Angela Snyder

State-based surveillance for selected hemoglobinopathies

Purpose:The lack of an ongoing surveillance system for hemoglobinopathies in the United States impedes the ability of public health organizations to identify individuals with these conditions, monitor their health-care utilization and clinical outcomes, and understand the effect these conditions have on the health-care system. This article describes the results of a pilot program that supported the development of the infrastructure and data collection methods for a state-based surveillance system for selected hemoglobinopathies.Methods:The system was designed to identify and gather information on all people living with a hemoglobinopathy diagnosis (sickle cell diseases or thalassemias) in the participating states during 2004–2008. Novel, three-level case definitions were developed, and multiple data sets were used to collect information.Results:In total, 31,144 individuals who had a hemoglobinopathy diagnosis during the study period were identified in California; 39,633 in Florida; 20,815 in Georgia; 12,680 in Michigan; 34,853 in New York, and 8,696 in North Carolina.Conclusion:This approach provides a possible model for the development of state-based hemoglobinopathy surveillance systems.Genet Med 17 2, 125–130.

Defining Sickle Cell Disease Mortality Using a Population-Based Surveillance System, 2004 through 2008:

Objective. Population-based surveillance data from California and Georgia for years 2004 through 2008 were linked to state death record files to determine the all-cause death rate among 12,143 patients identified with sickle cell disease (SCD). Methods. All-cause death rates, by age, among these SCD patients were compared with all-cause death rates among both African Americans and the total population in the two states. All-cause death rates were also compared with death rates for SCD derived from publicly available death records: the compressed mortality files and multiple cause of death files. Results. Of 12,143 patients identified with SCD, 615 patients died. The all-cause mortality rate for the SCD population was lower than the all-cause mortality rate among African Americans and similar to the total population all-cause mortality rates from birth through age 4 years, but the rate was higher among those with SCD than both the African American and total population rates from ages 5 through 74 years. The count of deceased patients identified by using population-based surveillance data (n=5615) was more than twice as high as the count identified in compressed mortality files using SCD as the underlying cause of death alone (n=5297). Conclusion. Accurate assessment of all-cause mortality and age at death requires long-term surveillance via population-based registries of patients with accurately diagnosed SCD.

Comparing preventive visits of children in foster care with other children in Medicaid.

Objective. This study compared preventive medical and dental visits of Georgia children in foster care with other children enrolled in Medicaid to determine if utilization differed. Methods. Two logistic regressions estimated the likelihood of an annual Health Check screening and the likelihood of at least one dental visit. Results. Compared with children in foster care, children in the adoption assistance ([AOR] .37, 95% confidence interval [CI] = 0.35-0.40), SSI (AOR .37, 95% CI = 0.35-0.38) and low-income (AOR .40, 95% CI = 0.39-0.42) Medicaid categories were less likely to receive an annual Health Check screening. Children in adoption assistance were also less likely to have a dental visit during the study period. Conclusion. Policies require a Health Check visit upon placement into foster care and annual check-ups consistent with pediatric guidelines; we found more Early and Periodic Screening, Detection, and Treatment screenings for foster care children in Georgia than for other children receiving Medicaid.

Estimating Premium Sensitivity for Children's Public Health Insurance Coverage: Selection but No Death Spiral

OBJECTIVE To estimate the effect of premium increases on the probability that near-poor and moderate-income children disenroll from public coverage. DATA SOURCES Enrollment, eligibility, and claims data for Georgias PeachCare for Kids(™) (CHIP) program for multiple years. STUDY DESIGN We exploited policy-induced variation in premiums generated by cross-sectional differences and changes over time in enrollee age, family size, and income to estimate the duration of enrollment as a function of the effective (per child) premium. We classify children as being of low, medium, or high illness severity. PRINCIPAL FINDINGS A dollar increase in the per-child premium is associated with a slight increase in a typical childs monthly probability of exiting coverage from 7.70 to 7.83 percent. Children with low illness severity have a significantly higher monthly baseline probability of exiting than children with medium or high illness severity, but the enrollment response to premium increases is similar across all three groups. CONCLUSIONS Success in achieving coverage gains through public programs is tempered by persistent problems in maintaining enrollment, which is modestly affected by premium increases. Retention is subject to adverse selection problems, but premium increases do not appear to significantly magnify the selection problem in this case.

Determining Adherence to Quality Indicators in Sickle Cell Anemia Using Multiple Data Sources.

INTRODUCTION Advances in primary prophylaxis have resulted in improved outcomes for patients with sickle cell anemia (SCA; i.e., hemoglobin SS- and Sβ(0)-thalassemia). Standard prophylactic measures include a first pneumococcal polysaccharide vaccine (PPV) and transcranial Doppler ultrasound (TCD) at age 2 years. Though efficacious, evidence suggests that delivery of these interventions is suboptimal. This study reports adherence to these measures and examines concordance across various data sources, using Registry and Surveillance for Hemoglobinopathies project data. METHODS Retrospective database and SCA center chart review identified children with SCA aged 24-36 months between January 1, 2004, and December 31, 2008. PPV and TCD administration were determined through Medicaid and Childrens Health Insurance Program administrative claims data, medical record review, and Georgia Registry of Immunization Transaction and Services. Analysis was conducted in 2015. RESULTS A total of 125 children met inclusion criteria. Forty-five (36.0%) children had documentation of both interventions, whereas 19 (15.2%) had no documentation of either intervention. Sixty-one (48.8%) children obtained only one intervention. Of these, more were likely to have had PPV than TCD (77.0% vs 23.0%, respectively, p<0.001). Agreement between claims data and medical record review was moderate for PPV (κ=0.55) and substantial for TCD (κ=0.74). CONCLUSIONS No single, reliable data source for tracking standard of care for children with SCA statewide was found. According to study data, prophylaxis measures were not universally implemented during the surveillance period. Further research is needed to adequately track changes over time, determine risk groups, and develop methods of evaluating important metrics.

Student-Perceived School Climate Is Associated With ADHD Medication Treatment Among Adolescents in Medicaid:

Objective: The objective of this study was to evaluate the relationship between school climate and ADHD medication treatment among adolescents in Medicaid in Georgia. Method: School climate and Medicaid claims data were aggregated for 159 GA counties. County-level school climate percentile and medicated ADHD prevalence were calculated. The t tests and regression models evaluated the relationship between school climate, medicated ADHD, and demographics, weighted by county population. Poorer 2008 school climate (<25th percentile) was regressed on 2011 medicated ADHD prevalence, controlling for potential confounders. Results: The prevalence of medicated ADHD was 7.8% among Medicaid-enrolled GA adolescents. The average county-level prevalence of medicated ADHD was 10.0% (SD = 2.9%). Poorer school climate was associated with lower rates of medicated ADHD (p < .0001); along with demographics, these factors accounted for 50% of the county variation in medicated ADHD. Conclusion: School climate is associated with medicated ADHD among adolescents in Medicaid. Additional research may reveal whether high medicated ADHD may reflect a lack of access to non-pharmacological therapies in some communities.

Examining the potential of information technology to improve public insurance application processes: enrollee assessments from a concurrent mixed method analysis

Objective To assess the perceived readiness of Medicaid and Childrens Health Insurance Program (CHIP) enrollees to use information technologies (IT) in order to facilitate improvements in the application processes for these public insurance programs. Methods We conducted a concurrent mixed method study of Medicaid and CHIP enrollees in a southern state. We conducted focus groups to identify enrollee concerns regarding the current application process and their IT proficiency. Additionally, we surveyed beneficiaries via telephone about their access to and use of the Internet, and willingness to adopt IT-enabled processes. 2013 households completed the survey. We used χ2 analysis for comparisons across different groups of respondents. Results A majority of enrollees will embrace IT-enabled enrollment, but a small yet significant group continues to lack access to facilitating technologies. Moreover, a segment of beneficiaries in the two programs continues to place a high value on personal interactions with program caseworkers. Discussion IT holds the promise of improving efficiency and reducing barriers for enrollees, but state and federal agencies managing public insurance programs need to ensure access to traditional processes and make caseworkers available to those who require and value such assistance, even after implementing IT-enabled processes. Conclusions The use of IT-enabled processes is essential for effectively managing eligibility and enrollment determinations for public programs and private plans offered through state or federally operated exchanges. However, state and federal officials should be cognizant of the technological readiness of recipients and provide offline help to ensure broad participation in the insurance market.