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The American Journal of Medicine | 2010

Higher Cardiovascular Disease Prevalence and Mortality among Younger Blacks Compared to Whites

Stacey E. Jolly; Eric Vittinghoff; Arpita Chattopadhyay; Kirsten Bibbins-Domingo

BACKGROUND Blacks have higher rates of cardiovascular disease than whites. The age at which these differential rates emerge has not been fully examined. OBJECTIVE We examined cardiovascular disease prevalence and mortality among black and white adults across the adult age spectrum and explored potential mediators of these differential disease prevalence rates. METHODS We conducted a cross-sectional analysis of National Health and Nutrition Examination Survey data from 1999-2006. We estimated age-adjusted and age-specific prevalence ratios (PR) for cardiovascular disease (heart failure, stroke, or myocardial infarction) for blacks versus whites in adults aged 35 years and older and examined potential explanatory factors. From the National Compressed Mortality File 5-year aggregate file of 1999-2003, we determined age-specific cardiovascular disease mortality rates. RESULTS In young adulthood, cardiovascular disease prevalence was higher in blacks than whites (35-44 years PR 1.9; 95% confidence interval [CI], 1.1-3.4). The black-white PR decreased with each decade of advancing age (P for trend=.04), leading to a narrowing of the racial gap at older ages (65-74 years PR 1.2; 95% CI, 0.8-1.6; > or =75 years PR 1.0; 95% CI, 0.7-1.4). Clinical and socioeconomic factors mediated some, but not all, of the excess cardiovascular disease prevalence among young to middle-aged blacks. Over a quarter (28%) of all cardiovascular disease deaths among blacks occurred in those aged <65 years, compared with 13% among whites. CONCLUSIONS Reducing black/white disparities in cardiovascular disease will require a focus on young and middle-aged blacks.


Annals of Internal Medicine | 2008

Interruptions in Medicaid Coverage and Risk for Hospitalization for Ambulatory Care–Sensitive Conditions

Andrew B. Bindman; Arpita Chattopadhyay; Glenna M. Auerback

Context Many persons in the United States experience interruptions in their health insurance coverage. Contribution This study of hospitalized California adults with Medicaid found an association between interruptions in coverage and a higher rate of hospitalization for ambulatory caresensitive conditions, such as heart failure, diabetes, and chronic obstructive pulmonary disease. Caution The study sample was limited to hospitalized patients, and some patients with interrupted coverage may have obtained private insurance. Implication Interruptions in insurance coverage were associated with hospitalization for ambulatory caresensitive conditions. Policies that reduce the interruptions in coverage might prevent some of these hospitalizations. The Editors Many U.S. citizens experience interruptions in health insurance coverage. A total of 85 million persons, or 38% of the U.S. population, younger than age 65 years were uninsured for at least part of a 3-year period (1). Low-income U.S. citizens are particularly at risk for periodic lack of insurance. Many poor persons move in and out of the Medicaid program with periods of being uninsured in between (2, 3). Medicaid reenrollment policies affect the number of beneficiaries who experience interruptions in their coverage. A shorter period for eligibility redetermination creates an administrative barrier to continuous coverage (4). Federal law requires that Medicaid eligibility be redetermined at least annually, but many states require this assessment at a shorter interval. In California, for example, adults need to redemonstrate their eligibility for Medicaid every 3 months. Research suggests that individuals with interrupted insurance coverage are less likely to receive primary care and preventive services (5). One potentially useful but as yet unexplored measure of morbidity and costs associated with interrupted Medicaid coverage is hospitalizations for ambulatory caresensitive conditions. Ambulatory caresensitive conditions, such as asthma, diabetes, and hypertension, are conditions that can often be managed with timely and effective treatment in an outpatient setting, thereby preventing hospitalization (6). Hospital admissions for these conditions reflect a decline in health status and, by association, the health consequences of access barriers. We performed a retrospective cohort study to determine whether interruptions in Medicaid enrollment are associated with an increased risk for hospitalizations in adults with ambulatory caresensitive conditions. Methods Data To conduct the analysis, the 1998 to 2002 California hospital patient discharge data available from the California Office of Statewide Health Planning and Development was linked with the Medicaid Monthly Eligibility File for the corresponding period from the California Department of Health Services. A deterministic match was done with social security numbers, sex, and year of birth available in both files, and a probabilistic match by using sex, date of birth, hospital identifier, and hospitalization dates was done on the residual to enhance the linkage. Judging by comparisons with separate Medicaid payment records, the California Department of Health Services estimated that more than 98% of Medicaid hospitalization records were successfully linked. Approximately 70% of the records were linked by using the deterministic method, and 27% were linked by using the probabilistic method (7). Furthermore, most records lacking a social security number needed for a deterministic match were for newborns, whom we excluded from this analysis. We were unable to correct for out-of-state hospitalizations of Medicaid beneficiaries. The California hospital patient discharge database includes a unique patient identifier and information about admission and discharge dates, patient demographic characteristics, diagnosis codes, and insurance status for the hospitalization. By linking the information available in the hospital discharge file with that available from the California Department of Health Services, we could confirm whether a hospitalized individual was in fact a Medicaid beneficiary and capture additional information on a monthly basis regarding Medicaid enrollment status, aid category, and whether the care was delivered through fee-for-service or managed care for all Medicaid beneficiaries, regardless of whether they were hospitalized. Furthermore, this linked file enabled us to capture hospitalizations for individuals who at one time may have had Medicaid coverage but did not have coverage at the time of a hospitalization. We limited our analysis to adults age 18 to 64 years. Outcome Measure We created longitudinal records of eligibility status and hospitalizations of any persons who were ever enrolled in Medicaid during the 5-year study period. We measured the duration of time within the study period from enrollment in Medicaid until the first hospitalization for an ambulatory caresensitive condition and the duration of time to subsequent hospitalizations thereafter. We classified hospitalizations in the patient discharge file as being for ambulatory caresensitive conditions on the basis of the definition provided by the Agency of Healthcare Research and Quality (AHRQ). We applied the AHRQ definitions of ambulatory caresensitive conditions, identifying hospitalizations in which the principal diagnosis International Classification of Disease, Ninth Edition, code was listed in the AHRQ 2001 guidelines (8). We have previously reported that these conditions comprise 26% of nonpregnancy-related hospitalizations for Medicaid beneficiaries in California (9). We compared the pattern of hospitalization rates for specific ambulatory caresensitive conditions between patients with continuous and those with interrupted Medicaid coverage. Because this pattern was quite similar, and for ease of interpretation and presentation, we followed the conventional practice of aggregating hospital admissions for any of the AHRQ ambulatory caresensitive conditions. Exposure Variable We modeled our primary exposure variable as a time-varying covariate indicating whether a beneficiary had or had not experienced an interruption of coverage. We identified an interruption of coverage when a monthly eligibility code after the first enrollment month was no longer present. The California Medicaid Monthly Enrollment file includes a code for Healthy Families, the California State Childrens Health Insurance Program (SCHIP). Healthy Families allows persons up to the age of 19 years to qualify for Medicaid-type benefits in California but at somewhat higher income levels. For the purposes of our analysis, we considered enrollment in Healthy Families as a form of Medicaid coverage and did not consider it to be an interruption in coverage if an individual changed between these 2 programs over time. We characterized all periods before the interruption as continuous and those after the interruption as being discontinuous. Potential Confounders We measured several characteristics of beneficiaries that could influence their risk for a hospitalization for an ambulatory caresensitive condition as well as their risk for interrupted Medicaid coverage. These included demographic characteristics, Medicaid aid category, Medicaid health care delivery model, and forms of insurance other than Medicaid. Many of these variables are used to determine payment and were therefore complete in the data set. However, 68807 beneficiaries (1%) had missing information on race/ethnicity and were classified with those reported as other. Beneficiary demographic characteristics and Medicaid aid category provide an estimate of health status. We categorized aid category as Temporary Assistance to Needy Families (TANF), Supplemental Security Income (SSI), or other by using previously described algorithms (10). Medicaid eligibility through TANF is available to low-income children and their parents regardless of their health status. On the other hand, beneficiaries enrolled in Medicaid through the SSI program are eligible as a result of a chronic disability and therefore tend to be sicker on average than those eligible through TANF (11). From calculations using the Medi-Cal eligibility file data, we determined that most (83%) of the other group is composed of low-income persons whose incomes are too high for them to qualify for Medicaid but who subsequently do qualify for the medically needy aid category because of their acute out-of-pocket spending on health care services. The remainder of the other group is primarily women who are eligible on the basis of a pregnancy (12%) and persons who are eligible through one of several immigration-related programs (4%). The AHRQ provides an option for including the Elixhauser comorbid condition measure in the calculation of ambulatory caresensitive hospitalization rates (12). Incorporating diagnoses from administrative data in risk adjustment could introduce overadjustment if the comorbid conditions are a product of the same access-to-care barriers that result in hospitalizations for ambulatory caresensitive conditions. Nonetheless, we performed additional analyses incorporating the Elixhauser comorbid condition measure and found that its inclusion did not substantially affect our findings. Therefore, to simplify the presentation, we have chosen not to display these results. Except for the managed care indicator variable, all potential confounders were measured when beneficiaries enrolled in Medicaid. We classified Medicaid beneficiaries as being in managed care depending on whether they spent most of their enrollment time before a hospitalization for an ambulatory caresensitive condition in managed care. This was necessary because some beneficiaries changed between fee-for-service and managed care during their enrollment time. Statistical Analysis We performed descriptive analysis of the characteristics of Medicaid beneficiaries who did and


Population Studies-a Journal of Demography | 2006

Migrant fertility in Ghana: Selection versus adaptation and disruption as causal mechanisms

Arpita Chattopadhyay; Michael J. White; Cornelius Debpuur

The aim of the study presented in this paper is to disentangle the roles of three mechanisms—selection, adaptation, and disruption—in influencing migrant fertility in Ghana. Using data from the 1998 Ghana Demographic and Health Survey, we fit Poisson and sequential logit regression models to discern the effects of the above mechanisms on cumulative fertility and annual probabilities of birth. Characteristics of migrants from four types of migration stream are examined and compared with those of non-migrants at origin and destination. We find substantial support for the selection hypothesis among both rural–urban and urban–rural migrants. Disruption is evident only in the fertility timing of second and higher-order births in Ghana. Our finding that migrants bear children at about the same rates as the natives at destination implies that the growth rate of cities will slow down quickly and that the rural population will continue to have high fertility. Thus to achieve a reduction in the national fertility level, family planning activities need to be directed towards rural areas.


Medical Care | 2008

Medicaid Re-Enrollment Policies and Children's Risk of Hospitalizations for Ambulatory Care Sensitive Conditions

Andrew B. Bindman; Arpita Chattopadhyay; Glenna M. Auerback

Background:Many poor children rotate through the Medicaid program with periods of being uninsured. Objective:To determine health and cost consequences of a Medicaid policy change that extended the Medicaid eligibility redetermination period for children in California from 3 to 12 months. Research Design:A pre/postevaluation with a comparison group of a natural experiment. Subjects:All California children ages 1–17 years who received a minimum of 1 month of Medicaid coverage in 1999–2000 (3,288,171) and/or 2001–2002 (3,230,120). Measures:The percentage of children with continuous Medicaid coverage and the hospitalization rate and costs for ambulatory care sensitive conditions in each time period. Results:In the 2 years before the policy change, 49% of children had continuous Medicaid coverage compared with 62% in the 2 years afterward (P < 0.0001). After adjusting for demographic and programmatic differences in the population of children in each time period, the relative hazard of a hospitalization for an ambulatory care sensitive condition for a child with at least 1 month of Medicaid coverage decreased to 0.74 (P < 0.0001) after the extension of the Medicaid enrollment period. There was


Medical Care | 2005

Accuracy of medicaid payer coding in hospital patient discharge data : Implications for medicaid policy evaluation

Arpita Chattopadhyay; Andrew B. Bindman

17 million less in estimated hospitalization costs for ambulatory care sensitive conditions with less frequent eligibility redetermination that partially offset the estimated


American Journal of Public Health | 2010

Unhealthy Competition: Consequences of Health Plan Choice in California Medicaid

Christopher Millett; Arpita Chattopadhyay; Andrew B. Bindman

150 million in additional costs to Medicaid for providing more continuous coverage. Conclusions:Reducing the frequency of eligibility redetermination for children in Medicaid was associated with higher costs to the program but more continuity of insurance coverage, improvements in health, and lower hospital spending.


JAMA | 2010

Linking a Comprehensive Payment Model to Comprehensive Care of Frail Elderly Patients: A Dual Approach

Arpita Chattopadhyay; Andrew B. Bindman

Background:Ambulatory care-sensitive hospitalization rates derived from hospital discharge data have been used to compare ambulatory care across insurance and delivery system groups. Objective:We sought to quantify the impact of coding inaccuracies in hospital discharge data on counts of hospitalizations for ambulatory care-sensitive conditions among Medicaid beneficiaries. Methods:This was a cross-sectional comparison of administrative databases of all California Medicaid beneficiaries younger than 65 years of age. We compared the number of hospitalizations that were attributed to Medicaid beneficiaries in Californias hospital discharge data for 1994 to 1999 with the number derived from a file that linked hospital discharge data with the Medicaid eligibility file. Results:Hospital discharge data undercounted 28.2% of hospitalizations for ambulatory care-sensitive conditions among Medicaid beneficiaries and overcounted 13.4% of such admissions among non-Medicaid beneficiaries. Approximately 5% of hospitalizations for ambulatory care-sensitive conditions captured as Medicaid admissions in routine hospital discharge data were among patients who gained Medicaid coverage as a result of the hospitalization. Patients who acquire Medicaid coverage as a result of a hospitalization are much more likely to be placed into Medicaid fee for service rather than Medicaid managed care which biases comparisons of these 2 delivery models. Conclusion:Caution should be used in the interpretation of Medicaid hospitalization rates as calculated from routine hospital discharge data. State agencies that provide hospital discharge data should consider the opportunity to improve the evaluation of Medicaid services by linking hospital discharge data with Medicaid enrollment files.


The Journal of ambulatory care management | 2007

Racial and ethnic differences in receipt of primary care services between medicaid fee-for-service and managed care plans.

Hilary K. Seligman; Arpita Chattopadhyay; Eric Vittinghoff; Andrew B. Bindman

OBJECTIVES We compared the quality of care received by managed care Medicaid beneficiaries in counties with a choice of health plans and counties with no choice. METHODS This cross-sectional study among California Medicaid beneficiaries was conducted during 2002. We used a multivariate Poisson model to calculate adjusted rates of hospital admissions for ambulatory care-sensitive conditions by duration of plan enrollment. RESULTS Among beneficiaries with continuous Medicaid coverage, the percentage with 12 months of continuous enrollment in a health plan was significantly lower in counties with a choice of plans than in counties with no choice (79.2% vs 95.2%; P < .001). Annual ambulatory care-sensitive admission rates adjusted for age, gender, and race/ethnicity were significantly higher among beneficiaries living in counties with a choice of plans (6.58 admissions per 1000 beneficiaries; 95% confidence interval [CI] = 6.57, 6.58) than among those in counties with no choice (6.27 per 1000; 95% CI = 6.27, 6.28). CONCLUSIONS Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care-sensitive conditions.


SpringerPlus | 2013

Cost-efficiency in Medicaid long-term support services: the role of home and community based services

Arpita Chattopadhyay; Yang Fan; Sudip Chattopadhyay

FRAIL OLDER PATIENTS WITH MULTIPLE CHRONIC CONditions and complex health care needs receive services that are fragmented, incomplete, inefficient, and ineffective. Many of these patients are vulnerable to poor health outcomes because of age, multiple comorbidities, and poverty. Older adults with chronic health conditions spend a higher percentage of their income on health care. As a result, many frail elderly adults receive Medicare for physician and hospital care, and Medicaid, which covers some out-of-pocket costs and personal and social care services. Six million elderly adults are enrolled in both Medicare and Medicaid, also known as dual eligibles; they comprise 21% of Medicare beneficiaries. At the federal level, the Centers for Medicare & Medicaid Services (CMS) administers the Medicare and Medicaid programs. Unlike Medicare, for which all financing is federal, Medicaid funding is shared between the federal government and the states, and therefore, many Medicaid administrative decisions are made by states. Most Medicaid beneficiaries receive services through managed care; in many states this delivery model is mandatory. In contrast, a minority of Medicare beneficiaries receive services through managed care, which for Medicare is voluntary. Managed care has emerged as a potential organizational structure to coordinate the payment and program administration for dual-eligible individuals, to support the integration of medical and social services for this population. For dual-eligible individuals in managed care, health plans receive separate capitated payment from the federal government for Medicare services and the state government for Medicaid services. To date, the enrollment numbers remain relatively low with fewer than 140 000 individuals (2% of dual-eligible individuals) enrolled in these programs nationwide. The Program for All-inclusive Care for the Elderly (PACE) is one such program for community-dwelling elders who are nursing home–eligible. PACE provides a single set of requirements regarding Medicare and Medicaid services, allowing PACE organizations to enter into capitation agreements with Medicare and Medicaid for their respective services, fully integrating funding, management, and clinical decisions. In February 2010, 18 000 dual-eligible individuals were enrolled in PACE programs in 30 states. Some states have developed demonstration programs other than PACE to test models of integrated payment and service delivery for this population, stimulated by the Medicare Modernization Act of 2003, which enabled the creation of Medicare Advantage Special Need Plans. Eight states (Arizona, Massachusetts, Minnesota, New Mexico, New York, Texas, Washington, and Wisconsin) have integrated the full range of Medicare and Medicaid benefits (primary care, acute care, behavioral health, and long-term care) for approximately 120 000 dual-eligible beneficiaries through Medicare Advantage Special Need Plans. Integrated Medicare and Medicaid managed care programs have many potential advantages, including a focus on prevention, care coordination, and access to home and community-based services. Evaluation of integration projects has been limited to observational studies, the best of which have used appropriate control groups and statistical techniques. Results suggest that dual-eligible beneficiaries in these programs, as compared with those receiving services outside of managed care, have better access to home and community-based long-term care services and lower use of highcost services such as emergency department visits, hospitalizations, and nursing home stays. The voluntary nature of program participation and case selection by plans limits the ability to distinguish whether these programs are truly successful or whether the results are merely a reflection of underlying differences in the health and needs of the populations who receive care through managed care vs feefor-service. The cost-effectiveness of these programs is unproven and is dependent on the ability of plans to substitute lower-cost services for high-cost ones. Decision makers need more rigorous evaluation of these projects to establish their effectiveness, safety, and costs, and to determine the degree to which results can be generalized to important subgroups of the elderly population. There are challenges at the patient, clinician, and administrative levels of the state and federal agencies that hinder


Journal for Healthcare Quality | 2013

Prediction of hospital acute myocardial infarction and heart failure 30-day mortality rates using publicly reported performance measures.

David S. Aaronson; Naomi S. Bardach; Grace A. Lin; Arpita Chattopadhyay; L. Elizabeth Goldman; R. Adams Dudley

We used a cross-sectional, population-based sample of Medicaid beneficiaries aged 18–64 to determine whether managed care enrollment was associated with reduced racial/ethnic disparities in self-reported access to primary care services compared with fee-for-service. Managed care beneficiaries reported greater access in each racial/ethnic category and for each outcome than did fee-for-service beneficiaries, although associations were not always statistically significant. Racial/ethnic minorities enrolled in managed care plans reported as much benefit from managed care enrollment as did whites. Within Medicaid, interventions aimed at the health insurance delivery model can facilitate increased access to primary care services without enhancing racial/ethnic disparities.

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Dennis Osmond

University of California

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Grace A. Lin

University of California

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