Health Policy & Management Research Works

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    Residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling by adults with lower incomes: Is increased access to primary care enough?
    (Wiley, 2023-07-08) Phillips, Aryn Z.; Karriker-Jaffe, Katherine J.; Bensley, Kara M. K.; Subbaraman, Meenakshi S.; Delk, Joanne; Mulia, Nina
    Background We investigate whether living in a state that expanded Medicaid eligibility is associated with receiving alcohol screening and brief counseling among nonelderly, low-income adults and a subgroup with chronic health conditions caused or exacerbated by alcohol use. Method Data are from the 2017 and 2019 Behavioral Risk Factor Surveillance System (N = 15,743 low-income adults; n = 7062 with a chronic condition). We used propensity score-weighted, covariate-adjusted, modified Poisson regression to estimate associations between residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling. Models estimated associations in the overall sample and chronic conditions subsample, as well as differential associations across sex, race, and ethnicity using interaction terms. Results Living in a state that expanded Medicaid eligibility was associated with being asked whether one drank (prevalence ratio (PR) = 1.15, 95% confidence interval (CI) = 1.08, 1.22), but not with further alcohol screening, guidance about harmful drinking, or advice to reduce drinking. Among individuals with alcohol-related chronic conditions, expansion state residence was associated with being asked about drinking (PR = 1.13, 95% CI = 1.05, 1.20) and, among past 30-day drinkers with chronic conditions, being asked how much one drank (PR = 1.28, 95% CI = 1.04, 1.59) and about binge drinking (PR = 1.43, 95% CI = 1.03, 1.99). Interaction terms suggest that some associations differ by race and ethnicity. Conclusions Living in a state that expanded Medicaid is associated with a higher prevalence of receiving some alcohol screening at a check-up in the past 2 years among low-income residents, particularly among individuals with alcohol-related chronic conditions, but not with the receipt of high-quality screening and brief counseling. Policies may have to address provider barriers to delivery of these services in addition to access to care.
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    Changes in prenatal care and birth outcomes after federally qualified health center expansion
    (Wiley, 2022-11-07) Gourevitch, Rebecca A.; Hatfield, Laura A.
    Objective To evaluate whether the expansion of Federally Qualified Health Centers (FQHCs) improved late prenatal care initiation, low birth weight, and preterm birth among Medicaid-covered or uninsured individuals. Data Sources and Study Setting We identified all FQHCs in California using the Health Resources and Services Administration's Uniform Data System from 2000 to 2019. We used data from the U.S. Census American Community Survey to describe area characteristics. We measured outcomes in California birth certificate data from 2007 to 2019. Study Design We compared areas that received their first FQHC between 2011 and 2016 to areas that received it later or that had never had an FQHC. Specifically, we used a synthetic control with a staggered adoption approach to calculate non-parametric estimates of the average treatment effects on the treated areas. The key outcome variables were the rate of Medicaid or uninsured births with late prenatal care initiation (>3 months' gestation), with low birth weight (<2500 grams), or with preterm birth (<37 weeks' gestation). Data Collection/Extraction Methods The analysis was limited to births covered by Medicaid or that were uninsured, as indicated on the birth certificate. Principal Findings The 55 areas in California that received their first FQHC in 2011–2016 were more populous; their residents were more likely to be covered by Medicaid, to be low-income, or to be Hispanic than residents of the 48 areas that did not have an FQHC by the end of the study period. We found no statistically significant impact of the first FQHC on rates of late prenatal care initiation (ATT: −10.4 [95% CI −38.1, 15.0]), low birth weight (ATT: 0.2 [95% CI −7.1, 5.4]), or preterm birth (ATT: −7.0 [95% CI −15.5, 2.3]). Conclusions Our results from California suggest that access to primary and prenatal care may not be enough to improve these outcomes. Future work should evaluate the impact of ongoing initiatives to increase access to maternal health care at FQHCs through targeted workforce investments.
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    Differential associations of homelessness with emergencydepartment visits and hospitalizations by race, ethnicity, andgender
    (Wiley, 2022-05-20) Yue, Dahai; Pourat, Nadereh; Essien, Elsie A.; Chen, Xiao; Zhou, Weihao; O'Masta, Brenna
    Objective To investigate the differential associations of homelessness with emergency department (ED) visits and hospitalizations by race, ethnicity, and gender. Data Sources California Medicaid enrollment and claims. Study Design We identified beneficiaries experiencing homelessness (BEH) and those who did not (NBEH) using diagnosis and place of service codes and residential addresses. Outcomes include four ED visit measures and four hospitalization measures. We compared the use of these services by BEH to NBEH overall and by race, ethnicity, and gender groups in regression models controlling for covariates. Data Collection We used a sample of Medicaid beneficiaries who met eligibility criteria for a California Medicaid demonstration program in 2017 and 2018 but were not enrolled in the program. We identified 473,069 BEH, and the rest (1,948,422) were considered NBEH. We used the 2018 data for utilization analyses and most covariates. We constructed lagged measures of health conditions using 2017 data. Principal Findings We found that homelessness was significantly associated with 0.34 more ED visits (p < 0.01) and a higher likelihood of frequent ED visits (2.77 percentage points [pp], p < 0.01), any ED visits due to mental health conditions (0.79 pp, p < 0.01), and any ED visits due to substance use disorders (1.47 pp, p < 0.01). Experiencing homelessness was also significantly associated with 0.03 more hospitalizations (p < 0.01), a higher likelihood of frequent hospitalizations (0.68 pp, p < 0.01) and high frequent hospitalizations (0.28 pp, p < 0.01), and a longer length of stay (0.53 days, p < 0.01). We found a larger association for American Indian and Alaska Native, Black, Native Hawaii or Pacific Islander, and White populations than that for Asian and Hispanic populations. The associations are larger for males than females. Conclusions Our findings identified distinct utilization patterns by race, ethnicity, and gender. They indicated the need for developing race, ethnicity, and gender-specific strategies to reduce ED visits and hospitalizations of BEH.
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    Reductions in under-5 mortality and public health improvements of the China Healthy Cities (Counties) initiative: a nationwide quasiexperimental study
    (BMJ, 2022-03-09) Yue, Dahai; Chen, Xiao; Zhu, Yuhui; Macinko, James; Meng, Qingyue
    Introduction The China Healthy Cities (Counties) public health initiative has been at the forefront of China’s efforts to counteract the growing challenges in the urban environment since the 1990s. It primarily focuses on improving the urban living environment. However, the nationwide health impacts of the initiative remain unexplored. Methods We constructed nationwide county-level and city-level panel data from 1996 to 2012 using data on under-5 mortality rates (U5MR), the list of China healthy cities and counties and socioeconomic factors. We used a two-step staggered difference-in-differences approach that exploits variations in the timing of achieving the title of China Healthy City/County. Subgroup analyses by region were performed. Results We included 707 cities in the China Healthy Cities study, and 1631 counties in the China Healthy Counties study. Our results indicate substantial and significant reductions in U5MR associated with the public health initiative in China. The association varies across regions with different socioeconomic statuses. China Healthy Cities were significantly associated with a reduction of 0.7/1000 (95% CI −1.2 to −0.2) in under-5 mortality 5 years after cities gained the title and a decrease of 1.4/1000 (95% CI −2.2 to −0.6) 10 years afterward. Cities from western China saw the largest statistically significant gains with 3.2/1000 and 7.2/1000 reductions in child mortality after 5 and 10 years, respectively. China Healthy Counties were also associated with significant reductions in under-5 mortality 8 years after achieving the title; it was associated with 2.6/1000 reductions in under-5 mortality nationwide and 3.8/1000 reductions in eastern China. Our results are robust to heterogeneous treatment effects across cities/counties over time and various model specifications. Conclusion Our results suggest significant reductions in under-5 mortality associated with this public health intervention focusing on living environment conditions. Future research could explore differential effects across regions and clarify the underlying causal mechanisms.
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    Umbrella Review: COVID-19 Public Health Measures and Patient and Public Involvement in Health and Social Care Research
    (2023-08-10) Fouladi, Negin; Tchangalova, Nedelina; Ajayi, Damilola; Millwee, Elizabeth; Lovett, Corinne; Del Sordi, Alana; Liggett, Samantha; De Silva, Malki; Bonilla, Laura; Nkwonta, Angel; Ramnarine, Leah; Munoz, Allyssa; Frazer, Kate; Kroll, Thilo
    Background: - Patient and public involvement (PPI) in health research refers to patients and other members of the public with relevant experience contributing to design, implementation, and dissemination of research. PPI entails research being carried out ‘with’ or ‘by’ members of the public, rather than ‘to’, ‘about’ or ‘for’ them.  - Over the past decade, there has been an increased emphasis on the importance of PPI in health and social research as it provides alternative views and insights into the needs of healthcare users to improve the quality and relevance of research. - PPI enhances the efficiency, design, and quality of healthcare initiatives and facilitates decision-making regarding resource allocations and the usability of services by including information about the capabilities, needs, and priorities of local people.  - The rapid response to the COVID-19 pandemic resulted in PPI being viewed as non-essential, leading to its minimal inclusion in research and, thereby, minimizing the contribution of patients, the public, and, particularly, minority groups in helping find solutions to the pandemic crisis. - Public health measures (PHM) aim to reduce the transmission, severity of illness, and death and are critical strategies to address pandemic outbreaks, therefore, PPI is crucial in building trust and acceptance in research, greater benefits for the community, new and improved services, valuable changes in practice/partnership leading to positive changes and outcomes.