Association between community-level social risk and spending among Medicare beneficiaries: Implications for social risk adjustment and health equity

IMPORTANCE: Payers are increasingly using approaches to risk adjustment that incorporate community-level measures of social risk with the goal of better aligning value-based payment models with improvements in health equity. OBJECTIVE: To examine the association between community-level social risk and health care spending and explore how incorporating community-level social risk influences risk adjustment for Medicare beneficiaries. DESIGN, SETTING, AND PARTICIPANTS: Using data from a Medicare Advantage plan linked with survey data on self-reported social needs, this cross-sectional study estimated health care spending health care spending was estimated as a function of demographics and clinical characteristics, with and without the inclusion of Area Deprivation Index (ADI), a measure of community-level social risk. The study period was January to December 2019. All analyses were conducted from December 2021 to August 2022. EXPOSURES: Census block group-level ADI. MAIN OUTCOMES AND MEASURES: Regression models estimated total health care spending in 2019 and approximated different approaches to social risk adjustment. Model performance was assessed with overall model calibration (adjusted R2) and predictive accuracy (ratio of predicted to actual spending) for subgroups of potentially vulnerable beneficiaries. RESULTS: Among a final study population of 61 469 beneficiaries (mean [SD] age, 70.7 [8.9] years; 35 801 [58.2%] female; 48 514 [78.9%] White; 6680 [10.9%] with Medicare-Medicaid dual eligibility; median [IQR] ADI, 61 [42-79]), ADI was weakly correlated with self-reported social needs (r = 0.16) and explained only 0.02% of the observed variation in spending. Conditional on demographic and clinical characteristics, every percentile increase in the ADI (ie, more disadvantage) was associated with a $11.08 decrease in annual spending. Directly incorporating ADI into a risk-adjustment model that used demographics and clinical characteristics did not meaningfully improve model calibration (adjusted R2 = 7.90% vs 7.93%) and did not significantly reduce payment inequities for rural beneficiaries and those with a high burden of self-reported social needs. A postestimation adjustment of predicted spending for dual-eligible beneficiaries residing in high ADI areas also did not significantly reduce payment inequities for rural beneficiaries or beneficiaries with self-reported social needs. CONCLUSIONS AND RELEVANCE: In this cross-sectional study of Medicare beneficiaries, the ADI explained little variation in health care spending, was negatively correlated with spending conditional on demographic and clinical characteristics, and was poorly correlated with self-reported social risk factors. This prompts caution and nuance when using community-level measures of social risk such as the ADI for social risk adjustment within Medicare value-based payment programs

Interleukin-17 limits hypoxia-inducible factor 1α and development of hypoxic granulomas during tuberculosis

Mycobacterium tuberculosis (Mtb) is a global health threat, compounded by the emergence of drug-resistant strains. A hallmark of pulmonary tuberculosis (TB) is the formation of hypoxic necrotic granulomas, which upon disintegration, release infectious Mtb. Furthermore, hypoxic necrotic granulomas are associated with increased disease severity and provide a niche for drug-resistant Mtb. However, the host immune responses that promote the development of hypoxic TB granulomas are not well described. Using a necrotic Mtb mouse model, we show that loss of Mtb virulence factors, such as phenolic glycolipids, decreases the production of the proinflammatory cytokine IL-17 (also referred to as IL-17A). IL-17 production negatively regulates the development of hypoxic TB granulomas by limiting the expression of the transcription factor hypoxia-inducible factor 1α (HIF1α). In human TB patients, HIF1α mRNA expression is increased. Through genotyping and association analyses in human samples, we identified a link between the single nucleotide polymorphism rs2275913 in the IL-17 promoter (-197G/G), which is associated with decreased IL-17 production upon stimulation with Mtb cell wall. Together, our data highlight a potentially novel role for IL-17 in limiting the development of hypoxic necrotic granulomas and reducing disease severity in TB

Comparison of JAWSII Cell Line and Bone Marrow-Derived Cells in Responsiveness to Tuberculosis Infection

Faculty Mentor: Shabaana Khader Mycobacterium tuberculosis (Mtb), the bacteria that causes tuberculosis (TB), infects one third of the world’s population, 5-10% of whom develop active TB, in which the bacteria invades and damages the lungs. One reason for this large global disease burden is the emergence of multi-drug resistant (MDR) strains of TB, which accounts for the majority of deaths. In order to address MDR-TB, a new vaccine must be formulated to protect against the infection. The determination of ideal candidates for vaccine adjuvants to help dendritic cells drive strong cytokine-mediated responses to TB challenge is the aim of the current research. The goal of this study was to determine whether or not the JAWSII cell line could be used as a substitute for the more costly, time-consuming bone marrow-derived cells (BMDC) in adjuvant testing. This study compared the sensitivity and reactivity of JAWSII cells and BMDC to infection with various strains of TB by assessing cytokine levels as a metric of immune activity. The central hypothesis of this study was that if JAWSII can be shown to respond to infection in a similar way as BMDC do, and a well-evidenced phenomenon in BMDC can be replicated in the JAWSII cell line, then JAWSII behaves in a way that is both similar to BMDC and is biologically relevant, meaning it can be used in lieu of BMDC for future experiments. The data suggest that the JAWSII should be grown in recommended media, that the JAWSII cell line is basally more active than BMDC, and that the JAWSII system is not as sensitive to infection as BMDC. Therefore, it is unlikely JAWSII is a suitable replacement for BMDC for future experiments. Future directions include running similar experiments with more trials, different cytokines, different concentrations of bacteria, and comparative RNA/cDNA analyses

Comparison of JAWSII Cell Line and Bone Marrow-Derived Cells in Responsiveness to Tuberculosis Infection

From the Washington University Senior Honors Thesis Abstracts (WUSHTA), 2017. Published by the Office of Undergraduate Research. Joy Zalis Kiefer, Director of Undergraduate Research and Associate Dean in the College of Arts & Sciences; Lindsey Paunovich, Editor; Helen Human, Programs Manager and Assistant Dean in the College of Arts and Sciences Mentor: Shabaana Khade

Association of affordable care act-related medicaid expansion with variation in utilization of surgical services

Background: We aim to understand how Medicaid expansion under the ACA has affected utilization of surgical services. Methods: The State Inpatient Databases were used to compare utilization of a broad array of surgical procedures among nonelderly adults (aged 19-64 years) in a multistate population that experienced ACA-related Medicaid expansion to one that did not. We performed a difference-in-differences (DID) analysis to determine the effect of Medicaid expansion on utilization of surgical services from 2012 to 2014. Results: There were 259,061 cases identified in the Medicaid expansion population and 261,269 in the control population. In the expansion group, there was a smaller decrease in utilization - by a margin of 21.68 cases per 100,000 individuals (p \u3c 0.001). Percent of surgical patients covered by Medicaid increased among the expansion group from 12.00% to 15.48% (DID = 3.93%; p \u3c 0.001). Conclusions: Year one of Medicaid expansion under the ACA was associated with a modest but statistically significant difference in utilization of surgical services as well as an increase in percent of surgery patients covered by Medicaid