Quasi-Experimental Evaluations of Pediatric Health Care: Clinical Practice Guidelines and Insurance Coverage

The underlying theme of this dissertation is the effects of clinical and federal policy on health, utilization, and expenditures among children and young adults. In Chapter 1, I evaluate the clinical and economic benefits of clinical practice guidelines recommending universal cerebrospinal fluid testing in the emergency department for febrile infants aged 29-56 days. Using a difference-in-differences approach and administrative data from 31 U.S. children’s hospitals, I find that these guidelines are not associated with better clinical outcomes or lower health care spending, suggesting that many families of older infants could be spared the stress associated with cerebrospinal fluid testing without harm. The optimal management of older febrile infants in the emergency department has been debated for decades, and results from this study have the potential to change clinical practice at the hospital level. In Chapter 2, I assess the impact of the Affordable Care Act dependent coverage provision on health care utilization, health, and health care expenditures among young adults aged 19-25 years. Using a difference-in-differences analysis of nationally representative data, I find that implementation of the provision was associated with improved self-reported health and improved financial protection against the costs of health care among young adults. These findings highlight the importance of continued efforts to expand insurance coverage in this population. In Chapter 3, I investigate whether insurance coverage loss drives differences in access and health care utilization between older adolescents and young adults with asthma. I find that young adults with asthma are less likely to have a usual source of care, to use outpatient care, and to fill asthma medication prescriptions compared with older adolescents with asthma. Differences in insurance coverage account for large proportions of these differences. In a longitudinal analysis, I also find that older adolescents with asthma who lose insurance coverage as they transition to young adulthood are less likely to have a usual source of care. Taken as a whole, these results suggest that insurance coverage plays a crucial role in ensuring access to care and encouraging optimal health care utilization patterns for adolescents and young adults with asthma.Health Polic

California's Early Coverage Expansion under the Affordable Care Act: A County-Level Analysis

Objective: To assess the coverage effects of California's 2011 Low-Income Health Program (LIHP), enacted as an “early expansion” under the Affordable Care Act (ACA), and to demonstrate the feasibility of using Census data to measure county-level coverage changes. Data Sources/Study Setting: 2008–2012 American Community Survey (ACS). The sample contained California adults ages 19–64 years (n = 237,876) and children 0–18 years (n = 113,159) with incomes below 200 percent of the federal poverty level. Study Design: Differences-in-differences analysis comparing public coverage, private insurance, and the uninsured rate in counties that expanded the LIHP in 2011 versus California counties not expanding during this time. Additional analyses tested for heterogeneous impacts of the LIHP and spillover effects on children. Principal Findings: Compared to nonexpansion counties, public coverage for adults increased by 1.8 percentage points (p = .02) in expanding counties, while the uninsured rate declined by 2.1 percentage points (p = .01). There was no significant change in private coverage. Public coverage gains were largest for Latinos and those with limited English proficiency. The expansion produced a positive spillover effect on children's Medicaid enrollment. Conclusions: California's 2011 expansion produced significant increases in public coverage for low-income individuals, particularly Latinos. Substate coverage analyses with the ACS can add valuable detail to future assessments of the ACA

IHPI Policy Brief: Opioid prescribing limits for acute pain

http://deepblue.lib.umich.edu/bitstream/2027.42/175313/1/IHPI Policy Brief - Opioid prescribing limits for acute pain - May 2020.pdfSEL

Report: Plans for school attendance and support for COVID-19 risk mitigation measures

http://deepblue.lib.umich.edu/bitstream/2027.42/175321/1/Report- Plans for school attendance and support for risk mitigation measures among parents and guardians - June 2020.pdfSEL

Association between dispensing of low-value oral albuterol and removal from Medicaid preferred drug lists

Abstract Background Oral albuterol has worse efficacy and side effects compared with inhaled albuterol, and thus its use has been discouraged for decades. Drug inclusion or exclusion on formularies have been associated with reductions in low-value care. This study examines dispensing of oral albuterol and inclusion of oral albuterol on state Medicaid drug formularies--Preferred Drug Lists (PDLs). It also evaluates the association between removal of oral albuterol from the PDL and dispensing levels. Methods This quasi-experimental study determined oral albuterol inclusion on PDLs and dispensing between 2011 and 2018, using Medicaid program websites and the State Drug Utilization Database. Using a difference-in-differences model, we examine the association between removal of oral albuterol from Arkansas’ Medicaid PDL in 2014 and dispensing of this drug through Medicaid, with Iowa as a control state. The outcome measure was the percent of all albuterol prescriptions that were for oral albuterol. Results A total of 28 state Medicaid PDLs included at least one formulation of oral albuterol in 2018. In 2018, 179,446 oral albuterol prescriptions were dispensed to Medicaid beneficiaries nationally. Medicaid programs paid approximately $3.0 million for oral albuterol prescriptions in 2018. Removal of oral albuterol syrup from the Arkansas PDL in March 2014 was associated with a more rapid decline in dispensing compared with Iowa which maintained this medication on their PDL. Conclusions Findings suggest that removal of low-value medications, such as oral albuterol, from PDLs may be one avenue by which state Medicaid programs can reduce wasteful spending while improving guideline-based care.http://deepblue.lib.umich.edu/bitstream/2027.42/173787/1/12913_2022_Article_7955.pd

Association between receipt of overlapping opioid and benzodiazepine prescriptions from multiple prescribers and overdose risk.

Question: Is overdose risk increased when overlapping opioid and benzodiazepine prescriptions are written by multiple prescribers vs 1 prescriber? Findings: In this cohort study of 529 053 patients with private insurance or Medicare Advantage, overdose risk was increased 1.8-fold when opioid-benzodiazepine overlap involved prescriptions from multiple prescribers vs 1 prescriber. This increase remained statistically significant after adjusting for prescribing patterns, demographics, and comorbidities. Meaning: This study found that observed factors did not fully account for the association between receipt of overlapping opioid and benzodiazepine prescriptions from multiple prescribers and overdose risk. This finding suggests that other factors, such as poor care coordination, may play a role

IHPI Policy Brief: Use of medications for opioid use disorder after overdoses among medicaid enrollees

http://deepblue.lib.umich.edu/bitstream/2027.42/177676/1/0318_MOUD-Brief_final-09072023.pdfDescription of 0318_MOUD-Brief_final-09072023.pdf : Policy BriefSEL

Usability of NewSTEPs Data for Assessing the Characteristics of Infants with Newborn Screening Disorders

Most state newborn screening programs in the U.S. currently contribute case data to the Newborn Screening Technical Assistance and Evaluation Program (NewSTEPs). To assess the usability of these data for research, we examined the completeness of key variables, particularly race and ethnicity. Data included 24,129 cases of 34 newborn screening disorders from 45 states available in NewSTEPs as of 31 August 2020. Birth years of cases ranged between 2006 and 2020. Rates of missing data for sex, gestational age, birth weight, and race/ethnicity were 3.8%, 31.7%, 7.0%, and 39.7%, respectively. After excluding 21 states for which ≥50% of cases had missing data on race and/or ethnicity, 16,010 cases from 24 states remained. The disorders with the highest proportions in which cases were recorded as Hispanic ethnicity/any race were methylmalonic acidemia (48.7%) and maple syrup urine disease (45.7%). Analyses indicated that sex and birth weight data in NewSTEPs are reasonably complete, but missing data are common for gestational age and race/ethnicity. Despite this, our analyses revealed several novel associations between race/ethnicity and newborn screening disorders, such as the high burden of maple syrup urine disease among Hispanic patients. This demonstrates the potential usefulness of NewSTEPs for research if investments in higher-quality data are made