Journal of urban health : bulletin of the New York Academy of Medicine
-
Immediately after the approval of direct-acting antiviral medications for the treatment of hepatitis C virus (HCV) in 2013, state Medicaid programs limited access to these expensive treatments based on liver disease stage, absence of active alcohol or substance use, and prescriber limitations. New York State fee-for-service (FFS) Medicaid eliminated these requirements in May 2016, but the effect on providers and patients obtaining prior authorization (PA) from Medicaid managed care organizations (MCOs) was unknown. We used a mixed methods approach to assess whether the removal of HCV treatment restrictions was associated with changes in Medicaid MCOs' PA approval processes and length of time to treatment initiation at two large urban New York City provider organizations participating in Project INSPIRE, an HCV care coordination demonstration project. ⋯ Univariate analysis of the Project INSPIRE participant data suggests a decrease in the percentage of participants with insurance/PA-related treatment delays pre- versus post-policy change (23% versus 15%, p value = 0.02). Interrupted time series analysis found a 2 percentage point decrease (p value = 0.02) in the proportion of PAs each month with insurance-related treatment delays that was attributable to policy change. These results from two urban clinics indicate New York State FFS Medicaid's policy change for HCV treatment may have been associated with some changes in Medicaid MCO PA decisions, but MCO PA denials and treatment delays were still observed "on the ground" by clinic staff.
-
Pragmatic Clinical Trial
The Effect of a Housing First Intervention on Acute Health Care Utilization among Homeless Adults with Mental Illness: Long-term Outcomes of the At Home/Chez-Soi Randomized Pragmatic Trial.
We assessed the effects of the Toronto Site Housing First (HF) intervention on hospitalizations and emergency department (ED) visits among homeless adults with mental illness over 7 years of follow-up. The Toronto Site is part of an unblinded multi-site randomized pragmatic trial of HF for homeless adults with mental illness in Canada, which followed participants up to 7 years. Five hundred seventy-five participants were recruited and classified as having high (HN) or moderate need (MN) for mental health support services. ⋯ HF with ICM resulted in an increase in the number of hospitalizations (RRR = 1.69, 95% CI 1.09-2.60) and ED visit rates (RRR = 1.42, 95% CI 1.01-2.01) but had no effect in days in hospital for MN participants. Addressing the health needs of this population and reducing acute care utilization remain system priorities. Trial registration: http://www.isrctn.com/identifier: ISRCTN42520374.
-
To provide data that can guide community-targeted practices, policies, and interventions in urban metropolitan areas, we used geospatial analysis to examine the community-level opioid overdose death determinants and their spatial variation across a study area. We obtained spatial datasets containing multiple, high-quality measures of socioeconomic conditions, public health status, and demographics for analysis and visualization in geographic information systems. We employed a multiscale modeling approach (multiscale geographically weighted regression; MGWR) to provide a comprehensive and robust analysis of opioid overdose death determinants, explain how geospatial patterns vary across scales across Milwaukee County in 2019, and examine the differential influence of factors locally, regionally, and globally. ⋯ The observed geographic variation in relationships included the impact of naloxone availability and incarceration rates on overdose deaths with pronounced differences between White communities and communities of color. Understanding, community-level factors that contribute to overdose risk should guide targeted community-level solutions. Overall, our findings demonstrate the value of precision epidemiology using MGWR analysis for defining and guiding responses to public health challenges.
-
Noncommunicable diseases (NCDs) represent a significant global public health burden. As more countries experience both epidemiologic transition and increasing urbanization, it is clear that we need approaches to mitigate the growing burden of NCDs. Large and growing urban environments play an important role in shaping risk factors that influence NCDs, pointing to the ineluctable need to engage sectors beyond the health sector in these settings if we are to improve health. ⋯ BRT system policies have the opportunity to improve lifestyle choices for NCDs through a focus on safe, affordable, and effective forms of transportation. There are opportunities to improve decision-making for health by involving more available data for health, building on existing infrastructures, building stronger political leadership and commitments, and establishing formal frameworks to improve multisectoral collaborations within megacities. Future research will benefit from addressing the political and bureaucratic processes of using health data when designing public transportation services, the political and social obstacles involved, and the cross-national lessons that can be learned from other megacities.
-
We sought to find a method that improves HIV estimates obtained through time-location sampling (TLS) used to recruit most-at-risk populations (MARPs). The calibration on residuals (CARES) method attributes weights to TLS sampled individuals depending on the percentile to which their logistic regression residues belong. ⋯ From each pseudo-population, 1000 TLS samples were drawn, and the HIV prevalence estimated by the TLS method and by the CARES method were recorded and compared with the HIV prevalence of the 9591 men. Results showed that the CARES method improves estimates given by the TLS method by getting closer to the real HIV prevalence.