Importance:The availability of flavored e-cigarettes contributes to adolescent and young adult e-cigarette initiation, exposing users to nicotine and other e-cigarette constituents. In 2020, several US states implemented comprehensive e-cigarette flavor bans to complement the federal e-cigarette flavor enforcement action that applied only to pod-based e-cigarette devices. Objective:To assess the association of state-level e-cigarette flavor bans with e-cigarette initiation across age groups in the US. Design, Setting, and Participants:This cross-sectional study conducted a difference-in-differences analysis accounting for variation in treatment timing using the Population Assessment of Tobacco and Health (PATH) Study survey waves 4 to 7 (January 2017 to April 2023). The PATH Study is an ongoing, nationally representative longitudinal cohort study of tobacco product use among noninstitutionalized US households. Adolescents (ages 12-17 years), young adults (ages 18-24 years), and adults (ages ≥25 years) who reported never using e-cigarettes at a baseline wave and completed the subsequent interview were included. Data were analyzed from January 2024 to June 2025. Exposures:A binary indicator for whether a state flavor ban was enacted as of the first day of the respondent baseline interview quarter. Main Outcomes and Measures:E-cigarette initiation was defined using the PATH Study variable never-to-ever electronic nicotine product user. Results:The study included 72 170 respondents (mean [SD] age, 45 [21] years; 36 893 female [54.4%; 95% CI, 53.7% to 55.5%]; 18 074 Hispanic [16.2%; 95% CI, 15.7% to 16.6%], 10 816 non-Hispanic Black [11.4%; 95% CI, 11.0% to 11.7%], and 34 749 non-Hispanic White [61.5%; 95% CI, 60.9% to 62.2%]). Among young adults, e-cigarette flavor bans were associated with a 6.05-percentage point (95% CI, -11.21 to -0.90 percentage point) decrease in initiation, representing a more than 50% decrease from the preban rate of 70 of 698 young adults (10.9%; 95% CI, 8.3% to 14.1%). However, no significant change was observed among adolescents or adults. Subgroup analyses of the young adult population revealed policy outcomes, as shown by adjusted difference-in-differences estimates, among populations typically considered to experience greater societal advantage, including non-Hispanic White individuals (-7.00 percentage points; 95% CI, -13.81 to -1.19 percentage points), young adults with higher household incomes (annual household income ≥$50 000; -6.92 percentage points; 95% CI, -13.12 to -0.73 percentage points), those without psychosocial distress (no internalizing symptoms: -5.58 percentage points; 95% CI, -11.00 to -0.16 percentage points; no externalizing symptoms: -7.07 percentage points; 95% CI, -12.01 to -2.13 percentage points), and individuals who were not members of sexual minority groups (-6.78 percentage points; 95% CI, -10.68 to -2.87 percentage points). Conclusions and Relevance:In this study, young adults living in states with e-cigarette flavor bans experienced significantly greater declines in e-cigarette initiation compared with those living in control states, but policies were not associated with change among adolescents or young adult subpopulations experiencing some form of societal disadvantage. These findings suggest that additional public health strategies are necessary to reduce adolescent e-cigarette initiation and ensure that current policies equitably benefit all populations.

BACKGROUND:Falls and fractures are a significant public health concern linked to visual impairment. Cataracts are the most common cause of visual impairment in older adults and can be corrected with cataract surgery. This study evaluated whether cataract surgery reduces the one-year risk of falls/fractures in Medicare beneficiaries with cataract. METHODS:Using 2019-2021 claims data from a nationally representative cohort of 940 233 Medicare fee-for-service enrollees (66+ years), we identified those with untreated cataract in 2019 and grouped them into those with and without cataract surgery in 2020. Using the surgery date (surgery group) or a randomly assigned date in 2020 (non-surgery group) as the index date, we identified incident falls/fractures (outpatient, emergency department, or inpatient) during the following 365 days. We used a propensity score-based (with average treatment effect on the treated weights) linear probability regression model to estimate the association of cataract surgery with the risk (likelihood) of falls/fractures, accounting for observed differences between those with and without surgery. RESULTS:Without surgery, the estimated likelihood of falls/fractures was 8.86% (95% CI, 8.53-9.18%). Cataract surgery was not associated with a significant difference in the risk of falls/fractures (risk difference = -0.15 percentage points; 95% CI, -1.0, 0.74). Similar findings were observed for subgroups by race and ethnicity, frailty, and fall/fracture history. CONCLUSIONS:Cataract surgery was not significantly associated with one-year risk of falls/fractures in Medicare beneficiaries. Future studies should evaluate fall risk over a longer follow-up period or the impact of surgery on self-reported falls not captured by the healthcare system.

BACKGROUND:As more older adults become homebound, home-based medical care (HBMC) has increased, but little is known about the HBMC workforce. This study analyzes national data on the size and structural features of HBMC providers from 2016 to 2022. METHODS:We analyzed annual primary care data for all traditional Medicare enrollees, classifying visits as HBMC (private residence or assisted living facility [ALF]) or non-HBMC (office or telemedicine). We evaluated trends in HBMC providers and visits by HBMC practice exclusivity (only-HBMC or both HBMC and non-HBMC), care setting (private residence, ALF), provider type (physician, nurse practitioner [NP], physician assistant [PA]), and visit volume. We assessed geographic variation in HBMC's share of primary care and payment differences between HBMC and non-HBMC services. RESULTS:In 2022, 16,125 of 304,326 (5%) primary care clinicians delivered 5.6 million HBMC visits, with most visits (66%) in ALFs. From 2016 to 2022, HBMC providers increased by 40% and visits by 29%. The proportion of only-HBMC providers rose from 50.2% to 61.7%, whereas providers with volume > 1000 visits/year fell from 46.8% to 38.9%. The increase in providers was higher in private residences (49%) than ALFs (33%), though average provider volume decreased in private residences (-24%) and rose in ALFs (7%). NPs among HBMC providers increased from 42.2% to 63.0%, PAs from 6.6% to 8.2%, and physicians dropped from 51.3% to 28.9%. HBMC's share of all visits increased from 3.9% to 5.4%, driven more by ALF visits. Non-HBMC service payments grew faster than those for HBMC services. CONCLUSIONS:Against the backdrop of an expanding HBMC workforce and rising visit volumes from 2016 to 2022, our findings highlight significant shifts in the structural composition of providers. These shifts emphasize the need for ongoing research to address their implications for access, quality, and outcomes in homebound older adults.

Introduction:As Alzheimer's disease and related dementias (ADRD) progress, many individuals become homebound and increasingly depend on home-based medical care (HBMC), such as clinician house calls. The COVID-19 pandemic spurred a rapid expansion of telemedicine under Medicare, but its impact on outpatient care by modality-HBMC, telemedicine, and office-based-among enrollees with ADRD remains unclear. Methods:Using national Medicare claims, we examined changes in primary care visits-categorized as office-based, HBMC, and telemedicine-between the pre-expansion period (March 2019-February 2020) and the late post-expansion period (March-November 2021), when telemedicine use had stabilized. Analyses were stratified by regions with low vs high HBMC provider availability. Results:Regions with high HBMC availability saw a 13.6% greater increase in HBMC visits and a 5.0% greater increase in all visits compared to low-availability regions. Both groups had similar increases in telemedicine and declines in office-based visits. HBMC growth reflected broader access, with more beneficiaries receiving HBMC post-expansion. However, gains were concentrated among non-Hispanic White enrollees, with no significant changes for non-Hispanic Black or Hispanic enrollees. Conclusion:These findings suggest that Medicare's telemedicine waivers expanded, rather than replaced, HBMC. Sustaining these policies may support aging in place for individuals with dementia, though disparities in access remain a critical concern.

This cohort study examines participation patterns in the Medicare Quality Payment Program to evaluate understudied obstacles to the Centers for Medicare & Medicaid Services goal of transitioning to value-based payment by 2030.

Introduction:Medicare Merit-based Incentive Payment System (MIPS), established by Centers for Medicare & Medicaid Services to transition Medicare reimbursement toward value-based care, has faced criticism for its administrative complexity and potential inequities affecting safety-net providers (SNPs). Methods:This study analyzed 5-year data (2018-2022) to evaluate the performance and financial outcomes of clinicians consistently participating in MIPS, focusing on disparities between SNPs and non-SNPs. Results:We found that safety-net specialists were 31% more likely than non-safety-net specialists to consistently receive positive payment adjustments and earned modestly higher average adjustment rates (0.35% points). However, despite this superior performance, safety-net specialists did not achieve greater cumulative financial rewards due to MIPS's percentage-based adjustment structure, which disadvantages clinicians with smaller billing volumes. Our analysis also showed that MIPS financial incentives were generally modest-ranging from $300 to $4000 over 5 years-far below the estimated $12 000 in annual administrative compliance costs per physician reported in prior research. Conclusion:To address these disparities and inefficiencies, policymakers should consider alternative models such as the American Medical Association's proposed Data-Driven Performance Payment System, which reduces administrative burden by simplifying the reporting process and ensures fairer financial rewards by uncoupling incentive payments from billing volume-thereby improving equity for safety-net clinicians.

Transitional care management (TCM) visits have been shown to reduce 30-day readmissions, but it is unclear whether the decrease arises from the TCM visit itself or from clinic-level changes to meet the requirements of the TCM visits. We conducted a cross-sectional analysis using data from Northwell Health to examine the association between the type of post-discharge follow-up visits (TCM visits versus non-TCM visits based on billing) and 30-day readmission. Furthermore, we assessed whether being seen by a provider who frequently utilizes TCM visits or the TCM visit itself was associated with 30-day readmission. We included adult patients hospitalized to Medicine service and subsequent follow-up visits within two weeks of discharge between February 24, 2018, and February 24, 2020. We examined 1) post-discharge follow-up visit type (TCM visit versus non-TCM visit) and 2) provider characteristics (frequent TCM visit utilization or not). The primary outcome was unplanned hospital readmission within 30 days following hospital discharge. After propensity matching, TCM follow-up visits were associated with decreased 30-day readmissions (hazard ratio = 0.74 [0.63-0.88]) compared to non-TCM visits. Among patients with non-TCM follow-up visits, those seen by a provider who frequently used TCM visits had decreased odds (OR = 0.84 [0.71-0.99]) of 30-day readmission compared to those seen by providers who did not use TCM visits regularly. Among patients who followed up with providers who frequently use TCM visits, TCM visits were associated with decreased 30-day readmission compared to patients with non-TCM visits (OR = 0.78 [0.62-0.98]). The study has limitations, including the health system database not capturing all out-of-network follow-up visits. The reduction in 30-day readmission associated with TCM visits likely arises from both the visit itself and being seen by a provider who frequently uses TCM visits.

OBJECTIVE:To investigate the relationship between physician-hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure. DATA SOURCES:The primary data were Massachusetts All-Payer Claims Database (2009-2013). STUDY SETTING:Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013. STUDY DESIGN:Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician-hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital. The study sample comprised non-elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30-day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date. DATA COLLECTION/EXTRACTION METHODS:Not applicable. PRINCIPAL FINDINGS:The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician-hospital integration was associated with a 10.6% reduction in 30-day expenditure (95% CI, -15.1% to -5.9%). Corresponding estimates for 45 and 60 days were - 9.7% (95%CI, -14.2% to -4.9%) and - 9.6% (95%CI, -14.3% to -4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, -22.6% to -8.2%) but unrelated to 30-day readmission rate. CONCLUSIONS:Our instrumental variable analysis shows physician-hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates.

In the complex landscape of health care, the relationship between medical practice and health insurance is increasingly crucial for effective care delivery. This paper emphasises the importance of integrating health insurance education into medical training, focusing on its impact on patient outcomes, health care accessibility, and system sustainability. It posits that health care providers with a comprehensive understanding of health insurance can offer more informed, efficient care by adeptly navigating coverage complexities. The study utilised a pretest-post-test design with a yearlong health insurance education curriculum at Wake Forest University School of Medicine. Student participants from various medical programmes self-assessed their knowledge and comfort across 13 health insurance topics before and after the intervention. The curriculum included workshops and a capstone project, emphasising real-life patient insurance challenges. Results show statistically significant improvements in 13 participants' understanding of health insurance concepts, highlighting the curriculum's effectiveness. The findings advocate for the inclusion of health insurance education in medical curricula. Such knowledge is vital in systems with diverse insurance models, like the United States, where understanding insurance intricacies is key to patient care. The study's limitations, such as a small sample size and reliance on self-reported data, suggest the need for further research with more participants and objective measures. In conclusion, incorporating health insurance education into medical training is essential for preparing health care professionals to navigate insurance complexities, make informed treatment decisions, and guide patients effectively. This approach fosters well-rounded professionals capable of managing both medical and financial aspects of patient care, leading to more equitable and efficient health care delivery. Future research should explore the long-term effects of this education on clinical practice and patient outcomes, particularly its impact on health care costs and patient satisfaction.

Introduction: This study aimed to examine changes in emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) among uninsured or Medicaid-covered Black, Hispanic, and White adults aged 26-64 in the first 5 years of the Affordable Care Act Medicaid expansion. Methods: Using 2010-2018 inpatient and ED discharge data from nine expansion and five nonexpansion states, an event study difference-in-differences regression model was used to estimate changes in number of annual ACSC ED visits per 100 adults ("ACSC ED rate") associated with the 2014 Medicaid expansion, overall and by race/ethnicity. A secondary outcome was the proportion of ACSC ED visits out of all ED visits ("ACSC ED share"). Analyses were conducted in 2022-2023. Results: Medicaid expansion was associated with no change in ACSC ED rates among all, Black, Hispanic, or White adults. When excluding California, where most counties expanded Medicaid before 2014, expansion was associated with a decrease in ACSC ED rate among all, Black, Hispanic, and White adults. Expansion was also associated with a decrease in ACSC ED share among all, Black, and White adults. White adults experienced the largest reductions in ACSC ED rate and share. Conclusions: Medicaid expansion was associated with reductions in ACSC ED rates in some expansion states and reductions in ACSC ED share in all expansion states combined, with some heterogeneity by race/ethnicity. Expansion should be coupled with policy efforts to better link newly insured Black and Hispanic patients to non-ED outpatient care, alongside targeted outreach and expanded primary care capacity, which may reduce disparities in ACSC ED visits. Am J Prev Med 2024;66(6):989-998. (c) 2024 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Cancer is the second leading cause of death in North Carolina and approximately half of cancers are diagnosed in older adults (≥ 65 years). Cancer clinical trials in older adults are limited and there is a lack of evidence on optimal care strategies in this population. We highlight how big data can fill in gaps in geriatric oncology research.

In February 2022, a fertilizer plant fire burned for four days and displaced thousands of residents, who were mainly low-income and Black or Latino, from their homes in Winston Salem, NC. In partnership with Black and Latino residents and nonprofit organizations, we sought to understand Black and Latino resident perceptions of the chronic and acute health risks, as well as the emotional and financial effects that resulted from the fire, which included the release of nitrous dioxide. We used the Environmental Health Disparities Framework to guide this community-engaged research study, capturing through semi-structured interviews: 1) how residents perceived their community before and after the fire, 2) how the fire impacted physical and mental health, and 3) how individuals coped with stress. We used thematic analysis to analyze the data and identified seven major themes. Participants: 1) perceived their neighborhood positively, 2) were unaware of the potential dangers of the fertilizer plant before the fire, 3) experienced adverse health and financial effects from the fire, 4) took action to protect themselves from the impacts of the fire, 5) raised concerns about the environmental impacts of the fire, 6) raised concerns about the city's response to the fire, and 7) provided recommendations for future city response.

OBJECTIVES:The objective was to understand the characteristics of patients who used telemedicine for diabetes management to inform future implementation of telemedicine. METHODS:We examined patient characteristics associated with telemedicine use for diabetes mellitus (DM) care between March 1, 2020 and April 1, 2021 (the coronavirus disease 2019 pandemic period) in a large university health system when telemedicine visits increased rapidly. Logistic regression models assessed patient characteristics associated with telemedicine visits and delays in DM process measures (hemoglobin A1c checks, nephropathy, and retinopathy evaluations) during the pandemic period after adjusting for potential confounders and corresponding values before the pandemic period (March 1, 2019-February 29, 2020). RESULTS:A total of 45,159 patients were seen from 987,791 visits during the pandemic period. The number of visits averaged one visit less during the pandemic period than before the pandemic period. Approximately 5.4% of patients used telemedicine during the pandemic period from 42,750 visits. The mean (standard deviation) telemedicine visit was 1.28 (0.91). Men, Asian, Black, and other race (vs White), having Medicare or uninsured (vs private insurance), were less likely to use telemedicine. Patients with more visits before the pandemic period were more likely to use telemedicine and less likely to experience a delay in DM process measures during the pandemic period. Telemedicine users were 18% less likely to experience a delay in nephropathy visits than nonusers, but without difference for other process measures. CONCLUSIONS:Race, sex, insurance, and prepandemic in-person visits were associated with telemedicine use for DM management in a large health system. Telemedicine use was not associated with delays in hemoglobin A1c testing, nephropathy, and retinopathy assessments. Understanding reasons for not using telemedicine is important to be able to deliver equitable DM care.

BACKGROUND:The extent to which sex, racial, and ethnic groups receive advanced heart therapies equitably is unclear. We estimated the population rate of left ventricular assist device (LVAD) and heart transplant (HT) use among (non-Hispanic) White, Hispanic, and (non-Hispanic) Black men and women who have heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS:We used a retrospective cohort design combining counts of LVAD and HT procedures from 19 state inpatient discharge databases from 2010 to 2018 with counts of adults with HFrEF. Our primary outcome measures were the number of LVAD and HT procedures per 1000 adults with HFrEF. The main exposures were sex, race, ethnicity, and age. We used Poisson regression models to estimate procedure rates adjusted for differences in age, sex, race, and ethnicity. In 2018, the estimated population of adults aged 35 to 84 years with HFrEF was 69 736, of whom 44% were women. Among men, the LVAD rate was 45.6, and the HT rate was 26.9. Relative to men, LVAD and HT rates were 72% and 62% lower among women (P<0.001). Relative to White men, LVAD and HT rates were 25% and 46% lower (P<0.001) among Black men. Among Hispanic men and women and Black women, LVAD and HT rates were similar (P>0.05) or higher (P<0.01) than among their White counterparts. CONCLUSIONS:Among adults with HFrEF, the use of LVAD and HT is lower among women and Black men. Health systems and policymakers should identify and ameliorate sources of sex and racial inequities.

BackgroundThe utilization of Annual Wellness Visits (AWVs), preventive healthcare visits covered by Medicare Part B, has grown steadily since their inception in 2011. However, longitudinal patterns and variations in use across enrollees, providers, and clinics remain poorly understood.ObjectiveThis study aimed to analyze AWV usage trends from 2018 to 2022 among a sizable cohort of Medicare beneficiaries, employing electronic health record (EHR) data. The goal was to assess AWV frequency and explore variations across enrollees, providers, and clinics.DesignThis retrospective observational study utilized EHR data from Medicare beneficiaries aged 66 and above, receiving continuous primary care from 2018 to 2022 (N = 24,549). Enrollees were classified into three categories based on their AWV utilization over a 5-year period: low users (0-1 AWVs), moderate users (2-3 AWVs), and regular users (4-5 AWVs). AWV usage patterns were examined across individual demographics and provider/clinic characteristics using multilevel regression models.Key ResultsOver the 2018-2022 period, 58.6% were regular AWV users, 27.7% were moderate users, and 13.7% were low users. Differences in primary care providers and clinics accounted for 56.4% (95% CI, 45.3%-66.9%) of the variation between low and regular users. Among enrollees who visited the same providers and clinics, individuals were less likely to be regular users of AWVs if they were 85 and older, Hispanic, from socioeconomically disadvantaged areas, or had multiple comorbidities.ConclusionsThe majority of Medicare beneficiaries in the study engaged with AWVs, with 86% having two or more over the 5-year period. These findings underscore the broad acceptance of AWVs among beneficiaries but also show that clinic and provider factors influence usage, especially among older, minoritized, and socioeconomically disadvantaged populations. Interventions at the provider and clinic levels are necessary to further improve AWV uptake, particularly for vulnerable groups.

Background In 2021, North Carolina switched 1.6 million beneficiaries from a fee-for-service Medicaid model to a managed care system. The state prepared beneficiaries with logistical planning and a communications plan. However, the rollout occurred during the COVID-19 pandemic, creating significant challenges. Little is known about how Medicaid Transformation impacted the experience of Medicaid en­rollees. Methods We conducted four focus groups (N = 22) with Medicaid beneficiaries from January to March 2022 to gain insight into their experience with Medicaid Transformation. A convenience sample was recruited. Focus groups were recorded, transcribed verbatim, and verified. A codebook was developed using inductive and deductive codes. Two study team members independently coded the transcripts; discrepancies were resolved among the research team. Themes were derived by their prevalence and salience within the data. Results We identified four major themes: 1) Participants expressed confusion about the signup process; 2) Participants had a limited understanding of their new plans; 3) Participants expressed difficulty accessing services through their plans; and 4) Participants primarily noted negative changes to their care. These findings suggest that Medicaid enrollees felt unsupported during the enrollment process and had difficulty accessing assistance to gain a better understanding of their plans and new services. Limitations Participants were recruited from a single institution in the Southeastern United States; results may not be transferable to other institutions. Participants were likely not representative of all Medicaid Transformation beneficiaries; only English-speaking participants were included. Conclusion As the transition process continues, the North Carolina Medicaid program can benefit from integrating recommendations identified by member input to guide strategies for addressing whole-person care.

Background:SARS-CoV-2 infection has caused variable clinical outcomes including hospitalization and death. We analyzed state-level data from the North Carolina COVID-19 Surveillance System (NC COVID) to describe demographics of those infected with SARS-CoV-2 and to describe factors associated with infection-fatality in North Carolina. Methods:This was a retrospective cohort study using surveillance data on positive SARS-CoV-2-infected individuals (N = 214,179) identified between March 1, 2020, and September 30, 2020. We present descriptive statistics and associations among demographics, medical comorbidities, and SARS-CoV-2 infection-fatality. Results:Median age for residents with reported SARS-CoV-2 was 38 (IQR 23-54). Age was strongly correlated with SARS-CoV-2 infection-fatality. Greater infection-fatality was noted among those who identified as Black across all comorbidities. Coexisting chronic disease was associated with greater infection-fatality, with kidney disease demonstrating the strongest association. Limitations:A high percentage of missing data for race/ethnicity and comorbidities limits the interpretation of our findings. Data were not available for socioeconomic measures that could aid in better understanding inequities associated with SARS-CoV-2 infection-fatality. Conclusions:Among North Carolinians identified with SARS-CoV-2 via surveillance efforts, age, race, and comorbidities were associated with infection-fatality; these findings are similar to those of studies using different source populations in the United States. In addition to age and other nonmodifiable variables, systematic differences in social conditions and opportunity may increase the risk of SARS-CoV-2 infection-fatality among Black Americans compared to other races/ethnicities.

Objective: Using data on 5 years of postexpansion experience, we examined whether the coverage gains from Affordable Care Act Medicaid expansion among Black, Hispanic, and White individuals led to improvements in objective indicators of outpatient care adequacy and quality. Research Design: For the population of adults aged 45–64 with no insurance or Medicaid coverage, we obtained data on census population and hospitalizations for ambulatory care sensitive conditions (ACSCs) during 2010–2018 in 14 expansion and 7 nonexpansion states. Our primary outcome was the percentage share of hospitalizations due to ACSC out of all hospitalizations (“ACSC share”) among uninsured and Medicaid-covered patients. Secondary outcomes were the population rate of ACSC and all hospitalizations. We used multivariate regression models with an event-study difference-in-differences specification to estimate the change in the outcome measures associated with expansion in each of the 5 postexpansion years among Hispanic, Black, and White adults. Principal Findings: At baseline, ACSC share in the expansion states was 19.0%, 14.5%, and 14.3% among Black, Hispanic, and White adults. Over the 5 years after expansion, Medicaid expansion was associated with an annual reduction in ACSC share of 5.3% (95% CI, −7.4% to −3.1%) among Hispanic and 8.0% (95% CI, −11.3% to −4.5%) among White adults. Among Black adults, estimates were mixed and indicated either no change or a reduction in ACSC share. Conclusions: After Medicaid expansion, low-income Hispanic and White adults experienced a decrease in the proportion of potentially preventable hospitalizations out of all hospitalizations.

Risk stratification and population management strategies are critical for providing effective and equitable care for the growing population of older adults in the USA. Both frailty and neighborhood disadvantage are constructs that independently identify populations with higher healthcare utilization and risk of adverse outcomes. To examine the joint association of these factors on acute healthcare utilization using two pragmatic measures based on structured data available in the electronic health record (EHR). In this retrospective observational study, we used EHR data to identify patients aged ≥ 65 years at Atrium Health Wake Forest Baptist on January 1, 2019, who were attributed to affiliated Accountable Care Organizations. Frailty was categorized through an EHR-derived electronic Frailty Index (eFI), while neighborhood disadvantage was quantified through linkage to the area deprivation index (ADI). We used a recurrent time-to-event model within a Cox proportional hazards framework to examine the joint association of eFI and ADI categories with healthcare utilization comprising emergency visits, observation stays, and inpatient hospitalizations over one year of follow-up. We identified a cohort of 47,566 older adults (median age = 73, 60