Understanding the spatial determinants of food intake is crucial for establishing links between maternal food environments, diet, and health outcomes. Therefore, this study aimed to identify how the distance and density of built food environments in proximity to African American pregnant women living in urban settings are associated with nutrient-dense, anti-inflammatory food intake. We hypothesized that living closer to grocery stores and farther from fast-food restaurants and convenience stores is associated with increased intake. We also hypothesized that higher grocery-store density and a lower density of fast-food restaurants and convenience stores is associated with increased intake. Using cross-sectional data from the Early Life Adversity, Biological Embedding (eLABE) and Risk for Developmental Precursors of Mental Disorders Study, as well as geographic information system (GIS) data and linear regression analyses, we examined the relationships between the built food environment and food intake in the St. Louis metropolitan area, adjusting for covariates. This analysis revealed that shorter distance to fast-food restaurants and longer distance to grocery stores were associated with higher legume intake in adjusted models. These findings highlight nuanced and counterintuitive associations, underscoring the need for additional research to understand why more distant grocery stores and closer fast-food restaurants are linked to higher legume intake among African Americans.

The Surveillance, Epidemiology, and End Results (SEER) program is a robust resource for U.S. cancer surveillance, capturing cancer patient data on diagnosis, treatment, survival, and demographics across diverse population-based cancer registries. The linkage of SEER data with Medicare and, more recently, Medicaid, enhances its utility for understanding treatment access, quality, and outcomes, as well as health policy impacts, on patients with brain tumors. This review describes the SEER-Medicaid and SEER-Medicare data resources and provides practical guidance for researchers to support robust epidemiologic and policy-relevant neuro-oncology investigations. We conducted a narrative review of SEER-Medicaid and SEER-Medicare resources, summarizing data structures, linkage mechanisms, data availability, application process, potential uses for neuro-oncology research with examples, strengths and limitations for research, and future directions. Both SEER-Medicaid and SEER-Medicare offer rich opportunities to study access to care, treatment patterns, service utilization, and outcomes in brain tumor populations. However, the use of these data sources for neuro-oncology studies is limited to date. SEER-Medicaid and SEER-Medicare are valuable yet underused resources in neuro-oncology. These databases enable a broader set of questions across the brain tumor care continuum, particularly for low-income and older patients, with relevance for addressing equity and improving outcomes in neuro-oncology.

Introduction Heavy alcohol use has the potential to derail progress towards UNAIDS 95-95-95 targets for countries in sub-Saharan Africa (SSA). Within couples, alcohol use is closely linked with factors such as intimate partner violence and economic insecurity and can result in poor adherence to antiretroviral therapy (ART) and HIV clinical outcomes. We hypothesise that a combined economic and relationship intervention for couples that builds on the prior success of standalone economic and relationship-strengthening interventions will be efficacious for improving HIV clinical outcomes and reducing alcohol use. The synergy of these interventions has not been assessed in SSA—specifically among people living with HIV who drink alcohol. To test this hypothesis, we will test Mlambe, an economic and relationship-strengthening intervention, found to be feasible and acceptable in a pilot study in Malawi. We will conduct a full-scale, randomised controlled trial (RCT) to evaluate the efficacy and cost-effectiveness of Mlambe.Methods and analysis We will enrol 250 adult married couples having at least one partner living with HIV and reporting heavy alcohol use. There will be two arms: Mlambe or an enhanced usual care control arm. Couples in the Mlambe arm will receive incentivised matched savings accounts and monthly sessions on financial literacy, relationship skills, and alcohol reduction education and counselling. Participants will be assessed at baseline, 11 months, 15 months and 20 months to examine effects on heavy alcohol use, HIV viral suppression, ART adherence and couple relationship dynamics. Study hypotheses will be tested using multilevel regression models, considering time points and treatment arms. Programmatic costs will be ascertained throughout the study and incremental cost-effectiveness ratios will be computed for each arm.Ethics and dissemination The RCT has been approved by the University of California, San Francisco (UCSF) (Human Research Protection Program; Protocol Number 23-40642), and the study has been approved by the National Health Sciences Research Committee (NHSRC; Protocol Number 24/05/4431) in Malawi. Adverse events and remedial actions will be reported to authorities both in Malawi and at UCSF. Results will be disseminated to study participants, local health officials and HIV policy makers and through presentations at conferences and publications in peer-reviewed journals.Trial registration number ClinicalTrials.gov Protocol Registration; NCT06367348 registered on 19 April 2024; https://register.clinicaltrials.gov/. Protocol Version 1.0: 22 October 2024.

Background The Federal Unemployment Insurance (UI) program provides income support to unemployed workers but varies substantially across states in benefit levels and eligibility, raising concerns about economic equity. Unemployment and financial strain are linked to adverse family outcomes, including increased risk of child maltreatment and CPS involvement. While economic hardship is a well-documented risk factor for CPS involvement, research on the role of UI generosity—particularly benefit amounts—in mitigating these risks is limited and offers mixed findings. Objectives This study investigates the role of UI generosity, measured by the earnings replacement ratio, in potentially mitigating the adverse relation of unemployment with child maltreatment, focusing on child protective services (CPS) involvement. Participants and setting This study analyzes data from the National Child Abuse and Neglect Data System (NCANDS) Child Files from Q1 2009 to Q1 2021, covering CPS-investigated maltreatment reports nationwide. Methods Using a two-way fixed-effects approach, we examine associations of variation in UI benefit generosity across states and over time, measured through earnings replacement ratios, with CPS investigation rates. Results Findings highlight the protective role of financial stability provided by UI, particularly in reducing child welfare system involvement for neglect cases. A 1-point increase in the UI benefit replacement ratio was associated with 9.2 to 15.6 fewer CPS investigations per 1000 children, and this effect was statistically significant at the 5 % level. However, this protective effect diminished as unemployment rates increased: each 1-point rise in the unemployment rate weakened the association by 0.84 to 1.86 investigations per 1000 children (also statistically significant). No statistically significant associations were found for substantiations. These findings suggest that UI generosity can reduce CPS investigations under typical economic conditions, but its effectiveness may be constrained during extreme economic shocks, such as the COVID-19 pandemic. Conclusions The study contributes to the literature by exploring the interaction between unemployment, UI generosity, and CPS involvement, offering insights for policymakers on designing robust economic support systems to protect children.

OBJECTIVE:This study aimed to compare rates of psychiatric and neurologic diagnoses on emergency department (ED) visit records of adults with versus without intellectual and developmental disabilities (IDDs). METHODS:This cross-sectional study used the 2019 Nationwide Emergency Department Sample of U.S. hospital ED visit discharges. Validated codes were used to compare psychiatric and neurologic diagnoses of patients ages ≥18 with versus without diagnosed IDDs. Diagnosed psychiatric and neurologic conditions included depression, anxiety, schizophrenia or psychosis, suicidality, seizure, dementia, and sleep disorder. RESULTS:The analysis identified 558,408 and 112,593,527 (nationally weighted) ED visits by adults with and without IDDs, respectively. Compared with the general population, adults with IDDs were twice as likely to have a mental disorder as the principal visit diagnosis, with higher probabilities of principal visit suicidality (1.6 times higher), neurologic disorder (5.6 times higher), and seizure (8.1 times higher) diagnoses. Compared with the general population, adults with intellectual disability were nearly twice as likely to have a dementia diagnosis, and patients with Down's syndrome were six times likelier to have a dementia diagnosis. More than one in five ED visit records of patients ages 50-54 with Down's syndrome included a dementia diagnosis; the dementia diagnosis rate for such patients ages ≥70 was 2.7 times higher than that of the general population. CONCLUSIONS:Adult ED patients with IDDs were more likely than those without IDDs to have co-occurring mental and neurologic disorders. Findings underscore the need to provide neuropsychiatric services across the lifespan to address the distinctive care needs of individuals with IDDs.

While China’s economy has experienced rapid growth in recent decades, there is still a large gap in the quality of employment between urban and rural areas. This paper investigates the impact of non-farm employment quality on the subjective well-being of rural residents in China. We use a multidimensional approach to construct the quality index of non-farm employment at the individual level, and then estimate the effect of non-farm employment quality on subjective well-being. The results show that high-quality employment for rural residents is significantly associated with higher levels of happiness and life satisfaction, and the results are robust to the test of omitted variable bias. Based on the mediation analysis, the positive relationship between the quality of non-farm employment and subjective well-being is mediated by income and health. Further evidence suggests that high-quality employment enhances subjective well-being primarily by providing better employment conditions for workers. Additionally, other aspects of employment quality (e.g., labor income, employment security, and employment skills) matter for improvement in well-being outcomes.

BACKGROUND:Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment.METHODS:SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates.RESULTS:Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively.CONCLUSIONS:Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher  distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.

Abstract Background: Access to breast cancer screening mammogram services decreased in association with the COVID-19 pandemic. There is also evidence for increases in late-stage breast cancer diagnoses. Our objectives were to determine: 1) the COVID-19-affected period on mammogram screening, 2) the proportion of pandemic-associated missed or delayed mammogram screening visits overall and by race/ethnicity and age group, and 3) evidence for pandemic-associated shifts in diagnosis stage. Methods: Screening mammogram encounter data between 1-1-2019 and 12-31-2022 were extracted from EPIC for females ≥ 40 years old for the screening analysis. We used Bayesian state space models to describe weekly screening mammogram counts, modeling an interruption that phased in and out from 3-1-2020 to 9-1-2020. We used the posterior predictive distribution to simulate differences between a predicted, uninterrupted process and the observed screening mammogram counts. Breast cancer diagnoses at ≥ 21 years from the tumor registry between 12-1-2018 and 11-30-2021 were included in the stage analysis. We used logistic regression models to estimate late-stage diagnosis odds comparing matched three-month periods during the pandemic to before the pandemic. Results: A total of 319,492 encounters among 146,644 women were included. Model-estimated screening mammograms dropped by 98.8% (95% CI 95.1 to 100) between 3-15-2020 and 5-24-2020, returning to pre-pandemic levels or higher after this period. Drops in screening mammogram encounters did not vary significantly by race/ethnicity or age group (p > .75). Among 4,669 breast cancer diagnoses, we found no significant differences in the odds of late-stage diagnoses for any period vs. the same period before the pandemic (Table). Conclusions: These data suggest a short-term pandemic effect on screening mammograms. Evidence for increases in late-stage diagnoses is limited. These results may inform future pandemic planning. OR (95% CI) Period comparison 1.19 (0.74 to 1.91) 3/2020 to 5/2020 vs. 3/2019 to 5/2019 1.05 (0.69 to 1.60) 6/2020 to 8/2020 vs. 6/2019 to 8/2019 1.14 (0.73 to 1.78) 9/2020 to 11/2020 vs. 9/2019 to 11/2019 0.92 (0.60 to 1.41) 12/2020 to 2/2021 vs. 12/2019 to 2/2020 1.08 (0.71 to 1.65) 3/2021 to 5/2021 vs. 3/2019 to 5/2019 0.89 (0.59 to 1.33) 6/2021 to 8/2021 vs. 6/2019 to 8/2019 1.31 (0.84 to 2.04) 9/2021 to 11/2021 vs. 9/2019 to 11/2019 Citation Format: Kimberly J. Johnson, RJ Waken, Caitlin P. O'Connell, Derek Brown. Impact of COVID-19 pandemic on breast cancer screening and diagnosis stage in a large midwestern United States academic medical center [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4797.

Using a life tables approach with 2011-2017 claims data, we calculated lifetime risks of Clostridioides difficile infection (CDI) beginning at age 18 years. The lifetime CDI risk rates were 32% in female patients insured by Medicaid, 10% in commercially insured male patients, and almost 40% in females with end-stage renal disease.

Background:Medicaid enrollment has been associated with disparities in younger cancer patient survival. To further understand this association for central nervous system (CNS) tumor patients, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid-linked data to examine associations between Medicaid enrollment and enrollment timing and (1) diagnosis stage, and (2) CNS tumor death. Methods:Individuals diagnosed with a first malignant primary CNS tumor between 0 and 39 years from 2006 to 2013 were included. Medicaid enrollment was first classified as enrolled versus not enrolled with those enrolled further classified as having continuous, discontinuous (at diagnosis or other discontinuous), or other enrollment. We used logistic and Cox Proportional Hazards regression stratified by age to calculate adjusted odds ratios (ORs) and hazard ratios (HRs) for those 0-14 and 15-39 years. Results:Among 10 107 CNS tumor patients, we found significantly higher odds of regional/distant versus in situ/localized stage diagnoses for those with other discontinuous (OR0-14 = 1.50, 95% CI: 1.15-1.95) and at diagnosis (OR15-39 = 1.41, 95% CI: 1.11-1.78) Medicaid enrollment versus those not enrolled. Those enrolled versus not enrolled in Medicaid had a higher hazard of CNS tumor death for both age groups (HR0-14 = 1.60 95% CI: 1.37-1.86; HR15-39 = 1.50, 95% CI: 1.39-1.62) with the highest hazards for those enrolled at diagnosis (HR0-14 = 1.83, 95% CI: 1.51-2.22; HR15-39 = 1.93, 95% CI: 1.77-2.10). Conclusions:Medicaid enrollment is associated with a higher risk of CNS tumor death with an almost 2-fold higher risk for young CNS tumor patients enrolled at diagnosis. These results support the critical need for consistent health insurance coverage for young CNS tumor patients.

Background Little is known regarding economic impacts of intimate partner violence (IPV) in humanitarian settings, especially the labor market burden. Examining costs of IPV beyond the health burden may provide new information to help with resource allocation for addressing IPV, including within conflict zones. This paper measures the incidence and prevalence of different types of IPV, the potential relationship between IPV and labor market activity, and estimating the cost of these IPV-associated labor market differentials.Methods The association between labor market outcomes, IPV experience, and conflict exposure among women ages 15-49 in Nigeria were studied using the 2018 Nigeria Demographic and Health Survey and 2013-17 Uppsala Conflict Data Program data. Descriptive analysis was used to identify patterns of IPV and labor outcomes by region. Based on this, multivariable logistic regression models were used to estimate the association between labor market participation and lifetime IPV exposure. These models were combined with earnings data from the United Nations Human Development Report 2021/2022 and a top-down costing approach to quantify the impacts in terms of lost productivity to the Nigerian economy.Results Substantial differences in IPV exposure and labor market outcomes were found between conflict and non-conflict-affected areas. Women with past year or lifetime exposure to physical, emotional, or "any" IPV were more likely to withdraw from the labor market in the past year, although no differences were found for sexual IPV or conflict-affected regions. We estimate an average reduction of 4.14% in the likelihood of working, resulting in nearly $3.0 billion USD of lost productivity, about 1% of Nigeria's total economic output.Conclusions Increased odds of labor market withdraw were associated with several measures of IPV. Withdrawal from the formal labor market sector has a substantial associated economic cost for all of Nigerian society. If stronger prevention measures reduce the incidence of IPV against women in Nigeria, a substantial portion of lost economic costs likely could be reclaimed. These costs underscore the economic case, alongside the moral imperative, for stronger protections against IPV for girls and women in Nigeria.

Introduction Sexual violence is a significant public health concern with severe physical, social and psychological consequences, which can be mitigated by health service utilisation. However, in Uganda and much of sub-Saharan Africa, these services are significantly underused, with 9 out of 10 survivors not seeking care due to a range of psychological, cultural, economic and logistical factors. Thus, there is a strong need for research to improve health service utilisation for survivors of sexual violence.Methods and analysis The proposed study seeks to address the underutilization of health services for female survivors of sexual violence using a discrete choice experiment (DCE). The study will be conducted in the greater Masaka region of southwestern Uganda and target adult female survivors of sexual violence. We will first undertake qualitative interviews with 56 survivors of sexual violence to identify the key attributes and levels of the DCE. In order to ensure a sufficiently powered sample, 312 women who meet inclusion criteria will be interviewed. Our primary analysis will employ a mixed (random parameters) logit model. We will also model the role of individual-specific characteristics through latent class models.Ethics and dissemination The study protocol was reviewed and approved by the following ethics review boards in Uganda and the USA: the Uganda Virus Research Institute (UVRI), the Uganda National Council for Science and Technology (HS2364ES), Washington University in St Louis and the University of Michigan. Our methods conform to established guidelines for the protection of human subjects involved in research. Our dissemination plan targets a broad audience, ranging from policymakers and government agencies to healthcare providers, academic communities and survivors themselves.

BACKGROUND:Although treatment advances have increased childhood and adolescent cancer survival, whether patient subgroups have benefited equally from these improvements is unclear.METHODS:Data on 42,865 malignant primary cancers diagnosed between 1995 and 2019 in individuals ≤ 19 years were obtained from 12 Surveillance, Epidemiology, and End Results registries. Hazard ratios (HRs) and 95 % confidence intervals (CIs) for cancer-specific mortality by age group (0-14 and 15-19 years), sex, and race/ethnicity were estimated using flexible parametric models with a restricted cubic spline function in each of the periods: 2000-2004, 2005-2009, 2010-2014 and 2015-2019, versus 1995-1999. Interactions between diagnosis period and age group (children 0-14 and adolescents 15-19 years at diagnosis), sex, and race/ethnicity were assessed using likelihood ratio tests. Five-year cancer-specific survival rates for each diagnosis period were further predicted.RESULTS:Compared with the 1995-1999 cohort, the risk of dying from all cancers combined decreased in subgroups defined by age, sex and race/ethnicity with HRs ranging from 0.50 to 0.68 for the 2015-2019 comparison. HRs were more variable by cancer subtype. There were no statistically significant interactions by age group (Pinteraction=0.05) or sex (Pinteraction=0.71). Despite non-significant differences in cancer-specific survival improvement across different races and ethnicities (Pinteraction=0.33) over the study period, minorities consistently experienced inferior survival compared with non-Hispanic Whites.CONCLUSIONS:The substantial improvements in cancer-specific survival for childhood and adolescent cancer did not differ significantly by different age, sex, and race/ethnicity groups. However, persistent gaps in survival between minorities and non-Hispanic Whites are noteworthy.

Patient-centered outcomes research (PCOR) is designed to generate high-quality evidence important to patients and families, clinicians, and policymakers about treatments, services, and other health care interventions. PCOR studies have traditionally focused on understanding causal relationships among the use of health care treatments and services, treatment effects, and clinical outcomes. That focus has broadened to include a more holistic understanding of health and well-being, including the significant economic impacts of health care use on individuals, families, and their communities, such as out-of-pocket spending and informal caregiving needs. In many cases, data to study the economic impacts of health care from the perspective of individuals, families, and communities are unmeasured, not routinely collected, or unavailable for research. The growing recognition that economic factors often impact health outcomes, decision-making, and equity in health care is the impetus for the articles in this special issue of Medical Care. The Affordable Care Act established the Patient-Centered Outcomes Research Trust Fund (PCORTF) in 2010 and structured it for use in strengthening the evidence base for decision-making.1 The trust fund provides resources to build data capacity, conduct research, disseminate research findings, train investigators on PCOR methods, and engage people with lived experience in carrying out these activities. Funding is provided by the PCORTF to the Secretary of Health and Human Services (HHS), the Agency for Healthcare Research and Quality, and the Patient-Centered Outcomes Research Institute, with each entity having a distinct yet related set of responsibilities for evidence generation, dissemination, and implementation. The Assistant Secretary for Planning and Evaluation (ASPE) has the unique responsibility of coordinating across relevant federal health programs to build data capacity for PCOR. ASPE works in partnership with all HHS agencies on a portfolio of projects that support the collection, linkage, and analysis of data for PCOR studies. This body of work is collectively referred to as the Office of the Secretary Patient-Centered Outcomes Research Trust Fund portfolio (https://aspe.hhs.gov/collaborations-committees-advisory-groups/os-pcortf/explore-portfolio) and has led to the production of a variety of data products, including standards, algorithms, and linked datasets that would not have been possible without the PCORTF. These products support evidence generation in health and health care by HHS agencies and for departmental priorities such as reducing maternal mortality and substance use, increasing emergency preparedness, and improving the equitable delivery of health care. The 2019 reauthorization of the PCORTF underscored the importance of assessing a full range of outcomes, explicitly expanding the scope of patient outcomes that should be considered in PCOR studies to include the potential burdens and economic impacts of the utilization of medical treatments, items, and services on different stakeholders and decision-makers respectively. These potential burdens and economic impacts include medical out-of-pocket costs, including health plan benefit and formulary design, nonmedical costs to the patient and family, including caregiving, effects on future costs of care, workplace productivity and absenteeism, and healthcare utilization.2 Following the reauthorization of the PCORTF, and in response to this new priority, HHS developed a new strategic plan for the Office of the Secretary Patient-Centered Outcomes Research Trust Fund3 based on input from a National Academies of Sciences, Engineering, and Medicine study committee4 and representatives across HHS.5 The fourth objective of the OS-PCORTF Strategic Plan focuses on addressing data capacity limitations to support a more comprehensive view of health outcomes, including improving the availability, quality, and relevance of data on economic outcomes.3 As part of its work to implement and achieve this objective, ASPE sponsored a symposium and this special issue of Medical Care to bring together multiple perspectives on building data capacity for economic outcomes in PCOR.6 The symposium was designed not only to review and discuss current efforts and challenges related to data capacity and infrastructure, as set forth in a set of invited manuscripts, but also to identify areas of importance not addressed in this work, interrogate underlying assumptions, and develop a foundation for initiating and sustaining efforts to advance data capacity for economic outcomes in PCOR studies. The work featured in this special issue draws on the themes that emerged from the symposium. These articles highlight specific and important challenges in building PCOR data capacity on economic outcomes. However, as noted by symposium attendees, particularly patient stakeholders, these articles (and the discussions around them) often lack an explicitly patient-centered focus. That is, what are the information needs of patients related to economic impacts, and how can we ensure that efforts to build data capacity on economic outcomes align with those needs? First, the measurement and collection of data on economic outcomes should reflect the types of questions and decisions patients, caregivers, clinicians, and policymakers face. Unfortunately, the evidence to inform these decisions and improve patient outcomes—and the data and data infrastructure needed to generate it—are generally lacking in most data sources. For example, as articles published in this issue of Medical Care have described, data are needed to understand household economic impacts7 and family decisions and trade-offs.8 The data needs for specific populations should also be considered. Palatucci and colleagues9 provide an overview of appropriate data collection on economic outcomes for individuals with intellectual disabilities, while efforts to build data capacity for economic outcomes among cancer patients and embed data collection within oncology practices are discussed by Halpern et al10 and Williams et al,11 respectively. Beyond improving the measurement and capture of data on economic outcomes, efforts are needed to build more comprehensive data resources through data linkage and improved data sharing and access. Brown et al12 report on a review of federally funded administrative and survey data sources linked or linkable to Medicare fee-for-service claims that can be used to increase the range of outcomes included in PCOR studies. Jones and colleagues13 describe a novel effort to link Medicare and Medicaid data in North Carolina and discuss how to support the development and use of patient-centered utilization measures, the development of integrated Medicare and Medicaid programs, and the evaluation of health equity impacts. Zhang and Meltzer14 discuss their work in developing an integrated dataset of Medicare beneficiaries to better understand cost-related medication nonadherence. Moving beyond specific linked datasets to integrated data infrastructure, Bradley et al15 and Waitman et al16 provide overviews of efforts to link a state-level All-Payer Claims Database in Colorado with a cancer registry and strengthen PCORnet, the National Patient-Centered Clinical Research Network, respectively, to support the inclusion of economic outcomes in PCOR studies. The final article in this collection responds to this imperative, synthesizing the robust discussions among symposium attendees to arrive at a set of cross-cutting considerations to guide efforts to build data capacity and identify initial opportunities to expand the availability and use of relevant, high-quality economic outcomes data in PCOR.17 Although the articles in this issue highlight the potential benefits of improved data capacity for economic outcomes in PCOR, they also make it clear that much work needs to be done—particularly in supporting the paradigm shift within health economics research to include the perspectives of patients and families. The significance of this shift mirrors the initial sea change in efforts to engage patients and other stakeholders in all aspects of clinical comparative effectiveness research following the establishment of the PCORTF in 2010. With the expanded scope of outcomes in the 2019 reauthorization, engaging patients and families in identifying questions, data, and research on economic impacts will be crucial to expanding the evidence about the outcomes and effectiveness of health care and providing equitable health care. More broadly, continued collaboration within the PCOR community around these and other opportunities to advance the collection, linkage, and analysis of economic outcomes data for PCOR will be needed to realize the gains from the nation’s investment in the PCORTF and support decision-makers in their efforts not only to improve health and well-being but also to limit the economic burdens of health care.

BACKGROUND:Medicare patients and other stakeholders often make health care decisions that have economic consequences. Research on economic variables that patients have identified as important is referred to as patient-centered outcomes research (PCOR) and can generate evidence that informs decision-making. Medicare fee-for-service (FFS) claims are widely used for research and are a potentially valuable resource for studying some economic variables, particularly when linked to other datasets.OBJECTIVE:The aim of this study was to identify and assess the characteristics of federally funded administrative and survey data sources that can be linked to Medicare claims for conducting PCOR on some economic outcomes.RESEARCH DESIGN:A targeted internet search was conducted to identify a list of relevant data sources. A technical panel and key informant interviews were used for guidance and feedback.RESULTS:We identified 12 survey and 6 administrative sources of linked data for Medicare FFS beneficiaries. A majority provide longitudinal data and are updated annually. All linked sources provide some data on social determinants of health and health equity-related factors. Fifteen sources capture direct medical costs (beyond Medicare FFS payments); 5 capture indirect costs (eg, lost wages from absenteeism), and 7 capture direct nonmedical costs (eg, transportation).CONCLUSIONS:Linking Medicare FFS claims data to other federally funded data sources can facilitate research on some economic outcomes for PCOR. However, few sources capture direct nonmedical or indirect costs. Expanding linkages to include additional data sources, and reducing barriers to existing data sources, remain important objectives for increasing high-quality, patient-centered economic research.

BACKGROUND:Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections. METHODS:We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type. RESULTS:Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections. CONCLUSIONS:Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.

Background: Globally, approximately 19.7 million children remain under-vaccinated; many more receive delayed vaccinations. Sustained progress towards global vaccination targets requires overcoming, or compensating for, incrementally greater barriers to vaccinating hard-to-reach and hard-to-vaccinate children. We prospectively assessed pregnant women's valuations of routine childhood vaccinations and preferences for alternative incentives to inform interventions aiming to increase vaccination coverage and timeliness in southern Tanzania. Methods: Between August and December 2017, 406 women in their last trimester of pregnancy were enrolled from health facilities and communities in the Mtwara region of Tanzania and asked contingent valuation questions about their willingness to vaccinate their child if they were (a) given an incentive, or (b) facing a cost for each vaccination. Interval censored regressions assessed correlates of women's willingness to pay (WTP) for timely vaccinations. Participants were asked to rank monetary and nonmonetary incentive options for the timely vaccination of their children. Findings: All women expected to get their children vaccinated according to the recommended schedule, even without incentives. Nearly all women (393; 96.8 %) were willing to pay for vaccinations. The average WTP was Tanzania Shilling (Tsh) 3,066 (95 % confidence interval Tsh 2,523-3,610; 1 USD ti Tsh 2,200) for each vaccination. Women's valuations of timely vaccinations varied significantly with vaccine-related knowledge and attitudes, economic status, and rural vs urban residence. Women tended to prefer nonmonetary over monetary incentives for the timely vaccination of their children. Interpretation: Women placed a high value on timely childhood vaccinations, suggesting that unexpected system-level barriers rather than individual-level demand factors are likely to be the primary drivers of missed vaccinations. Systematic variation in the value of vaccinations across women reflects variation in perceived benefits and opportunity costs. In this setting, nonmonetary incentives and other interventions to increase demand and compensate for system-level barriers hold significant potential for improving vaccination coverage and timeliness. (c) 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Abstract BACKGROUND Disparities in younger cancer patient survival between individuals with Medicaid and private insurance have been reported. To further understand this association for brain tumor survival, we used Surveillance, Epidemiology, and End RESULTS (SEER)-Medicaid-linked data to test two hypotheses: 1) those enrolled in Medicaid have lower brain tumor survival than those not enrolled, and 2) those with discontinuous enrollment in Medicaid around the time of diagnosis have lower survival than those with continuous enrollment. METHODS SEER-Medicaid linked data on individuals diagnosed with a first malignant primary brain cancer between 0 to 39 years from 2006 to 2013 were obtained with follow-up through 2018. Medicaid enrollment was classified as continuous (enrolled six months before through six months after diagnosis) and discontinuous (enrolled non-continuously in the twelve months surrounding the diagnosis month). We used Kaplan-Meier (KM) curves and Cox Proportional Hazards (PH) regression models with SEs clustered on state to evaluate survival differences in association with Medicaid enrollment timing after adjusting for age, race/ethnicity, and a measure of census tract poverty. RESULTS Our analytic dataset included 10,110 children, adolescents, and young adults, including 3,148 brain tumor deaths. Consistently lower survival probabilities over time were observed for those enrolled in Medicaid, particularly those with discontinuous enrollment for both age groups. Higher hazards of death were observed for those enrolled in Medicaid vs. not enrolled (HR0-19 =1.66 95% CI 1.41-1.95; HR20-39=1.38, 95% CI 1.27-1.51) and with discontinuous vs. continuous in Medicaid enrollment (HR0-19 =1.60, 95% CI 1.43-1.81; HR20-39=2.03, 95% CI 1.75-2.36). CONCLUSIONS These results indicate Medicaid enrollment continuity has an impact on the risk of death, with discontinuous enrollment associated with an over two times higher risk of death for young brain tumor patients. These results further support the critical need for consistent health insurance coverage for children, adolescents, and young adults.

Objective To evaluate potential effect modification by health insurance coverage on racial and ethnic disparities in cancer survival among US children and adolescents. Study design Data from 54 558 individuals diagnosed with cancer at <= 19 years between 2004 and 2010 were obtained from the National Cancer Database. Cox proportional hazards regression was used for analyses. An interaction term between race/ethnicity and health insurance type was included to examine racial/ethnic disparities in survival by each insurance status category. Results Racial/ethnic minorities experienced a 14%-42% higher hazard of death compared with non-Hispanic Whites (NHWs) with magnitudes varying by health insurance type (P-interaction < .001). Specifically, among those reported as privately insured, the hazard of death was higher for non-Hispanic Blacks (NHBs) (hazard ratio [HR] = 1.48, 95% CI: 1.36-1.62), non-Hispanic American Indian/Alaskan Natives (HR = 1.99, 95% CI: 1.36-2.90), non-Hispanic Asians or Pacific Islanders (HR = 1.30, 95% CI: 1.13-1.50), and Hispanics (HR = 1.28, 95% CI: 1.17-1.40) vs NHWs. Racial/ethnic disparities in survival among those reported as covered by Medicaid were present for NHBs (HR = 1.30, 95% CI: 1.19-1.43) but no other racial/ethnic minorities (HR ranges: 0.98 similar to 1.00) vs NHWs. In the uninsured group, the hazard of death for NHBs (HR = 1.68, 95% CI: 1.26-2.23) and Hispanics (HR = 1.27, 95% CI: 1.01-1.61) was higher vs NHWs. Conclusions Disparities in survival exist across insurance types, particularly for NHB childhood and adolescent cancer patients vs NHWs with private insurance. These findings provide insights for research and policy, and point to the need for more efforts on promoting health equity while improving health insurance coverage.