Insurance Expansion and Hospital Emergency Department Access: Evidence From the Affordable Care Act

Background: Little is known about whether insurance expansion affects the location and type of emergency department (ED) use. Understanding these changes can inform state-level decisions about the Medicaid expansion under the Patient Protection and Affordable Care Act (ACA). Objective: To investigate the effect of the 2014 ACA Medicaid expansion on the location, insurance status, and type of ED visits. Design: Quasi-experimental observational study from 2012 to 2014. Setting: 126 investor-owned, hospital-based EDs. Participants: Uninsured and Medicaid-insured adults aged 18 to 64 years. Intervention: ACA expansion of Medicaid in January 2014. Measurements: Number of ED visits overall, type of visit (for example, nondiscretionary or nonemergency), and average travel time to the ED. Interrupted time-series analyses comparing changes from the end of 2013 to end of 2014 for patients from Medicaid expansion versus nonexpansion states were done. Results: There were 1.06 million ED visits among patients from 17 Medicaid expansion states, and 7.87 million ED visits among patients from 19 nonexpansion states. The EDs treating patients from Medicaid expansion states saw an overall 47.1% decrease in uninsured visits (95% CI, −65.0% to −29.3%) and a 125.7% (CI, 89.2% to 162.6%) increase in Medicaid visits after 12 months of ACA expansion. Average travel time for nondiscretionary conditions requiring immediate medical care decreased by 0.9 minutes (−6.2% [CI, −8.9% to −3.5%]) among all Medicaid patients from expansion states. We found little evidence of similar changes among patients from nonexpansion states. Limitation: Results reflect shifts in ED care at investor-owned facilities, which limits generalizability to other hospital types. Conclusion: Meaningful changes in insurance status and location and type of ED visits in the first year of ACA Medicaid expansion were found, suggesting that expansion provides patients with a greater choice of hospital facilities. Primary Funding Source: Robert Wood Johnson Foundation.

Let's Not SPRINT to Judgment About New Blood Pressure Goals

Update on Novel Drugs for Primary Care Practice: Drugs Approved by the U.S. Food and Drug Administration in 2015

Proprotein Convertase Subtilisin/Kexin Type 9 Monoclonal Antibodies for Acute Coronary Syndrome: A Narrative Review: Annals of Internal Medicine: Vol 164, No 9

Monoclonal antibodies that inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9) are an emerging therapy for dyslipidemia. Acute coronary events induce a dynamic increase of PCSK9 levels that may play a role in plaque vulnerability of both culprit and nonculprit coronary vessels. Growing evidence highlights a potential key role of PCSK9 antibodies in managing acute coronary syndrome. This review describes the influence of PCSK9 antibodies on plaque composition and instability, as well as the pharmacokinetic profile and the potential anti-inflammatory and antithrombotic mechanisms associated with PCSK9 inhibition that may confer benefits during the early phase of acute coronary syndrome. The authors posit a rationale for the use of PCSK9 antibodies in patients with acute coronary syndrome and highlight the need for further investigation in this area.

Screening for Depression in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

Description: Update of the 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for major depressive disorder (MDD) in children and adolescents. Methods: The USPSTF reviewed the evidence on the benefits and harms of screening; the accuracy of primary care–feasible screening tests; and the benefits and harms of treatment with psychotherapy, medications, and collaborative care models in patients aged 7 to 18 years. Population: This recommendation applies to children and adolescents aged 18 years or younger who do not have a diagnosis of MDD. Recommendation: The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger. (I statement)

Change in Bone Mineral Density Is an Indicator of Treatment-Related Antifracture Effect in Routine Clinical Practice: A Registry-Based Cohort Study: Annals of Internal Medicine: Vol 165, No 7

Background: Whether change in bone mineral density (BMD) is an accurate indicator of antifracture effect in clinical practice is unknown. Objective: To evaluate repeated BMD testing as an indicator of treatment-related fracture risk reduction. Design: Registry-based cohort study. Setting: Manitoba, Canada. Patients: 6629 women aged 40 years or older initiating osteoporosis treatment with 2 consecutive dual-energy x-ray absorptiometry scans (mean interval, 4.5 years). Measurements: Change in BMD between the first and second dual-energy x-ray absorptiometry scans categorized as stable, detectable decrease, or detectable increase. Incident fractures were ascertained from health services data. Results: During a mean of 9.2 years, 910 (13.7%) women developed incident fractures, including 198 with hip fractures. After adjustment for baseline fracture probability, women with a detectable decrease in total hip BMD compared with stable BMD had an absolute increase of 2.9% (95% CI, 1.5% to 4.4%) and 5.5% (CI, 2.8% to 8.1%) in the 5- and 10-year cumulative incidence of any fracture, respectively. In contrast, risk for any fracture in women with a detectable increase in total hip BMD was 1.3% (CI, 0.4% to 2.2%) and 2.6% (CI, 0.7% to 4.5%) lower after 5 and 10 years, respectively. Consistent results were seen for change in femoral neck and lumbar spine BMD and across a range of subgroup analyses. Limitation: Lack of standardization in the BMD testing interval. Conclusion: Treatment-related increases in total hip BMD are associated with reduced fracture risk compared with stable BMD, whereas decreases in BMD are associated with greater risk for fractures. Monitoring BMD in clinical practice may help to identify women with a suboptimal response to osteoporosis treatment. Primary Funding Source: None.

Yes, You Can: Physicians, Patients, and Firearms

Physicians have unique opportunities to help prevent firearm violence. Concern has developed that federal and state laws or regulations prohibit physicians from asking or counseling patients about firearms and disclosing patient information about firearms to others, even when threats to health and safety may be involved. This is not the case. In this article, the authors explain the statutes in question, emphasizing that physicians may ask about firearms (with rare exceptions), may counsel about firearms as they do about other health matters, and may disclose information to third parties when necessary. The authors then review circumstances under which questions about firearms might be most appropriate if they are not asked routinely. Such circumstances include instances when the patient provides information or exhibits behavior suggesting an acutely increased risk for violence, whether to himself or others, or when the patient possesses other individual-level risk factors for violence, such as alcohol abuse. The article summarizes the literature on current physician practices in asking and counseling about firearms, which are done far less commonly than recommended. Barriers to engaging in those practices, the effectiveness of clinical efforts to prevent firearm-related injuries, and what patients think about such efforts and physicians who engage in them are discussed. Proceeding from the limited available evidence, the authors make specific recommendations on how physicians might counsel their patients to reduce their risk for firearm-related death or serious injury. Finally, the authors review the circumstances under which disclosure of patient information about firearms to third parties is supported by regulations implementing the Health Insurance Portability and Accountability Act.

Genotyping for Human Papillomavirus Types 16 and 18 in Women With Minor Cervical Lesions: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 166, No 2

Background: High-risk human papillomavirus (hrHPV) testing to triage women with minor cervical lesions generates many referrals. Purpose: To evaluate the accuracy of genotyping for HPV types 16 and 18 and its utility as a second triage step after hrHPV testing in women with minor cervical lesions. Data Sources: Searches of 4 bibliographic databases, without language restrictions, from 1 January 1999 to 1 February 2016. Study Selection: Studies involving women with atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL) who were triaged with tests for hrHPV and HPV 16/18 to find cervical intraepithelial neoplasia (grade ≥2 [CIN2+] or grade ≥3 [CIN3+]). Data Extraction: Independent study selection, extraction of data, and quality assessment by 2 reviewers. Data Synthesis: Twenty-four moderate- to good-quality studies involving 8587 women with ASC-US and 5284 with LSIL were found. The pooled sensitivity of HPV 16/18 genotyping for CIN3+ was about 70% for women with either ASC-US or LSIL. The pooled specificity (with a threshold of grade <2 CIN) was 83% (95% CI, 80% to 86%) for women with ASC-US and 76% (CI, 74% to 79%) for those with LSIL. The average risk for CIN3+ was 17% and 19% in HPV 16/18–positive women with ASC-US and LSIL, respectively, and was 5% in hrHPV-positive but HPV 16/18–negative women with either ASC-US or LSIL. Limitation: Methodological and technical heterogeneity among studies; insufficient data to assess accuracy of separate assays. Conclusion: Testing for HPV 16/18 to triage women with minor abnormal cytology is poorly sensitive but may be useful as a second triage test after hrHPV testing, with direct referral if the woman is positive for HPV 16/18. Whether colposcopy or repeated testing is recommended for hrHPV-positive but HPV 16/18–negative women depends on local decision thresholds that can be derived from pretest–posttest probability plots. Primary Funding Source: 7th Framework Programme of the European Commission.

Association Between Patient-Centered Medical Homes and Adherence to Chronic Disease Medications: A Cohort Study: Annals of Internal Medicine: Vol 166, No 2

Background: Despite the widespread adoption of patient-centered medical homes into primary care practice, the evidence supporting their effect on health care outcomes has come primarily from geographically localized and well-integrated health systems. Objective: To assess the association between medication adherence and medical homes in a national patient and provider population, given the strong ties between adherence to chronic disease medications and health care quality and spending. Design: Retrospective cohort study. Setting: Claims from a large national health insurer. Patients: Patients initiating therapy with common medications for chronic diseases (diabetes, hypertension, and hyperlipidemia) between 2011 and 2013. Measurements: Medication adherence in the 12 months after treatment initiation was compared among patients cared for by providers practicing in National Committee for Quality Assurance–recognized patient-centered medical homes and propensity score–matched control practices in the same Primary Care Service Areas. Linear mixed models were used to examine the association between medical homes and adherence. Results: Of 313 765 patients meeting study criteria, 18 611 (5.9%) received care in patient-centered medical homes. Mean rates of adherence were 64% among medical home patients and 59% among control patients. Among 4660 matched control and medical home practices, medication adherence was significantly higher in medical homes (2.2% [95% CI, 1.5% to 2.9%]). The association between medical homes and better adherence did not differ significantly by disease state (diabetes, 3.0% [CI, 1.5% to 4.6%]; hypertension, 3.2% [CI, 2.2% to 4.2%]; hyperlipidemia, 1.5% [CI, 0.6% to 2.5%]). Limitation: Clinical outcomes related to medication adherence were not assessed. Conclusion: Receipt of care in a patient-centered medical home is associated with better adherence, a vital measure of health care quality, among patients initiating treatment with medications for common high-cost chronic diseases. Primary Funding Source: CVS Health.

Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States

Background: The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear. Objective: To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID. Design: Empirically calibrated dynamic compartmental model. Data Sources: Published literature and expert opinion. Target Population: Adult U.S. PWID. Time Horizon: 20 years and lifetime. Intervention: PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage. Outcome Measures: Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results of Base-Case Analysis: PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000 per QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years. Results of Sensitivity Analysis: Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence. Limitation: Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited. Conclusion: PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained. Primary Funding Source: National Institute on Drug Abuse.