Steffani R. Bailey

An Early Look at Rates of Uninsured Safety Net Clinic Visits After the Affordable Care Act

PURPOSE The Affordable Care Act of 2010 supports marked expansions in Medicaid coverage in the United States. As of January 1, 2014, a total of 25 states and the District of Columbia expanded their Medicaid programs. We tested the hypothesis that rates of uninsured safety net clinic visits would significantly decrease in states that implemented Medicaid expansion, compared with states that did not. METHODS We undertook a longitudinal observational study of coverage status for adult visits in community health centers, from 12 months before Medicaid expansion (January 1, 2013 to December 31, 2013) through 6 months after expansion (January 1, 2014 to June 30, 2014). We analyzed data from 156 clinics in the OCHIN practice-based research network, with a shared electronic health record, located in 9 states (5 expanded Medicaid coverage and 4 did not). RESULTS Analyses were based on 333,655 nonpregnant adult patients and their 1,276,298 in-person billed encounters. Overall, clinics in the expansion states had a 40% decrease in the rate of uninsured visits in the postexpansion period and a 36% increase in the rate of Medicaid-covered visits. In contrast, clinics in the nonexpansion states had a significant 16% decline in the rate of uninsured visits but no change in the rate of Medicaid-covered visits. CONCLUSIONS There was a substantial decrease in uninsured community health center visits and a significant increase in Medicaid-covered visits in study clinics in states that expanded Medicaid in 2014, whereas study clinics in states opting out of the expansion continued to have a high rate of uninsured visits. These findings suggest that Affordable Care Act–related Medicaid expansions have successfully decreased the number of uninsured safety net patients in the United States.

Efficacy and Tolerability of Pharmacotherapies to Aid Smoking Cessation in Adolescents

Adolescent smoking remains a public health problem. Despite concerns regarding adolescent nicotine dependence, few well-designed smoking cessation studies have been conducted with teen smokers. This is particularly true regarding pharmacologic treatments for nicotine dependence. Currently, pharmacologic aids are not recommended for treating adolescent nicotine dependence, as efficacy has not been shown in this population.This review includes studies that have examined the efficacy of pharmacotherapy for smoking abstinence and/or reduction in cigarette consumption among adolescent smokers who want to quit smoking, laboratory-based adolescent studies that have examined the efficacy of these medications in reducing cravings and/or withdrawal symptoms, and/or studies that have assessed the tolerability of medications for smoking cessation in adolescent smokers. It provides information on the pharmacologic action of each medication, the efficacy of each medication for adolescent smoking cessation, the tolerability of each medication based on reported adverse events, and compliance with the medication protocols.Thirteen relevant articles were identified and included in the review. Nicotine patch (NP), nicotine gum, nicotine nasal spray, bupropion, and varenicline have been studied in adolescent smokers. The adverse events reported in the studies on pharmacology for adolescent smoking suggest that the side effect profiles for nicotine replacement therapy, bupropion, and varenicline are similar to those reported in adult studies. There is some evidence of efficacy of NP and bupropion at the end of treatment (efficacy of varenicline has not been assessed), but none of the medications included in this review were efficacious in promoting long-term smoking cessation among adolescent smokers. It is noted that many of the study protocols did not follow the recommended dose or length of pharmacotherapy for adults, rendering it difficult to determine the true efficacy of medication for adolescent smoking cessation. Future efficacy studies are warranted before recommending pharmacotherapy for adolescent smoking cessation.

The impact of cigarette deprivation and cigarette availability on cue-reactivity in smokers.

AIMS This experiment was conducted to determine the impact of cigarette deprivation and cigarette availability on reactivity measures to cigarette cues. PARTICIPANTS Smokers were recruited who were 18 years of age or older, not attempting to quit or cut down on their smoking, smoked at least 20 cigarettes daily, had been smoking regularly for past year and had an expired carbon monoxide level of at least 10 parts per million. DESIGN Smokers were assigned randomly to abstain from smoking for 24 hours (n = 51) or continue smoking their regular amount (n = 50). Twenty-four hours later, they were exposed to trials of either a lit cigarette or a glass of water with a 0, 50 or 100% probability of being able to sample the cue on each trial. Craving, mood, heart rate, skin conductance, puff topography and latency to access door to sample the cue were measured. FINDINGS Both exposure to cigarette cues and increasing availability of those cues produced higher levels of craving to smoke. Deprivation produced a generalized increase in craving. There was no consistent evidence, however, that even under conditions of high cigarette availability, deprived smokers were sensitized selectively to presentations of cigarette cues. CONCLUSIONS The data suggest that, even under conditions of immediate cigarette availability, deprivation and cue presentations have independent, additive effects on self-reported craving levels in smokers.

Development of a Neurobehavioral Battery for Children Exposed to Neurotoxic Chemicals

In recent years there has been heightened concern over the potential impact of environmental exposures on neurological function in children. Children are thought to be especially vulnerable to neurotoxic effects due to a number offactors including play behavior, differences in metabolism, and the development state of the brain. Performance tests from the computerized Behavioral Assessment and Research System (BARS) and other non-computerized tests have been combined to develop a brief battery that assesses multiple neurobehavioral functions in preschool children aged 4-6. Tests were selected to assess a variety of cognitive functions including attention, memory, motor speed and coordination and other executive functions. The battery has also been translated into Spanish and developed for use with Latino populations. Four to six-year-old children are particularly challenging because of the shorter attention span and lower motivation to complete an extended test session. When testing this group it is important to maintain the motivation of the child throughout the entire session in order to obtain accurate performance measures. A series of sequential pilot studies were used to select and develop appropriate methods and parameters for the tests in the battery. Although English-speaking children were able to complete the initial battery with minimal difficulties, several difficulties were encountered when the tests were administered to a Latino population. Cultural differences made some material inappropriate for testing due to unfamiliarity with the material, and in some cases items in a test had more than one correct translation which made administration difficult.

Agreement of Medicaid claims and electronic health records for assessing preventive care quality among adults.

To compare the agreement of electronic health record (EHR) data versus Medicaid claims data in documenting adult preventive care. Insurance claims are commonly used to measure care quality. EHR data could serve this purpose, but little information exists about how this source compares in service documentation. For 13 101 Medicaid-insured adult patients attending 43 Oregon community health centers, we compared documentation of 11 preventive services, based on EHR versus Medicaid claims data. Documentation was comparable for most services. Agreement was highest for influenza vaccination (κ =  0.77; 95% CI 0.75 to 0.79), cholesterol screening (κ = 0.80; 95% CI 0.79 to 0.81), and cervical cancer screening (κ = 0.71; 95% CI 0.70 to 0.73), and lowest on services commonly referred out of primary care clinics and those that usually do not generate claims. EHRs show promise for use in quality reporting. Strategies to maximize data capture in EHRs are needed to optimize the use of EHR data for service documentation.

Withdrawal symptoms over time among adolescents in a smoking cessation intervention: Do symptoms vary by level of nicotine dependence?

Nicotine dependence may be expressed differently in teens than in adults. Thus, it may not be sufficient to build diagnostic and cessation treatment strategies for teens based on adult-derived clinical and research data. This is the first study to prospectively examine the development of withdrawal symptoms by level of nicotine dependence among adolescent smokers. Forty-seven adolescent smokers completed nicotine withdrawal symptoms measures during 10 weeks of cessation treatment. Nicotine dependence was assessed at baseline using the mFTQ. Change in withdrawal symptoms over time by level of nicotine dependence was examined via mixed model ANOVA. Nicotine withdrawal in daily adolescent smokers was strongly and prospectively associated with the level of nicotine dependence. Craving was rated as the most problematic symptom at the baseline assessment. The results of this study may help guide the development of future research on diagnostic and cessation treatment strategies for teens.

A Randomized Clinical Trial of the Efficacy of Extended Smoking Cessation Treatment for Adolescent Smokers

INTRODUCTION Relatively few well-designed smoking cessation studies have been conducted with teen smokers. This study examined the efficacy of extended cognitive-behavioral treatment in promoting longer term smoking cessation among adolescents. METHODS Open-label smoking cessation treatment consisted of 10 weeks of school-based, cognitive-behavioral group counseling along with 9 weeks of nicotine replacement (nicotine patch). A total of 141 adolescent smokers in continuation high schools in the San Francisco Bay Area were randomized to either 9 additional group sessions over a 14-week period (extended group) or 4 monthly smoking status calls (nonextended group). Intention-to-treat logistic regression analysis was used to assess the primary outcome of biologically confirmed (carbon monoxide < 9 ppm) point prevalence abstinence at Week 26 (6-month follow-up from baseline). RESULTS At Week 26 follow-up, the extended treatment group had a significantly higher abstinence rate (21%) than the nonextended treatment (7%; OR = 4.24, 95% CI: 1.20-15.02). Females also were more likely to be abstinent at the follow-up than males (OR = 4.15, 95% CI: 1.17-14.71). CONCLUSIONS The significantly higher abstinence rate at follow-up for the extended treatment group provides strong support for continued development of longer term interventions for adolescent smoking cessation.

Tobacco, Alcohol, and Marijuana Use Among First-Year U.S. College Students : A Time Series Analysis

The present study sought to evaluate the day-to-day patterns of tobacco, alcohol, and marijuana use among first-year college students in the United States. Using 210 days of weekly time-line follow-back diary data collected in 2002 to 2003, the authors examined within-person patterns of use. The sample was 48% female and 90% Caucasian. Sixty-eight percent of the participants were permanent residents of Indiana. Univariate time series analysis was employed to evaluate behavioral trends for each substance across the academic year and to determine the predictive value of day-to-day substance use. Some of the most common trends included higher levels of substance use at the beginning or end of the academic year. Use on any given day could be predicted best from the amount of corresponding substance use 1 day prior. Conclusions: Although universal intervention might best be focused in the earliest weeks on campus and at the end of the year when substance use is at its highest, the diversity of substance use trajectories suggests the need for more targeted approaches to intervention. Study limitations are noted.

Community Health Center Use After Oregon’s Randomized Medicaid Experiment

PURPOSE There is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon’s 2008 randomized Medicaid expansion (the “Oregon Experiment”). METHODS We probabilistically matched demographic data from adults (aged 19–64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849). We performed intent-to-treat analyses using zero-inflated Poisson regression models to compare 36-month (2008–2011) usage rates among those selected to apply for Medicaid vs not selected, and instrumental variable analyses to estimate the effect of gaining Medicaid coverage on use. Use outcomes included primary care visits, behavioral/mental health visits, laboratory tests, referrals, immunizations, and imaging. RESULTS The intent-to-treat analyses revealed statistically significant differences in rates of behavioral/mental health visits, referrals, and imaging between patients randomly selected to apply for Medicaid vs those not selected. In instrumental variable analyses, gaining Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals, and imaging; rate ratios ranged from 1.27 (95% CI, 1.05–1.55) for laboratory tests to 1.58 (95% CI, 1.10–2.28) for referrals. CONCLUSIONS Our results suggest that use of many different types of CHC services will increase as patients gain Medicaid through Affordable Care Act expansions. To maximize access to critical health services, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings.

Estimating demand for care after a medicaid expansion: lessons from Oregon

To estimate how the Affordable Care Acts Medicaid expansions will affect demand for services, we measured ambulatory care utilization among adult patients who gained insurance during Oregons 2008 Medicaid expansion. Using electronic health record data from 67 community health centers, we assessed pre- and postcoverage utilization among patients who gained insurance, compared with patients continuously insured or uninsured. In comparisons of the pre- and postcoverage periods, mean annual encounters among persons who gained insurance increased 22% to 35%, but declined in the comparison groups. These findings suggest that providers should expect a significant increase in demand among patients who gain Medicaid coverage through the Affordable Care Act.