Faculty Bibliography

BACKGROUND: The adoption of Medicaid expansion in some states and not others provided a unique natural experiment to study the effects of Medicaid. Research stemming from this natural experiment suggests that Medicaid expansion increased health insurance coverage, improved access to care, and reduced cost-related barriers to prescription drugs among low income individuals. Findings with respect to health outcomes, however, have been more mixed. Therefore, we analyzed recently released national data from the Behavioral Risk Factor Surveillance System (BRFSS) to assess the relationship between Medicaid expansion and self-reported health measures among low-income individuals. METHODS: We used 2011-2015 BRFSS data, which provided 3 years of data prior to implementation of Medicaid expansion and 2 years of follow-up data in the majority of expansion states. Our study sample consisted of all individuals age 18-64 with household incomes below $15,000, targeting individuals who would have qualified for Medicaid coverage in expansion states. As in prior work, we excluded five states that had previously expanded Medicaid. Our outcomes were self-reported general health, poor physical health days, poor mental health days, and disability following Medicaid expansion. We used a difference-in-differences approach to estimate the effect of Medicaid expansion on our outcomes of interest. Our key independent variable was equal to 1 for individuals living in states where expansion was in effect during the month of their interview. Estimates were obtained with multivariable linear probability models and adjusted for age, race/ethnicity, sex, education, marital status, and children, as well as state-level and quarter year fixed effects. We used BRFSS sampling weights and estimated robust standard errors clustered at the state level to account for serial autocorrelation. RESULTS: In adjusted analyses of the influence of Medicaid expansion, we found that expansion was associated with a significant reduction in fair/poor self-rated health (2.5 percentage points [95% CI, -3.5 to -1.5]). While expansion was not associated with a statistically significant change in the number of poor physical health days (-0.20 days [95% CI, -0.68 to 0.28]), it was associated with a significant reduction in the number of poor mental health days (-0.52 days [95% CI, -0.99 to -0.04]). Change in disability prevalence did not vary between expansion and non-expansion states (P = 0.73). Adjusted linear time trends prior to expansion (2011 to 2013) for all outcomes were similar in expansion and non-expansion states (P > .05 for all comparisons). CONCLUSIONS: To our knowledge this is the first national study to report positives changes in self-reported general health following the ACA's Medicaid expansion provision, driven by changes in mental health. Whether these trends continue to improve will likely depend on whether policymakers choose to improve or repeal the ACA in the coming months

INTRODUCTION: Until recently, there has not been a valid and reliable screening test for lung cancer. As compared to chest X-ray, low-dose computed tomography (LDCT) lung cancer screening has demonstrated greater sensitivity resulting in lung cancer diagnosis at an earlier stage, thereby reducing lung cancer mortality among high-risk individuals by 20%. In the current study, we sought to examine knowledge and attitudes about LDCT screening for lung cancer among an ethnically and racially diverse sample of high risk (HR) community members and primary care providers (PCP). METHODS: Eligible individuals participated in a focus group using semi-structured interview guides. Focus groups were conducted with PCPs (by telephone) and HRs (in-person). Sessions were audio-taped and transcribed verbatim. The constant comparison method and content analysis were used to analyze results. RESULTS: The majority of PCPs had limited knowledge of lung cancer CT screening. PCPs cited barriers to recommendation including, cost/insurance barriers and the potential for false positives. PCPs perceived the main benefit to be early detection of lung cancer. The majority of HRs had never heard of lung LDCT screening and had never had a healthcare provider recommend it to them. Perceived barriers included fear of results (bad news) and financial costs. The main perceived benefit was early detection. CONCLUSION: Lack of knowledge about LDCT was a key a barrier across both the PCP and HR. RESPONDENTS: Understanding the barriers to lung screening across diverse community populations is necessary to improve screening rates and shared decision-making.

BACKGROUND: In the Spring and Summer of 2016, a text-messaging intervention to titrate basal insulin in patients with type 2 diabetes and poor glycemic control was implemented at two safety net health care systems in New York City. The goal of the current study was to conduct a qualitative evaluation assessing barriers to, and facilitators of, implementation of the mobile insulin titration intervention (called "MITI"). METHODS: We conducted in-depth qualitative interviews with patients (N = 36) and physician, nursing and administrative staff (N = 19) at the two health care systems implementing MITI. Interviews were transcribed and coded by two study investigators using a codebook guided by the Consolidated Framework for Implementation Research and through iterative, consensus driven content analysis. RESULTS: Patients and staff perceived MITI as convenient and timesaving for patients, easy to use, and effective at achieving its clinical goals. Patients were comfortable sharing health information via text, and felt good about communicating with their health team remotely. Interviewees across stakeholder groups felt that MITI was helpful beyond insulin titration by reminding and motivating patients to engage in healthy behaviors and improving medication adherence. Staff felt MITI worked well with existing workflows and expressed a desire to see MITI expanded to other chronic conditions. Nurses responsible for weekly titration reported initial concerns over safety/liability, time required to deliver the program, difficulties reaching patients for titration calls and the need for ongoing support/training in using the online texting platform. Perceived barriers to MITI implementation reported by providers included perceived lack of patient cell phone access or texting capabilities and patient language barriers. There was also a theme that emerged across interviewees of an unmet need for additional diabetes management support among this population, beyond insulin support provided by MITI. The project team made several modifications to MITI operations in response to these findings. CONCLUSIONS: Patients and staff were overwhelmingly supportive of MITI and believed it had many benefits. Initial implementation of MITI should address nurse comfort, workload and training, and sites should provide ongoing support and training for nurses after implementation. Future research should explore options for integrating additional diabetes support for patients enrolled in MITI or after they are discharged from the program

OBJECTIVE: To use novel geographic methods and large-scale claims data to identify the local distribution of pediatric chronic diseases in New York City. METHODS: Using a 2009 all-payer emergency claims database, we identified the proportion of unique children aged 0 to 17 with diagnosis codes for specific medical and psychiatric conditions. As a proof of concept, we compared these prevalence estimates to traditional health surveys and registry data using the most geographically granular data available. In addition, we used home addresses to map local variation in pediatric disease burden. RESULTS: We identified 549,547 New York City children who visited an emergency department at least once in 2009. Though our sample included more publicly insured and uninsured children, we found moderate to strong correlations of prevalence estimates when compared to health surveys and registry data at prespecified geographic levels. Strongest correlations were found for asthma and mental health conditions by county among younger children (0.88, P = .05 and 0.99, P < .01, respectively). Moderate correlations by neighborhood were identified for obesity and cancer (0.53 and 0.54, P < .01). Among adolescents, correlations by health districts were strong for obesity (0.95, P = .05), and depression estimates had a nonsignificant, but strong negative correlation with suicide attempts (-0.88, P = .12). Using SaTScan, we also identified local hot spots of pediatric chronic disease. CONCLUSIONS: For conditions easily identified in claims data, emergency department surveillance may help estimate pediatric chronic disease prevalence with higher geographic resolution. More studies are needed to investigate limitations of these methods and assess reliability of local disease estimates.

OBJECTIVE: To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation. DATA SOURCES/STUDY SETTING: Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files. STUDY DESIGN: We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time. DATA COLLECTION/EXTRACTION METHODS: Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas. PRINCIPAL FINDINGS: In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time. CONCLUSIONS: Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.

BACKGROUND: A clinical study team performing three multicultural dementia screening studies identified the need to improve data management practices and facilitate data sharing. A collaboration was initiated with librarians as part of the National Library of Medicine (NLM) informationist supplement program. The librarians identified areas for improvement in the studies' data collection, entry, and processing workflows. CASE PRESENTATION: The librarians' role in this project was to meet needs expressed by the study team around improving data collection and processing workflows to increase study efficiency and ensure data quality. The librarians addressed the data collection, entry, and processing weaknesses through standardizing and renaming variables, creating an electronic data capture system using REDCap, and developing well-documented, reproducible data processing workflows. CONCLUSIONS: NLM informationist supplements provide librarians with valuable experience in collaborating with study teams to address their data needs. For this project, the librarians gained skills in project management, REDCap, and understanding of the challenges and specifics of a clinical research study. However, the time and effort required to provide targeted and intensive support for one study team was not scalable to the library's broader user community.

The World Trade Center (WTC) disaster released large amounts of various chemical substances into the environment, including perfluoroalkyl substances (PFASs). Yet, no studies have examined exposures in children living or attending schools near the disaster site. We measured serum PFASs in WTC Health Registry (WTCHR) respondents who were