Category: Nevin Manimala

JAMA Netw Open. 2025 May 1;8(5):e258469. doi: 10.1001/jamanetworkopen.2025.8469.

ABSTRACT

IMPORTANCE: After the Medicaid continuous enrollment provision ended on March 31, 2023, millions of Medicaid patients were disenrolled, a process called “Medicaid unwinding.” Whether this process was associated with changes in dispensing of buprenorphine, a medication for opioid use disorder preventing opioid overdose deaths, is unknown.

OBJECTIVE: To evaluate changes in buprenorphine dispensing during Medicaid unwinding.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used difference-in-differences analysis to assess data from the IQVIA Longitudinal Prescription Database, capturing 92% of US retail prescriptions. Treatment and comparison states were those in the top vs bottom quartile of the percentage change in adult Medicaid enrollment between the month before the state resumed Medicaid eligibility determinations and December 31, 2023. Analyses included Medicaid-insured adults with active buprenorphine prescriptions in quarter 1 from 2017 to 2023.

EXPOSURE: State-level change in adult Medicaid enrollment. The preexposure period was from July 1, 2017, to December 31, 2022, and the postexposure period was from July 1 to December 31, 2023 (quarters 3 and 4).

MAIN OUTCOMES AND MEASURES: Four outcomes assessed buprenorphine dispensing in quarters 3 and 4 from 2017 to 2023: the number of days with active buprenorphine prescriptions, no active prescriptions, 1 or more active prescriptions paid with private insurance, and 1 or more active cash-pay prescriptions. Linear and logistic regression models compared changes in outcomes over time among treatment and comparison states.

RESULTS: Analyses included 754 675 person-years from 569 069 patients (mean [SD] age, 39.2 [9.6] years; 386 719 men [51.2%]). Among adults in treatment states, the number of days with active buprenorphine prescriptions in quarters 3 and 4 decreased by 3.9 days (95% CI, -6.7 to -1.1 days) more compared with adults in comparison states. Adults in treatment states also had an increase of 1.8 percentage points (95% CI, 0.6-3.0 percentage points) in the probability of having no days with active prescriptions, an increase of 1.9 percentage points (95% CI, 0.4-3.4 percentage points) in the probability of having 1 or more active prescriptions paid with private insurance, and an increase of 0.9 percentage points (95% CI, 0.1-1.7 percentage points) in the probability of having 1 or more active cash-pay prescriptions.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study using difference-in-differences analysis, Medicaid patients in states with the highest vs lowest magnitude of Medicaid disenrollment through December 2023 were more likely to decrease or discontinue buprenorphine use and more likely to transition to private insurance or cash to pay for prescriptions. Findings suggest that Medicaid unwinding was associated with disruptions in buprenorphine therapy, raising concerns about the potential for increased opioid-related morbidity and mortality among patients in this population.

PMID:40314954 | DOI:10.1001/jamanetworkopen.2025.8469

JAMA Netw Open. 2025 May 1;8(5):e258491. doi: 10.1001/jamanetworkopen.2025.8491.

ABSTRACT

IMPORTANCE: Less than half of the US population with any mental health condition receives services. Cost is the most commonly cited barrier to treatment.

OBJECTIVE: To examine whether service use and out-of-pocket expenditures among Medicare beneficiaries with depression changed after Medicare implemented equal cost-sharing for outpatient mental health and medical services (Medicare parity).

DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used a single-group, interrupted time series design and examined data from the Medical Expenditure Panel Survey Household Component from 2008 to 2019. The sample included Medicare beneficiaries aged 65 years or older with depression. Data were analyzed from June 2, 2023, to June 17, 2024.

EXPOSURE: Under the Medicare Improvements for Patients and Providers Act of 2008, beneficiary cost-sharing for outpatient mental health services decreased from 50% prior to 2010 to 20% in 2014, creating parity with equivalent medical care.

MAIN OUTCOMES AND MEASURES: The primary outcomes were outpatient mental health service use, as assessed by mean use, proportion of beneficiaries with any use, and intensity of use (ie, mean use among users), and out-of-pocket expenditures.

RESULTS: The analysis included 5831 Medicare beneficiaries. Using the Medical Expenditure Panel Survey person-level survey weights, this number corresponded to a nationally representative sample of 72 436 656 beneficiaries (median [IQR] age, 72 [68-79] years; 64.2%-72.2% female per study year). After Medicare parity, mean use of outpatient mental health services among beneficiaries with depression increased by 0.54 visits per year (95% CI, 0.31-0.76 visits per year), and proportion of use increased by 6.61% per year (95% CI, 2.23%-10.99% per year). Intensity of use decreased at parity by a factor of 0.90 (95% CI, 0.82-1.00) and increased after parity by a multiple of 1.07 per year (95% CI, 1.04-1.10 per year). Mean out-of-pocket expenditures for these services increased after parity by $12.25 per year (95% CI, $2.42-$22.08 per year). Sensitivity analysis using the 2016 US Preventive Services Task Force recommendation for routine adult depression screening indicated that the proportion of use increased 28.26% (95% CI, 24.33%-32.19%) once the recommendation was issued.

CONCLUSIONS AND RELEVANCE: In this economic evaluation of Medicare parity, implementation of Medicare parity coupled with routine adult depression screening was associated with significant increases in outpatient mental health service use among Medicare beneficiaries with depression. These findings suggest that parity policies alone may not be sufficient to effectively address multiple barriers to mental health care but in tandem with physician screening, diagnosis, and referral practices, may increase the accessibility of mental health services.

PMID:40314953 | DOI:10.1001/jamanetworkopen.2025.8491

JAMA Netw Open. 2025 May 1;8(5):e258498. doi: 10.1001/jamanetworkopen.2025.8498.

ABSTRACT

IMPORTANCE: Emergency department (ED) triage may impact timeliness of care for high-risk conditions.

OBJECTIVE: To determine the association of ED undertriage with delays in care for patients with subarachnoid hemorrhage (SAH), aortic dissection (AD), and ST-elevation myocardial infarction (STEMI).

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included adult ED patients diagnosed with SAH, AD, or STEMI from January 1, 2016, to December 31, 2020, from a multicenter, community-based health care delivery system. Data analysis were completed in March 2023 to October 2024.

EXPOSURE: Undertriage vs correct triage, defined by operational measures of mistriage.

MAIN OUTCOMES AND MEASURES: Using a lognormal distribution, the outcomes of interest for patients with SAH and AD were adjusted median time to noncontrast computed tomography (CT) (head CT for patients with SAH, chest CT for patients with AD), antihypertensive medication orders (SAH), and β-blocker orders (AD), and ED length of stay (LOS). For patients with STEMI, outcomes of interest were adjusted median time to electrocardiogram (ECG) and troponin orders.

RESULTS: A total of 5929 patients (median [IQR] age, 63.0 [54.0 to 73.0] years; 3876 [65.4%] male) were identified, including 915 with SAH, 480 with AD, and 4534 with STEMI. There were 1129 Asian patients (19.0%), 553 Black patients (9.3%), 889 Hispanic patients (15.0%), and 2906 non-Hispanic White patients (49.0%). Overall, 2175 patients (36.7%) were undertriaged. For patients with SAH, the lognormal estimate for delay in time to head CT was 0.2 (95% CI, 0.0-0.3), or a delay of 2.4 minutes, and for antihypertensive orders, the lognormal estimate was 4.8 (95% CI, 3.6-5.9), or a delay of 33.3 minutes; the lognormal estimate for ED LOS was 0.1 (95% CI, 0.0-0.1), or 7.7 minutes longer. For patients with AD, the lognormal estimate for delays were 0.2 (95% CI, 0.0-0.4), or 8.9 minutes, for chest CT and 0.5 (95% CI, 0.2-0.7), or 17.6 minutes, for β-blocker orders, and ED LOS was 0.2 (95% CI, 0.1-0.3), or 64 minutes longer. For patients with STEMI, differences in time to ECG and troponin orders were not statistically significant, at less than 1 minute, comparing correctly and undertriaged patients.

CONCLUSIONS AND RELEVANCE: In this cohort study of patients diagnosed with SAH, AD, or STEMI, ED undertriage was associated with small but significant delays in key diagnostic and therapeutic orders for patients with SAH and AD but not for patients with STEMI.

PMID:40314952 | DOI:10.1001/jamanetworkopen.2025.8498

Eval Rev. 2025 May 2:193841X251339686. doi: 10.1177/0193841X251339686. Online ahead of print.

ABSTRACT

This study demonstrates how to evaluate a university-wide online course designed to support student transition into university by using Propensity Score Matching (PSM) and Doubly Robust Estimation (DRE). Using data from seven academic years, from 2016/17 to 2022/23, with more than 28,000 students, we examine whether enrolment in this optional pre-arrival course affects first-year pass rates. We also conducted additional analyses to compare outcomes from the year before and after the course’s implementation, as well as to examine these patterns across recent cohorts to potentially account for contextual changes over time. Results indicate that enrolled students show a 6.2 percentage point increase in the likelihood of passing Year 1, controlling for factors including sex, domicile, age, ethnicity, disability and socioeconomic status. We demonstrate how utilising existing institutional data can potentially strengthen evidence of impact for centralised initiatives and conclude with reflections on the use of such institutional data and matching techniques and their viability for future evaluations.

PMID:40314949 | DOI:10.1177/0193841X251339686

JAMA Health Forum. 2025 May 2;6(5):e250033. doi: 10.1001/jamahealthforum.2025.0033.

ABSTRACT

IMPORTANCE: The first US Food and Drug Administration-approved interchangeable biosimilar designation-that for insulin glargine-occurred in 2021, enabling pharmacy substitution for the branded originator. However, the impacts of this interchangeable designation on prescription dispensing are unknown.

OBJECTIVE: To assess impacts of the transition of Semglee to interchangeable designation on prescription dispensing.

DESIGN AND SETTING: This economic evaluation analyzed changes in insulin glargine dispensing before and after the introduction of the interchangeable designation using data collected from IQVIA’s National Prescription Audit, a nationally representative comprehensive database of pharmacy dispensing for the US, and PayerTrak. Data cover the time period from September 2019 through June 2024 and were analyzed from June 2023 to December 2024.

EXPOSURE: Any medical diagnosis that would make insulin glargine a relevant treatment.

MAIN OUTCOMES AND MEASURES: The primary outcomes were monthly US aggregate pharmacy dispensing of Semglee and insulin glargine-yfgn, measured both in prescription counts (in thousands of prescriptions) and as a proportion of the US aggregate insulin glargine market. Results were disaggregated into Semglee and insulin glargine-yfgn to show that changes in dispensing were associated with the interchangeable designation even after accounting for Semglee’s formulary changes. This evaluation additionally examined dispensing channel and payer type.

RESULTS: After the introduction of interchangeable Semglee and insulin glargine-yfgn in November 2021, there was a discontinuous increase in aggregate Semglee/insulin glargine-yfgn dispensing of 47.41 (95% CI, 19.45-75.38; P = .001), suggesting that the interchangeable designation was associated with substantially increased utilization. In addition, Semglee and insulin glargine-yfgn’s share of the total insulin glargine market matched its dispensing trends, demonstrating that the jump in dispensing was not associated with changes in the market as a whole. When disaggregating by channel, there were also statistically significant increases in all 3 channels: retail (20.27; 95% CI, 2.58-37.95; P = .03), mail (6.63; 95% CI, 3.58-9.67; P < .001), and long-term care (20.52; 95% CI, 11.06-29.98; P < .001). This jump, however, coincided with advantageous formulary changes for Semglee but not insulin glargine-yfgn, the increased utilization of which was still associated with the interchangeable designation. In the Medicare Part D, Medicaid, and cash channels, insulin glargine-yfgn adoption grew faster than Semglee, reaching higher levels of dispensing in every single period measured after launch.

CONCLUSIONS AND RELEVANCE: In this economic evaluation, the first US Food and Drug Administration approval of interchangeable status was associated with increased dispensing of the follow-on. This suggests that interchangeability designation may play an important role in decreasing costs and increasing access to biosimilar prescription drugs for patients.

PMID:40314944 | DOI:10.1001/jamahealthforum.2025.0033

JAMA Health Forum. 2025 May 2;6(5):e250992. doi: 10.1001/jamahealthforum.2025.0992.

ABSTRACT

IMPORTANCE: Health-related social needs, downstream manifestations of social determinants or drivers of health, impact patients’ health and well-being. To develop equity-driven social care interventions, health care systems must apply an intersectional equity lens when assessing patients’ social needs.

OBJECTIVE: To evaluate racial, ethnic, and sex differences in social needs and receipt of support among veterans receiving health care in the Veterans Health Administration (VHA).

DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey study of VHA primary care patients seen in January or February 2023 was carried out in a national sample of veterans, stratified by race and ethnicity (Black, Hispanic, White), and sex (male, female). Participants were invited by mail to complete a survey online or by mail. Of those invited (N = 38 759), 7095 (18.3%) responded. Data collection occurred from March 2, 2023, through May 9, 2023. Analyses were conducted from February 15, 2024, through July 16, 2024.

EXPOSURES: Intersection of self-identified race, ethnicity, and sex.

MAIN OUTCOMES AND MEASURES: Age-adjusted prevalence ratio (aPR) of reported need for and receipt of support across 13 social need domains.

RESULTS: Analyses included 6611 respondents representing 939 467 veterans (unweighted No. of participants [weighted %]; 1089 [4.1%] Black women; 1144 [19.4%] Black men; 941 [1.6%] Hispanic women; 1281 [11.3%] Hispanic men; 805 [5.3%] White women; 1351 [58.4%] White men). After age adjustment, compared with White men, Black men had significantly higher aPRs of need for support in all domains except childcare and employment (aPRs ranged from 1.35 [95% CI, 1.09-1.69] for social isolation to 2.73 [95% CI, 1.89-3.95] for managing discrimination). Hispanic women had higher aPRs in 8 domains: childcare (aPR, 2.78; 95% CI, 1.19-6.48), discrimination (aPR, 2.69; 95% CI, 1.68-4.29), internet (aPR, 1.81; 95% CI, 1.17-2.79), housing (aPR, 1.81; 95% CI, 1.10-2.99), legal issues (aPR, 1.70; 95% CI, 1.02-2.84), loneliness (aPR, 1.67; 95% CI, 1.28-2.18), food (aPR, 1.55; 95% CI, 1.03-2.35), and social isolation (aPR, 1.40; 95% CI, 1.05-1.87). Black women had higher aPRs for discrimination (aPR, 2.68; 95% CI, 1.82-3.95), legal issues (aPR, 2.04; 95% CI, 1.40-2.97), food (aPR, 1.74; 95% CI, 1.28-2.37), loneliness (aPR, 1.60; 95% CI, 1.28-2.01), paying for basics (aPR, 1.57; 95% CI, 1.15-2.14), and social isolation (aPR, 1.48; 95% CI, 1.18-1.87). Hispanic men had higher aPRs for housing (aPR, 1.88; 95% CI, 1.18-3.02), legal issues (aPR, 1.81; 95% CI, 1.14-2.86), internet (aPR, 1.56; 95% CI, 1.13-2.16), and loneliness (aPR, 1.44; 95% CI, 1.10-1.88). White women had higher aPRs for childcare (aPR, 3.37; 95% CI, 1.36-8.35) and discrimination (aPR, 1.60; 95% CI, 1.03-2.50). There was 1 significant difference in receiving support: Black women had a lower prevalence of receiving support for work (aPR, 0.58; 95% CI, 0.35-0.94).

CONCLUSIONS AND RELEVANCE: This study found that there was wide variation in the health-related social need domains in which VHA race, ethnicity, and sex subpopulations reported needing support. Applying an intersectional lens when evaluating social needs lays the groundwork for equity-guided social care interventions in the VHA.

PMID:40314941 | DOI:10.1001/jamahealthforum.2025.0992

Spine Deform. 2025 May 2. doi: 10.1007/s43390-025-01093-0. Online ahead of print.

ABSTRACT

PURPOSE: Single occupancy inpatient recovery rooms are perceived by health care professionals to positively influence patients’ experience, while double rooms are associated with higher noise levels, sleep disturbances, and a lack of privacy. These differing physical environments may manifest in differing length of stay, pain scores, and opioid use. When bed space is scarce, identifying ideal populations for double occupancy rooming is important. This study aims to assess how inpatient room assignment impacts recovery time, opioid consumption, and patient reported pain for adolescent idiopathic scoliosis (AIS) patients undergoing a posterior spinal fusion (PSF).

METHODS: A retrospective cohort study of AIS patients who underwent PSF from 2011 to 2017 at a single center was conducted. Demographics and baseline radiographic measurements were summarized using appropriate statistics. Intraoperative and postoperative outcomes, as well as numerical ranking scale (NRS) pain scores and total daily opioid administration, were compared across room types using t tests, Wilcoxon rank sum tests, Chi-squared tests, or Fisher’s exact tests, as appropriate. GEE models were constructed to examine the influence of room type and days since surgery on outcomes.

RESULTS: The cohort included 635 patients: 448 (71%) assigned to a double room and 187 (29%) to a single room. The mean age was 15 ± 2 years and 83% of patients were female. Length of hospital stay, complication rates, 2-year outcomes, inpatient pain scores, and daily opioid usage did not significantly differ between room types (all p > 0.05). Adjusted GEE models revealed no significant associations between room type and pain scores (p = 0.9) or between room type and total opioid dosage (p = 0.95).

CONCLUSION: When bed space is scarce, double occupancy rooming for pediatric patients after PSF surgery for AIS can serve as a relief valve to continue elective practices without compromising post-operative outcomes.

PMID:40314926 | DOI:10.1007/s43390-025-01093-0

Health Care Manag Sci. 2025 May 2. doi: 10.1007/s10729-025-09702-0. Online ahead of print.

ABSTRACT

Benchmark efficiency analysis in public health typically focuses on hospitals rather than primary care providers. Data Envelopment Analysis (DEA) is widely used to assess resource efficiency among decision-making units (DMUs). However, traditional DEA struggles to differentiate between efficient units and is sensitive to the selection of inputs and outputs. Methods like super-efficiency and cross-efficiency address some of these limitations but often exclude outliers and may overlook efficiency related to specialisation. DEA Visualisation integrates DEA with multivariate statistical methods allowing for the identification of inefficiency sources and specialisation patterns without losing discriminatory power or removing extreme cases from the sample. This study analyses 82 public primary health centres in Madrid serving senior citizens in 2018. The findings reveal inefficiencies such as a preference for prescribing specific rather than generic drugs, increasing public health costs. Additionally, two extreme cases (outliers or mavericks) were identified as having high infrastructure costs and disproportionate staffing. Redistributing patients from overcrowded centres could enhance efficiency, while centres focused on preventive care showed greater cost-effectiveness, particularly in reducing prescription costs.

PMID:40314922 | DOI:10.1007/s10729-025-09702-0

Eur Arch Paediatr Dent. 2025 May 2. doi: 10.1007/s40368-025-01038-1. Online ahead of print.

ABSTRACT

AIM: This in vitro study aimed to evaluate the marginal gap and fracture resistance of 3D printing microfilled hybrid resin crowns in comparison to prefabricated zirconia crowns on pulpotomized primary teeth.

MATERIALS AND METHODS: Twenty primary molars were selected for the study and randomly divided into two groups (n = 10). Group1 received 3D printed microfilled hybrid resin crowns; Group 2 received prefabricated zirconia crowns. To simulate 6 months of oral conditions, thermodynamic cycling was performed, and the marginal gap was measured using a stereomicroscope with digital camera at 40 × magnification. For each sample, eight points along the margins for each axial surface were captured. The fracture resistance of each group was assessed by applying increasing load till crown fracture using a computer-controlled universal testing machine. Data were tested for normality using the Shapiro-Wilk test. Data were analyzed using an independent t test. A significant level was set at P < 0.05.

RESULTS: Regarding fracture resistance, 3D printed crowns group had statistically significant higher mean values than the prefabricated zirconia crowns group; the values were 1235.97 ± 412.12 N and 576.56 ± 221.53 N, respectively (P < 0.001). However, there was no significant difference in the marginal gap between the two types of crowns with average 32.00 ± 7.54 for 3D printed crowns and average 34.14 ± 9.79 for zirconia crowns (P < 0.001).

CONCLUSION: 3D printed microfilled hybrid resin crowns could be a suitable esthetic alternative for restoring pulp-treated primary molars. It is possible to provide an additional esthetic solution for the parents/children to satisfy the need for esthetic restoration of primary molars.

CLINICAL TRIAL: Not applicable (in vitro study).

PMID:40314911 | DOI:10.1007/s40368-025-01038-1

Ann Surg Oncol. 2025 May 2. doi: 10.1245/s10434-025-17377-8. Online ahead of print.

NO ABSTRACT

PMID:40314903 | DOI:10.1245/s10434-025-17377-8