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Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high risk of poor outcomes. Telehealth expansion may boost utilization, but it is unclear whether telehealth can increase utilization for patients with SUDs beyond that expected for other chronic diseases amenable to remote treatment, like type 2 diabetes. This information is needed by health systems striving to improve SUD outcomes, specifically. This study compared the impact of telehealth expansion during the COVID-19 public health emergency (PHE) on utilization for patients with SUDs and diabetes. Using Wisconsin Medicaid administrative, enrollment and claims data 12/1/2018-12/31/2020, this cohort study included nonpregnant, nondisabled adults 19-64 years with SUDs (N = 17,336) or diabetes (N = 8,499). Outcomes included having a primary care visit in the week (any, and telehealth) for any diagnosis, or a SUD or diabetes diagnosis; and the weekly fraction of visits completed by telehealth. Logistic and fractional regression examined outcomes pre- and post-PHE. Covariates included age, sex, race, ethnicity, income, geography, and comorbid medical and psychotic disorders. Post-PHE, patients with SUDs exhibited greater likelihood of telehealth utilization (percentage point difference (PPD) per person-week: 0.2; 95% CI: 0.001-0.003; p<0.001) and greater fractional telehealth use (PPD: 1.8; 95%CI: 0.002-0.033; p = 0.025) than patients with diabetes despite a larger overall drop in visits (PPD: -0.5; 95%CI: -0.007- -0.003; p<0.001). Following telehealth expansion, patients with SUDs exhibited greater likelihood of telehealth utilization than patients with diabetes. This advantage lessened the substantial PHE-induced healthcare disruption experienced by patients with SUDs. Telehealth may boost utilization for patients with SUDs.

Background Same‐day discharge following radical prostatectomy has become increasingly common, with single‐institution series suggesting it reduces healthcare costs without increasing adverse events. However, this practice has not been studied nationally, outside of specialized centers. This study assesses 30‐day readmissions, observation stays, and emergency department visits among men with prostate cancer undergoing prostatectomy. Study Design We used national Medicare data to identify men undergoing prostatectomy for prostate cancer between 2016 and 2021. We focused on patients discharged either the same day or the day after surgery to include only those with an uneventful postoperative course presumably eligible for same‐day discharge. We used multivariable logistic regression to measure relationships between discharge day (same‐day vs. next‐day) and 30‐day readmissions, adjusted for patient factors. We also assessed the association between the day of discharge and a secondary outcome, a composite of readmission, observation stay, or emergency department visits within 30 days. Results Our cohort included 528 men discharged the same day and 11,513 discharged the next day. By 2021, same‐day discharges rose to 9.2%. Same‐day discharge was associated with an almost two‐fold increase in the odds of a readmission within 30 days (adjusted OR: 1.93; 95% CI 1.35–2.76; p < 0.01). However, the odds of an acute care event, measured by a composite of any readmission, observation stay, or emergency department visit, were similar in both groups (adjusted OR: 1.16; 95% CI 0.90–1.50; p = 0.27). Conclusions Same‐day discharges after prostatectomy have increased substantially but were associated with a two‐fold increase in odds of a readmission within 30 days. However, global adverse events, as measured by our composite outcome, were similar.

Studies assessing the impact of advanced practice providers (APPs), including nurse practitioners and physician assistants, have demonstrated a similar quality of care for patients admitted to the hospital for medical diagnoses. However, no studies have examined the relationship between APP integration and morbidity after cancer surgery. This study assesses the relationship between APP staffing intensity and patient outcomes following major abdominal cancer surgery. We used 100% national Medicare data (2010-2019) to assess the link between APP staffing intensity and surgical outcomes for patients undergoing major abdominal cancer surgery, including cystectomy, colectomy, hepatectomy, esophagectomy, gastrectomy, and pancreatectomy. The primary exposure was the ratio of APPs per 100 hospital beds, and patients were empirically divided into tertiles. Outcomes included readmission rates and length of stay, adjusted for patient and hospital level factors. As a secondary outcome, we measured 30-day perioperative mortality. We analyzed 326,547 colectomy patients, 50,400 cystectomy patients, 14,112 esophagectomy patients, 27,152 gastrectomy patients, 15,225 hepatectomy patients, and 46,287 pancreatectomy patients. Surgery at centers with the most advanced practice providers per beds (i.e., the highest tertile) was associated with shorter length of stays for most surgery types analyzed. Unadjusted 30-day readmissions tended to be lower in patients undergoing more complex procedures, such as esophagectomy (21.5% vs. 24.3%; p = 0.006) but not for the less complex operations studied, such as colectomy (13.6% vs. 13.5%; p = 0.22). However, clinical differences in outcomes were lost on analyses controlling for patient and hospital factors (IRR length of stay: 0.98-1.01; p = 0.002-087) (OR readmissions: 0.86-1.01; p = 0.003-0.80). The relationship between hospital APP staffing intensity and surgical outcomes was varied and heterogenous. However, differences in outcomes were primarily explained by hospital factors. More work is needed to determine process measures associated with the deployment of inpatient APPs.

Introduction Men with newly diagnosed prostate cancer often appropriately elect for either immediate treatment or conservative management. The out‐of‐pocket costs they face vary by management strategy, with immediate treatment often superseding those of conservative management, potentially influencing patient decisions. We estimated the anticipated out‐of‐pocket costs that commercially insured men with newly diagnosed prostate cancer face and measured their association with immediate treatment. Methods From MarketScan, we identified men with newly diagnosed prostate cancer from 2010–2020. Separately, using actual out‐of‐pocket costs (summing deductible, copay, coinsurance) among patients undergoing arthroscopic meniscal repair (n = 383,187), we derived regression coefficients for patient‐level variables (e.g., health plan type) that inform their financial liability. We applied these coefficients to men with prostate cancer and estimated their predicted out‐of‐pocket costs, our main exposure. We sorted patients into quartiles and used logistic regression to calculate adjusted probabilities of immediate treatment (versus conservative management). Results We identified 58,206 men with prostate cancer and rank ordered them by predicted out‐of‐pocket cost. Approximately 12% of men had a predicted out‐of‐pocket cost of zero, and among those with non‐zero cost sharing, the median out‐of‐pocket cost was$350 (IQR: $ 275, $486). Across quartiles of predicted out‐of‐pocket costs, adjusted percentages of immediate treatment were in a narrow range between 77.8% (95% CI: 76.8%, 78.8%) for Quartile 1% and 78.6% (95% CI: 77.7%, 79.5%) for Quartile 4. Conclusion Among commercially insured men with prostate cancer, predicted out‐of‐pocket costs varied substantially. However, the choice of management, immediate treatment or conservative management, appears insensitive (i.e., inelastic) to patient anticipated financial liability.

Racial and ethnic disparities in COVID-19 vaccine access are well-documented; however, few studies have examined whether racial disparities are modified by other factors, including geographic location and area-level deprivation. We conducted an observational study using the COVVAXAGE database. Medicare beneficiaries who received the COVID-19 vaccine primary series (two doses) between 01/01/2021 and 12/31/2021 were included. Racial differences in the time between doses was assessed by urbanicity using g-formula methods. We identified 11,924,990 beneficiaries (mean age = 75.4; 60 % female; 80 % White). Most beneficiaries (97.1 %) received their second vaccine on time. Delayed second doses were more common among beneficiaries who were Black (RRdelayed = 1.30, 95 %CI = 1.28–1.31) and rural (RRdelayed = 1.27, 95 %CI = 1.25–1.29) relative to White and urban beneficiaries. Racial disparities in delayed vaccinations varied in magnitude by degree of urbanicity. Most beneficiaries received their second COVID-19 vaccine on time. Racial disparities were observed and shown to vary by geographic area. •Most Medicare beneficiaries received their second COVID-19 vaccine dose on time.•Delayed doses were more common among Black, Hispanic, and Native American beneficiaries.•Beneficiaries living in rural areas were more likely to have a delayed second dose.•Racial differences in vaccine dose timing varied slightly by geography and time.

The National Center for Health Statistics implemented the ICD-10 code U09.9 for “Long COVID” or “post COVID-19 condition” on October 1st, 2021. Overall utilization, trends, and variation in the use of the U09.9 ICD code in long term care (LTC) residents remains understudied. We therefore conducted a serial cross sectional study using the COVVAXAGE database, by linking CVS Health and Walgreens’ customers data to the 100% Medicare enrollment files. Monthly, from October 2021 through April 2023, we identified individuals living in LTC and enrolled continuously in Medicare FFS for 12 months. We used Medicare Part A and B claims to identify long COVID (U09.9). We estimated the monthly occurrence of a long COVID code among all LTC residents and stratified by a recent (8 weeks) and latent (52 weeks) diagnosis of COVID-19, and by region. We identified over 200,000 LTC residents each month (mean age = 82.8; 69% women; 79.4% White; 11.9% Black). The overall long COVID coding rate was lowest in April, 2023 (1 per 10,000 residents) and highest in February, 2022 (14 per 10,000 residents). Residents with recent COVID-19 diagnosis had the highest long COVID coding rate (e.g., 58 per 10,000 residents) in January 2023. Temporal trends in long COVID coding rates varied widely by geography and were cyclical, following epidemic trends in LTC residents. Long COVID U09.9 ICD code documentation rates were generally low and varied in LTC residents. Remarkable variation in coding rates by region, urbanicity, and frailty status occurred, and needs further study.

We investigated county-level variation in mRNA COVID-19 vaccine use among Medicare beneficiaries throughout the United States. There was greater use of Pfizer-BioNTech vaccines than Moderna vaccines in urban areas for first and booster doses. Vaccines have been highly effective at reducing SARs-CoV-2 infection, COVID-19 severity, and viral transmission.1-3 The messenger RNA (mRNA) vaccines produced by Pfizer-BioNTech (BNT162b2) and Moderna Inc. (mRNA-1273) are the most used,2,3 aligning with public health recommendations and evidence of their superior safety and efficacy.3,4 As of August 2023, 81 percent of the US population had received at least one COVID-19 vaccine, with greater coverage (95 percent) among those ages sixty-five and older. Region-, state-, and county-level variation in COVID-19 vaccine uptake is well documented.1,5 However, to our knowledge, no studies have examined geographic variation in the use of specific mRNA vaccine products. To explore geographic variation within and across US states in the use of Pfizer-BioNTech and Moderna mRNA vaccines, we used a novel data set of CVS Health and Walgreens customers linked to Medicare claims. We found substantial countylevelvariation in mRNA vaccine products (exhibits 1 and 2), with urban counties showing greater use of Pfizer-BioNTech and rural counties less use of Pfizer-BioNTech for both first doses and booster doses.Although both vaccines are more than 90 cent they differ in their effectiveness and risk for adverse events.6 For example, US veterans who received the Pfizer-BioNTech vaccine had a higher risk for documented SARSCoV-2 infection, symptomatic COVID-19, and COVID-19 hospitalization relative to those receiving Moderna vaccines.6 Furthermore, among Medicare beneficiaries, Moderna was associated with lower risk for pulmonary embolism and other adverse events, possibly due to its greater effectiveness against SARS-CoV-2 compared with Pfizer-BioNTech.7Although the Centers for Disease Control and Prevention (CDC) reported weekly allocations of Pfizer-BioNTech and Moderna vaccines at the state level, they did not disaggregate allocated vaccines at the county level or report doses administered by vaccine product. Some rural hospitals expressed preferences for Moderna vaccines8,9 because of differences in shipment batch sizes and cold storage requirements. Given differences in mRNA vaccines' effectiveness,4,6 geographic variation in the use of vaccine products may have important public health implications (for example, community-level differences in breakthrough infections).