Justin Blackburn

Background: Clinical decision support (CDS) systems may improve chronic pain management by providing guideline-based recommendations within clinical workflows. However, low clinician use can limit their effectiveness. Understanding the association between CDS use and guideline-recommended care may help distinguish implementation challenges from limitations in CDS functionality. Objective: To estimate the association of OneSheet, a CDS system for chronic pain management, and guideline-recommended care when the system was used during patient encounters. Methods: We conducted a per-protocol secondary data analysis of data from a pragmatic randomized clinical trial conducted from October 2020 to May 2022 across 25 primary care clinics at 2 academic health systems in Indiana and North Carolina. The parent trial enrolled 137 primary care clinicians. This analysis included 145511 eligible chronic pain encounters and 15480 long term opioid therapy (LTOT) encounters that occurred after OneSheet implementation. OneSheet use at a patient encounter was the exposure of interest. Propensity score matching was used to create comparable groups of encounters with and without OneSheet use. Outcomes included documentation of pain-related goals, documentation of pain and function using the Pain, Enjoyment of Life and General Activity (PEG) scale, prescription drug monitoring (PDMP) review, urine drug screening (UDS) orders, and naloxone orders. Results: OneSheet was used in 959 of 145511 chronic pain encounters (0.7%) and 582 of 15480 LTOT encounters (4.0%). In matched analyses, OneSheet use was associated with increased documentation of pain-related goals (relative risk (RR)=11.70 (95% CI 4.25-32.50) and PEG score documentation (RR=9.70 (95% CI 4.14-22.31). Among LTOT encounters, OneSheet use was associated with increased UDS ordering (RR=1.52 (95% CI 1.40-1.65) and PDMP review (RR=1.06 (95% CI 1.03-1.09), but decreased naloxone ordering (RR=0.13 (95% CI, 0.02-0.90). Conclusions: OneSheet use was associated with several guideline-recommended chronic pain management actions, suggesting that they system may support care quality when clinicians use it. However, use was rare, indicating that increasing routine use through better workflow integration may be necessary to achieve population-level improvements in chronic pain care.

Objective: To determine whether personal responsibility incentives in Medicaid differentially affect enrollment and the comprehensiveness of plan benefits among members who are non‐Hispanic Black and non‐Hispanic White. Study Setting and Design: We conducted an interrupted time series analysis to estimate trends in racial disparity ratios of enrollment across more comprehensive Healthy Indiana Plans (HIP) before and during the COVID‐19 Public Health Emergency (PHE) when the state suspended personal responsibility incentives, including monthly premium contributions. Data Sources and Analytic Sample: We analyzed restricted‐access administrative data from the Indiana Family and Social Services Administration from 2018 through 2023. The analytic cohort comprised 939,667 non‐Hispanic Black and non‐Hispanic White adults (19–64 years) enrolled in one of four HIP tiers, including HIP Plus or HIP Basic, and HIP State Plan Plus or HIP State Plan Basic in which presence of a qualifying health condition is required for eligibility. Principal Findings: Before the PHE, members who are non‐Hispanic Black were approximately 23 percentage points less likely to be in the more comprehensive HIP Plus plan relative to members who are non‐Hispanic White. An increase in the disparity ratio of 0.076 points toward parity (95% CI, 0.054–0.097 points) for HIP Plus recipients was observed following suspension of personal responsibility incentives during the PHE. After an administrative upgrade of all HIP Basic recipients to HIP Plus plans during July 2021, this disparity ratio increased an additional 0.146 points from the start of the PHE (95% CI, 0.141–0.151 points) to 0.994 (95% CI, 0.993–0.994). Conclusions: Personal responsibility incentives in Medicaid are associated with substantial and persistent racial disparities in enrollment and plan comprehensiveness. The study indicates that while the temporary removal of these incentives can reduce disparities, proactive policy interventions may be necessary to achieve and maintain equitable access to care.

Background: Medicaid administrative spending funds core program operations such as fraud and waste detection and prevention, technological infrastructure, and eligibility determination. Though typically lower than private insurance administrative costs, such spending varies across states and may respond to policy and economic shocks. Purpose: This study examined trends in Medicaid administrative expenditures before and during the federal maintenance of effort (MOE) policy enacted during the COVID-19 Public Health Emergency (PHE). Methods: Using state-level panel data from 2018–2022 for all 50 states and the District of Columbia, we regressed Medicaid administrative spending outcomes (percent changes in dollar amount, per-enrollee, and per capita spending) on a binary indicator for MOE period and controlled for unemployment rates, enrollment changes, and managed care characteristics using linear regression models with state fixed effects. We also estimated models stratified by administrative burden tertiles. Results: Percent change in Medicaid administrative spending (amount in United States dollars) remained stable during the MOE period relative to pre-MOE years. Per-enrollee administrative spending declined by 9.1 percentage points. Conclusions: Despite record enrollment under MOE policies, Medicaid administrative spending did not significantly increase. The findings suggest that states maintained administrative cost stability, potentially achieving economies of scale, and that administrative burden levels and other time varying state characteristics did not meaningfully influence these trends.

Lack of transportation can be a barrier to healthcare access for older adults. State-administered home and community-based services (HCBS) often include transportation to aid in independent living. Indiana provides HCBS to Medicaid enrollees 60 and older through an Aged and Disabled (A&D) Waiver. A Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey collects data about these services, including transportation. Since 2021, Indiana has collected HCBS CAHPS data annually from A&D waiver participants for internal quality improvement, including demographics, self-reported overall and mental health ratings, and unmet needs. Among 4,199 CAHPS survey respondents, 22.1% reported an unmet need in transportation to medical appointments. Survey-weighted logistic regression was used to estimate how participant characteristics were associated with transportation unmet needs. Poor ratings of physical health and female sex were associated with greater unmet transportation needs. Black/African American race was associated with fewer unmet transportation needs and may reflect Black respondents were more likely to have urban residence than White respondents. These findings suggest health status and other patient characteristics should be considered when addressing older adults' unmet transportation needs.

Recent federal investments have accelerated a nationwide transformation of the behavioral health crisis care (BHCC) system, raising pertinent questions about quality and effectiveness. In response to calls to collect more data and define outcomes for assessing BHCC, this study sought to identify patient-centered outcomes (PCOs) from the perspectives of individuals with lived experience of a behavioral disorder and individuals who have delivered BHCC services. Via a multiphased recruitment approach, qualitative interviews were conducted with 120 stakeholders: peers with lived experience (N=21), direct-service providers (N=47), program directors and managers (N=44), and executive leaders (N=8). All interview transcripts were analyzed by using an open coding approach to generate emerging themes that captured measurable components of BHCC and outcomes of interest meaningful to stakeholders. A PCO framework for evaluating BHCC was developed by mapping emerging themes to a conceptual framework adapted from Donabedian's structure-process-outcome model. Forty-five themes were identified and grouped under five domains: system structure, system implementation, system use, social outcomes, and health outcomes. Although further efforts are needed to engage patients and providers in the process of developing specific measures, this framework provides a starting point for PCO research on BHCC.

Health-related social needs (HRSNs) encompass various non-medical risks from a patient’s life circumstances. The emergency department (ED) is a crucial yet challenging setting for addressing patient HRSNs, a clinical decision support (CDS) intervention could assist in identifying patients at high risk of having HRSNs. This project aims to implement and evaluate a CDS intervention that offers ED clinicians risk prediction scores to determine which patients will likely screen positive for one or more HRSNs. The FHIR-based CDS intervention, implemented in the ED setting of a health system in Indianapolis, Indiana, will use health information exchange data to generate logit-derived probability scores that estimate an adult patient’s likelihood of screening positive for each of the following HRSNs: housing instability, food insecurity, transportation barriers, financial strain, and history of legal involvement. For each HRSN, ED clinicians will have access to the patient’s likelihood of screening positive categorized as “high,” “medium,” or “low” based on tertiles in the distribution of each likelihood score. Clinician participation in the CDS will be voluntary. The intervention’s effects will be assessed using a difference-in-difference approach with a pre-post design and a propensity-matched comparison group of ED patients from the same metropolitan area. Outcomes of interest include whether a formal HRSN screening was conducted, whether a referral was made to an HRSN service provider (e.g., social worker), and whether a repeat ED revisit (at 3, 7, and 30 days) or primary care follow-up (within 7 days) occurred. Efficiently and accurately identifying patients with HRSNs could help link them to needed services, improving outcomes and reducing healthcare costs. This protocol will contribute to a growing body of research on the role of CDS interventions in facilitating improved screenings and referrals for HRSNs. Clincialtrials.gov NCT06655974

Objective: Patient data is subject to missingness and errors. Patient portals enable patients managing type 2 diabetes mellitus (T2DM) to review and correct data to avoid retesting, medication errors, and diagnostic mistakes. We examined whether patient portal use was associated with electronic health record (EHR) data timeliness in T2DM care. Research Design and methods: We analyzed EHR data from a panel of adult patients to determine whether portal use improved data timeliness. EHR data timeliness is measured as the number of days between patient encounters, accounting for mean attribute update periods, where available EHR attribute updates for T2DM measurements were present, including body mass, weight, glycated hemoglobin A1c, cholesterol, blood pressure, serum creatinine, and smoking status. We performed negative binomial regressions with fixed effects to estimate the association between patient portal use and EHR data timeliness. Sensitivity analyses were conducted using Poisson regressions. Results: Nearly a third (31.3%) of patients in our sample actively used the health portal. There were fewer days (111.9 days vs. 136.7 days; p < 0.001) between EHR attribute updates for patients who used health portals compared to patients who did not. Data timeliness was lower among female, non-Hispanic White Medicare beneficiaries. Based on regression analyses, portal use was associated with an expected 3.6 (p < 0.001) percentage point decrease in days between attribute updates, indicating improved EHR timeliness. Conclusion: Improving the quality of health information may streamline decision-making in partnership with patients who produce data points across clinical settings. Active use of patient portals and digital health tools in chronic disease care are critical for care management and clinical decision-making, especially for patients managing type 2 diabetes across clinical settings.

Purpose To examine the longitudinal relationship between the age or shelf-life of common type 2 diabetes laboratory tests for serum creatinine, cholesterol, and glycated hemoglobin A1c conducted in outpatient settings and subsequent inpatient hospitalizations and emergency department visits. Methods This study analyzes panel data from two healthcare delivery systems’ electronic health records (EHR) for patients aged 18 years and older managing type 2 diabetes. We used EHR data to quantify the age of three laboratory tests: serum creatinine, cholesterol, and glycated hemoglobin A1c. Encounter data were used to determine the frequency of inpatient hospitalizations and emergency department visits. Negative binomial regressions with fixed effects were performed to compute marginal effects, levels of statistical significance, and 95% confidence intervals. Results The average age for serum creatinine laboratory tests was 1.51 months (95%CI: 1.49–1.53). We computed older average ages for hemoglobin A1c (mean:6.17 months; 95%CI: 6.11–6.23) and serum creatinine tests (mean: 8.73; 95%CI: 8.65–8.81). Older laboratory tests were associated with an increase in the total expected counts of subsequent inpatient hospitalizations (ME = 0.047; p < 0.001) and ED visits (ME = 0.034; p < 0.001). Conclusion Findings from this study indicate that older type 2 diabetes laboratory tests are associated with increases in the total expected count of subsequent inpatient hospitalizations and emergency department visits. Future research should examine the actionability of laboratory test values to determine associations with healthcare outcomes.

Objective: To determine whether preventive dental visits are associated with fewer subsequent nonpreventive dental visits and lower dental expenditures.Data Sources: Indiana Medicaid enrollment and claims data (2015–2018) and the Area Health Resource File.Study Design: A repeated measures design with individual and year fixed effects examining the relationship between preventive dental visits (PDVs) and nonpreventive dental visits (NPVs) and dental expenditures.Data Collection/Extraction Methods: Not applicable.Principal Findings: Of 28,152 adults (108,349 observation‐years) meeting inclusion criteria, 36.0% had a dental visit, 27.8% a PDV, and 22.1% a NPV. Compared to no PDV in the prior year, at least one was associated with fewer NPVs (β = −0.13; 95% CI –0.12, −0.11), lower NPV expenditures (β = −$29.12.53; 95% CI –28.07, −21.05), and lower total dental expenditures (−$70.12; 95% –74.92, −65.31), as well as fewer PDVs (β = −0.24; 95% CI –0.26, −0.23).Conclusions: Our findings suggest that prior year PDVs are associated with fewer subsequent NPVs and lower dental expenditures among Medicaid‐enrolled adults. Thus, from a public insurance program standpoint, supporting preventive dental care use may translate into improved population oral health outcomes and lower dental costs among certain low‐income adult populations, but barriers to consistent utilization of PDV prohibit definitive findings.