements of wealth varied greatly. The majority of studies in the full review (n = 56, 58%) and half of the studies in the longitudinal charted review (n = 16, 50%) reported an inverse relation between wealth and depression. The longitudinal charted review showed that (1) macro-economic events influenced depression, (2) wealth status influenced depression across the lifecourse, (3) wealth protected against depression in the face of stressors such as job loss, (4) subjective or psychosocial factors such as perception of wealth, relative comparison, and social status modified the relation between wealth and depression, and (5) savings interventions were successful in reducing depression and varied by context.These findings suggest that wealth should be included in our consideration of the forces that shape mental health.

PURPOSE: The World Health Organization (WHO) advocates for patients to play an active role in their healthcare in order to improve the quality of care delivery. However, there is limited research on provider perceptions of the role of the patient during a medical encounter in an HIV setting in Sub-Saharan Africa. METHODS: This qualitative study was conducted between September 2014 and August 2015. Sixty healthcare providers were recruited using convenience sampling methods from three sites (Moi Teaching and Referral Hospital, Webuye, and Busia) within the Academic Model Providing Access to Healthcare (AMPATH) HIV care and treatment program. In-depth interviews were conducted in either Swahili or English, transcribed, and translated if necessary into English. Data was analyzed thematically. RESULTS: Provider expectations were mainly influenced by their professional role. Despite this variance, providers expect patients to communicate openly during their clinical encounters. Overall, there was a shift in provider expectations of the patient from a traditional paternalistic role to a more active role. CONCLUSION: This study provides valuable insight into provider expectations of patients during medical encounters in HIV settings. Findings from this study may contribute to developing appropriate interventions for providers as well as to design patient empowerment initiatives.

To promote HIV antiretroviral therapy (ART) outcomes in Haiti, we developed a culturally relevant intervention (InfoPlus Adherence) that combines an electronic medical record alert identifying patients at elevated risk of treatment failure and provider-delivered brief problem-solving counseling. We conducted a quasi-experimental mixed-methods study among 146 patients at two large ART clinics in Haiti with 728 historical controls. We conducted quantitative assessments of patients at baseline and intervention completion (6 months) as well as focus groups with health workers and exit interviews with patients. The primary quantitative outcome measures were HIV viral suppression according to medical record and ART adherence in terms of >=90% for “proportion of days covered” (PDC) according to pharmacy dispensing data. Results indicated that the proportion of intervention patients with suppressed VL during the study/historical periods was 80.0%/86.0% and 76.8%/87.4% for controls. In a difference-in-differences (DID) analytic model, the adjusted relative risk for viral suppression with the intervention was 1.15 (95% CI: 0.92 – 1.45, p=0.21), representing favorable but non-significant association between the intervention and the trajectory of VL outcomes. PDC >= 90% during the study/historical periods was 30.9%/11.0% among intervention participants and 16.9%/19.4% among controls. In the adjusted DID model, the relative risk for of PDC>=90% with the intervention was 4.00 (95% CI: 1.91–8.38, p

The study examines the reliability and validity of a 3-item self-report adherence measure among people with HIV (PWH) experiencing homelessness, substance use, and mental health disorders. 336 participants were included from nine sites across the US between September 2013 and February 2017. We assessed the validity of a self-report scale for adherence to antiretroviral therapy by comparing it with viral load (VL) abstracted from medical records at baseline, 6, 12, and 18 months. The items had high internal consistency (Cronbach’s alpha coefficients at each time point were > 0.8). The adherence scale scores were higher in the group that achieved VL suppression compared to the group that did not. The c-statistic for the receiver-operating characteristic curves pooled across time points was 0.77 for each adherence sub-item and 0.78 for the overall score. The self-report adherence measure shows good internal consistency and validity that correlated with VL suppression in homeless populations.

Background: Human immunodeficiency virus–infected (HIV+) individuals are disproportionately at risk for human papillomavirus (HPV)-associated cancers, but the magnitude of risk estimates varies widely. We conducted a retrospective study using a large U.S.-based cohort to describe the relationship between HIV infection and incident cervical, oropharyngeal, and anal cancers. Methods: Using 2001–2012 U.S. Medicaid data from 14 states, we matched one HIV+ to three HIV-uninfected (HIV−) enrollees on sex, race, state, age, and year, and followed persons for up to 10 years. We developed Cox proportional hazards models comparing HIV+ to HIV− for time to cancer diagnosis adjusted for demographic and comorbidity attributes. Results: Our cohorts included 443,592 women for the cervical cancer analysis, and 907,348 and 906,616 persons for the oropharyngeal and anal cancer analyses. The cervical cancer cohort had a mean age of 39 years and was 55% Black. The oropharyngeal and anal cancer cohorts were 50% male, had a mean age of 41 years, and were 51% Black. We estimated the following HRs: cervical cancer, 3.27 [95% confidence interval (CI), 2.82–3.80]; oropharyngeal cancer, 1.90 (95% CI, 1.62–2.23; both sexes), 1.69 (95% CI, 1.39–2.04; males), and 2.55 (95% CI, 1.86–3.50; females); and anal cancer, 18.42 (95% CI, 14.65–23.16; both sexes), 20.73 (95% CI, 15.60–27.56; males), and 12.88 (95% CI, 8.69–19.07; females). Conclusions: HIV+ persons were at an elevated risk for HPV-associated cancers, especially anal cancer. Impact: Medicaid claims data corroborate previous estimates based on registries and clinical cohorts.

Timely postpartum care is associated with lower maternal morbidity and mortality, yet fewer than half of Medicaid beneficiaries attend a postpartum visit. Medicaid enrollees are at higher risk of postpartum disruptions in insurance because pregnancy-related Medicaid eligibility ends sixty days after delivery. We used Medicaid claims data for 2013-15 from Colorado, which expanded Medicaid under the Affordable Care Act, and Utah, which did not. We found that after expansion, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.

Background The COVID-19 pandemic and its consequences have been associated with an increase in poor population mental health. We assessed how depressive symptoms changed among U.S. adults over the course of the COVID-19 pandemic and identified the key risk factors for these symptoms. Methods Longitudinal panel study of a nationally representative group of U.S. adults ages 18 years and older surveyed in March-April 2020 (Time 1; N=1441) and March-April 2021 (Time 2; N=1161) in the COVID-19 and Life Stressors Impact on Mental Health and Well-being study (CLIMB). The Patient Health Questionnaire-9 (PHQ-9) was used to define elevated depressive symptoms (cut-off ≥10) and depressive symptoms score (0-27). Findings The prevalence of elevated depressive symptoms persisted from 27.8% in 2020 (95% CI: 24.9, 30.9) to 32.8% in 2021 (95% CI: 29.1, 36.8). Over time, the central drivers of depressive symptoms were low household income, not being married, and experiencing multiple stressors during the COVID-19 pandemic. The odds ratio of elevated depressive symptoms for low income relative to high income persons increased from 2.3 (95% CI: 1.2, 4.2) in 2020 to 7.0 (95% CI: 3.7, 13.3) in 2021. Fewer people reported experiencing 4 or more COVID-19 stressors in 2021 than in 2020 (47.5% in 2020 vs 37.1% in 2021), but the odds ratio of elevated depressive symptoms associated with 4 or more stressors relative to 1 stressor or less increased from 1.9 (95% CI: 1.2, 3.1) in 2020 to 5.4 (95% CI: 3.2, 9.2) in 2021. Interpretation The burden of depressive symptoms in the U.S. adult population increased over the course of the COVID-19 pandemic. Mental health gaps grew between populations with different assets and stressor experiences during the COVID-19 pandemic. Funding CLIMB Time 1 was sponsored by the Rockefeller Foundation-Boston University 3-D Commission. CLIMB Time 2 was sponsored by the de Beaumont Foundation.

Patient-reported outcome and experience measures are increasingly important in health care and health research. The use of these measures is growing in the US and overseas, and performance measures that incorporate patient-reported outcomes are being considered, particularly in cancer. A major challenge for the use of these measures is patient non-response, especially for diseases such as cancer and dementia. A commonly used approach is to ask a proxy such as the patient’s spouse or child to complete the measure on their behalf. Proxy reporting is used in major surveys, including those used in pay-for-performance approaches. No standards exist regarding how to adjust for the use of proxy-reported measures in analyses. As patients requiring proxies likely differ in important ways from those who can self-report, adjusting for these differences is important. In this paper, we evaluate the use of propensity score models when adjusting for proxy-reported data, including weighting, matching with replacement, and non-parametric multiple imputation. Additionally, because previous analyses using propensity scores for proxy reports have employed stepwise or p value based algorithms, we evaluated the sensitivity of our results to the inclusion of respondent-sensitive variables such as proxy reports of patient health status, as well as auxiliary covariates. Under all propensity score methods, estimates obtained from propensity scores using respondent-insensitive variables were different from those obtained when respondent-sensitive variables were incorporated in the propensity score. Propensity score methods have limitations in these contexts and their assumptions should be carefully examined.

This cohort study examines the association of Medicaid expansion in Arkansas with continuous postpartum coverage, postpartum health care use, and change in racial disparities., Key Points Question Was Arkansas’ Medicaid expansion associated with an increase in postpartum insurance coverage and visits, and did racial disparities in these outcomes change after expansion? Findings In this cohort study with difference-in-differences analysis of 60 990 childbirths, Medicaid expansion was associated with increased continuous postpartum insurance coverage and outpatient visits. While disparities between non-Hispanic Black and White individuals in continuous postpartum coverage decreased after expansion, racial disparities in postpartum outpatient visits were unchanged. Meaning Medicaid expansion, and 12-month extensions of pregnancy Medicaid, may increase postpartum coverage and outpatient visits, but additional efforts are needed to reduce racial disparities in postpartum outpatient visits., Importance Non-Hispanic Black individuals are disproportionally covered by Medicaid during pregnancy and, compared with non-Hispanic White individuals, have higher rates of postpartum coverage loss and mortality. Expanded Medicaid coverage under the Affordable Care Act may have increased continuity of coverage and access to care in the critical postpartum period in expansion states. Objective To examine the association of Medicaid expansion in Arkansas with continuous postpartum coverage, postpartum health care use, and change in racial disparities in the study outcomes. Design, Setting, and Participants This cohort study with a difference-in-differences analysis compared persons with Medicaid and commercially financed childbirth, stratified by race, using Arkansas’ All-Payer Claims Database for persons with a childbirth between 2013 and 2015. Race and ethnicity from birth certificate data were classified as Hispanic, non-Hispanic Black (hereafter Black), non-Hispanic White (hereafter White), and other (including Asian, Native American or Alaska Native, and Pacific Islander) or unknown race. Data were analyzed between June 2020 and August 2021. Exposures Medicaid-paid childbirth after January 1, 2014. Main Outcomes and Measures Continuous health insurance coverage and the number of outpatient visits during the first 6 months postpartum. Results A total of 60 990 childbirths (mean [SD] age of birthing person, 27 [5.3] years; 67% White, 22% Black, and 7% Hispanic) were included, among which 72.3% were paid for by Medicaid and 27.7% were paid for by a commercial payer. Medicaid expansion in Arkansas was associated with a 27.8 (95% CI, 26.1-29.5) percentage point increase in continuous insurance coverage and an increase in outpatient visits of 0.9 (95% CI, 0.7-1.1) during the first 6 months postpartum, representing relative increases of 54.9% and 75.0%, respectively. Racial disparities in postpartum coverage decreased from 6.3 (95% CI, 3.9-8.7) percentage points before expansion to −2.0 (95% CI, −2.8 to −1.2) percentage points after expansion. However, disparities in outpatient care between Black and White individuals persisted after Medicaid expansion (preexpansion difference, 0.4 [95% CI, 0.2-0.6] visits; postexpansion difference, 0.5 [95% CI, 0.4-0.6] visits). Conclusions and Relevance In this cohort study with a difference-in-differences analysis of 60 990 childbirths, Medicaid expansion was associated with higher rates of postpartum coverage and outpatient visits and lower racial and ethnic disparities in postpartum coverage. However, disparities in outpatient visits between Black and White individuals were unchanged. Additional policy approaches are needed to reduce racial and ethnic disparities in postpartum care.

The aim was to examine the association of patient-reported physician awareness of biological CAM use and patient perceptions of care experience and quality with a population-based study of patients with incident lung and colorectal cancer. This was a secondary data analysis using regression models. Outcomes of interest were patient reports of medical care experience and quality ratings. Among 716 patients who reported biological CAM use, 69% reported their physicians were aware of this. Patients who reported physician awareness of biological CAM use had higher adjusted scores for medical care experience ( + 5.4, 95%CI:2.3,8.6) and care quality ( + 3.6, 95%CI:−0.3, + 7.5). These associations suggest that physicians should be encouraged to inquire about biological CAM use.

Provider-patient communication (PPC) skills are key in promoting patient satisfaction. Our study examined the relationship between clinician PPC skills and patient satisfaction with care among virally unsuppressed adult HIV patients in Busia County, Kenya. This cross-sectional study was conducted among 360 HIV patients on first line antiretroviral regimen and having a recent viral load ≥400 copies HIV RNA/ml. We conducted logistic regression analysis. The mean age of participants was 48.2 years [standard deviation (SD): 12.05]. Overall, the mean score on clinician PPC skills was 33.3 (SD: 9.0). A high proportion (85%) of participants reported satisfaction with the HIV care services. After adjusting for covariates, the odds of being satisfied with care increased by 19% (adjusted odds ratio: 1.19, 95% CI: 1.11-1.30) for every one unit increase in the clinician PPC skills score. Promoting good PPC skills may be key to improving patient satisfaction with HIV care.

Background Patient engagement is effective in promoting adherence to HIV care. In an effort to promote patient-centered care, we implemented an enhanced patient care (EPC) intervention that addresses a combination of system-level barriers including provider training, continuity of clinician-patient relationship, enhanced treatment dialogue and better clinic scheduling. We describe the initial implementation of the EPC intervention in a rural HIV clinic in Kenya, and the factors that facilitated its implementation. Methods The intervention occurred in one of the rural Academic Model Providing Healthcare (AMPATHplus) health facilities in Busia County in the western region of Kenya. Both qualitative and quantitative data were collected through training and meeting proceedings/minutes, a patient tracking tool, treatment dialogue and a peer confirmation tool. Qualitative data were coded and emerging themes on the implementation and adaptation of the intervention were developed. Descriptive analysis including percentages and means were performed on the quantitative data. Results Our analysis identified four key factors that facilitated the implementation of this intervention. (1) The smooth integration of the intervention as part of care that was facilitated by provider training, biweekly meetings between the research and clinical team and having an intervention that promotes the health facility agenda. (2) Commitment of stakeholders including providers and patients to the intervention. (3) The adaptability of the intervention to the existing context while still maintaining fidelity to the intervention. (4) Embedding the intervention in a facility with adequate infrastructure to support its implementation. Conclusions This analysis demonstrates the value of using mixed methods approaches to study the implementation of an intervention. Our findings emphasize how critical local support, local infrastructure, and effective communication are to adapting a new intervention in a clinical care program.

BACKGROUND/OBJECTIVES As the national population of persons living with human immunodeficiency virus (HIV) ages, they will require greater postacute and long-term care use. Little is known about the quality of nursing homes (NHs) to which patients with HIV are admitted. In this study, we assess the association between the number of persons with HIV admitted annually to a given NH (HIV concentration) and that NH's quality outcomes. DESIGN A cross-sectional comparative study. SETTING NHs in nine states, from 2001 to 2012. PARTICIPANTS A total of 46 918 NH-years accounting for 67 301 admissions by patients with HIV. MEASUREMENTS We used 100% Medicaid Analytic Extract, Minimum Dataset 2.0 and 3.0, and Medicare claims from 2001 to 2012 from nine states to examine the association between HIV concentration and NH quality. Persons were classified as HIV positive on the basis of all available data sources, and a NH's percentage of new admissions with HIV was calculated (HIV concentration). We then compared differences in star ratings, rehospitalization rates, NH survey deficiencies, and restraint use by a NH's percentage of admissions with HIV, using linear random effects models. RESULTS After adjusting for NH characteristics, zip code characteristics, and state and year fixed effects, NHs with greater than 0% to 5% of admissions with HIV had a 0.6 lower star rating (P

Discontinuous Medicaid insurance erodes access to care, increases administrative costs, and exposes enrollees to substantial out-of-pocket spending. To assess the impact of Medicaid expansion under the Affordable Care Act on continuity of Medicaid coverage among those enrolled prior to expansion. Using a difference-in-differences framework, we compared Colorado, a state that expanded Medicaid, to Utah, a nonexpansion state, before and after Medicaid expansion implementation. Adults ages 18–62 who were enrolled in Medicaid coverage in Colorado and Utah prior to expansion, from the Utah and Colorado All Payer Claims Databases, 2013–2015. The primary outcomes were the duration of Medicaid enrollment and rates of disrupted coverage. Following Medicaid expansion, enrollees in Colorado gained an additional 2 months of coverage over two years of follow-up and were 16 percentage points less likely to experience a coverage disruption in a given year relative to enrollees in Utah. Increasing Medicaid eligibility levels under the Affordable Care Act appears to be an effective strategy to reduce churning in the Medicaid program, with important implications for other states that are considering Medicaid expansion.

Objectives Given an aging human immunodeficiency virus (HIV) population, we aimed to determine the prevalence of HIV for long-stay residents in US nursing homes (NHs) between 2001 and 2010 and to compare characteristics and diagnoses of HIV-positive (HIV+) and negative (HIV-) residents. Also, for residents with dementia diagnoses, we compared antipsychotic (APS) medication receipt by HIV status. Design A cross-sectional comparative study. Setting NHs in the 14 states accounting for 75% of persons living with HIV. Participants A total of 9 245 009 long-stay NH residents. Measurements Using Medicaid fee-for-service claims data in the years 2001 to 2010, together with Medicare resident assessment and Chronic Condition Warehouse data, we identified long-stay (more than 89 days) NH residents by HIV status and dementia presence. We examined dementia presence by age groups and APS medication receipt by younger (aged younger than 65 years) vs older (aged 65 years or older) residents, using logistic regression. Results Between 2001 and 2010, the prevalence of long-stay residents with HIV in NHs increased from 0.7% to 1.2%, a 71% increase. Long-stay residents with HIV were younger and less often female or white. For younger NH residents, rates of dementia were 20% and 16% for HIV+ and HIV- residents, respectively; they were 53% and 57%, respectively, for older residents. In adjusted analyses, younger HIV+ residents with dementia had greater odds of APS medication receipt than did HIV- residents (AOR = 1.3; 95% confidence interval [CI] = 1.2-1.4), but older HIV residents had lower odds (AOR = 0.9; 95% CI = 0.8-0.9). Conclusion The prevalence of long-stay HIV+ NH residents has increased over time, and given the rapid aging of the HIV population, this increase is likely to have continued. This study raises concern about potential differential quality of care for (younger) residents with HIV in NHs, but not for those aged 65 years and older. These findings contribute to the evidence base needed to ensure high-quality care for younger and older HIV+ residents in NHs.

BACKGROUND: Midyear disenrollment from Marketplace coverage may have detrimental effects on continuity of care and risk pool stability of individual health insurance markets. OBJECTIVE: The main objective of this study was to assess associations between insurance plan characteristics, individual and area-level demographics, and disenrollment from Marketplace coverage. DATA: All payer claims data from individual market enrollees, 2014–2016. STUDY DESIGN: We estimated Cox proportional hazards models to assess the relationship between plan actuarial value and Marketplace enrollment. The primary outcome was disenrollment from Marketplace coverage before the end of the year. We also calculated the proportion of enrollees who transitioned to other coverage after leaving the Marketplace, and identified demographic and area-level factors associated with early disenrollment. Finally, we compared monthly utilization rates between those who disenrolled early and those who maintained coverage. RESULTS: Nearly 1 in 4 Marketplace beneficiaries disenrolled midyear. The hazard rate of disenrollment was 30% lower for individuals in plans receiving cost-sharing reductions and 21% lower for those enrolled in gold plans, compared with silver plans without cost-sharing subsidies. Young adults had a 70% increased hazard of disenrollment compared with older adults. Those who disenrolled midyear had greater hospital and emergency department utilization before disenrollment compared with those who maintained continuous coverage. CONCLUSIONS: Plan generosity is significantly associated with lower disenrollment rates from Marketplace coverage. Reducing churning in Affordable Care Act Marketplaces may improve continuity of care and insurers’ ability to accurately forecast the health care costs of their enrollees.

Objective To examine the population-level impacts of the introduction of novel cancer therapies with high cost in the United States, using immunotherapies in advanced nonsmall cell lung cancer (NSCLC) as an example. Data sources Surveillance, Epidemiology, and End Results data in 2012-2015 linked to Medicare fee-for-service claims until 2016. Study design We examined population-level trends in treatment patterns, survival, and Medicare spending in patients diagnosed with advanced NSCLC, the leading cause of cancer death in the United States, between 2012 and 2015. We estimated the percentage of patients who received any antineoplastic therapy within two years of diagnosis, including novel immunotherapies. We compared the trends in overall survival and mean two-year Medicare spending per each patient before and after the introduction of immunotherapies in 2015. Data collection/extraction methods Not Applicable. Principal findings The percentage of patients treated with any antineoplastic therapy remained the same at 46.7% in 2012 and 2015, whereas the use of immunotherapies increased from 0% to 15.2%. The two-year survival rate and median survival increased by 3.3 percentage points (95% CI: 2.0, 4.5) and 0.4 months (CI: 0.0, 0.9), respectively, during the same period. The mean two-year total Medicare spending and outpatient spending per patient increased by $5735 (CI: 3479, 8040) and $7661 (CI: 5902, 9311), respectively, which were largely attributable to the increases in immunotherapy spending by $5806 (CI: 5165, 6459). Conclusions The introduction of lung cancer immunotherapies was accompanied by improvements in survival and increases in spending between 2012 and 2015 in the Medicare population. As novel immunotherapies and other target therapies continue to change the clinical management of various cancers, further efforts are needed to ensure their effective and efficient use, and to understand their population-level impacts in the United States.

INTRODUCTION The COVID-19 pandemic has caused unprecedented social, geopolitical, and health systems factors that may affect types of patients presenting for essential, non-ambulatory care. Social distancing and lockdowns may reduce the incidence of trauma; however, a significant decline in presentations of acute medical conditions such as stroke and ACS have been reported. Furthermore, health system capacities are substantially altered, with elective surgeries postponed to devote resources to COVID-related illness and high acuity non-COVID illness. METHODS We reviewed all emergency department and inpatient consultations to the neurosurgical service at a Level 1 Trauma Center during an 8-week post-lockdown period (3/15-5/4), quantifying overall volume, as well the distribution of problem types and management endpoints. RESULTS Pandemic period consult volumes were significantly lower than those of parallel periods in 2016–2019 (388 vs. a 4-year average of 576, P

Aims Managing adherence to medications is a priority for health systems worldwide. Adherence research is accumulating, yet the quality of the evidence is reduced by various methodological limitations. In particular, the heterogeneity and low accuracy of adherence measures have been highlighted in many literature reviews. Recent consensus-based guidelines advise on best practices in defining adherence (ABC) and reporting of empirical studies (EMERGE). While these guidelines highlight the importance of operational definitions in adherence measurement, such definitions are rarely included in study reports. To support researchers in their measurement decisions, we developed a structured approach to formulate operational definitions of adherence. Methods A group of adherence and research methodology experts used theoretical, methodological and practical considerations to examine the process of applying adherence definitions to various research settings, questions and data sources. Consensus was reached through iterative review of discussion summaries and framework versions. Results We introduce TEOS, a four-component framework to guide the operationalization of adherence concepts: (1) describe treatment as four simultaneous interdependent timelines (recommended and actual use, conditional on prescribing and dispensing); (2) locate four key events along these timelines to delimit the three ABC phases (first and last recommended use, first and last actual use); (3) revisit study objectives and design to fine-tune research questions and assess measurement validity and reliability needs, and (4) select data sources (e.g., electronic monitoring, self-report, electronic healthcare databases) that best address measurement needs. Conclusion Using the TEOS framework when designing research and reporting explicitly on these components can improve measurement quality.

BACKGROUND As the population with human immunodeficiency virus (HIV) continues to age, the need for nursing home (NH) care is increasing. OBJECTIVES To assess whether NH's experience in treating HIV is related to outcomes. RESEARCH DESIGN We used claims and assessment data to identify individuals with and without HIV who were admitted to NHs in 9 high HIV prevalent states. We classified NHs into HIV experience categories and estimate the effects of NH HIV experience on patient's outcomes. We applied an instrumental variable using distances between each individual's residence and NHs with different HIV experience. SUBJECTS In all, 5,929,376 admissions for those without HIV and 53,476 admissions for residents with HIV. MEASURES Our primary outcomes were 30-day hospital readmissions, likelihood of becoming a long stay resident, and 180-day mortality posthospital discharge. RESULTS Residents with HIV tended to have poorer outcomes than residents without HIV, regardless of the NH they were admitted to. Residents with HIV admitted to high HIV experience NHs were more likely to be readmitted to the hospital than those admitted to NHs with lower HIV experience (19.6% in 0% HIV NHs, 18.7% in 05% HIV NHs and 22.9% in 5%-50% HIV NHs). CONCLUSIONS Residents with HIV experience worse outcomes in NHs than residents without HIV. Increased HIV experience was not related to improved outcomes.

BACKGROUND Excellent adherence to HIV antiretroviral therapy (ART) remains a cornerstone of HIV care. A three-item adherence self-report scale was recently developed and validated, but the scale has not been previously tested in a nationally representative sample. DESIGN We administered the adherence scale to participants in the Centers for Disease Control and Prevention's Medical Monitoring Project, which is a probability sample of US adults with diagnosed HIV. METHODS We combined sociodemographic and clinical participant data from three consecutive cycles of the Medical Monitoring Project (6/2015-5/2018). We used medical record reviews to determine most recent viral load, and whether viral loads were suppressed at all measurement points in the past 12 months. We describe the relationship between adherence scale score and two measures of viral load suppression (most recent and sustained), and estimate linear regression models using sampling weights to determine independent predictors of ART adherence scores. RESULTS Of those using ART, the median adherence score was 93 (100 = perfect adherence), and the standardized Cronbach's alpha was 0.83. For both measures of viral load suppression, the relationship with the adherence score was generally linear; there was no 'cutoff' point indicating good vs. poor adherence. In the multivariable model, younger age, nonwhite race, poverty, homelessness, depression, binge-drinking, and both non-IDU and IDU were independently associated with lower adherence. CONCLUSION The adherence measure had good psychometric qualities and a linear relationship with viral load, supporting its use in both clinical care and research. Adherence interventions should focus on persons with the highest risk of poor adherence.