Explore the vast range of titles available.

ABSTRACTObjectivesTo investigate whether health insurance generated improvements in cardiovascular risk factors (blood pressure and hemoglobin A1c (HbA1c) levels) for identifiable subpopulations, and using machine learning to identify characteristics of people predicted to benefit highly.DesignSecondary analysis of randomized controlled trial.SettingMedicaid insurance coverage in 2008 for adults on low incomes (defined as lower than the federal-defined poverty line) in Oregon who were uninsured. Participants12 134 participants from the Oregon Health Insurance Experiment with in-person data for health outcomes for both treatment and control groups.InterventionsHealth insurance (Medicaid) coverage.Main outcomes and measuresThe conditional local average treatment effects of Medicaid coverage on systolic blood pressure and HbA1c using a machine learning causal forest algorithm (with instrumental variables). Characteristics of individuals with positive predicted benefits of Medicaid coverage based on the algorithm were compared with the characteristics of others. The effect of Medicaid coverage was calculated on blood pressure and HbA1c among individuals with high predicted benefits.ResultsIn the in-person interview survey, mean systolic blood pressure was 119 (standard deviation 17) mmHg and mean HbA1c concentrations was 5.3% (standard deviation 0.6%). Our causal forest model showed heterogeneity in the effect of Medicaid coverage on systolic blood pressure. Individuals with lower baseline healthcare charges, for example, had higher predicted benefits from gaining Medicaid coverage. Medicaid coverage significantly lowered systolic blood pressure (−2.93 mmHg (95% confidence interval −5.82 to −0.32)) for people predicted to benefit highly. No evidence showed that Medicaid coverage lowered HbA1c for people with high predicted benefits.ConclusionsAlthough Medicaid coverage did not improve cardiovascular risk factors on average, improvements were noted in blood pressure among a subset of individuals with higher predicted benefits. These individuals were more likely to have no or low prior healthcare charges, for example. The findings suggest that Medicaid coverage leads to improved blood pressure for some people, but those benefits may be diluted by individuals who did not benefit. Although the effect size may be of limited clinical significance for any individual, at a broad population level that includes individuals who are both hypertensive and normotensive, the findings may be of public health importance for policy interventions.

Persistent use of secondary prevention therapies after acute myocardial infarction (MI) is critical to optimizing long-term outcomes. Medication persistence was assessed among 7,955 MI patients in 216 hospitals participating in the Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome study from 2010 to 2012. Persistence was defined as continuation of aspirin, adenosine diphosphate receptor inhibitors, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins from discharge to 6 months post-MI. Multivariable logistic regression modeling was used to determine factors associated with nonpersistence, defined as <80% persistence with all medication classes. Overall, 31% of MI patients stopped taking a least 1 medication by 6 months. The most common reasons cited for medications discontinuation were side effects and physician instruction (57%), whereas financial concerns were cited in 8% overall. After multivariable modeling, black race (odds ratio 1.36, 95% CI 1.15-1.62), older age (odds ratio 1.07, 95% CI 1.02-1.12), atrial fibrillation (odds ratio 1.67, 95% CI 1.33-2.09), dialysis (odds ratio 1.79, 95% CI 1.15-2.78), and depression (odds ratio 1.22, 95% CI 1.02-1.45) were associated with lower likelihood of persistence. Private insurance (odds ratio 0.85, 95% 0.76-0.95), prescription cost assistance (odds ratio 0.63, 95% CI 0.54-0.75), and outpatient follow-up arranged before discharge (odds ratio 0.89, 95% CI 0.80-0.99) were associated with higher persistence. Nearly one-third of MI patients are no longer persistent with their prescribed medications by 6 months. Patients at high risk for nonpersistence may be identified by clinical and sociodemographic features. These observations underscore key opportunities to optimize longitudinal use of secondary prevention therapies.

Efforts to reduce the ranks of the uninsured hinge on take-up of available programs and subsidies, but take-up of even free insurance is often less than complete. The evidence of the effectiveness of policies aiming to increase take-up is limited. We used a randomized controlled design to evaluate the impact of improved communication and behaviorally informed ?nudges? designed to increase Medicaid take-up among eligible populations. Fielding randomized interventions in two different study populations in Oregon, we found that even very low-cost interventions substantially increased enrollment. Effects were larger in a population whose members had already expressed interest in obtaining coverage, but the effects were more persistent in low-income populations whose members were already enrolled in other state assistance programs but had not expressed interest in health insurance. The effects were similar across different demographic groups. Our results suggest that improving the design of enrollment processes and using low-cost mass-outreach efforts have the potential to substantially increase insurance coverage of vulnerable populations.

Background Despite growing emphasis on transitional care to reduce costs and improve quality, few studies have examined transitional care improvements in socioeconomically disadvantaged adults. It is important to consider these patients separately as many are high-utilizers, have different needs, and may have different responses to interventions. Objective To evaluate the impact of a multicomponent transitional care improvement program on 30-day readmissions, emergency department (ED) use, transitional care quality, and mortality. Design Clustered randomized controlled trial conducted at a single urban academic medical center in Portland, Oregon. Participants Three hundred eighty-two hospitalized low-income adults admitted to general medicine or cardiology who were uninsured or had public insurance. Intervention Multicomponent intervention including (1) transitional nurse coaching and education, including home visits for highest risk patients; (2) pharmacy care, including provision of 30 days of medications after discharge for those without prescription drug coverage; (3) post-hospital primary care linkages; (4) systems integration and continuous quality improvement. Measurements Primary outcomes included 30-day inpatient readmission and ED use. Readmission data were obtained using state-wide administrative data for all participants (insured and uninsured). Secondary outcomes included quality (3-item Care Transitions Measure) and mortality. Research staff administering questionnaires and assessing outcomes were blinded. Results There was no significant difference in 30-day readmission between C-TraIn (30/209, 14.4 %) and control patients (27/173, 16.1 %), p  = 0.644, or in ED visits between C-TraIn (51/209, 24.4 %) and control (33/173, 19.6 %), p  = 0.271. C-TraIn was associated with improved transitional care quality; 47.3 % (71/150) of C-TraIn patients reported a high quality transition compared to 30.3 % (36/119) control patients, odds ratio 2.17 (95 % CI 1.30–3.64). Zero C-TraIn patients died in the 30-day post-discharge period compared with five in the control group (unadjusted p  = 0.02). Conclusions C-TraIn did not reduce 30-day inpatient readmissions or ED use; however, it improved transitional care quality.

Latinos have the highest US childhood uninsurance rate of any race/ethnicity, but little is known about effective ways to eliminate this disparity. We evaluated the effects of parent mentors-Latino parents with children covered by Medicaid or the Children's Health Insurance Program-on insuring Latino children in a randomized, controlled, community-based trial of 155 uninsured children conducted in the period 2011-15. Parent mentors were trained to assist families in getting insurance coverage, accessing health care, and addressing social determinants of health. We found that parent mentors were more effective than traditional methods in insuring children (95 percent versus 69 percent), achieving faster coverage and greater parental satisfaction, reducing unmet health care needs, providing children with primary care providers, and improving the quality of well-child and subspecialty care. Children in the parent-mentor group had higher quality of overall and specialty care, lower out-of-pocket spending, and higher rates of coverage two years after the end of the intervention (100 percent versus 70 percent). Parent mentors are highly effective in insuring uninsured Latino children and eliminating disparities.

Depression is common in patients with type 2 diabetes and associated with poor diabetes-related outcomes. We evaluated the factors associated with antidepressant use in a low-income, racially and ethnically diverse sample of patients with type 2 diabetes. We performed a cross-sectional study of baseline data from participants in a cluster randomized trial evaluating a health literacy intervention for diabetes care in safety net clinics. Depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale (CES-D); antidepressant use was abstracted from medication lists. Multivariable mixed effects logistic regression was used to evaluate the relationship between antidepressant use and race/ethnicity adjusting for depressive symptoms, age, gender, income, and health literacy. Of 403 participants, 58% were non-Hispanic White, 18% were non-Hispanic Black, and 24% were Hispanic. Median age was 51 years old; 60% were female, 52% of participants had a positive screen for depression, and 18% were on antidepressants. Black and Hispanic participants were significantly less likely to be on an antidepressant compared with white participants, adjusted odds ratios 0.31(95% CI: 0.12 to 0.80) and 0.26 (95% CI: 0.10 to 0.74), respectively. In this vulnerable population with type 2 diabetes, we found a high prevalence of depressive symptoms, and a small proportion of participants were on an antidepressant. Black and Hispanic participants were significantly less likely to be treated with an antidepressant. Our findings suggest depression may be inadequately treated in low-income, uninsured patients with type 2 diabetes, especially racial and ethnic minorities.

Background Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children’s coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children’s insurance assistance. Methods We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics ( n  = 15,024) to those at 4 matched control clinics ( n  = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use ( n  = 2240) to intervention clinic patients without tool use (n = 12,784). Results Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14–1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68–0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64–2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53–0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used. Conclusions This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care. Trial registration ClinicalTrials.gov, NCT02298361 ; retrospectively registered on November 5, 2014.

To determine the impact of losing health insurance coverage on perceived need for and access to mental health care in women screened for postpartum depression (PPD) in primary care settings. The study sample included 2343 women enrolled in a 12-month, multisite, randomized trial that compared clinical outcomes of a comprehensive PPD screening and management program with usual care (March 1, 2006, through August 31, 2010). Screening for PPD occurred at the first postpartum visit (5-12 weeks) using the Edinburgh Postnatal Depression Scale followed by the 9-item Patient Health Questionnaire. Insurance status during the prenatal period, at delivery, and during the first postpartum year and perceived need for and access to mental health care during the first postpartum year were assessed via questionnaires completed by individual patients and participating practices. Rates of uninsured increased from 3.8% during pregnancy and delivery (n=87 of 2317) to 10.8% at the first postpartum visit (n=253 of 2343) and 13.7% at any subsequent visit to the practice after 2 months post partum (n=226 of 1646) (P<.001, both comparisons vs baseline). For patients with data on insurance type during follow-up, insurance loss occurred primarily in Medicaid beneficiaries. Nine-item Patient Health Questionnaire scores and self-reported need for mental health care did not differ significantly between patients who remained insured and those who lost insurance during the first postpartum year. However, of patients who reported the need for mental health care, 61.1% of the uninsured (n=66 of 108) vs 27.1% of the insured (n=49 of 181) reported an inability to obtain mental health care (P<.001). Loss of insurance during the first postpartum year did not significantly affect depressive symptoms or perceived need for mental health care but did adversely affect self-reported ability to obtain mental health care.

Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.

A community-based health insurance scheme operated by the Self-Employed Women's Association in Gujarat, India reported that the leading reasons for inpatient hospitalisation claims by its members were diarrhoea, fever and hysterectomy - the latter at the average age of 37. This claims pattern raised concern regarding potentially unnecessary hospitalisation amongst low-income women. A cluster randomised trial and mixed methods process evaluation were designed to evaluate whether and how a community health worker-led education intervention amongst insured and uninsured adult women could reduce insurance claims, as well as hospitalisation and morbidity, related to diarrhoea, fever and hysterectomy. The 18-month intervention consisted of health workers providing preventive care information to women in a group setting in 14 randomly selected clusters, while health workers continued with regular activities in 14 comparison clusters. Claims data were collected from an administrative database, and four household surveys were conducted amongst a cohort of 1934 randomly selected adult women. 30% of insured women and 18% of uninsured women reported attending sessions. There was no evidence of an intervention effect on the primary outcome, insurance claims (risk ratio (RR) = 1.03; 95% confidence interval (CI) 0.81, 1.30) or secondary outcomes amongst insured and uninsured women, hospitalisation (RR = 1.05; 95% CI 0.58, 1.90) and morbidity (RR = 1.09; 95% CI 0.87, 1.38) related to the three conditions. The process evaluation suggested that participants retained knowledge from the sessions, but barriers to behaviour change were not overcome. We detected no evidence of an effect of this health worker-led intervention to decrease claims, hospitalisation and morbidity related to diarrhoea, fever and hysterectomy. Strategies that capitalise on health workers' role in the community and knowledge, as well as those that address the social determinants of diarrhoea, fever and the frequency of hysterectomy - such as water and sanitation infrastructure and access to primary gynaecological care - emerged as areas to strengthen future interventions.