Medicaid Managed Care And Its Impact On Potentially Preventable Hospital Utilization (inpatient And Emergency Room Visits)

Introduction: The objective of this study is to compare the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the prevalence of potentially preventable hospitalizations and emergency room (ER) visits, a recognized measure of outpatient care quality. Methods: Nationally representative data on non-institutionalized Medicaid recipients, ages 18-64, from the 2003-2012 Medical Expenditure Panel Survey. Separate analyses are conducted for recipients insured through both Medicaid and Medicare (“dual eligibles”) and recipients whose only health insurance is Medicaid (“non-duals”). In each group the occurrence of potentially preventable hospital use is measured, and then survey-weighted multivariable logistic regression models are fit to quantify the relationship between Medicaid HMO status and the occurrence of such stays. The possibility of selection bias into HMOs is considered and explicitly addressed in model estimation using propensity score methods. Results: Adjusting for covariates and confounders dual eligibles are more likely to have a potentially preventable hospitalization relative to those covered under FFS Medicaid (survey weighted logit model OR = 1.68, 95% CI = 0.95-2.97; propensity score weighted logit model OR = 1.83, 95% CI = 1.05-3.19). In contrast, the odds ratios did not differ among non-duals in Medicaid HMOs versus FFS Medicaid. Furthermore, no significant differences exist in the patterns of ER use (any or avoidable) between Medicaid HMO and Medicaid FFS enrollees for both duals and non-duals Conclusion: These findings suggest that, at least for dual eligibles, the quality of outpatient care in Medicaid HMOs may be worse than under FFS Medicaid. Better and more streamlined clinical preventive approaches for this high risk and vulnerable population might be required in Medicaid HMOs

Determinants of food security in rural areas of Pakistan

Abstract: Out of 120 districts of Pakistan (for rural areas) only 40 are food secure while 80 (67 percent) are food insecure. Within these food insecure districts, 38 (46 percent) are extremely food insecure. The matter of food security in rural areas is of immense nature and needs to be probed. A number of factors are responsible for the situation. The current paper examines the determinants of three aspects of food security in rural areas of Pakistan, i.e. food availability, accessibility and absorption. For the purpose a series of models is applied on district level data of rural areas of Pakistan. The production of wheat, rice, maize, pulses, oilseeds, poultry meat and fish at the district level is found to affect food availability positively. All the district except of Sindh are more probable to be food insecure in availability. In the food accessibility electrification and adult literacy emerged as the factors having negative effect. Child immunization, safe drinking water and number of hospitals have shown positive effect on food absorption

Determinants of food security in rural areas of Pakistan

Abstract: Out of 120 districts of Pakistan (for rural areas) only 40 are food secure while 80 (67 percent) are food insecure. Within these food insecure districts, 38 (46 percent) are extremely food insecure. The matter of food security in rural areas is of immense nature and needs to be probed. A number of factors are responsible for the situation. The current paper examines the determinants of three aspects of food security in rural areas of Pakistan, i.e. food availability, accessibility and absorption. For the purpose a series of models is applied on district level data of rural areas of Pakistan. The production of wheat, rice, maize, pulses, oilseeds, poultry meat and fish at the district level is found to affect food availability positively. All the district except of Sindh are more probable to be food insecure in availability. In the food accessibility electrification and adult literacy emerged as the factors having negative effect. Child immunization, safe drinking water and number of hospitals have shown positive effect on food absorption

Medicaid managed care and preventable emergency department visits in the United States.

ObjectivesIn the United States the percentage of Medicaid enrollees in some form of Medicaid managed care has increased more than seven-fold since 1990, e.g., up from 11% in 1991 to 82% in 2017. Yet little is known about whether and how this major change in Medicaid insurance affects how recipients use hospital emergency rooms. This study compares the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the occurrence of potentially preventable emergency department (ED) use.MethodsUsing data from the 2003-2015 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the non-institutionalized US population, we estimated multivariable logistic regression models to examine the relationship between Medicaid HMO status and potentially preventable ED use. To accommodate the composition of the Medicaid population, we conducted separate repeated cross-sectional analyses for recipients insured through both Medicaid and Medicare (dual eligibles) and for those insured through Medicaid only (non-duals). We explicitly addressed the possibility of selection bias into HMOs in our models using propensity score weighting.ResultsWe found that the type of Medicaid held by a recipient, i.e., whether an HMO or FFS coverage, was unrelated to the probability that an ED visit was potentially preventable. This finding emerged both among dual eligibles and among non-duals, and it occurred irrespective of the adopted analytical strategy.ConclusionsWithin the U.S. Medicaid program, Medicaid HMO and FFS enrollees are indistinguishable in terms of the occurrence of potentially preventable ED use. Policymakers should consider this finding when evaluating the pros and cons of adopting Medicaid managed care

Nasopharyngeal rapid diagnostic testing to reduce unnecessary antibiotic use and individualize management of acute otitis media

Abstract Background: Acute otitis media (AOM) is the most common indication for antibiotics in children. The associated organism can influence the likelihood of antibiotic benefit and optimal treatment. Nasopharyngeal polymerase chain reaction can effectively exclude the presence of organisms in middle-ear fluid. We explored the potential cost-effectiveness and reduction in antibiotics with nasopharyngeal rapid diagnostic testing (RDT) to direct AOM management. Methods: We developed 2 algorithms for AOM management based on nasopharyngeal bacterial otopathogens. The algorithms provide recommendations on prescribing strategy (ie, immediate, delayed, or observation) and antimicrobial agent. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed as cost per quality-adjusted life day (QALD) gained. We used a decision-analytic model to evaluate the cost-effectiveness of the RDT algorithms compared to usual care from a societal perspective and the potential reduction in annual antibiotics used. Results: An RDT algorithm that used immediate prescribing, delayed prescribing, and observation based on pathogen (RDT-DP) had an ICER of $1,336.15 per QALD compared with usual care. At an RDT cost of$278.56, the ICER for RDT-DP exceeded the willingness to pay threshold; however, if the RDT cost was <$212.10, the ICER was below the threshold. The use of RDT was estimated to reduced annual antibiotic use, including broad-spectrum antimicrobial use, by 55.7$4.7 million for RDT vs $10.5 million for usual care). Conclusion: The use of a nasopharyngeal RDT for AOM could be cost-effective and substantially reduce unnecessary antibiotic use. These iterative algorithms could be modified to guide management of AOM as pathogen epidemiology and resistance evolve

Associations Between Midlife Functional Limitations and Self-Reported Health and Cognitive Status: Results from the 1998-2016 Health and Retirement Study.

BackgroundLife-course approaches to identify and help improve modifiable risk factors, particularly in midlife, may mitigate cognitive aging.ObjectiveWe examined how midlife self-rated physical functioning and health may predict cognitive health in older age.MethodsWe used data from the Health and Retirement Study (1998-2016; unweighted-N = 4,685). We used survey multinomial logistic regression and latent growth curve models to examine how midlife (age 50-64 years) activities of daily living (ADL), physical function, and self-reported health affect cognitive trajectories and cognitive impairment not dementia (CIND) and dementia status 18 years later. Then, we tested for sex and racial/ethnic modifications.ResultsAfter covariates-adjustment, worse instrumental ADL (IADL) functioning, mobility, and self-reported health were associated with both CIND and dementia. Hispanics were more likely to meet criteria for dementia than non-Hispanic Whites given increasing IADL impairment.ConclusionMidlife health, activities limitations, and difficulties with mobility are predictive of dementia in later life. Hispanics may be more susceptible to dementia in the presence of midlife IADLs. Assessing midlife physical function and general health with brief questionnaires may be useful for predicting cognitive impairment and dementia in later life

Longitudinal Daily Living Limitations and Cognitive Status: Results from the 1998-2016 Health and Retirement Study

Data increasingly points to midlife health and modifiable risk factors as critical targets for improving older-age health outcomes and mitigating potential cognitive impairment and disease. We used biennial Health and Retirement Study data (1998-2016) collected on adults ages 50-64 years who did not meet criteria for dementia at baseline and who remained living by 2016 (unweighted-n=4,803). Cognitive status was defined using Langa-Weir criteria: Normal, Cognitively Impaired Not Dementia (CIND), and Dementia. We examined how 18-year patterns in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) predicted cognitive status in 2016. We used latent class analysis to extract longitudinal phenotypes of activities limitations, followed by survey multinomial logistic regressions to examine their associations with cognitive status and test for race/ethnic modifications. We identified three groups of functional impairment: (1) gradually increasing (15.7%), (2) stable elevated (5.6%), and (3) minimal dysfunction (78.7%). After covariates adjustment, both the gradual and stable elevated impairment groups (vs. minimal) had substantially higher relative risk ratios (RRR) for dementia (RRR=5.71[3.89;8.39] and RRR=7.87[4.23,14.64]) and CIND (RRR=2.21 [1.69,2.88] and RRR=1.92[1.16;3.17]). We detected modifications by race/ethnicity such that Hispanics with stable elevated impairment had a higher probability of dementia compared to their White counterparts. The results varied for Blacks and did not significantly differ from Whites. Data-driven methods may improve our understanding of heterogeneous functional impairment patterns among late middle-aged adults and allow for tailored ADRD prevention strategies. Focused risk-based interventions can yield important public health savings and reductions in structural, social, and individual health burdens