Browsing School, Graduate by Subject "Quality of Health Care"
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Longitudinal Patterns of Early Mental Health Service Utilization in a Medicaid-insured Birth Cohort and the Impact of Continuity of Care on the Quality of Pediatric Mental Health TreatmentBackground: The prevalence of pediatric mental health (MH) diagnosis and treatment have expanded in the U.S. We assessed the longitudinal patterns of incident diagnosis and new psychotropic medication use in a Medicaid-insured birth cohort. Additionally, continuity and quality of MH service utilization were assessed in a publicly-insured pediatric population. Quality care was defined by the 2009 Children's Health Insurance Program Reauthorization Act (CHIPRA) mandated children's health care quality measures. Methods: We applied longitudinal designs to Medicaid claims data from a Mid-Atlantic state (2007-2014). Using Kaplan-Meier estimators we assessed the cumulative incidence of MH service use in a cohort of newborns (aim 1). We assessed the association between relational patient-provider continuity of care and: 1) emergency department (ED) visits or hospitalizations in the 12 months following first MH diagnosis among 3-16 year olds (aim 2); and 2) the quality of follow-up care among 6-12 year old new users of ADHD medications (aim 3), using logistic regression models. Quality was defined as having ≥1 follow-up outpatient visit in the 30 days following medication initiation and ≥2 follow-up visits in the 270 days after the first follow-up visit, with a total medication supply of ≥210 days. Results: By age 8, 19.7% and 10.2% of the birth cohort (n=35,244) had received a MH diagnosis or psychotropic medication, respectively. Among medication users, 80.5% received monotherapy, 16.4% received 2 medication classes, and 4.3% received ≥3 medication classes concomitantly for ≥60 days. Compared to children with high CoC, the odds of ED visits was significantly higher among youths with low CoC [Odds Ratio(OR)=1.27; 95% CI=1.13-1.41] and low CoC was associated with greater odds of hospitalization [OR=1.17; 95% CI=1.06-1.29]. Compared to those with low CoC, children with higher continuity of care had greater odds of meeting CHIPRA initiation- [OR=1.41; 95% CI=1.25-1.60] and continuation-phase [OR=1.45; 95% CI=1.29-1.64] visit-based measures. Conclusions: Early exposure to psychotropic medications and prolonged duration of use have implications for long-term safety, highlighting the need for safety and outcomes research in pediatric populations. Our findings suggest a need for more research in the areas of quality assessment and continuity of care among youths with mental health conditions.
Medicare Disabled Patients with Hepatitis C: Determinants of Quality of Care Receipt, Peg-Interferon Treatment Initiation, and Risk of Metabolic and Vascular DisordersBackground: Due to years of undetected hepatitis C virus (HCV) infection, the burden of liver and extrahepatic disorders will continue to increase in the US. HCV patients receiving Social Security Disability Benefits represent~70% of HCV patients in Medicare and are an understudied population facing numerous barriers to HCV management. We explored pre-treatment quality of care (QC) patterns, determined the factors associated with differential QC receipt and peg-interferon treatment initiation, and examined the effectiveness of peg-interferon therapy for ?24 weeks at reducing metabolic/vascular risk in Medicare disabled HCV patients. Methods: Medicare claims (2006-2009) linked to the Area Health Resource Files were used. We used a random forest model of conditional inference trees to aggregate QC indicators into high, good, fair, and low QC groupings. Ordinal partial proportional odds regression modelled the receipt of differential QC levels. Modified Poisson regressions, propensity-score weighted for the level of QC received, examined the association between treatment initiation and patient- and county-level characteristics. Poisson regression with weights for treatment selection, discontinuation, and informative censoring due to mortality quantified the effect of peg-interferon treatment on the risk of incident mild, severe, or mild and severe metabolic/vascular events, compared to the untreated. Results: We identified 1,936 patients with continuous enrolment, of whom 10.4% initiated peg-interferon. The five strongest QC metrics predicting treatment included "having received liver biopsy", "HCV genotype testing", "visit to specialist", "confirmation of HCV viremia", and "iron overload testing". While county of residence had no effect on QC receipt, residence in rural counties with high screening capacity was associated with higher prevalence ratio [PR] of treatment initiation (PR=1.42, p=0.09). High QC (PR=5.61, p<0.01) and good QC (PR=2.46, p<0.01) were associated with higher treatment rates. Multiple comorbidities were associated with lower odds of QC receipt (OR=0.76, p=0.05) and treatment initiation (PR=0.27, p<0.01). Over two years of follow-up, there was no difference in metabolic/vascular risk between those treated≥24 weeks (n=43) and untreated (n=879) patients. Conclusion: As barriers to eradicating the HCV infection would likely persist even with novel interferon-free regimens, future research should use our findings to better characterize and optimize treatment in HCV patients with disabilities.