Background The 2006 Massachusetts health reform substantially decreased uninsurance rates. Yet, little is known about the reform’s impact on actual healthcare utilization among poor and minority populations, particularly for receipt of inpatient surgical procedures that are commonly initiated by outpatient physician referral. Methods Using discharge data on MA hospitalizations for 21 months preceding and following health reform implementation (7/1/2006 – 12/31/2007), we identified all non-obstetrical major therapeutic procedures for patients aged ≥ 40 and for which ≥70 percent of hospitalizations were initiated by outpatient physician referral. Stratifying by race/ethnicity and patient residential zip code median (area) income, we estimated pre- and post-reform procedure rates, and their changes, for those aged 40–64 (non-elderly), adjusting for secular changes unrelated to reform by comparing to corresponding procedure rate changes for those aged >= 70 (elderly), whose coverage (Medicare) was not affected by reform. Results Overall increases in procedure rates (among 17 procedures identified) between pre- and post-reform periods were higher for non-elderly low area income (8%, p=0.04) and medium area income (8%, p<0.001) cohorts than for the high area income cohort (4%); and for Hispanics and Blacks (23% and 21% respectively; p values <0.001) than for Whites (7%). Adjusting for secular changes unrelated to reform, post-reform increases in procedure utilization among non-elderly were: by area income, low=13% (95% CI=[9%, 17%]), medium=15% ([6%, 24%]) and high=2% ([−3%, 8%]), and by race/ethnicity, Hispanics=22% ([5%, 38%]), Blacks=5% ([−20%, 30%]) and Whites=7% ([5%, 10%]). Conclusions Post-reform use of major inpatient procedures increased more among non-elderly lower and medium area income populations, Hispanics, and whites, suggesting potential improvements in access to outpatient care for these vulnerable subpopulations.

Little is known about how different types of substances affect oral health. Our objective was to examine the respective effects of alcohol, stimulants, opioids, and marijuana on oral health in substance-dependent persons. Using self-reported data from 563 substance-dependent individuals, we found that most reported unsatisfactory oral health, with their most recent dental visit more than 1 year ago. In multivariable logistic regressions, none of the substance types were significantly associated with oral health status. However, opioid use was significantly related to a worse overall oral health rating compared to 1 year ago. These findings highlight the poor oral health of individuals with substance dependence and the need to address declining oral health among opioid users. General health and specialty addiction care providers should be aware of oral health problems among these patients. In addition, engagement into addiction and medical care may be facilitated by addressing oral health concerns.

Clinicians are often uncertain about how to manage elevated blood pressure (BP) when a patient reports that he/she has recently missed several doses of antihypertensive medications. While we know that better adherence can improve BP during several months, the magnitude of this relationship in the short term is poorly understood. The authors examined this issue using a group of patients who monitored adherence using a Medication Events Monitoring System (MEMS) cap and had BP measurements in the course of routine clinical practice. BP readings were compared following 7 days of excellent adherence (100%) or poor adherence (<60%), omitting BP values following intermediate adherence. Using several different methods, BP following 7 days of excellent adherence was between 12/7 mm Hg and 15/8 mm Hg lower than after 7 days of poor adherence. Clinicians can use this effect size to calibrate their impressions of what the BP might have been with improved adherence. J Clin Hypertens (Greenwich). 2011;13:416–421. ©2011 Wiley Periodicals, Inc.

BackgroundDespite the vast literature examining disparities in medical care, little is known about racial/ethnic and mental health disparities in sexual health care. The objective of this study was to assess disparities in safe sex counseling and resultant behavior among a patient population at risk of negative sexual health outcomes.MethodsWe conducted a cross-sectional analysis among a sample of substance dependent men and women in a metropolitan area in the United States. Multiple logistic regression models were used to explore the relationship between race/ethnicity (non-Hispanic black; Hispanic; non-Hispanic white) and three indicators of mental illness (moderately severe to severe depression; any manic episodes; ≥3 psychotic symptoms) with two self-reported outcomes: receipt of safe sex counseling from a primary care physician and having practiced safer sex because of counseling.ResultsAmong 275 substance-dependent adults, approximately 71% (195/275) reported ever being counseled by their regular doctor about safe sex. Among these 195 subjects, 76% (149/195) reported practicing safer sex because of this advice. Blacks (adjusted odds ratio (AOR): 2.71; 95% confidence interval (CI): 1.36,5.42) and those reporting manic episodes (AOR: 2.41; 95% CI: 1.26,4.60) had higher odds of safe sex counseling. Neither race/ethnicity nor any indicator of mental illness was significantly associated with practicing safer sex because of counseling.ConclusionsThose with past manic episodes reported more safe sex counseling, which is appropriate given that hypersexuality is a known symptom of mania. Black patients reported more safe sex counseling than white patients, despite controlling for sexual risk. One potential explanation is that counseling was conducted based on assumptions about sexual risk behaviors and patient race. There were no significant disparities in self-reported safer sex practices because of counseling, suggesting that increased counseling did not differentially affect safe sex behavior for black patients and those with manic episodes. Exploring the basis of how patient characteristics can influence counseling and resultant behavior merits further exploration to help reduce disparities in safe sex counseling and outcomes.Trial registrationNCT00278447

Background: Boston Medical Center (BMC) is the primary safety net hospital for Eastern Massachusetts and has a diverse patient population with diverse insurance types. Such types include commercial and public insurance (Medicare and Medicaid) and Free Care, limited coverage funded by money distributed to safety-net institutions to care for uninsured patients. In 2006, the state expanded Medicaid eligibility and began offering Commonwealth Care, comprehensive subsidized coverage with retail pharmacy benefits, for uninsured patients. The impact of these insurance types on individual cardiovascular conditions has not been studied. Venous thromboembolism (VTE), comprised of deep venous thrombosis and pulmonary embolism, is a condition whose clinical course is dependent on high quality anticoagulation care including easy access to medication and providers. Time in the therapeutic range (TTR), the percentage of time a patient spends with INR between 2 and 3, has emerged as the preeminent way to measure quality of anticoagulation care. In this study, we compared quality of anticoagulation among different insurance types. Methods: Using clinical data, we identified adults aged 18 to 64 with a new episode of VTE diagnosed in the years 2003 to 2010 at BMC or its affiliated health centers. To be eligible for inclusion, each patient had to have an ICD-9-CM code for VTE and an INR test in the month following VTE diagnosis. We computed TTR using all INR values from diagnosis to 12 months according to the Rosendaal method. We then measured the mean TTR for each of six insurance categories based on primary insurance at time of diagnosis. Using multiple linear regression, we adjusted measurements for sex, age, race, language preference, area poverty, VTE type, recent surgery, and number of Elixhauser comorbidities. Results: We identified 1099 patients with VTE. Twenty-three percent had commercial insurance, 37% Medicaid, 16% Medicare, 4% Commonwealth care, 18% Free Care, and 2% other. Mean TTR was 39.3%. Patients with Free Care and Commonwealth Care had similar TTR compared to those with commercial insurance. Patients with Medicaid, Medicare or other insurance had significantly lower TTR, compared to those with commercial insurance. Conclusion: Quality of anticoagulation care was low in this population. Residual confounding such as from healthy worker effect may account for higher TTR in patients with commercial insurance. In future work we plan to expand measurement of insurance effects to patients receiving anticoagulation for indications other than VTE and adjust our measurements for temporal bias

BACKGROUND The 2006 Massachusetts (MA) health reform increased insurance coverage to near-universal levels, but its impact on access to care or disparities in access is unclear. We examined post-reform change in racial/ethnic differences in use of two cardiovascular (CV) procedures, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG), for which disparities in use have been noted in numerous past studies. As use of these procedures is sensitive to outpatient referral, impact of reform on procedure use can serve as a marker for impact on access to care. We hypothesized that reform will result in increased use of procedures, and that the increase in use will be greater among minorities. We contrasted the results with those for two comparable orthopedic procedures (total knee replacement [TKR] and total hip replacement [THR]). METHODS Using the comprehensive MA Hospital Inpatient Data of all discharges in all non-Federal hospitals from 1/1/2004 to 9/30/2009, we obtained state-level counts of individual procedures stratified into 30 cohorts by age (40-44, 45-49, 50-54, 55-59 & 60-64), sex and race/ethnicity (Whites, Blacks and Hispanics) for each quarter. To separate the impact of MA reform from secular changes, we used corresponding data from New York (SPARCS Inpatient Data) to capture changes unrelated to MA reform. To convert procedure counts into rates (# procedures/10,000 population), we obtained Census data to create a measure of population at risk for each cohort. Treating a quarter as the unit of time, the study period comprised of 10 pre-reform, 6 transition and 7 post-reform quarters. Applying a difference-in-difference specification, we used segmented time series Poisson regression models to estimate the impact of MA reform on the procedure rates for Blacks and Hispanics relative to those for Whites. RESULTS There was a secular decrease in MA in the use of PTCA and CABG (-8.0% per year for each) throughout the study period. In MA, compared to Whites, pre-reform rates of both procedures were lower among Blacks (Incidence Rate Ratio [IRR]: PTCA=0.79 & CABG=0.73; all p values < 0.001) but similar among Hispanics. For the post-reform period, the procedure rate in MA was unchanged for PTCA but was 11% higher (95%CI=[2%, 20%]) for CABG. MA reform was associated with 11% higher post-reform rates of PTCA+CABG (combined) use among Hispanics, albeit with marginal significance (95% CI=[-1%, 25%]), than that among Whites; no significant impact was noted for Blacks (2%; 95% CI=[-10%, 16%]). Orthopedic procedures experienced secular increases in use. Reform was associated with increased use of both procedures among Blacks (16%, 95% CI=[3%, 31%]) and Hispanics (42%, 95% CI=[20%, 69%]) than that among Whites. CONCLUSIONS MA health reform may have increased the use of CV and orthopedic procedures among minorities. While orthopedic procedure use increased among both Blacks and Hispanics, the increase for CV procedures was smaller in magnitude and limited to Hispanics. Impact of reform on use may vary with procedure type due to differences in pent-up demand and acuity of conditions treated.

Introduction: After Massachusetts (MA) health reform, the percent of uninsured residents fell, particularly among minorities. Studies have not examined the effect of this policy change on 30-day readmission rates, and disparities in such rates, following acute myocardial infarction (AMI). Hypothesis : 30-day readmission rates will decline in patients age 18-64 (affected by health reform) vs. patients age ≥ 65 (most unaffected) Methods: We used 2004-2009 MA discharge data. We compared all-cause 30-day readmission rates after a hospitalization for AMI overall, and among racial subgroups, for patients age 18-64 vs. age ≥ 65 in the period prior to and following reform. We used chi-square tests to compare unadjusted 30-day readmissions for AMI between groups. Treating patients age 18-64 as the intervention cohort, and those age ≥ 65 as the control cohort, we used logistic regression to conduct difference-in-difference analysis that estimates odds of readmission in the post-reform period vs. the pre-reform period in MA adjusted for secular changes. The model was also adjusted for age, gender, and medical comorbidity. To assess differences in white vs. minority disparities over time between the pre and post reform periods among patients age 18-64 vs. age ≥ 65, we used logistic regression to conduct difference-in-difference-in-differences analysis. Results: Among patients age 18-64, pre-reform and post reform readmission rates were 11.5% and 10.5%. Among patients age ≥ 65, they were 24.0% and 22.2%. The post-reform decrease among patients age 18-64 was not different than the decrease among patients age ≥ 65 (difference-in-difference adjusted OR (AOR) =1.0; 95% CI=0.9-1.2). Among patients age 18-64, blacks had higher readmission rates than whites pre and post-reform. Post-reform changes in readmission rates among non-elderly and elderly adults were not significantly different among whites, blacks, and Hispanics. There was no significant change in the presence of disparities between whites and blacks or between whites and Hispanics among non-elderly and elderly adults pre- and post-reform. Conclusions: A major coverage expansion in MA was not associated with a reduction in 30-day readmissions for AMI overall or a reduction in racial and ethnic disparities.

Research Objective: Massachusetts (MA) health reform increased the number of insured residents, particularly among racial/ethnic minorities. Yet, it is not known if this insurance expansion translated into improvements or decreased racial/ethnic disparities in access to medical care. Ambulatory care sensitive conditions (ACSCs) such as congestive heart failure (CHF), hypertension and angina are a set of medical conditions for which good outpatient care can potentially prevent the need for hospitalization. Thus, we used changes in rates of hospitalization for these 3 ACSCs to assess potential changes in access to care following MA health care reform. Methods: Using complete data on acute care hospital admissions in MA and in two states that did not implement comprehensive health care reform, New York (NY) and Pennsylvania (PA), we identified all hospital admissions for cardiovascular ACSCs (CHF, angina and hypertension) during the 21 months preceding and following health reform implementation (7/1/2006-12/31/2007). Using US census population data we calculated pre- and post-reform age- and sex-standardized admission rates for the 3 ACSCs combined among patients 18-64 (those affected by reform). Treating MA as the intervention cohort, and NY and PA together as the control cohort we used multivariate Poisson regression models to conduct “difference-in-difference” analyses to estimate post-reform changes in admission rates in MA adjusted for contemporaneous changes occurring in control states. The models were also adjusted for age, gender and race. Using this approach, we also assessed whether health reform was associated with decreases in admission rates for racial and ethnic minorities compared with whites. Principal Findings: There were 84,286 hospital admissions for CHF, angina and hypertension combined in the pre- and post-reform periods in MA and 535,726 during the same time periods in control states. The hospital admission rate (number/100k population) for ACSCs declined in MA (128.7 to 121.7 [5.4%]) and in control states (232.2 to 208.4 [10.2%] from the pre- to post-reform period. When adjusted for secular trends in control states, age, gender and race, however, there was a 6.2% (95% CI, 2.9-9.6) increase in admissions in MA. After adjustment, there was no significant change in the admission rate for blacks compared with whites in MA (+3.7% [95% CI, -11.1 - 4.5]) or for Hispanics compared with whites in MA (+9.3% [95% CI, -18.2 - 0.6]). Conclusions: Hospital admissions for cardiovascular ACSCs did not decline in MA as a whole, or for minorities relative to whites, in comparison with 2 large control states that did not implement health reform. Additional insurance or health care system reforms in MA may be needed to decrease potentially avoidable hospitalizations and improve access to care.