Jianyi Zhang

Factors associated with initiation and completion of human papillomavirus vaccine series among young women enrolled in medicaid.

PURPOSE To determine age- and race-specific uptake rates of human papillomavirus (HPV) vaccine among females aged 9-20 years who participated in the Florida Medicaid during the first 2 years after approval by the Food and Drug Administration, and to identify factors associated with HPV vaccine initiation and series completion. METHODS Medicaid administrative data were used to identify claims for HPV vaccination together with individual, provider, and practice characteristics linked to each vaccination. RESULTS As of June 2008, 9.4% of females aged 11-18 years had ever received an HPV vaccination, and 1.8% had completed the three-vaccine series. In multivariate analysis, receipt of an HPV vaccination was found to be associated with age and race/ethnicity. In comparison with their white counterparts, black females were approximately half as likely to complete the three-vaccine series after initiation. CONCLUSIONS The data obtained suggest relatively slow initial uptake and completion of the HPV vaccine series in this population who are at an increased risk for cervical cancer, with racial disparities in vaccine uptake and vaccine series completion.

Psychiatric diagnosis in children and adolescents with obesity-related health conditions.

Objective: Childhood obesity is linked with a number of problematic health conditions. While data suggest that children who are obese are at increased risk of psychosocial distress relative to nonobese peers, there are limited data outlining the rates of psychiatric diagnoses in children with obesity-related health conditions such as type 2 diabetes and the metabolic syndrome. Methods: This study used Medicaid claims data from the State of Florida to compare the rates of psychiatric diagnoses for children with obesity-related health conditions, aged 5 to 18 years, to those of children with comparison chronic health conditions. Results: Overall, 35% of children with an obesity-related diagnosis had a psychiatric diagnosis. While controlling for age, gender, and race, youths with type 2 diabetes, the metabolic syndrome, and dyslipidemia had higher rates of International Classification of Disease, Ninth Revision (ICD-9) psychiatric diagnoses than children with cystic fibrosis, sickle cell disease, and juvenile rheumatoid arthritis (p < .001), but similar to those of children with asthma. Non-Hispanic white children with an obesity-related health condition had greater odds of receiving a psychiatric diagnosis than African American (odds ratio [OR] = 0.54, p < .001) or Hispanic (OR = 0.41, p < .001) children. Males and females differed in rates of externalizing and internalizing diagnoses. Conclusions: The data suggest that children with an obesity-related health condition have higher rates of internalizing and externalizing mental health conditions relative to children with other chronic health conditions. Prospective, longitudinal research is needed to further confirm these findings and examine factors that affect this association and potential impacts on the health care system.

Lapses in Medicaid Coverage : Impact on Cost and Utilization Among Individuals With Diabetes Enrolled in Medicaid

Background:Gaps in Medicaid coverage can result in inadequate access to care. This can be particularly detrimental to those with a chronic disease such as diabetes. Objective:To assess whether a lapse in Medicaid coverage is associated with an increase in expenditures, and acute care utilization upon reenrollment among beneficiaries with diabetes. Research Design:Using multivariate regression analyses, we compared pre- versus post-expenditures and utilization among 2102 individuals with diabetes who had experienced at least one 1-month lapse in their Medicaid coverage. Measures:Dependent variables were the number of inpatient episodes, total length of stay, total number of emergency room visits, total expenditure, and pharmaceutical expenditures. These were aggregated over 3-month spans that either immediately preceded or immediately followed a lapse in coverage. Key predictor variables included a variable that identified the span as occurring pre-lapse or post-lapse in coverage, and a continuous variable identifying the length of the lapse. Predicted expenditure and utilization were calculated. Results:Overall total program expenditures were higher for post-lapse periods compared with pre-lapse periods. Total expenditures were estimated to increase by

The Relationship Among Child Weight Status, Psychosocial Functioning, and Pediatric Health Care Expenditures in a Medicaid Population

239 per member per month for the 3-month period. The likelihood of having any expenditure was actually lower in the post-lapse period. However inpatient and emergency room use was higher. Conclusions:The results from this study suggest that interruptions in Medicaid coverage are associated with overall greater program expenditures in the post-lapse periods. However, this increase in expenditures seems to be driven by a subset of individuals whose greater use of inpatient and emergency room services increased overall program costs.

The association between chronic disease and physical disability among female Medicaid beneficiaries 18-64 years of age.

OBJECTIVES To examine the association between weight status and health service use, while considering the influence of psychosocial functioning and demographic variables. METHODS Two hundred child-parent dyads were recruited from pediatric primary care clinics and completed measures of height, weight, and questionnaires assessing psychosocial functioning. Claims and expenditure data over a 12-month retrospective period were extracted from the Medicaid claims database. RESULTS Children who were obese incurred greater health service use and expenditures than children who were of a healthy weight, even after controlling for psychosocial functioning and other demographic variables. Children who were overweight (but not obese) did not have differing levels of claims or expenditures than their healthy weight peers. CONCLUSIONS Understanding the impact of pediatric obesity on long-term expenditures is critical. These results provide some indication of the financial savings that might be achieved if obese children were supported to achieve a healthier weight status.

Patterns in primary health care utilization among individuals with intellectual and developmental disabilities in Florida.

BACKGROUND Rates of physical disability are higher in women than in men, and economically disadvantaged women are at greater risk for physical disability than women with higher incomes. Chronic diseases increase the risk of physical disability, and people with physical disability experience some added risks of secondary conditions including chronic disease. Yet, little is known about the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population. OBJECTIVE This study described the prevalence of chronic disease among adult (18-64 years), female, Florida Medicaid beneficiaries living with a physical disability between 2001 and 2005. METHODS Using Medicaid eligibility and claims files, we extracted ICD-9 codes for physically-disabling conditions and Current Procedure Terminology codes for mobility-assistive devices to define three levels of physical disability. RESULTS Participants appeared to be at high risk for both physical disability and chronic diseases. Close to half of the women had been diagnosed with one or more physically-disabling conditions, and 5.3% used mobility devices. One-third of the women had hypertension and sizeable proportions had other chronic diseases. Women with physical disability were more likely to have co-morbid chronic diseases than their able-bodied counterparts. DISCUSSION Our findings support the need for improved chronic disease prevention among female Medicaid beneficiaries, particularly those with physical disability. Strategies to improve prevention, screening and treatment in this population may mitigate the trends toward higher physical disability rates in the low-income, working-age population and may prevent high Medicare and Medicaid costs in the long-run.

The Association of Psychiatric Diagnoses, Health Service Use, and Expenditures in Children with Obesity-related Health Conditions

Individuals living with intellectual and developmental disabilities face complex medical problems. Primary care physicians tend to provide basic medical care, serving as a base through which other forms of care can be accessed. In this study we describe patterns of primary care utilization among adults enrolled on the Florida Medicaids Home and Community-Based Services Waiver. About 40% of the adults on the Waiver did not see a primary care provider between 1999 and 2003. Primary health care utilization was higher in the northern parts of Florida and conversely lower in the southeast. The establishment of a medical home can ensure the timely receipt of preventive care as well as help coordinate the complex care that many individuals with disabilities need.

Estimating a weighted average of stratum‐specific parameters

OBJECTIVE To examine the association of psychiatric diagnoses and use of health care services in children with obesity-related health conditions. METHOD A retrospective, longitudinal design was used to examine Medicaid claims data. The data set consisted of 13,688 youth diagnosed with type 2 diabetes, metabolic syndrome, dyslipidemia, or obesity. RESULTS The presence of any type of psychiatric diagnosis was associated with higher health service use. In particular, the presence of an internalizing diagnosis was more consistently associated with higher service use than the presence of an externalizing diagnosis. Children with both an externalizing and internalizing disorder diagnosis had greater service use than children with a diagnosis in only one of these categories. CONCLUSIONS These data highlight a subgroup of children with obesity-related health conditions who are at greater risk for higher health service use, and the need for further research on the association between psychiatric diagnosis and health service use.

Changes in Health Care Use and Costs After a Break in Medicaid Coverage Among Persons With Depression

This article investigates estimators of a weighted average of stratum-specific univariate parameters and compares them in terms of a design-based estimate of mean-squared error (MSE). The research is motivated by a stratified survey sample of Florida Medicaid beneficiaries, in which the parameters are population stratum means and the weights are known and determined by the population sampling frame. Assuming heterogeneous parameters, it is common to estimate the weighted average with the weighted sum of sample stratum means; under homogeneity, one ignores the known weights in favor of precision weighting. Adaptive estimators arise from random effects models for the parameters. We propose adaptive estimators motivated from these random effects models, but we compare their design-based performance. We further propose selecting the tuning parameter to minimize a design-based estimate of mean-squared error. This differs from the model-based approach of selecting the tuning parameter to accurately represent the heterogeneity of stratum means. Our design-based approach effectively downweights strata with small weights in the assessment of homogeneity, which can lead to a smaller MSE. We compare the standard random effects model with identically distributed parameters to a novel alternative, which models the variances of the parameters as inversely proportional to the known weights. We also present theoretical and computational details for estimators based on a general class of random effects models. The methods are applied to estimate average satisfaction with health plan and care among Florida beneficiaries just prior to Medicaid reform.