Browsing by Author "Stockbridge, Erica L."
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Item A Bigger View: US public TB prevention initiatives with a broader health systems perspective(2019-03-05) Miller, Thaddeus; Grebennikov, Sarah; Stockbridge, Erica L.; Hussain, AnushaBackground: Tuberculosis (TB) is a complex disease and persists as a greater threat than most understand. Responsibility for TB treatment and control has generally fallen to public health agencies. Unfortunately, important limitations to the public health sector’s of TB control are beginning to show. UNTHSC recently hosted a “systems thinking symposium” with the goal of helping public health authorities view their work in broader context. This project presents an analysis of industry perspectives on public TB control initiatives drawn from symposium discussions. Purpose: We analyzed 36 hours of discussions to better understand how CDC’s messaging around TB prevention and managing latent TB infection (LTBI) in particular is heard, accepted, and potentially acted on in various health care sectors. Methods: Approximately 30 participants from across the US healthcare system discussed how incentives and disincentives within their industry might affect TB-related public health initiatives. Discussion sessions focused on how at-risk patients self-identify and seek care; how providers identify potentially at-risk patients; how clinical evaluation is initiated and conducted; treatment initiation; and treatment completion. We analyzed discussion transcripts to identify industry perspectives, opportunities and barriers, and potential gaps in TB control initiatives. The unit of study was the program or industry represented by responses, not individual respondents, and the North Texas Regional IRB determined the project not to be human subjects research. Results: We identified the 15 most commonly used context appropriate words from a 78,604 word transcript. These were mapped to broad themes such as improving screening target populations, continuity of care, and potential roles of the non-public health sector. Notable barriers were identified within the clinical and managed care sectors, including consistent questioning of TB prevention as a priority activity, including potential risks, benefits, and the value proposition. Conclusions: CDC’s promotion of targeted LTBI screening and treatment, and TB prevention in general, is not well reflected in the attitudes of the non-public healthcare sector in our sample. Most health care professionals would choose not to prioritize LTBI due to the logistics of insurance and more urgent and emergent diseases. It may be important for CDC to consider who and how they target TB elimination messaging in order to enhance impact.Item A cross-sectional study of latent tuberculosis infection, insurance coverage, and usual sources of health care among non-US-born persons in the United States(Wolters Kluwer Health, Inc., 2021-02-19) Annan, Esther; Stockbridge, Erica L.; Katz, Dolly; Mun, Eun-Young; Miller, Thaddeus L.ABSTRACT: More than 70% of tuberculosis (TB) cases diagnosed in the United States (US) occur in non-US-born persons, and this population has experienced less than half the recent incidence rate declines of US-born persons (1.5% vs 4.2%, respectively). The great majority of TB cases in non-US-born persons are attributable to reactivation of latent tuberculosis infection (LTBI). Strategies to expand LTBI-focused TB prevention may depend on LTBI positive non-US-born persons' access to, and ability to pay for, health care.To examine patterns of health insurance coverage and usual sources of health care among non-US-born persons with LTBI, and to estimate LTBI prevalence by insurance status and usual sources of health care.Self-reported health insurance and usual sources of care for non-US-born persons were analyzed in combination with markers for LTBI using 2011-2012 National Health and Nutrition Examination Survey (NHANES) data for 1793 sampled persons. A positive result on an interferon gamma release assay (IGRA), a blood test which measures immunological reactivity to Mycobacterium tuberculosis infection, was used as a proxy for LTBI. We calculated demographic category percentages by IGRA status, IGRA percentages by demographic category, and 95% confidence intervals for each percentage.Overall, 15.9% [95% confidence interval (CI) = 13.5, 18.7] of non-US-born persons were IGRA-positive. Of IGRA-positive non-US-born persons, 63.0% (95% CI = 55.4, 69.9) had insurance and 74.1% (95% CI = 69.2, 78.5) had a usual source of care. IGRA positivity was highest in persons with Medicare (29.1%; 95% CI: 20.9, 38.9).Our results suggest that targeted LTBI testing and treatment within the US private healthcare sector could reach a large majority of non-US-born individuals with LTBI. With non-US-born Medicare beneficiaries' high prevalence of LTBI and the high proportion of LTBI-positive non-US-born persons with private insurance, future TB prevention initiatives focused on these payer types are warranted.Item A Market-based Approach to Improving Passive Surveillance of Tuberculosis in Tarrant County(2018-03-14) Stockbridge, Erica L.; Miller, Thaddeus; Moreno, ArmandoPurpose: To explore a new method of public health action to further domestic tuberculosis (TB) elimination efforts through cooperation with private healthcare partners in the Tarrant County, Texas public health catchment. U.S. efforts towards TB elimination have recently stalled. Research has shown that these efforts should be expanded to include latent TB infection (LTBI). However, limited resources, a vague mandate, and more make it difficult for public health to maintain consistent surveillance and treatment of LTBI. Therefore, a market-based approach is an attractive method for addressing this new focus. Understanding facilitators and barriers is paramount to developing such an approach. Experience from this limited context, a largely urban population of just over 2 million, will inform if and how a market-based approach can contribute to national TB control efforts. Methods: Interviews and focus group discussions with key individuals from the Tarrant County public health catchment were held beginning 5/19/2017 to explore (1) supporting research, (2) community partners serving at-risk populations, (3) facilitators and (4) barriers. Results: (1) Supportive evidence from epidemiology, economics, public health, private healthcare, etc. potential gross for local providers exceeding $7 million estimated 14.5% of Tarrant’s 2015 population are high risk (2) In Tarrant County, there is one federally qualified healthcare center organization that serves a significant portion of high risk individuals. (3) Facilitators include partner healthcare organizations, CDC support, provider advocates, etc. (4) Barriers include costs (real and perceived), changes to clinical and documentation practices, coding/billing, etc. Conclusions: There is a wealth of evidence to support the feasibility of such a project. Identification of the appropriate at-risk population(s) and their respective healthcare providers highlights community partners likely to be interested in such a project. Through the collection of appropriate resources, use of identified facilitators, and addressing of respective barriers, the project could be implemented at little to no direct cost to the private healthcare organization. Furthermore, the combination of these could yield an effective program that is financially lucrative, thereby meeting the goals of both public health and private healthcare.Item Changes in Healthcare Utilization and Charges Among Supportive Housing Residents Enrolled in a Health Coaching Program(2019-05) Chhetri, Shlesma; Spence-Almaguer, Emily; Walters, Scott T.; Stockbridge, Erica L.; Aryal, SubhashThe effectiveness of self-management programs on healthcare use outcomes is an active area of research with inconsistent results. This study was the first to evaluate changes in healthcare utilization (including hospital encounters, inpatient visits, outpatient visits, and emergency visits) and charged amounts among supportive housing residents enrolled in a health coaching program. We utilized retrospective longitudinal medical claims data and a qualitative examination of participants' perceptions of the program's influence on their healthcare use. Zero-inflated negative binomial model and log-gamma models were used to assess change in count variables and charged amounts respectively. Although participants reported a positive impact of the program on their overall quality of life through improved health self-management strategies, the analysis of claims data showed no significant change in healthcare use and charged amounts in all analyses spanning 12 months prior to 24 months post enrollment. These findings may potentially demonstrate the success of health coaching programs in stabilizing healthcare utilization among individuals who otherwise might have increased their healthcare use over time. During interviews and focus groups, participants also shared personal and systems level challenges that influenced their healthcare use. The inclusion of a control group in future analyses would help measure the actual impact of health coaching on healthcare utilization measures among supportive housing residents with high health needs.Item Dental visits in Medicaid-enrolled youth with mental illness: an analysis of administrative claims data(BioMed Central Ltd., 2020-12-11) Stockbridge, Erica L.; Dhakal, Eleena; Griner, Stacey B.; Loethen, Abiah D.; West, Joseph F.; Vera, Joseph W.; Nandy, KarabiBACKGROUND: State Medicaid plans across the United States provide dental insurance coverage to millions of young persons with mental illness (MI), including those with attention deficit hyperactivity disorder (ADHD), depression, anxiety, bipolar disorder, and schizophrenia. There are significant oral health challenges associated with MI, and providing dental care to persons with MI while they are young provides a foundation for future oral health. However, little is known about the factors associated with the receipt of dental care in young Medicaid enrollees with MI. We aimed to identify mental and physical health and sociodemographic characteristics associated with dental visits among this population. METHODS: We retrospectively analyzed administrative claims data from a Medicaid specialty health plan (September 2014 to December 2015). All enrollees in the plan had MI and were >/= 7 years of age; data for enrollees aged 7 to 20 years were analyzed. We used two-level, mixed effects regression models to explore the relationships between enrollee characteristics and dental visits during 2015. RESULTS: Of 6564 Medicaid-enrolled youth with MI, 29.0% (95% CI, 27.9, 30.1%) had one or more visits with a dentist or dental hygienist. Within youth with MI, neither anxiety (Adjusted odds ratio [AOR] = 1.15, p = 0.111), post-traumatic stress disorder (AOR = 1.31, p = 0.075), depression (AOR = 1.02, p = 0.831), bipolar disorder (AOR = 0.97, p = 0.759), nor schizophrenia (AOR = 0.83, p = 0.199) was associated with dental visits in adjusted analyses, although having ADHD was significantly associated with higher odds of dental visits relative to not having this condition (AOR = 1.34, p < 0.001). Age, sex, race/ethnicity, language, and education were also significantly associated with visits (p < 0.05 for all). CONCLUSIONS: Dental utilization as measured by annual dental visits was lower in Medicaid-enrolled youth with MI relative to the general population of Medicaid-enrolled youth. However, utilization varied within the population of Medicaid-enrolled youth with MI, and we identified a number of characteristics significantly associated with the receipt of dental services. By identifying these variations in dental service use this study facilitates the development of targeted strategies to increase the use of dental care in - and consequently improve the current and long-term wellbeing of - the vulnerable population of Medicaid-enrolled youth with MI.Item Developing Tuberculosis Prevention Strategies via Interdisciplinary Systems-Thinking: Latent Tuberculosis Infection Risk Recognition and Care(2019-03-11) Chhetri, Shlesma; Dhakal, Eleena; Stockbridge, Erica L.; Miller, Thaddeus; Jose, RoslinBackground: Tuberculosis (TB) remains a threat to public health, both globally and within the US. An estimated 80% of active TB cases in the US are from reactivation of latent TB infection (LTBI). Reactivation is preventable with proactive, targeted LTBI screening and treatment but public health agencies lack the capacity to mitigate this threat. Recent guidelines recommend that LTBI-related services be rendered by private sector healthcare providers. In order to identify systemic barriers to appropriate LTBI-related care in the private sector and brainstorm new strategies to facilitate this care, UNTHSC hosted an LTBI Systems Thinking Symposium. Aims: 1) To identify barriers and facilitating factors that influence patient and provider recognition of LTBI risk and subsequent care-seeking or care-recommending behavior, as articulated by symposium participants. 2) To determine whether the factors identified by attendees varied by attendee profession. Methods: Thirty healthcare and public health professionals were divided into 6 interdisciplinary groups. Participants identified barriers to care and opportunities to facilitate care by discussing each step in the LTBI care continuum. We used Grounded Theory approach to code participants’ distinct ideas. Each open code was systematically categorized into axial codes by two independent coders. A third coder calculated inter-coder reliability; the two coders agreed 80% of the time. Coders collaborated on the remaining 20% to create a final list of axial codes, which were further categorized into selective themes. Results: Barriers (78%) to targeted LTBI screening and treatment were mentioned more frequently than strategies to facilitate care (22%). The top three barriers were lack of awareness among patients, lack of ideal testing tools, and lack of health insurance among high-risk persons. Facilitators included increasing patient awareness, health insurance that covers LTBI services, community outreach, and population-level health communication. Variations in perceived barriers and facilitating factors based on the industries our participants represented were observed. Conclusion: Both patient and health systems-related factors present barriers to the initial identification of LTBI in the private sector healthcare setting, but there are opportunities to overcome these barriers. The facilitating factors identified by symposium participants can serve as beacons for prevention strategies and future health policies.Item Latent Tuberculosis Infection Testing and Treatment in the Private Sector: Evidence from Commercial Health Insurance Claims(2017-05) Stockbridge, Erica L.; Miller, Thaddeus L.; Carlson, Erin K.; Ho, ChristineTargeted identification and treatment of people with latent tuberculosis infection (LTBI) are key components of the US tuberculosis (TB) elimination strategy. Little research on LTBI testing and treatment has been conducted outside of public healthcare settings, so there is a dearth of information about the provision of LTBI-related services in the private sector environment. This gap was highlighted by recent health insurance-related regulatory changes that are expected to increase LTBI testing and treatment by private providers. Our research aimed to provide insight on the LTBI-related services provided to commercially insured individuals in the private sector setting. We analyzed a national sample of commercial insurance medical and pharmacy claims data from the Optum National Research Database for 4 million people ages 0 to 64; these data represented insurance-paid healthcare services received between January 2011 and December 2013 at minimum. We estimated private sector LTBI testing rates and examined patient characteristics associated with private sector LTBI testing. We also developed a claims-based method to identify LTBI treatment in the private sector and subsequently used this method to estimate treatment completion rates and identify clinical and system factors associated with treatment completion. We found that LTBI testing was not uncommon in the private sector and it is generally targeted to patients at the highest risk of TB/LTBI. Further, our claims-based method to identify and evaluate LTBI treatment successfully identified such treatment occurring in the private sector. Private sector LTBI treatment completion rates were in the range of those found in public health settings. Additionally, we identified factors unique to the private healthcare system that are associated with LTBI treatment completion. Our results suggest that the commercial sector may be a valuable adjunct to more traditional venues for TB prevention. Moreover, medical and pharmacy claims data and the claims-based methods we developed offer a means to gain important insights and open new avenues to monitor, evaluate, and coordinate TB prevention.Item Opportunities for Tuberculosis Prevention in Private Sector Healthcare: Health Insurance and Usual Sources of Healthcare in Foreign-Born Persons with Latent Tuberculosis Infection(2019-03-05) Stockbridge, Erica L.; Miller, Thaddeus; Mun, Eun-Young; Annan, EstherOpportunities for Tuberculosis Prevention in Private Sector Healthcare: Health Insurance and Usual Sources of Healthcare in Foreign-Born Persons with Latent Tuberculosis Infection E. Annan 1, E. L. Stockbridge 2, T. L. Miller 2, E.Y. Mun2 1Department of Biostatistics & Epidemiology, University of North Texas Health Science Center, Fort Worth, TX, United States. 2 Department of Health Behavior & Health Systems, University of North Texas Health Science Center, Fort Worth, TX, United States. Abstract Background: Preventing TB in the foreign-born US population is a priority, as over two-thirds of active TB cases in the US occur among foreign-born persons. With 90% of incident active TB cases among foreign-born persons stemming from reactivation of latent TB infections (LTBI), there is a need to increase targeted LTBI testing and treatment in foreign-born persons. It may be feasible to conduct these activities within the US private healthcare sector, but LTBI-positive foreign-born persons' use of healthcare and ability to pay for care will facilitate or impede such a strategy. These characteristics are not well-described in current literature. Aims: (1) Estimate LTBI prevalence among foreign-born individuals by health insurance status and usual source of healthcare (USHC); and (2) examine patterns of insurance coverage and USHC among foreign-born persons with LTBI. Methods: We analyzed 2011-12 National Health and Nutrition Examination Survey (NHANES) self-reported health insurance and USHC data for foreign-born individuals in combination with markers for LTBI. The sample was restricted to civilian, noninstitutionalized, foreign-born persons ages 6 years or older with interferon gamma release assay (IGRA) results and self-reported insurance and USHC data (N=1,793). We used Stata /SE 15.1 to conduct analyses and adjust for complex sampling design. Results: Overall, 15.9% of our sample were LTBI-positive. Of LTBI-positive persons, 37.0% had some form of insurance and 76.9% had a USHC. LTBI prevalence was highest in persons who used a clinic or health center as a USHC (17.3%), but 44.6% of persons with LTBI use a physician’s office or HMO as a USHC. Insured persons had a slightly higher prevalence of LTBI than uninsured persons (16.2% and 15.3%, respectively). While LTBI prevalence was highest in persons with Medicare, persons with LTBI were most likely to be uninsured (37.0%) or have private insurance (33.1%). In total, 56.7% of persons with LTBI had both health insurance and a USHC, while 20.2% had neither insurance nor a USHC. Conclusion: Both health insurance and USHC were common within foreign-born individuals with LTBI residing in the US. Although different strategies are needed to address LTBI within the vulnerable population of foreign-born persons without health insurance or USHC, our results suggest that targeted LTBI testing and treatment within the US private healthcare sector could reach the majority of foreign-born individuals with LTBI.Item Public policy, private practice: Tuberculosis/latent tuberculosis infection (TB/LTBI) surveillance in the commercial healthcare sector(2016-03-23) Carlson, Erin; Miller, Thaddeus; Stockbridge, Erica L.Objective: To estimate the prevalence and explore the pattern of TB/LTBI testing and retesting in the commercially insured US population. Domestic TB elimination is a cornerstone of US public health policy, yet progress toward elimination has slowed. One reason for this is the lack of emphasis on identifying and addressing LTBI. Systematic efforts to find and treat persons with active TB or persons with LTBI have defaulted to local and regional public health departments but, given limited resources and murky mandates, LTBI surveillance and treatment by public health is inconsistent. At the same time, TB/LTBI testing is not uncommon in the private sector. Unleveraged synergies exist between the testing conducted by private healthcare providers and the surveillance conducted by public health departments. Understanding the patterns of TB/LTBI screenings conducted in the private sector is a crucial first step toward realizing this potential. Methods: De-identified paid medical claims for services rendered between 4/1/2010 and 3/31/2013 for a sample of 4 million people from the Optum Research Database were analyzed. People in the sample were ages/1/2010 and 3/31/2013. TB/LTBI testing via tuberculin skin testing (TST) and interferon gamma release assay (IGRA) was identified using CPT codes. The index TB/LTBI test per person was identified based on each individual’s first TST or IGRA with a service date between 6/2010 and 5/2011. Subsequent tests were identified based on service dates following the index test through 3/2013. Results: Of the 4 million people, 67,168 (1.68%) had an index TB/LTBI test between 6/2010 and 5/2011. TSTs were more common than IGRAs; 64,788 (96.5%) of index tests were TSTs and 2,355 (3.5%) were IGRAs. Of those with an index TST, 21,645 (33.4%) had another test on a later date. Retesting methods differed depending on how quickly retesting occurred. In patients with a retest within 30 days, 6.4% received an IGRA next instead of another TST, while 2.6% of patients who had a retest in [greater than] 30 days received an IGRA. Conclusion: Much TB/LTBI testing is conducted by providers outside of the US public health system. Data collected by commercial insurers can provide insight into TB/LTBI testing in this setting. These results indicate that TSTs are far more prevalent than IGRAs, but IGRAs are being used in practice for post-TST retesting when retesting is conducted shortly after initial testing.Item Using Big Data to Examine Healthcare Quality and Outcomes: Claims Data Illuminate Association Between Behavioral Health and Preventable Hospitalization in Diabetic Patients(2017-03-14) Polcar, Leah; Miller, Thaddeus; Stockbridge, Erica L.Objective: High quality outpatient care for individuals with diabetes reduces the likelihood of acute diabetes-related complications and associated potentially preventable hospitalization (PPH). Comorbid behavioral health (BH) conditions can be a barrier to high quality outpatient diabetes care and may contribute to PPHs, but the association between BH comorbidities and PPHs has not been well-studied. We sought to determine if comorbid BH conditions are associated with an increased likelihood of diabetes-related PPHs. Study Design: We used a multivariable negative binomial-logit hurdle regression model to determine whether BH conditions were associated with diabetes-related PPHs as defined by the Agency for Healthcare Research and Quality. Covariates included sociodemographic and other comorbid medical condition variables. Materials: A national sample of medical and pharmacy claims data from the Optum Impact Research Database representing commercial insurer-covered healthcare received between 2011 and 2013 for 4,000,000 people. A total of 229,039 individuals met inclusion criteria (diagnosed/treated diabetes, aged 20-64, and complete data) and were included in analysis. Results: Claims effectively identified increased risk for PPH among diabetic patients with BH comorbidities. 20.7% had ≥1 BH condition and the risk for multiple PPHs increased as individuals’ counts of BH conditions increased. Schizophrenia, mood disorders, alcohol use disorders, and substance use disorders were each independently associated with increased risk of ≥1 PPH and an increasing number of PPHs. Conclusions: People with diabetes and comorbid BH conditions have a higher likelihood of and volume of PPHs. The results suggest that enhanced treatment approaches or improved care quality may be useful to improve health and other outcomes for this population. Claims data provide an accessible and effective approach to evaluation. Implications: Targeted interventions including case management, home health services, pharmacy management, or other structural enhancements may reduce hospitalizations in persons with comorbid diabetes and BH conditions. Given the significant proportion of diabetic patients with ≥1 diagnosed BH comorbidity, integrating diabetes care into BH treatment may drive improved health outcomes and cost savings. Evaluations of quality improvement activities focused on this population should consider using PPHs as outcome measures and claims as a data source.