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Archives of Physical Medicine and... May 2022To investigate social determinants of health (SDoH) interventions on individual health outcomes, population health, and cost for persons in the United States over age 18... (Review)
Review
OBJECTIVE
To investigate social determinants of health (SDoH) interventions on individual health outcomes, population health, and cost for persons in the United States over age 18 living with disabilities and receiving long-term services and supports (LTSS) in noninstitutional settings.
DATA SOURCES
A review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted of literature from PubMed, PsycINFO, REHABDATA, and Web of Science Core Collection published between January 1997 and July 2020.
STUDY SELECTION
Search terms were based on the primary SDoH domains identified by the Centers for Medicare and Medicaid's Accountable Health Communities Model. A total of 5082 abstracts were screened based on identification criteria of persons age 18 and above living in non-institutional, community-based settings receiving LTSS.
DATA EXTRACTION
During Level 2 review, articles were reviewed based on population focus, type of LTSS (personal assistance services, home care, adult day care, home modification, durable medical equipment, community transition services, caregiver supports and/or prevention services related to home- and community-based care), SDoH intervention and association with health outcomes, population health and/or cost. A total of 1037 abstracts underwent Level 2 review, yielding 131 publications or 1.3% for full review.
DATA SYNTHESIS
Studies (n=33) designed a priori to test outcomes of interventions were rated according to Grading Recommendations Assessment Development and Evaluation (GRADE) criteria. Qualifying articles that did not include interventions (n=98) were included in our summary of the literature but were not assessed by GRADE.
CONCLUSIONS
The preponderance of research surrounding SDoH and health outcomes has focused on older adults living with disabilities, and most interventions scored low or very low using GRADE criteria. Evidence is limited to the extent SDoH interventions are measured against outcomes for persons of all ages living with disabilities. Robust evaluation of models that feature SDoH interventions in partnership with community-based organizations is recommended as home and community-based care infrastructure expands in response to the American Rescue Plan Act of 2021.
Topics: Adolescent; Aged; Disabled Persons; Home Care Services; Humans; Medicare; Social Determinants of Health; United States
PubMed: 34756446
DOI: 10.1016/j.apmr.2021.06.021 -
Journal of the American Academy of... Jan 2021Rapid growth of antipsychotic use among children and adolescents at the turn of the 21st century led Medicaid programs to implement 3 types of system-wide interventions:... (Review)
Review
OBJECTIVE
Rapid growth of antipsychotic use among children and adolescents at the turn of the 21st century led Medicaid programs to implement 3 types of system-wide interventions: antipsychotic monitoring programs, clinician prescribing supports, and delivery system enhancements. This systematic review assessed the available evidence base for and relative merits of these system-wide interventions that aim to improve antipsychotic treatment and management.
METHOD
Using PRISMA guidelines, eligible studies were written in English and evaluated system-wide interventions to monitor antipsychotic treatment or promote antipsychotic management among children and adolescents (0-21 years of age). Studies were identified through Ovid MEDLINE and PsychInfo (years 1990-2018) and an environmental scan. From an initial review of 824 publications, 17 studies met eligibility criteria. Two authors independently conducted quality assessments using the Crowe Critical Appraisal Tool. Findings were summarized descriptively.
RESULTS
Identified studies (n = 17) evaluated prior authorization programs (n = 10), drug utilization reviews (n = 2), quality improvement (n = 4), care coordination programs (n = 1), and multimodal initiatives (n = 2). Studies were predominantly pre-post analyses, without a comparison group. With the exception of care coordination and drug utilization reviews, more than half of the interventions in each category were associated with significant reduction in antipsychotic treatment or promotion of best practice parameters.
CONCLUSION
This evidence review concludes that evaluations of prior authorization programs demonstrate reductions in antipsychotic treatment, though evidence of impact of other system-wide interventions and other outcomes is limited. Additional research is necessary to investigate whether interventions influenced antipsychotic prescribing independent of secular trends, the comparative effectiveness and cost-effectiveness of interventions, the effect on functional outcomes, and the potential for unintended consequences.
Topics: Adolescent; Antipsychotic Agents; Child; Cost-Benefit Analysis; Humans; Medicaid; United States
PubMed: 32966838
DOI: 10.1016/j.jaac.2020.08.441 -
International Journal of Environmental... Apr 2021Access to healthcare for adolescents is often overlooked in the United States due to federal and state-sponsored insurance programs such as Medicaid and the Children's... (Review)
Review
Access to healthcare for adolescents is often overlooked in the United States due to federal and state-sponsored insurance programs such as Medicaid and the Children's Health Insurance Program. While these types of programs provide some relief, the issue of healthcare access goes beyond insurance coverage and includes an array of ecological factors that hinder youths from receiving services. The purpose of this scoping review was to identify social-ecological barriers to adolescents' healthcare access and utilization in the United States. We followed the PRISMA and scoping review methodological framework to conduct a comprehensive literature search in eight electronic databases for peer-reviewed articles published between 2010 and 2020. An inductive content analysis was performed to thematize the categories identified in the data extraction based on the Social-Ecological Model (SEM). Fifty studies were identified. Barriers across the five SEM levels emerged as primary themes within the literature, including intrapersonal-limited knowledge of and poor previous experiences with healthcare services, interpersonal-cultural and linguistic barriers, organizational-structural barriers in healthcare systems, community-social stigma, and policy-inadequate insurance coverage. Healthcare access for adolescents is a systems-level problem requiring a multifaceted approach that considers complex and adaptive behaviors.
Topics: Adolescent; Child; Health Facilities; Health Services; Health Services Accessibility; Humans; Insurance Coverage; Medicaid; United States
PubMed: 33919813
DOI: 10.3390/ijerph18084138 -
JBJS Reviews Apr 2020Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to...
BACKGROUND
Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to improve patients' ability to undergo this procedure. However, despite this, the role of Medicaid insurance in patient outcomes remains unclear. The purpose of this study was to perform a systematic review of the literature to explore the relationship between preoperative Medicaid insurance status and outcomes following primary total knee arthroplasty.
METHODS
A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies examining outcomes in patients who had Medicaid and were undergoing total knee arthroplasty. Studies including complex revision operations or less common indications for total knee arthroplasty were excluded. Data on insurance status, postoperative complications, length of stay, readmissions, and subsequent revision surgical procedures were collected for each article.
RESULTS
A total of 13 studies showing 6.18 million patients undergoing total knee arthroplasty were included in the qualitative synthesis. Seven analyses described an important association between Medicaid coverage and short-term readmissions, and 2 analyses showed a relationship between Medicaid and prolonged length of stay. However, the included studies did not describe a significant association between Medicaid and postoperative mortality or revision rates.
CONCLUSIONS
Patients with Medicaid undergoing total knee arthroplasty may be more likely to experience an increased length of stay and to be readmitted postoperatively. The unique factors associated with these patients may help to inform customized perioperative surveillance and optimization to improve outcomes in this group.
LEVEL OF EVIDENCE
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Topics: Arthroplasty, Replacement, Knee; Humans; Medicaid; Treatment Outcome; United States
PubMed: 32304495
DOI: 10.2106/JBJS.RVW.19.00085 -
Journal of Public Health Dentistry Dec 2021Dental-related emergency department (ED) visits are a growing public health concern. Dental insurance coverage is a strong predictor of dental service access. The...
OBJECTIVES
Dental-related emergency department (ED) visits are a growing public health concern. Dental insurance coverage is a strong predictor of dental service access. The objective of this study was to conduct a systematic review to assess the incidence of dental-related ED visits for Medicaid dental enrollees compared to those with other insurances.
METHODS
PubMed, EMBASE, and Google Scholar were searched for surveillance and observational data published in English from January 1999 to April 2020 to address the following PECOT question: Do patients with nontraumatic dental conditions (NTDC) (P1), or patients with any dental condition (P2) who have Medicaid (E) compared to other insurance status (private insurance, Medicare, no insurance) (C) have a differential incidence of single dental-related ED visits (O) in the literature search results from 1999 to April 2020 (T)? A critical appraisal was performed using a combination of the AXIS tool (for cross-sectional studies with observational data and MetaQAT (for public health evidence).
RESULTS
This systematic review included 32 studies. Overall, risk of bias was low. Due to significant statistical heterogeneity, a synthesis without meta-analysis was conducted. NTDC ED visits ranged from 16.0 percent to 79.8 percent for Medicaid patients and 0.9 percent to 57.2 percent for uninsured patients. The range for any dental visit to the ED was 2.2-63.8 percent for Medicaid patients and 2.9-40.8 percent for uninsured patients.
CONCLUSIONS
The results of this study support expanding insurance coverage in Medicaid programs to reduce ED use for NTDC visits in the United States.
Topics: Aged; Cross-Sectional Studies; Dental Care; Emergency Service, Hospital; Humans; Insurance Coverage; Medicaid; Medically Uninsured; Medicare; United States
PubMed: 34075587
DOI: 10.1111/jphd.12458 -
Journal of the National Cancer Institute Jul 2020Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among...
BACKGROUND
Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival.
METHODS
We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively.
RESULTS
Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions.
CONCLUSIONS
Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes.
Topics: Early Detection of Cancer; Health Services Accessibility; Humans; Insurance Coverage; Insurance, Health; Medicaid; Medically Uninsured; Neoplasms; Observational Studies as Topic; Patient Protection and Affordable Care Act; Poverty; Publications; United States
PubMed: 32337585
DOI: 10.1093/jnci/djaa048 -
Journal of Cancer Policy Sep 2021Insurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This...
BACKGROUND
Insurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This study assessed the consequences of this policy change for cancer care after expansion in 2014.
METHODS
National Cancer Database (NCDB) public benchmark reports were queried for each malignancy in 2013 and 2016. Furthermore, a systematic search [PubMed, Embase, Scopus and Cochrane] was performed. Data on insurance status, access to cancer screening and treatment, and socioeconomic disparities in these metrics was collected.
RESULTS
Two-tailed analysis of the NCDB revealed that 14 out of 18 eligible states had a statistically significant increase in Medicaid-insured patients with cancer after expansion. The average percentage increase was 51 % (13.2-204 %). From the systematic review, 229 studies were identified, 26 met inclusion. All 21 relevant articles reported lower uninsured rates. The average increase of Medicaid-insured patients was 77 % (9.5-230 %) and the average decrease of uninsured rates was 55 % (13.4-73 %). 15 out of 21 articles reported increased access to care. 16 out of 17 articles reported reductions in inequities.
CONCLUSION
Medicaid expansion in 2014 increased the number of insured patients with cancer. Expansion also improved access to screening and treatment in most oncologic care, and reduced socioeconomic disparities. Further studies evaluating correlative survival outcomes are needed.
POLICY SUMMARY
This study informs debates on expansion of Medicaid in state governments and electorates in the United States, and on health insurance reform broadly, by providing insight into how health insurance can benefit people with cancer while revealing how less insurance coverage could harm patients with cancer before and after their diagnosis. This study also contributes to discussions of health insurance mandates, subsidized coverage for people with low incomes, and covered healthcare services determinations by public and private health insurance providers in other countries.
Topics: Humans; Insurance Coverage; Mass Screening; Medicaid; Neoplasms; Patient Protection and Affordable Care Act; United States
PubMed: 35559947
DOI: 10.1016/j.jcpo.2021.100292 -
JACC. Cardiovascular Interventions Jun 2023Mitral regurgitation is the most common valvular disease and is estimated to affect over 5 million Americans. Real-world data collection contributes to safety and... (Review)
Review
Mitral regurgitation is the most common valvular disease and is estimated to affect over 5 million Americans. Real-world data collection contributes to safety and effectiveness evidence for the U.S. Food and Drug Administration, quality evaluation for the Centers for Medicare and Medicaid Services and hospitals, and clinical best practice research. We aimed to establish a minimum core data set in mitral interventions to promote efficient, reusable real-world data collection for all of these purposes. Two expert task forces separately evaluated and reconciled a list of candidate elements derived from: 1) 2 ongoing transcatheter mitral trials; and 2) a systemic literature review of high-impact mitral trials and U.S multicenter, multidevice registries. From 703 unique data elements considered, unanimous consensus agreement was achieved on 127 "core" data elements, with the most common reasons for exclusion from the minimum core data set being burden or difficulty in accurate assessment (41.2%), duplicative information (25.0%), and low likelihood of affecting outcomes (19.6%). After a systematic review and extensive discussions, a multilateral group of academicians, industry representatives, and regulators established and implemented into the national Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapies Registry 127 interoperable, reusable core data elements to support more efficient, consistent, and informative transcatheter mitral device evidence for regulatory submissions, safety surveillance, best practice development, and hospital quality assessments.
Topics: Aged; Humans; United States; Medicare; Treatment Outcome; Cardiology; Catheters; Centers for Medicare and Medicaid Services, U.S.; Multicenter Studies as Topic
PubMed: 37380225
DOI: 10.1016/j.jcin.2023.03.034 -
European Journal of Surgical Oncology :... Aug 2021Head and neck cancers (HNC) are relatively fast-growing tumours, and delay in treatment initiation is associated with tumour progression and adverse outcome. An overview...
INTRODUCTION
Head and neck cancers (HNC) are relatively fast-growing tumours, and delay in treatment initiation is associated with tumour progression and adverse outcome. An overview of factors contributing to delay can provide critical insights on necessary adjustments to optimize care pathways. This systematic review aims to identify factors associated with delay and summarize the effect of delay on oncological outcome measures.
METHODS
A search strategy was conducted according to PRISMA guidelines to search electronic databases for studies assessing the carepathway interval (days between first visit in head and neck oncology center and treatment initiation) and/or time-to-treatment-initiation interval (days between histological diagnosis and treatment initiation) and 1) determinants of delay and/or 2) effect of delay on outcome within these timeframes. Due to heterogeneity between included studies, a meta-analysis was not possible.
RESULTS
Fifty-two studies were eligible for quantitative analysis. Non-Caucasian race, academic setting, Medicaid/no insurance and radiotherapy as primary treatment were associated with delay. Advanced tumour stage was related to increased time-to-treatment initiation in the four common sites combined (oral cavity, oropharynx, hypopharynx, larynx). Separate determinants for delay in different tumour locations were identified. In laryngeal, oral cavity cancer and the four common HNC sites combined, delay in start of treatment is associated with decreased overall survival, although no cut-off time point could be determined.
CONCLUSION
Race, facility type, type of insurance and radiotherapy as primary treatment were associated with delay and subsequent inferior survival in the four common sites combined.
Topics: Academic Medical Centers; Ethnic and Racial Minorities; Ethnicity; Head and Neck Neoplasms; Humans; Insurance, Health; Medicaid; Medically Uninsured; Neoplasm Staging; Radiotherapy; Risk Factors; Squamous Cell Carcinoma of Head and Neck; Survival Rate; Time-to-Treatment; United States
PubMed: 33715909
DOI: 10.1016/j.ejso.2021.02.029