IMPORTANCE The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion. OBJECTIVE To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis. DESIGN, SETTING, AND PARTICIPANTS Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017. EXPOSURE Living in a Medicaid expansion state. MAIN OUTCOMES AND MEASURES The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis. RESULTS A total of 142 724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93 522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, −0.8 percentage points; 95% CI, −1.1 to −0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, −0.2 percentage points; 95% CI, −0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of −0.6 percentage points (95% CI, −1.0 to −0.2). Mortality reductions were largest for black patients (−1.4 percentage points; 95% CI, −2.2, −0.7; P=.04 for interaction) and patients aged 19 to 44 years (−1.1 percentage points; 95% CI, −2.1 to −0.3; P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7–13.2) increase in Medicaid coverage at dialysis initiation, a −4.2-percentage-point (95% CI, −6.0 to −2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6–4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant. CONCLUSIONS AND RELEVANCE Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.

Objective To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf-hurricanes Methods Observational study using Medicare claims, and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 non-hurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days. Results Among 36,389 NH residents exposed to a storm, the 30 and 90 day mortality/hospitalization rates increased compared to non-hurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7-5.3% and hospitalization by 1.8-8.3%, independent of other factors. Conclusion Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.

Objective The aim of this study is to investigate both maternal and paternal contributions in the familial aggregation of small for gestational age. Design Nested case -control study.Setting Metropolitan area of Haguenau, France.Population Data were drawn from a French population-based maternity registry. After selection, 256 cases born either small for gestational age or average for gestational age were included. Methods Controlling for known pregnancy-related risk factors, logistic regression models were used to determine the risk of the child being small for gestational age, given that the mother, father or both were small for gestational age, and to examine interactions between maternal small for gestational age and pregnancy risk factors. Main outcome measures Specifically, we investigate to what extent having either or both parents born small for gestational age increases the risk of small for gestational age in their offspring, after controlling for the established risk factors of small for gestational age and maternal and paternal characteristics. We also explore the extent to which the intergenerational predictors of small for gestational age may modify the effect of current pregnancy-related risk factors. Results The risk of a small for gestational age offspring was 4.7 times greater for mothers and 3.5 times greater for fathers who were small for gestational age, compared with average for gestational age counterparts. Furthermore, the risk of a small for gestational age offspring was 16.3 times greater when both parents were small for gestational age. No significant interactions between maternal small for gestational age and maternal smoking, hypertension or parity were observed. Conclusion These results indicate that small for gestational age in both mother and father significantly influences the risk of their offspring being small for gestational age. While previous research has indicated that the birth outcome of the mother is an important determinant of the birth outcome of her offspring, these data indicate that the birth outcome of the father plays an equally critical role in determining fetal growth, strongly suggesting a genetic component in the familial aggregation of small for gestational age.

First time mothers aged 35 and above have higher odds of having a second pregnancy shortly after their first pregnancy. Given the increasing number of first time mothers aged 35 and above, these findings are of relevance for preconception counseling for this unique population of women.

Since 1973 Medicare has provided health insurance coverage to all people who have been diagnosed with end-stage renal disease, or kidney failure. In this article we trace the history of payment policies in Medicare’s dialysis program from 1973 to 2011, while also providing some insight into the rationale for changes made over time. Initially, Medicare adopted a fee-for-service payment policy for dialysis care, using the same reimbursement standards employed in the broader Medicare program. However, driven by rapid spending growth in this population, the dialysis program has implemented innovative payment reforms, such as prospective bundled payments and pay-for-performance incentives. It is uncertain whether these strategies can stem the increase in the total cost of dialysis to Medicare, or whether they can do so without adversely affecting the quality of care. Future research on the intended and unintended consequences of payment reform will be critical.

Objective. To identify the effect of competition on health maintenance organizations' (HMOs) quality measures. Study Design. Longitudinal analysis of a 5-year panel of the Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Health Plans Survey s (CAHPS) data (calendar years 1998-2002). All plans submitting data to the National Committee for Quality Assurance (NCQA) were included regardless of their decision to allow NCQA to disclose their results publicly. Data Sources. NCQA, Interstudy, the Area Resource File, and the Bureau of Labor Statistics. Methods. Fixed-effects models were estimated that relate HMO competition to HMO quality controlling for an unmeasured, time-invariant plan, and market traits. Results are compared with estimates from models reliant on cross-sectional variation. Principal Findings. Estimates suggest that plan quality does not improve with increased levels of HMO competition (as measured by either the Herfindahl index or the number of HMOs). Similarly, increased HMO penetration is generally not associated with improved quality. Cross-sectional models tend to suggest an inverse relationship between competition and quality. Conclusions. The strategies that promote competition among HMOs in the current market setting may not lead to improved HMO quality. It is possible that price competition dominates, with purchasers and consumers preferring lower premiums at the expense of improved quality, as measured by HEDIS and CAHPS. It is also possible that the fragmentation associated with competition hinders quality improvement.Key Words. HMOs, NCQA, HEDIS, CAHPS, managed care, quality, performance measurement, competition, markets Reform of the health care system to promote improved quality of care and lower cost growth has been a policy objective for decades. A strategy frequently discussed as a means to achieve these goals is the pursuit of a competitive health care delivery and financing system, including a system of r Health Research and Educational Trust

Background/Objectives To examine the hospitalization rate and mortality associated with forced mass transfer of nursing home residents with the highest levels of functional impairment. Design Retrospective cohort study. Setting 119 Texas and Louisiana nursing homes that were identified as being “at-risk” for evacuation for Hurricane Gustav. Participants 6,464 long-stay residents residing in “at-risk” nursing homes for at least three consecutive months prior to landfall of Hurricane Gustav. Measurements Using Medicare claims and instrumental variable analysis, we compared the differential mortality (death at 30 and 90 days) and hospitalization rates (at 30 and 90 days) of the most functionally-impaired long-stay residents who evacuated for Hurricane Gustav relative to the most functionally impaired residents who did not evacuate. Results Results suggest that the effect of evacuation was associated with an 8% increase in hospitalizations by 30 and 90 days for the most functionally impaired residents. Evacuation was not significantly related to mortality for the most functionally impaired residents. Conclusion Our results suggest that the most functionally impaired nursing home residents experience an increase in hospitalizations but not mortality as a consequence of forced mass transfer. With the inevitability of nursing home evacuations for many different reasons, harm mitigation strategies focused on the most impaired residents are needed.

Delayed initiation of childbearing is associated with a persistent risk of adverse perinatal outcomes in the second pregnancy, with a short IPI contributing to this risk. As numbers of women delaying childbearing beyond age 30 increase, providers should consider these risks in counseling women about their reproductive plans.