Category: Statistics

Ann Intern Med. 2025 Jul 8. doi: 10.7326/ANNALS-24-00713. Online ahead of print.

ABSTRACT

BACKGROUND: A 2020 consensus statement proposed body mass index (BMI)-specific waist circumference (WC) thresholds to improve patient care.

OBJECTIVE: To determine whether stratifying BMI categories by BMI-specific WC thresholds improves mortality risk prediction.

DESIGN: Prospective cohort study.

SETTING: Women’s Health Initiative multicenter, population-based U.S. study, with enrollment from 1993 to 1998 and follow-up through 2021.

PARTICIPANTS: 139 213 postmenopausal women aged 50 to 79 years were included in a development cohort (n = 67 774) and 2 external validation cohorts. Validation Cohort 1 had high prevalence of overweight or obesity (n = 48 335), and Validation Cohort 2 included diverse, geographically separate centers (n = 23 104).

MEASUREMENTS: Height, weight, and WC measured at enrollment. BMI categories were normal weight (18.5 to <25 kg/m²), overweight (25 to <30 kg/m²), obesity-1 (30 to <35 kg/m²), obesity-2 (35 to <40 kg/m²), and obesity-3 (≥40 kg/m²), with further stratification by prespecified WC thresholds (≥80, ≥90, ≥105, ≥115, and ≥115 cm, respectively). Mortality was ascertained annually and was supplemented with serial National Death Index queries. Ten- and 20-year mortality prediction models that included BMI categories were compared to models with BMI categories stratified by WC thresholds using c-statistics and continuous net reclassification improvement (NRI).

RESULTS: Over a median of 24 years of follow-up, 69 297 participants died. Multivariable-adjusted mortality risk was consistently greater for BMI categories with large WC than those with normal WC. Compared with women with normal weight and normal WC, women with normal or overweight BMI but large WC (hazard ratios [HRs], 1.17 [95% CI, 1.12 to 1.21] and 1.19 [CI, 1.15 to 1.24], respectively) had risk similar to those with obesity-1 but normal WC (HR, 1.12 [CI, 1.08 to 1.16]). Mortality associated with obesity-1 and large WC (HR, 1.45 [CI, 1.35 to 1.55]) was similar to that with obesity-3 and normal WC (HR, 1.40 [CI, 1.28 to 1.54]). Models with BMI-specific WC thresholds improved discrimination and risk stratification at 10 years for Validation Cohort 1; c-statistics improved by 0.7% (CI, 0.3% to 1.0%) to 61.3% (CI, 60.2% to 62.5%), and continuous NRI was 20.4% (CI, 17.3% to 23.6%). Results were mixed for Validation Cohort 2; risk stratification improved (continuous NRI, 12.3% [CI, 8.5% to 16.0%]), but not discrimination. Results were similar at 20 years.

LIMITATION: The study did not include men or younger women.

CONCLUSION: Further stratifying BMI categories by WC thresholds modestly improved mortality risk stratification, with larger WC predicting greater mortality, although the degree of improvement varied by cohort. Discrimination did not improve consistently.

PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute of the National Institutes of Health.

PMID:40623313 | DOI:10.7326/ANNALS-24-00713

Health Aff (Millwood). 2025 Jul;44(7):821-829. doi: 10.1377/hlthaff.2024.01160.

ABSTRACT

In 2019, Connecticut became the first state to implement a deidentified notification policy for infants with prenatal substance exposure in response to updated provisions contained in the federal Child Abuse Prevention and Treatment Act (CAPTA) of 1974. Our study aimed to test whether Connecticut’s notification policy was associated with an increase in Child Protective Services (CPS) interactions for this population. We analyzed child welfare and vital records over the course of a sixty-six-month time frame starting two years before the policy took effect. We used interrupted time series models to estimate monthly reports to CPS and foster care placements for infants with prenatal substance exposure in Connecticut’s eight counties between March 2017 and July 2022. Reports and foster placements decreased for newborns with prenatal substance exposure after policy implementation. After covariates were controlled for, the adjusted rate of reports per birth decreased by 7 percent per month after the policy’s implementation. The proportion of prenatal substance exposure reports resulting in foster care placement decreased by 4 percent per month. These findings suggest that Connecticut’s approach to CAPTA was associated with a reduction in child welfare encounters among infants with prenatal substance exposure.

PMID:40623260 | DOI:10.1377/hlthaff.2024.01160

Health Aff (Millwood). 2025 Jul;44(7):846-854. doi: 10.1377/hlthaff.2024.01014.

ABSTRACT

Studies have found that sexual minority populations more often report worse overall health, lower health-related quality of life, and greater risk for disability than their heterosexual counterparts. This study used a novel approach to identify people in same-sex relationships, using insurance administrative claims data, and compared the prevalence of morbidity in that population with its prevalence in the population of those in different-sex relationships. This observational retrospective cohort study used the Merative MarketScan Research Database, which pooled data from private insurers from the period 2016-22. We identified 340,728 people in same-sex relationships, making this one of the largest studies on sexual minority populations to date, and found that they had higher Elixhauser morbidity scores than their counterparts in different-sex relationships. Sexual minorities experienced a greater prevalence of mental health morbidities (that is, depression, psychoses, and alcohol and drug use disorders) than their peers in different-sex relationships, with adjusted prevalence risk ratios (PRRs) ranging from 1.23 to 2.07. Sexual minority men also were more likely to have HIV (PRR: 93.62) and lymphoma (PRR: 1.34) than their male counterparts in different-sex relationships. These findings support the survey literature that has documented that sexual minority populations experience greater mental health and HIV-related morbidity, and they offer a novel approach to identifying members of sexual minorities.

PMID:40623259 | DOI:10.1377/hlthaff.2024.01014

Health Aff (Millwood). 2025 Jul;44(7):806-811. doi: 10.1377/hlthaff.2024.01552.

ABSTRACT

We identified obstetric service status for every rural and urban short-term acute care hospital in every US state. During 2010-22, seven states had at least 25 percent of hospitals close their obstetric service lines. By 2022, more than two-thirds of rural hospitals in eight states were without obstetric services.

PMID:40623258 | DOI:10.1377/hlthaff.2024.01552

Health Aff (Millwood). 2025 Jul;44(7):878-886. doi: 10.1377/hlthaff.2024.01189.

ABSTRACT

To address low take-up of Medicare Savings Programs for low-income Medicare beneficiaries, the Centers for Medicare and Medicaid Services issued regulations in 2023 aimed at streamlining the enrollment process. We analyzed 2016-22 data from the Medicare Current Beneficiary Survey to examine recent take-up of the largest and most generous Medicare Savings Program, the Qualified Medicare Beneficiary (QMB) program. We compared beneficiary characteristics and cost-related barriers to care among QMB enrollees and beneficiaries who were eligible but not enrolled. QMB take-up rose from 62 percent in 2016 to 66 percent in 2022. QMB-eligible beneficiaries who were Asian or Hispanic were more likely than eligible White beneficiaries to enroll in the program. Eligible beneficiaries younger than age sixty-five were more likely to enroll than those ages sixty-five and older, and beneficiaries in Medicaid expansion states were more likely to enroll than those in nonexpansion states. QMB enrollees were less likely than Medicare beneficiaries who were eligible but not enrolled to report delaying care because of cost or having problems paying for care. These findings suggest that additional policies and programs may be needed to increase QMB take-up and to improve health care access and affordability for millions of low-income Medicare beneficiaries.

PMID:40623256 | DOI:10.1377/hlthaff.2024.01189

Health Aff (Millwood). 2025 Jul;44(7):862-868. doi: 10.1377/hlthaff.2024.01111.

ABSTRACT

There has been a significant shift in the composition of the Medicaid managed care market over the course of the past two decades. The market is consolidated among five national firms, and those firms have nearly half of all beneficiaries enrolled in managed care plans. State markets are even more consolidated, typically giving Medicaid beneficiaries only a few plan options. This article describes the Medicaid managed care market during the period 2006-20, using enrollment data and a novel data set on acquisitions. Our study found a marked decrease in the number of parent payers (unique firms that own at least one Medicaid managed care plan), despite an increase in total enrollment, as well as a high volume of acquisitions. In fact, approximately one in four plans were involved in at least one acquisition during the study period. National payers are playing an increasingly dominant role in Medicaid managed care, with both the number and the market share of local payers decreasing during the study period. Future research is needed to understand the consequences of these shifts for the level of competition in this market, state finances, and beneficiary health.

PMID:40623255 | DOI:10.1377/hlthaff.2024.01111

Health Aff (Millwood). 2025 Jul;44(7):839-845. doi: 10.1377/hlthaff.2024.01484.

ABSTRACT

Utilization management criteria influence patients’ access to specialty drugs, yet the processes used by health plans to establish these criteria are not well understood. This study examined the alignment between clinical practice guidelines and plans’ utilization management criteria. Using the Tufts Medicine Specialty Drug Evidence and Coverage Database (December 2023), we reviewed US-based guidelines for 389 drug-indication pairs, excluding oncology and biosimilar treatments. We categorized guidelines as recommending or not recommending utilization management, based on alignment with each drug’s Food and Drug Administration label-specifically, line of therapy and clinical requirements (for example, disease severity). We analyzed 5,699 coverage policies from eighteen large commercial health plans. When guidelines recommended utilization management, 67 percent of plans’ coverage decisions aligned with the recommendation; when guidelines did not recommend utilization management, only 37 percent of decisions were consistent. Most plans imposed utilization management criteria (61 percent of all decisions), and plans were more likely to be consistent with guideline recommendations when utilization management was recommended, indicating a weak alignment with guideline recommendations.

PMID:40623253 | DOI:10.1377/hlthaff.2024.01484

Health Aff (Millwood). 2025 Jul;44(7):869-877. doi: 10.1377/hlthaff.2024.01163.

ABSTRACT

Recent policy initiatives such as the 988 Suicide and Crisis Lifeline aim to increase the use of crisis services. We conducted a probability survey of 5,006 US adults in 2023 and used latent class analysis to identify population segments that vary in crisis help-seeking preferences. We identified five segments: “Seek Help Nowhere,” “Definitely Not 988, Yes Friends And Family-Distressed,” “Seek Help Everywhere,” “Seek Help Most Places, But Not Religious Network,” and “Relatively Indifferent-Not Distressed.” Having serious prior-thirty-day psychological distress was positively associated with membership in the Definitely Not 988 segment and was negatively associated with the Relatively Indifferent segment. Respondents who were not aware of the 988 Lifeline were more likely to be in the Seek Help Nowhere and Definitely Not 988 segments. Political party affiliation was associated with membership in all segments. Communication campaigns that encourage the use of crisis services and help seeking may consider tailoring messages for these different audience segments.

PMID:40623251 | DOI:10.1377/hlthaff.2024.01163

Health Aff (Millwood). 2025 Jul;44(7):812-820. doi: 10.1377/hlthaff.2024.01250.

ABSTRACT

Maternal involvement with Child Protective Services (CPS) is common around childbirth, particularly for women with economic and health challenges. Federal and state policies aim to improve health care access and use for CPS-involved families, but evidence is needed to understand how CPS contact relates to health care for new mothers. We used linked population-based administrative data, representing all Medicaid-covered births in Wisconsin during the period 2010-19, to produce estimates of the associations of CPS interventions with maternal receipt of postpartum health care. After we adjusted for factors influencing risk for CPS involvement, women whose births were brought to the attention of CPS were around 13 percentage points less likely to receive postpartum care within twelve weeks after delivery, and this relation was present across different levels of CPS intervention and key population subgroups. These findings highlight the need to consider how child welfare and health care policies and practices can support connections with health care for new mothers and their infants.

PMID:40623250 | DOI:10.1377/hlthaff.2024.01250

Pain. 2025 Jul 2. doi: 10.1097/j.pain.0000000000003703. Online ahead of print.

ABSTRACT

Exacerbations of existing low back pain (LBP) or new LBP episodes are colloquially referred to as “flares.” Although the experience of flares is common to many people with LBP, few validated measures enable people to self-report if they are experiencing a flare. This study examined the convergent validity of a person-dependent definition of flares (“a worsening of your low back pain that lasts from hours to weeks”) as compared with (1) LBP intensity, (2) LBP-related pain interference, and (3) analgesic use, in a large, prospective research study of Veterans with LBP. Veterans seeking care for LBP (n = 465) were followed prospectively for up to 1 year. Participants completed up to 36 scheduled surveys and additional patient-initiated surveys (triggered by the onset of new flares) over follow-up. Each survey inquired about current flare status, pain intensity measured on a 0 to 10 numeric rating scale (NRS), LBP-related pain interference, and analgesic use. Linear mixed-effects models estimated the association between current flare status and pain intensity, with and without adjustment for potential confounding factors; secondary analyses examined associations with pain interference and analgesic use. In longitudinal analyses of 11,817 surveys, flare status was significantly associated with a 2.8-NRS point greater pain intensity (P < 0.0001), with and without adjustment for other factors. Statistically significant associations were found between flare status and LBP-related pain interference and analgesic use. New flare periods were associated with impacts on coping, functional limitations, and mood/emotions. These findings support the convergent validity of a person-dependent flare definition.

PMID:40623243 | DOI:10.1097/j.pain.0000000000003703