ForHealth Consulting at UMass Chan Medical School (formerly Commonwealth Medicine) partners with purposeful organizations to make healthcare and human services more equitable, effective, and accessible. This collection showcases journal articles and other publications and presentations produced by ForHealth Consulting researchers.


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Recently Published

  • Strengthening Quality Measurement to Predict Success for Total Knee Arthroplasty: Results from a Nationally Representative Total Knee Arthroplasty Cohort

    Zheng, Hua; Ash, Arlene S.; Yang, Wenyun; Liu, Shao-Hsien; Allison, Jeroan J.; Ayers, David C (2024-01-25)
    Background: When performed well on appropriate patients, total knee arthroplasty (TKA) can dramatically improve quality of life. Patient-reported outcome measures (PROMs) are increasingly used to measure outcome following TKA. Accurate prediction of improvement in PROMs after TKA potentially plays an important role in judging the surgical quality of the health-care institutions as well as informing preoperative shared decision-making. Starting in 2027, the U.S. Centers for Medicare & Medicaid Services (CMS) will begin mandating PROM reporting to assess the quality of TKAs. Methods: Using data from a national cohort of patients undergoing primary unilateral TKA, we developed an original model that closely followed a CMS-proposed measure to predict success, defined as achieving substantial clinical benefit, specifically at least a 20-point improvement on the Knee injury and Osteoarthritis Outcome Score, Joint Arthroplasty (KOOS, JR) at 1 year, and an enhanced model with just 1 additional predictor: the baseline KOOS, JR. We evaluated each model's performance using the area under the receiver operator characteristic curve (AUC) and the ratio of observed to expected (model-predicted) outcomes (O:E ratio). Results: We studied 5,958 patients with a mean age of 67 years; 63% were women, 93% were White, and 87% were overweight or obese. Adding the baseline KOOS, JR improved the AUC from 0.58 to 0.73. Ninety-four percent of those in the top decile of predicted probability of success under the enhanced model achieved success, compared with 34% in its bottom decile. Analogous numbers for the original model were less discriminating: 77% compared with 57%. Only the enhanced model predicted success accurately across the spectrum of baseline scores. The findings were virtually identical when we replicated these analyses on only patients ≥65 years of age. Conclusions: Adding a baseline knee-specific PROM score to a quality measurement model in a nationally representative cohort dramatically improved its predictive power, eliminating ceiling and floor effects and mispredictions for readily identifiable patient subgroups. The enhanced model neither favors nor discourages care for those with greater knee dysfunction and requires no new data collection. Level of evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
  • Economic analysis of a new four-panel rapid screening test in antenatal care in Kenya, Rwanda, and Uganda

    Shepard, Donald S; Halasa-Rappel, Yara A; Rowlands, Katharine R; Kulchyckyj, Maria; Basaza, Robert K; Otieno, Emmanuel D; Mutatina, Boniface; Kariuki, Simon; Musange, Sabine F (2023-07-31)
    Background: We performed an economic analysis of a new technology used in antenatal care (ANC) clinics, the ANC panel. Introduced in 2019-2020 in five Rwandan districts, the ANC panel screens for four infections [hepatitis B virus (HBV), human immunodeficiency virus (HIV), malaria, and syphilis] using blood from a single fingerstick. It increases the scope and sensitivity of screening over conventional testing. Methods: We developed and applied an Excel-based economic and epidemiologic model to perform cost-effectiveness and cost-benefit analyses of this technology in Kenya, Rwanda, and Uganda. Costs include the ANC panel itself, its administration, and follow-up treatment. Effectiveness models predicted impacts on maternal and infant mortality and other outcomes. Key parameters are the baseline prevalence of each infection and the effectiveness of early treatment using observations from the Rwanda pilot, national and international literature, and expert opinion. For each parameter, we found the best estimate (with 95% confidence bound). Results: The ANC panel averted 92 (69-115) disability-adjusted life years (DALYs) per 1,000 pregnant women in ANC in Kenya, 54 (52-57) in Rwanda, and 258 (156-360) in Uganda. Net healthcare costs per woman ranged from $0.53 ($0.02-$4.21) in Kenya, $1.77 ($1.23-$5.60) in Rwanda, and negative $5.01 (-$6.45 to $0.48) in Uganda. Incremental cost-effectiveness ratios (ICERs) in dollars per DALY averted were $5.76 (-$3.50-$11.13) in Kenya, $32.62 ($17.54-$46.70) in Rwanda, and negative $19.40 (-$24.18 to -$15.42) in Uganda. Benefit-cost ratios were $17.48 ($15.90-$23.71) in Kenya, $6.20 ($5.91-$6.45) in Rwanda, and $25.36 ($16.88-$33.14) in Uganda. All results appear very favorable and cost-saving in Uganda. Conclusion: Though subject to uncertainty, even our lowest estimates were still favorable. By combining field data and literature, the ANC model could be applied to other countries.
  • Matching medical staff to long term care facilities to respond to COVID-19 outbreak

    Zarei, Hamid Reza; Ghanbarpour Mamaghani, Mahsa; Ergun, Ozlem; Yu, Patricia; Winchester, Leanne; Chen, Elizabeth (2023-06-07)
    Background: Staff shortage is a long-standing issue in long term care facilities (LTCFs) that worsened with the COVID-19 outbreak. Different states in the US have employed various tools to alleviate this issue in LTCFs. We describe the actions taken by the Commonwealth of Massachusetts to assist LTCFs in addressing the staff shortage issue and their outcomes. Therefore, the main question of this study is how to create a central mechanism to allocate severely limited medical staff to healthcare centers during emergencies. Methods: For the Commonwealth of Massachusetts, we developed a mathematical programming model to match severely limited available staff with LTCF demand requests submitted through a designed portal. To find feasible matches and prioritize facility needs, we incorporated restrictions and preferences for both sides. For staff, we considered maximum mileage they are willing to travel, available by date, and short- or long-term work preferences. For LTCFs, we considered their demand quantities for different positions and the level of urgency for their demand. As a secondary goal of this study, by using the feedback entries data received from the LTCFs on their matches, we developed statistical models to determine the most salient features that induced the LTCFs to submit feedback. Results: We used the developed portal to complete about 150 matching sessions in 14 months to match staff to LTCFs in Massachusetts. LTCFs provided feedback for 2,542 matches including 2,064 intentions to hire the matched staff during this time. Further analysis indicated that nursing homes and facilities that entered higher levels of demand to the portal were more likely to provide feedback on the matches and facilities that were prioritized in the matching process due to whole facility testing or low staffing levels were less likely to do so. On the staffing side, matches that involved more experienced staff and staff who can work afternoons, evenings, and overnight were more likely to generate feedback from the facility that they were matched to. Conclusion: Developing a central matching framework to match medical staff to LTCFs at the time of a public health emergency could be an efficient tool for responding to staffing shortages. Such central approaches that help allocate a severely limited resource efficiently during a public emergency can be developed and used for different resource types, as well as provide crucial demand and supply information in different regions and/or demographics.
  • How Back Pain Affects Patient Satisfaction After Primary Total Knee Arthroplasty

    Ayers, David C; Zheng, Hua; Yang, Wenyun; Yousef, Mohamed (2023-03-30)
    Background: Although back pain (BP) has been shown to be a predictor of dissatisfaction after total knee arthroplasty (TKA) in some reports, these studies did not use a scale to quantify the degree of pain. The purpose of this study was to quantify the effect of BP intensity on patient satisfaction reported at 1 year after TKA. Methods: A multicenter prospective cohort was taken in which 9,057 patients undergoing primary unilateral TKA were enrolled in FORCE-TJR and demographic and clinical data were collected. Back pain (BP) intensity was assessed using the Oswestry back disability index (ODI) pain intensity questionnaire. Patients were classified into 4 categories based on the severity of BP. Patient-reported outcomes (PROs) were collected preoperatively and postoperatively after 1 year including the Knee injury and Osteoarthritis Outcome Score (KOOS) (total score, pain, Activities of Daily Living (ADL), and Quality of Life (QOL), Short-Form health survey 36-item (SF-36) Physical Component Score (PCS), and Mental Component Score (MCS)). We used a validated 5-point Likert satisfaction scale. Univariate analyses of the difference between the satisfied and dissatisfied patients' groups was performed. Multivariate logistic regression models with 95% confidence interval (CI) were used to quantify the effect of BP intensity on patient dissatisfaction at 1 year. Receiver operating characteristic (ROC) analyses were performed with measurement of area under curve (AUC). Results: At 1 year, a total of 1,657 TKA patients (18.3%) were dissatisfied. A total of 4,765 patients (52.6%) reported back pain at the time of surgery, including mild BP in 2,264 patients (24.9%), moderate BP in 1,844 patients (20.3%), and severe BP in 657 patients (7.2%). Severe back pain was significantly associated with patient dissatisfaction at 1 year after TKA (P = .0006). The multivariate regressions showed that patients who had severe BP were 1.6 times more likely to be dissatisfied when compared to patients who had no BP [odds ratio (OR) 1.63; 95% confidence interval (CI) (1.23-2.16), P = .0006]. While patients who had mild BP [OR 0.98; 95% CI (0.82-1.17), P = .87] or moderate BP [OR 0.97; 95% CI (0.80-1.18), P = .78] were not associated with an increased likelihood of dissatisfaction. Other predictive variables for dissatisfaction, include age [OR for younger patients <65 years versus older patients ≥65 years, 0.74; 95% CI (0.59-0.92)], educational level [OR for post high school versus less, 0.83; 95% CI (0.71, 0.97)], smoking [OR for nonsmoker versus current smoker, 0.63; 95% CI (0.45, 0.87)], and Charlson comorbidity index [OR for CCI ≥2 versus 0, 1.25; 95% CI (1.05, 1.49)]. Conclusion: Increased BP intensity was associated with increased risk of dissatisfaction 1 year after TKA. Only patients who had severe BP were 1.6 times more likely to be dissatisfied. The data presented here can help to improve shared decision-making and patient counseling before surgery. Surgeons should consider a spine evaluation in patients who have severe BP prior to TKA.
  • Evaluating the impact of community health worker certification in Massachusetts: Design, methods, and anticipated results of the Massachusetts community health worker workforce survey

    Nielsen, Victoria M; Ursprung, W W Sanouri; Song, Glory; Hirsch, Gail; Mason, Theresa; Santarelli, Claire; Guimaraes, Erica; Marshall, Erica; Allen, Caitlin G; Lei, Pei-Pei; et al. (2023-01-12)
    Background: Professional certification of community health workers (CHWs) is a debated topic. Although intended to promote CHWs, certification may have unintended impacts given the grassroots nature of the workforce. As such, both intended effects and unintended adverse effects should be carefully evaluated. However, there is a lack of published literature describing such effective evaluations with a robust methodology. In this methods paper, we describe a key component of evaluating CHW certification in Massachusetts-the Massachusetts CHW Workforce Survey. Methods: Design of the surveys was informed by a program theory framework that delineated both positive and negative potential impacts of Massachusetts CHW certification on CHWs and CHW employers. Using this framework, we developed measures of interest and preliminary CHW and CHW employer surveys. To validate and refine the surveys, we conducted cognitive interviews with CHWs and CHW employers. We then finalized survey tools with input from state and national stakeholders, CHWs, and CHW employers. Our sample consisted of three frames based on where CHWs are most likely to be employed in Massachusetts: acute care hospitals, community-based organizations, and ambulatory care health centers, primarily community health centers and federally qualified health centers. We then undertook extensive outreach efforts to determine whether each organization employed CHWs and to obtain CHW and CHW employer contact information. Our statistical analysis of the data utilized inverse probability score weighting accounting for organizational, site, and individual response. Anticipated results: Wave one of the survey was administered in 2016 prior to launch of Massachusetts CHW certification and wave two in 2021. We report descriptive statistics of the three sample frames and response rates of each survey for each wave. Further, we describe select anticipated results related to certification, including outcomes of the program theory framework. Conclusions: The Massachusetts CHW Workforce Survey is the culmination of 5 years of effort to evaluate the impact of CHW certification in Massachusetts. Our comprehensive description of our methodology addresses an important gap in CHW research literature. The rigorous design, administration, and analysis of our surveys ensure our findings are robust, valid, and replicable, which can be leveraged by others evaluating the CHW workforce.
  • Community-Based HIV and Viral Hepatitis Fellowship Evaluation: Results from a Qualitative Study

    Bolduc, Philip; Day, Philip G; Behl-Chadha, Bittie; Karapanos, Melissa; Carson-Sasso, Vanessa; Simpson, E. Hatheway; Hebert, Scott (2022-12-01)
    Purpose: The UMass Chan Medical School/New England AIDS Education and Training Center Community-Based HIV and Viral Hepatitis Fellowship was launched in 2014 to train physicians and nurse practitioners to become experts in outpatient management of HIV, hepatitis B and C, and latent tuberculosis. The purpose of this study was to identify areas of strength and improvement and understand fellows' perceptions of the program and its impact on their current positions and career trajectories. Methods: Qualitative study utilizing a semi-structured interview guide with (11) fellowship graduates (8 MDs; 3 NPs). 45 to 60 min interviews were conducted in April and May 2021, recorded and transcribed. Transcripts were analyzed for representative themes and general patterns in the data. Results: Results indicate high satisfaction with the fellowship, which left a positive and indelible impact on their careers and patient care. Fellows highlighted the program's commitment to health equity, its role in transforming them into leaders and advocates for HIV in primary care, and their ability to balance their work and training demands with their personal lives and needs. The fellowship motivated them to become more involved in public health initiatives, serve marginalized communities and reduce their health disparities. They expressed confidence in their ability to independently manage outpatient HIV, viral hepatitis B and C, and latent tuberculosis, and found areas of overlap with their work in primary care. Conclusion: As the care of people with HIV becomes more commonplace in primary care clinics, it is imperative that primary care providers receive the necessary training and education to meet this need. Our study of 11 former fellows shows that the Community-Based HIV and Viral Hepatitis Fellowship offers such training, spreads it to other institutions, and can be a model for other programs nationwide.
  • Getting Started with the Scholarly Journal Publication Process

    Sefton, Laura A. (2022-08-25)
    Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA). Shares resources related to getting started in the publication process.
  • Pay-for-Performance in the Massachusetts Medicaid Delivery System Transformation Initiative

    Sefton, Laura; Tierney, Laxmi (2022-08-24)
    Pay-for-performance (P4P) is among the alternative payment models (APMs) that are designed to incentivize enhancements to healthcare efficiency and quality. Massachusetts' Office of Medicaid implemented a delivery system transformation initiative (DSTI) through an 1115(a) Demonstration Waiver to support and incentivize seven safety net hospitals to implement clinical care changes and transition to risk-based APMs. Comparative case study design was used to describe achievement of hospital-specific clinical and operational measures. Qualifying hospitals implemented 47 projects across three categories: (1) development of a fully integrated delivery system, (2) health outcomes and quality, and (3) ability to respond to statewide transformation to value-based purchasing and to accept alternatives to fee-for-service payments that promote system sustainability. Projects commonly focused on care transitions improvements, physical and behavioral healthcare integration, and chronic disease care management interventions. Collectively, the hospitals met all or most of 60 population-focused improvement measures and 10 common measures' targets, indicative of the progress. Some hospitals achieved substantial positive gains; however, missed targets suggest substantial organizational and workflow changes over a longer timeframe as well as consistent patient engagement may be necessary. Overall, the P4P structure of DSTI was effective in encouraging organizational change and supporting the transition of these hospitals towards APMs.
  • The Expanding Use of Continuous Glucose Monitoring in Type 2 Diabetes

    Dabbagh, Zakery; McKee, M Diane; Pirraglia, Paul A; Clements, Karen M; Liu, Feifan; Amante, Daniel J; Shukla, Prateek; Gerber, Ben S (2022-06-09)
    Over the last two decades, continuous glucose monitoring (CGM) has become a common self-monitoring strategy in type 1 diabetes (T1D). CGM, in which a minimally invasive, sensor-based device automatically measures and reports one's glucose levels up to every 5 min, improves hemoglobin A1c (HbA1c), reduces the frequency of dysglycemia, improves quality of life, and is cost-effective for people living with T1D compared to self-monitoring blood glucose (SMBG). CGM studies in type 2 diabetes (T2D) have been limited to date, especially those involving participants not requiring intensive insulin therapy.
  • Medicaid Policymaker Approaches to Prior Authorization Policies for Direct-Acting Antivirals for the Treatment of Hepatitis C Virus

    Greenwood, Bonnie C.; Pratt, Carter; Sefton, Laura; Goldman, Roberta; Gurewich, Deborah; Clements, Karen M.; Clark, Melissa (2022-06-05)
    Research Objective: In response to the high cost of direct‐acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV), many Medicaid agencies implemented prior authorization (PA) policies designed to restrict access based on advanced liver disease, prescriber specialty, and/or substance use disorder history. Although PA policies have since been loosened, we have limited insight about the association between PA policies and DAA uptake, and factors impacting Medicaid agency policy decisions. In this mixed‐methods study evaluating the uptake of DAAs in four New England Medicaid programs, the objective of this analysis is to understand how and why the external context supports and impedes DAA uptake and the specific PA policies Medicaid agencies adopt. Study Design: Qualitative, recorded videoconference interviews were conducted between November 2020 and January 2021 using a semi‐structured interview guide. Key domains of inquiry included: 1) the PA policies adopted and why; 2) the systems and structures established to support these policies; and 3) factors that facilitate and impede policy implementation. Rapid qualitative analysis techniques were used to identify content and themes within the interviews. We compared results across states defined by relative uptake of DAAs (i.e., high versus low). DAA uptake was defined in the quantitative analysis as annually between 2014 and 2017. High uptake was defined as >10% uptake annually for all four years of the study. Population Studied: Interviews were conducted with the pharmacy director and other senior administrators responsible for setting medication PA policies from Medicaid agencies in four New England states. Two to three individuals were interviewed per state (N=11). Principal Findings: One state had high DAA uptake relative to the other three states. The interviews explored eight topic areas with only one emerging as varied between the high and low uptake states: the high uptake state did not have managed care organizations (MCOs); all low‐uptake states did. All states consulted with multiple internal stakeholders such as the Medicaid agency’s pharmacy team, drug utilization review board, medical director, and/or senior agency staff. All states consulted with multiple external stakeholders such as clinicians, academic institutions, departments of health, national and professional organizations, pharmacy benefit manager or fiscal agent, and/or MCOs. Supplemental rebates were leveraged by all states. Only one state implemented a specialized PA process for the DAAs. Conclusions: Overall, there were few differences in DAA PA policies and the development process between high and low‐uptake states but there were differences with respect to presence of MCOs. This suggests that variation in DAA uptake may be less driven by PA policies than by provider‐ and possibly patient‐level factors. Implications for Policy or Practice: To understand the variation in DAA uptake in Medicaid it is necessary to explore contextual factors beyond PA policy, such as provider‐ and possibly patient‐level factors. This research suggests there may be differences in how PA policies are mediated at the provider level. Understanding the broader context for medication uptake can allow Medicaid agencies to ensure they are achieving intended utilization patterns among their membership.
  • Direct Acting Antiviral Uptake for Hepatitis C Virus among Medicaid Members with Substance Use Disorder

    Clements, Karen M.; Kunte, Parag; Person, Sharina D.; Greenwood, Bonnie C.; Gurewich, Deborah; Sefton, Laura; Pratt, Carter; Clark, Melissa (2022-06-05)
    Research Objective: Substance use disorder (SUD) is a risk factor for contracting hepatitis C virus (HCV). Direct acting antivirals (DAA), introduced in late 2013, are highly effective in treating HCV regardless of SUD status. Many state Medicaid agencies initially imposed prior authorization (PA) requirements mandating a period of abstinence or SUD treatment prior to authorizing DAAs in this population. Over time some states relaxed requirements, although as of 2021 such requirements remain in 28 states. We evaluated DAA uptake from 2014‐2017 among Medicaid members to compare uptake among members with and without SUD and to assess the effect of SUD‐related PA requirements over time for predicting treatment among members with SUD. Study Design: This retrospective cohort study used enrollment, medical, and pharmacy claims from Medicaid enrollees in 13 Medicaid plans from three New England states. We used chi‐square tests to compare DAA uptake (1+ pharmacy claims for a DAA) among members with and without an ICD‐9/10 code for SUD and to compare uptake among members with SUD in plans with no SUD‐related PA requirements, plans that lifted requirements between 2014‐2017, and plans with requirements through 2017. Generalized estimating equations with binomial distribution and log link function identified the independent role of SUD‐related PA requirements and calendar time, adjusting for demographic and clinical variables, for predicting uptake. Adjusted risk ratios (aRR) are presented. Population Studied: The population included Medicaid members ages 18‐64 years with HCV (2+ claims with ICD‐9/10 code for HCV or 1+ claim for chronic HCV) from 12/2013–12/2017. Individuals remained in the sample until treatment initiation or Medicaid disenrollment. Uptake was identified through 12/2017. Principal Findings: Overall, 21,186 members (65% of those with HCV) had a SUD diagnosis during the study period. Cumulatively, 13.4% with SUD vs 34.1% without SUD (p<0.0001) were treated for HCV. Among members with SUD, 2,561 (15.2%) members in a plan with no SUD‐related PA requirements, compared with 1,772 (11.5%) in a plan that lifted SUD‐related PA requirements during the study period and 268 (12.8%) in a plan with SUD‐related PA requirements through 2017 (p<0.0001) were treated. In multivariable analyses, members with SUD were less than half as likely to be treated in a month during which SUD‐related PA requirements were in place in their plan relative to months with no SUD‐related PA requirement (aRR = 0.42, 95% CI 0.38‐0.47). Nevertheless, over time uptake increased more steeply, 8%/month, for members during months under SUD requirements (aRR=1.08, 95% CI 1.07‐1.09), and increased 1%/month during months not under requirements (aRR = 1.01, 95%CI 1.01‐1.01). Conclusions: Medicaid members with SUD were less likely to be treated for HCV than their peers without SUD. SUD‐related PA requirements exacerbated the discrepancy in treatment, although over time DAA uptake has increased among members in plans that imposed SUD‐related requirements. Policy implications: While SUD‐related PA requirements limited DAA treatment among Medicaid members with HCV, the increase in treatment over time among members subject to these requirements suggests a clinical, cultural and/or policy shift towards facilitating HCV treatment in this population. Future research ought to explore the merits of continued SUD‐related PA requirements.
  • Do Patient Outcomes Vary by Patient Age Following Primary Total Hip Arthroplasty?

    Ayers, David C; Yousef, Mohamed; Zheng, Hua; Yang, Wenyun; Franklin, Patricia D (2022-05-31)
    Background: Multiple authors have sought to determine what patient characteristics influence outcome after total hip arthroplasty (THA). Age has shown no effect on outcome in some evaluations, while others have reported higher functional improvement in younger patients. The aim of this study was to determine if outcome after THA varies based on patient age. Methods: A prospective, multicenter cohort of 7,934 unilateral primary THA patients from the FORCE-TJR comparative effectiveness consortium was evaluated. Demographic data, comorbid conditions, and Patient-Reported Outcome Measures, including (HOOS), HOOS-12, HOOS JR, and SF-36 (PCS) and (MCS), were collected preop and at 1-year postop. Descriptive statistics were generated, stratified by age (<55 years [younger adult], 55-64 years [older adult], 65-74 years [early elder], and ≥75 years [late elder]), and differences in pain, function, and quality of life among the 4 age groups were evaluated. A multivariate regression model with 95% confidence interval (CI) was used to assess the role of patient age as a predictive factor for HOOS pain and function scores reported 1 year after primary THA. Results: Prior to surgery, younger patients (<55 years) reported worse pain, function, and quality of life than the other 3 patient groups. At 1 year after THA, younger patients (<55 years) reported slightly worse pain and quality of life but better function scores than the 3 older patients' groups. Younger patients (<55 years) achieved higher baseline to 1-year pain, and function score changes when compared to the older patients' groups. The quality of life score changes was not different among the 4 age groups. The differences in 1-year postop scores (ranging from 2.74 to 8.46) and the magnitude of score changes from baseline to 1 year (ranging from 1.9 to 5.85), although statistically significant (P < .001), did not reach the minimal clinically important difference (MCID). The multivariate regression analysis shows that age is a significant predictor for pain at 1 year but not for function. Although HOOS pain score is predicted to be higher by 4.38 points (less pain) 1 year after THA in older patients (≥75), when compared to younger patients (<55 years), again the difference is well below the MCID and is clinically insignificant. Conclusion: Although there are statistically significant differences in pain relief, functional improvement, and quality of life between younger and older patients among different patients' age groups, there is no clinically significant difference. THA provides an improvement in quality of life by decreasing pain and increasing function in all 4 age groups, with large improvements in Patient-Reported Outcome Measures scores (>2 standard deviations) without clinically significant age-related differences in THA outcome at 1 year.
  • Uptake of hepatitis C virus treatment in a multi-state Medicaid population, 2013-2017

    Clements, Karen M; Kunte, Parag S; Clark, Melissa A; Gurewich, Deborah; Greenwood, Bonnie C; Sefton, Laura; Pratt, Carter; Person, Sharina D.; Wessolossky, Miryea A (2022-05-04)
    Objective: To examine trends in the direct acting antiviral (DAA) uptake in a multi-state Medicaid population with hepatitis C virus (HCV) prior to and after ledipasvir/sofosbuvir (LDV/SOF) approval and changes in prior authorization (PA) requirements. Data sources: Analyses utilized enrollment, medical, and pharmacy claims in four states, December 2013-December 2017. Study design: An interrupted time series examined trends in uptake (1+ claim for a DAA) before and after two events: LDV/SOV approval (October 2014) and lifting of PA requirements for 40% of members (July 2016). Analyses were also performed in subgroups defined by the number and dates of change in PA requirements in members' Medicaid plans. Data collection/extraction methods: Members aged 18-64 years with an ICD code for HCV were included in the sample from diagnosis date until treatment initiation or Medicaid disenrollment. Principal findings: The annual sample size ranged from 38,302 to 45,005 with approximately 30% ages 18-34 years and 40% female. In December 2013, 0.08% was treated, rising to 0.74% in December 2017 (p < 0.001). Uptake increased from 0.34%/month in October 2014 to 0.70%/month after LDV/SOF approval, (p < 0.001), and increased relative to the pre-LDV/SOV trend through June 2016 (p = 0.04). Uptake increased to 1.18%/month after PA change, (p < 0.001) and remained flat through 2017 (p = 0.64). Cumulatively, 20.1% were treated by December 2017. In plans with few/no requirements through 2017, uptake increased to 1.19%/month after LDV/SOF approval (p < 0.001) and remained flat through 2017 (p = 0.11), with 22.2% cumulatively treated. Among plans that lifted PA requirements from three to zero in mid-2016, uptake did not increase after LDV/SOF approval (p = 0.36) but did increase to 1.41%/month (p < 0.001) after PA change, with 18.1% cumulatively treated. Conclusions: HCV Treatment increased through 2017. LDV/SOF approval and lifting PA requirements led to an increase in uptake followed by flat monthly utilization. Cumulative uptake was higher in plans with few/no PA requirements relative to those with three requirements through mid-2016.
  • Evaluating proactive outreach for prior authorization recertifications in Medicaid patients

    Vishwanath, Soumya; Tran, Stephanie N; Pomfret, Thomas C; Boss, Kaelyn C; Tesell, Mark; Price, Mylissa; Alper, Caroline J; Muchnik, Lorean; Clements, Karen M; Lenz, Kimberly (2021-11-01)
    Objectives: To assess the effectiveness of a proactive provider intervention in prompting prior authorization (PA) submissions or provider response prior to PA expiration for medically complex Medicaid patients. Study design: Pre-post outreach study with data from pharmacy claims and provider outreach. Methods: The intervention and historical comparison (control) groups included expired PAs from December 2019 to February 2020 and from December 2018 to February 2019, respectively. Provider outreach, including telephonic and fax attempts, was conducted over a 2-week period prior to PA expiration. Outcomes were classified as positive or negative based on provider conversation coupled with the result (eg, PA submission) for the intervention group and based solely on pharmacy claims for the control group. The primary end point was the percentage of positive outcomes between the groups, analyzed via χ2 test. The time from PA expiration to the new PA submission was evaluated via t test. Results: A total of 342 outreach attempts were conducted for 270 PAs representing 193 unique patients. Outreach was more likely to result in positive outcomes in the intervention group vs no outreach in the control group (87% vs 25%; P < .00001). On average, PAs were submitted 3.5 days prior to expiration in the intervention group vs 13.0 days after expiration in the control group (t = -7.50; P < .00001). Conclusions: Proactive outreach resulted in a greater percentage of PA submissions and a significantly reduced time to PA submission. These findings provide important information for payers in guiding clinical programs to enhance continuity of care among at-risk populations.
  • Perceived Barriers of Using Modern Family Planning Methods among Women in Jordan: A Qualitative Study

    Shattnawi, Khulood K; Khader, Yousef S; Al-Sheyab, Nihaya; Alyahya, Mohammad; Ready, Kelley; Halasa-Rappel, Yara A; Prince, Heath (2021-10-01)
    Background: Some cultural and social factors may discourage the use of modern family planning (MFP) methods. The purpose of this study was to better understand the barriers and social norms that might affect women's ability to take optimal advantage of the free family planning services offered by the Jordanian Ministry of Health (MOH). Methods: Using a qualitative descriptive design, 7 focus group discussions were conducted from January to February 2018, with a purposive sample of 52 married women. Each group consisted of 6-12 participants. Ethical approvals were obtained. Data were analysed using inductive thematic analysis. Results: Data analysis revealed three main themes and four subthemes. The first theme 'conforming to social and cultural norms' included the following subthemes: 'to conform to family and social pressure to bear children' and 'to prioritize having male children'. The second theme 'unmet needs in expected family planning counselling' included the following subthemes: 'need for consistency across providers in family planning counselling', and 'need for follow-up counselling'. The third theme was the 'undesirable side-effects' of the MFP methods, which included both the 'experienced' and the 'anticipated' side effects. Conclusion: This study identified a number of women's perceived barriers to using MFP methods. These included conforming to the social pressure, inconsistency of the counselling process, and undesirable side effects. Their perspectives should be carefully addressed in any family planning program.
  • Individual and Area-Level Predictors of Direct Acting Antiviral Uptake for Hepatitis C Virus in a New England Medicaid Population

    Clements, Karen M.; Kunte, Parag; Greenwood, Bonnie C.; Pratt, Carter; Sefton, Laura; Clark, Melissa; Leary, Amy; Person, Sharina D.; Gurewich, Deborah (2021-06-14)
    Research Objective: Direct acting antivirals (DAAs) offer significant improvement over previous options for hepatitis C virus (HCV) treatment. Although uptake has increased since their introduction in 2013, many with HCV remain untreated. While some individual- and area-level disparities in prescribing have been documented, including age, disease stage, substance use disorder, and rural residence, research focusing in the Medicaid population is sparse. We examined individual- and area-level predictors of DAA use in a multi-state Medicaid population. Study Design: This retrospective cohort study used enrollment, medical, and pharmacy claims from Medicaid enrollees in three New England states, linked to databases with area-level information about socioeconomic indicators and healthcare providers. Predictors of DAA uptake (1+ pharmacy claims for a DAA) were examined overall, by individual-level characteristics, including demographic (age, gender, homeless status) and clinical (disease stage, HIV, psychiatric diagnoses, substance use disorder, other comorbidity) characteristics, and area-level characteristics (rural-urban designation, education and unemployment levels in zip code, number of gastroenterologists and primary care providers (PCPs)/100,000 population in county). Generalized estimating equations with binomial distribution and log link identified independent predictors of uptake. Adjusted risk ratios (aRR) are presented. Population Studied: The population included Medicaid members ages 18-64 years with HCV (2+ claims with ICD-9/10 code for HCV diagnosis or 1+ claim for chronic HCV) from 12/2013–6/2018. Uptake was identified through 6/2018. Principal Findings: Overall, 55,207 members with HCV comprised the sample and 18.2% received a DAA. The strongest individual-level predictors of uptake included older age (aRR = 1.25, 95% CI 1.20-1.31 and 1.25, 95% CI 1.19-1.31 for ages 35-49 and 50-64 years, respectively, compared with ages 18-34 years), HIV diagnosis (aRR = 1.44, 95% CI 1.36-1.54), and advanced liver disease (aRR = 1.42, 95% CI 1.35-1.50). Individuals with alcohol use disorder (aRR = 0.74, 95% CI 0.70-0.78) and opioid use disorder (aRR = 0.78, 95% CI 0.74–0.72) were less likely to receive treatment. Female gender, other substance use disorders, some psychiatric diagnoses, tobacco use, and documented homelessness were also associated with lower uptake. The strongest area-level predictor of uptake was living in a county with few gastroenterologists (aRR = 1.31, 95% CI 1.11-1.53 for 0-1 gastroenterologists /100,000 vs. 6-20/100,000 population). Uptake was also higher among members living in a zip code with the lowest area-level education attainment and lower in counties both with the lowest and highest number of PCPs/1000 population relative to counties with an average density of PCPs. Conclusions: Among the high percentage of Medicaid members with HCV who remain untreated, women, younger adults, individuals at early disease stage, homeless, and with substance use disorders appear at higher risk of not being treated. Medicaid members living in areas with higher socioeconomic indicators and highest density of specialists and PCPs are also at higher risk. Implications for Policy or Practice: These findings identify groups in the Medicaid population that may benefit from targeted interventions designed to increase HCV treatment. The unexpected finding of lower uptake among individuals living in geographical areas with higher socioeconomic indicators and high density of healthcare providers merits further exploration into healthcare access of Medicaid members living in these areas.
  • Barriers and Facilitators to Implementation of Value-Based Care Models in New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol

    Goff, Sarah L.; Gurewich, Deborah; Alcusky, Matthew J; Kachoria, Aparna; Nicholson, Joanne; Himmelstein, Jay (2021-04-06)
    Introduction: Massachusetts established 17 new Medicaid accountable care organizations (ACOs) and 24 affiliated Community Partners (CPs) in 2018 as part of a large-scale healthcare reform effort to improve care value. The new ACOs will receive $1.8 billion dollars in state and federal funding over 5 years through the Delivery System Reform Incentive Program (DSRIP). The multi-faceted study described in this protocol aims to address gaps in knowledge about Medicaid ACOs' impact on healthcare value by identifying barriers and facilitators to implementation and sustainment of the DSRIP-funded programs. Methods and analysis: The study's four components are: (1) Document Review to characterize the ACOs and CPs; (2) Semi-structured Key Informant Interviews (KII) with ACO and CP leadership, state-level Medicaid administrators, and patients; (3) Site visits with selected ACOs and CPs; and (4) Surveys of ACO clinical teams and CP staff. The Consolidated Framework for Implementation Research's (CFIR) serves as the study's conceptual framework; its versatile menu of constructs, arranged across five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Processes) guides identification of barriers and facilitators across multiple organizational contexts. For example, KII interview guides focus on understanding how Inner and Outer Setting factors may impact implementation. Document Review analysis includes extraction and synthesis of ACO-specific DSRIP-funded programs (i.e., Intervention Characteristics); KIIs and site visit data will be qualitatively analyzed using thematic analytic techniques; surveys will be analyzed using descriptive statistics (e.g., counts, frequencies, means, and standard deviations). Discussion: Understanding barriers and facilitators to implementing and sustaining Medicaid ACOs with varied organizational structures will provide critical context for understanding the overall impact of the Medicaid ACO experiment in Massachusetts. It will also provide important insights for other states considering the ACO model for their Medicaid programs. Ethics and dissemination: IRB determinations were that the overall study did not constitute human subjects research and that each phase of primary data collection should be submitted for IRB review and approval. Study results will be disseminated through traditional channels such as peer reviewed journals, through publicly available reports on the mass.gov website; and directly to key stakeholders in ACO and CP leadership.
  • Comment on: COVID-19 in Nursing Homes: Calming the Perfect Storm

    Zorowitz, Robert A.; Bergman, Christian; Haimowitz, Daniel; Kalender-Rich, Jessica L.; Polakoff, David F.; Steinberg, Karl; Wright, James L. (2021-02-01)
    To the Editor: Ouslander's and Grabowski's recent article which included recommendations for “Calming the Perfect Storm” of COVID‐19 in nursing facilities was timely and thorough.Although excellent in scope, in our opinion it did not address one critical area, namely, the vital role of clinical leadership to navigate this crisis. We assert that this role belongs to the nursing home medical director in an often overlooked and yet critically important partnership with the administrator, director of nursing and infection preventionist.
  • Improving Performance with Flowcharts

    Aboagye, Ruth (2020-08-26)
    Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness.
  • Opioid Overdoses Among High-Risk Medicaid Members: Healthcare Cost, Service Utilization, and Risk Factor Analysis

    Savageau, Judith A.; Brindisi, Melissa; Miller, Faye; Sefton, Laura A.; Stoler, Adam; Harvey, Margaret; Bernson, Dana (2020-07-28)
    Research Objective: Identify risk factors associated with opioid overdoses among three high-risk populations of Medicaid members related to cost and service utilization. Study Design: Repeated cross-sectional study using five years of Massachusetts Medicaid (MassHealth) claims and state agency data. Population Studied: MassHealth members aged 11-64 years considered to be high-risk (homeless, unstably housed, and/or criminal justice-involved) and in need of support services, especially those with extensive behavioral health (BH) needs. These three populations were identified as being particularly vulnerable to non-fatal and/or fatal opioid overdoses. Principal Findings: MassHealth members who were both justice-involved and unstably housed were at much higher risk of an opioid overdose than the MassHealth population overall, especially those with a substance use disorder (SUD) or a serious mental illness (SMI). Experiencing both homelessness and justice involvement substantially compounded members’ non-fatal overdose risk, regardless of BH diagnosis. Co-occurring SUD/SMI was a key driver of high overdose prevalence, particularly among the justice-involved. Compared to MassHealth members in general, those with justice involvement and unstable housing had costs that were 50-65% higher; members who experienced homelessness had triple the costs. Healthcare service use both before and after an overdose was relatively low, including the timeframe between multiple non-fatal overdoses. In multivariate analyses, all three high-risk factors (i.e., populations) were significantly related to an increased opioid overdose risk after controlling for additional risk factors (BH diagnoses, chronic medical conditions, and demographic characteristics). Males and whites were more likely to have an opioid overdose; those with diabetes or hypertension were less likely. These results were similar when assessing various opioid overdose outcomes (non-fatal and/or fatal). Conclusions: These findings helped inform MassHealth’s understanding of its members’ experiences regarding medical and BH services, especially among high-risk populations with an opioid overdose. The identification of risk factors most predictive of a subsequent overdose may help address the needs of these high-risk groups. For most of the populations studied, prevalence of co-occurring BH diagnoses was much higher than MassHealth members in general and appeared to impact opioid overdose rates. Most members received services for 1-2 months in both the pre- and post-overdose periods; service use was relatively low in the year following a non-fatal overdose, suggesting retention was also low. Multivariate analyses consistently showed that gender and race were significantly associated with increased overdose risk. Implications for Policy or Practice: Understanding opioid overdose risk factors and identifying service utilization gaps and missed opportunities are important. As payment reforms evolve under the umbrella of accountable care organizations, BH community partnership models are key for collaborating with healthcare and social service providers, and community resources for care management, care coordination, and referrals to support services. Our study initially developed an in-depth descriptive analysis of individuals with SUD, SMI, or both identified as being at high risk for an opioid overdose. Understanding service trajectory and outcomes through additional analyses was critical for planning and prioritizing appropriate services. As payors are actively making decisions about effective systems of care, they are particularly interested in understanding the need for community-based and residential services, particularly for those with housing instability and/or criminal justice involvement.

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