Lisa M. Cohn

Worsening disparities in HPV vaccine utilization among 19–26 year old women

We evaluated the characteristics associated with uptake of HPV vaccine by 19-26 year old women seen in primary care university-based clinics. Of the 11,545 women analyzed only 18% had initiated the 3-dose vaccine series. Series completion among the sample overall was only 10% in the 30 month study period. Decreased series initiation was associated with older age, public insurance, white race and non-family medicine specialty. Decreased series completion was associated with public insurance and African American race. Utilization disparities by race and insurance worsened over time suggesting that the highest risk populations of women were not getting vaccinated.

Patient and clinic factors associated with adolescent human papillomavirus vaccine utilization within a university-based health system

We reviewed clinical and billing data from a university-based health system to assess HPV vaccine utilization among 9-18-year-old girls by individual, visit and medical specialty characteristics. Our sample included 10,082 adolescent patients with 27,928 visits to outpatient family medicine (FM), pediatric and gynecology clinics between January 2007 and March 2008. Vaccine series completion was low among eligible adolescents (15%), with important disparities in vaccine utilization by medical specialty, age, race and insurance status. Missed opportunities for vaccination were common. Our findings may help to target future interventions aimed at increasing adolescent HPV vaccine utilization.

Antihypertensive Prescribing Patterns for Adolescents With Primary Hypertension

Background: Hypertension is an increasingly common problem in adolescents yet current medical management of primary hypertension in adolescents has not been well-described. Methods: We identified adolescents with primary hypertension by International Classification of Diseases, Ninth Revision codes and looked at prescription patterns chronologically for antihypertensive drug class prescribed and the specialty of prescribing physician. We also examined patient demographics and presence of obesity-related comorbidities. Results: During 2003–2008, there were 4296 adolescents with primary hypertension (HTN); 66% were boys; 73% were aged 11 to 14 years; 53% were black, 41% white, and 4% Hispanic; and 48% had obesity-related comorbidity. Twenty-three percent (977) received antihypertensive prescription. White subjects (odds ratio [OR]: 1.61; confidence interval [CI]: 1.39–1.88), older adolescents (≥15 years, OR: 2.11; CI: 1.79–2.48), and those with comorbidity (OR: 1.57; CI: 1.36–1.82) were more likely to receive antihypertensive prescriptions controlling for gender and years of Medicaid eligibility in logistic regression. Angiotensin converting enzyme inhibitors were the most frequently prescribed monotherapy. Nearly two-thirds of adolescents received prescriptions from adult primary care physicians (PCPs) only. More than one-quarter of adolescents who received a prescription received combination therapy, which was most often prescribed by adult PCPs. Conclusions: Adult PCPs were the leading prescribers of antihypertensives for adolescents with primary HTN. Race differences exist in physicians’ prescribing of antihypertensives to adolescents with primary HTN. The choice of antihypertensives by physicians of different specialties warrants additional study to understand the underlying rationale for treatment decisions and to determine treatment effectiveness.

Interhospital transfer of critically ill and injured children: An evaluation of transfer patterns, resource utilization, and clinical outcomes

OBJECTIVE To describe patterns of transfer, resource utilization, and clinical outcomes associated with interhospital transfer of critically ill and injured children. DESIGN Secondary analysis of administrative claims data. PARTICIPANTS Children 0 to 18 years in the Michigan Medicaid program who underwent interhospital transfer for intensive care from January 1, 2002 to December 31, 2004. The 3 sources of transfer from referring hospitals were: emergency department (ED), ward, or intensive care unit (ICU). MEASUREMENTS Mortality and duration of hospital stay at the receiving hospitals. RESULTS Of 1643 interhospital transfer admissions to intensive care at receiving hospitals, 62%, 31%, and 7% were from the ED, ward, and ICU of referring hospitals, respectively. Nineteen percent had comorbid illness, while 11% had organ dysfunction at the referring hospital. After controlling for comorbid illness, patient age, and pretransfer organ dysfunction; compared with ED transfers, mortality in the receiving hospital was higher for ward transfers (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.02-3.03) but not for ICU transfers. Also, compared with ED transfers, hospital stay was longer by 1.5 days for ward transfers and by 13.5 days for ICU transfers. CONCLUSION In this multiyear, statewide sample, mortality and resource utilization were higher among children who underwent interhospital transfer to intensive care after initial hospitalization, compared with those transferred directly from emergency to intensive care. Decision-making underlying initial triage and subsequent interhospital transfer of critically ill children warrants further study.

Follow-up Analysis of Adolescents Partially Vaccinated Against Human Papillomavirus

PURPOSE To evaluate factors associated with human papillomavirus vaccination among a cohort of female adolescents previously identified as receiving only one or two doses of vaccine. METHODS This was a 15-month follow-up analysis of a previously identified cohort of 9-18-year-old female adolescents seen in primary clinics within a university-based health system. Vaccine receipt and associated factors were identified by review of administrative records. RESULTS Among the 1,714 partially vaccinated female adolescents, 53% eventually completed the vaccination series. There was a wide range of dosing intervals ranging from 31 to 840 days between first and second doses and from 85 to 666 days between second and third doses. Race and insurance type were associated with lower rates of series completion, but not with receiving second doses. CONCLUSIONS Approximately half of the partially vaccinated girls in our cohort eventually completed the series, albeit often over a longer than recommended interval. There were important disparities in human papillomavirus vaccination.

Use of antihypertensive medications and diagnostic tests among privately insured adolescents and young adults with primary versus secondary hypertension.

PURPOSE To compare the use of antihypertensive medications and diagnostic tests among adolescents and young adults with primary versus secondary hypertension. METHODS We conducted retrospective cohort analysis of claims data for adolescents and young adults (12-21 years of age) with ≥3 years of insurance coverage (≥11 months/year) in a large private managed care plan during 2003-2009 with diagnosis of primary hypertension or secondary hypertension. We examined their use of antihypertensive medications and identified demographic characteristics and the presence of obesity-related comorbidities. For the subset receiving antihypertensive medications, we examined their diagnostic test use (echocardiograms, renal ultrasounds, and electrocardiograms). RESULTS The study sample included 1,232 adolescents and young adults; 84% had primary hypertension and 16% had secondary hypertension. The overall prevalence rate of hypertension was 2.6%. One quarter (28%) with primary hypertension had one or more antihypertensive medications, whereas 65% with secondary hypertension had one or more antihypertensive medications. Leading prescribers of antihypertensives for subjects with primary hypertension were primary care physicians (80%), whereas antihypertensive medications were equally prescribed by primary care physicians (43%) and sub-specialists (37%) for subjects with secondary hypertension. CONCLUSIONS The predominant hypertension diagnosis among adolescents and young adults is primary hypertension. Antihypertensive medication use was higher among those with secondary hypertension compared with those with primary hypertension. Further study is needed to determine treatment effectiveness and patient outcomes associated with differential treatment patterns used for adolescents and young adults with primary versus secondary hypertension.

Treatment Patterns for Early Pregnancy Failure in Michigan

AIMS We describe current treatment patterns for early pregnancy failure (EPF) among women enrolled in two Michigan health plans. METHODS We conducted a retrospective review of EPF treatment among Michigan Medicaid enrollees between January 1, 2001, and December 31, 2004, and enrollees of a university-affiliated health plan between January 1, 2001, and December 31, 2005. Episodes were identified by the presence of a diagnostic code for EPF. Surgical treatment was distinguished from nonsurgical management using procedure codes. Facility charges, procedure, and place of service codes were used to determine whether a procedure was done in an office as opposed to an operating room. Cases without a claim for surgical uterine evacuation were examined for a misoprostol pharmacy claim and, if present, were classified as medical management. Cases without a procedure or pharmacy claim were classified as expectant management. RESULTS Respectively, we identified 21,311 and 1,493 episodes of EPF in the Medicaid and university-affiliated health plan databases, respectively. Women enrolled in Medicaid were more likely to be treated with surgery than were enrollees of the university-affiliated health plan (35.3 vs. 18.0%, respectively, p < 0.000). Among Medicaid enrollees, only 0.5% of surgical evacuations occurred in the office, but office procedures were common among enrollees of the university-affiliated health plan (30.5%, p < 0.000). The proportion of cases managed with misoprostol was <1% in both groups. Caucasian race and age were both associated with having a surgical uterine evacuation (p < 0.001). CONCLUSIONS EPF is primarily being treated with expectant management or surgical evacuation in an operating room and may not reflect evidence-based practices or patient preferences.

Clonidine Utilization Trends for Medicaid Children

Objective. To characterize clonidine utilization trends among children. Design/Methods. Serial cross-sectional analysis of Michigan Medicaid claims data for children aged 6 to 18 years. The authors identified children with ≥1 clonidine prescription; the authors examined their ICD-9 diagnoses categorized as simple and complex attention deficit hyperactivity disorder (ADHD), non-ADHD mental health disorder, hypertension, or others. Also identified were child demographics and prescribing physician specialty. Results. From 2003 to 2008, the proportion of children receiving clonidine prescription nearly doubled in all demographics. Across years, the majority of clonidine prescription was for simple and complex ADHD and other mental health disorders. Leading prescribers were psychiatrists followed by general pediatricians and adult primary care physicians. Conclusions. Clonidine was used extensively to treat simple and complex ADHD in children although FDA approval for this indication did not occur until 2010. Further study is warranted to better understand clinical outcomes and costs associated with clonidine use for the treatment of children with ADHD.

Continuity of prescribers of short-acting beta agonists among children with asthma.

OBJECTIVE To determine whether short-acting beta-agonist (SABA) prescriber continuity was associated with emergency department visits among children with asthma. STUDY DESIGN An analysis of Michigan Medicaid administrative claims (2004-2005) for children ages 5 to 18 with asthma. Logistic regression models assessed the effect of SABA prescriber continuity (the number and site of prescribers) on emergency department visits, controlling for demographics, historical (2004) asthma use and SABA prescription frequency (2-5 low; > or = 6 high). RESULTS Most children had one SABA prescriber (62%); 13% had multiple prescribers in the same practice as the primary care provider and 25% had multiple prescribers in different practices. Children with multiple prescribers in different practices had increased odds of an emergency department visit compared with those with 1 prescriber, among those with high SABA prescription frequency (AOR: 2.7, 95% CI: 1.9, 3.9), as well as those with low prescription frequency (AOR: 1.7, 95% CI: 1.3, 2.2). CONCLUSIONS Children with discontinuity of SABA prescribers have an increased risk of asthma emergency department visits, irrespective of their SABA prescription frequency. Primary care providers may have difficulty identifying patients at high risk with asthma solely on the basis of SABAs prescribed within their own practices.

Missed Opportunities for Transcranial Doppler Screening Among Children With Sickle Cell Disease

Transcranial Doppler (TCD) screening rates remain low among children with sickle cell disease (SCD). We assessed TCD screening rates and missed opportunities for TCD screening. Children 2 to 16 years old with SCD enrolled in Michigan Medicaid for ≥1 year (2007-2011) were identified through newborn screening. Receipt of TCD screening and presence of a missed opportunity (≥1 SCD-related outpatient visit, no TCD screening) were identified through administrative claims. Potential correlates of missed opportunities included SCD-related health services, comorbidities, and demographics. Logistic regression with generalized estimating equations modeled associations between a missed opportunity and correlates. Overall, 353 children contributed 1066 person-years. TCD screening was low yearly (10%-32%); missed opportunities occurred in 73% of the person-years. Increasing age (odds ratio [OR] = 1.11; confidence interval CI = 1.07, 1.15), previous TCD screening (OR = 0.26; CI = 0.16, 0.41), and 4 to 5 (OR = 0.48; CI = 0.26, 0.87) or ≥6 outpatient visits (OR = 0.26; CI = 0.14, 0.49) were associated with a missed opportunity. Reduction of missed opportunities is a potential strategy to increase TCD screening rates.