Continued Importance of Sexually Transmitted Disease Clinics in the Era of the Affordable Care Act.
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ABSTRACT:
SUBMITTER: Mehtani NJ
PROVIDER: S-EPMC4992609 | biostudies-literature | 2016 Sep
REPOSITORIES: biostudies-literature
Publications
Continued Importance of Sexually Transmitted Disease Clinics in the Era of the Affordable Care Act.
Mehtani Nicky J NJ Schumacher Christina M CM Johnsen Luke E LE Khaldun Joneigh S JS Chaulk C Patrick CP Ghanem Khalil G KG Jennings Jacky M JM Page Kathleen R KR
American journal of preventive medicine 20160527 3
<h4>Introduction</h4>Following the 2014 expansions of Medicaid and private health insurance through the Affordable Care Act, municipal sexually transmitted disease (STD) clinics-which have historically served predominantly uninsured patients-have been threatened with budget cuts nationwide. This study was conducted to evaluate the impact of the insurance expansions on the demand for STD clinic services.<h4>Methods</h4>The proportion of total incident sexually transmitted infections in Baltimore ...[more]
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Project description:The Affordable Care Act (ACA) eliminated cost-sharing for evidence-based preventive services in an effort to encourage use.To evaluate use of colorectal cancer (CRC) screening in a national population-based sample before and after implementation of the ACA.Repeated cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS) between 2009 and 2012 comparing CRC screening rates before and after implementation of the ACA.Adults 50-64 with private health insurance and adults 65-75 with Medicare.Self-reported receipt of screening colonoscopy, sigmoidoscopy, or fecal occult blood test (FOBT) within the past year among those eligible for screening.Our study included 8617 adults aged 50-64 and 3761 adults aged 65-75. MEPS response rates ranged from 58 to 63%. Among adults aged 50-64, 18.9-20.9% received a colonoscopy in the survey year, 0.59-2.1% received a sigmoidoscopy, and 7.9-10.4% received an FOBT. For adults aged 65-75, 23.6-27.7% received a colonoscopy, 1.3-3.2% a sigmoidoscopy, and 13.5-16.4% an FOBT. In adjusted analyses, among participants aged 50-64, there was no increase in yearly rates of colonoscopy (-0.28 percentage points, 95% CI -2.3 to 1.7, p?=?0.78), sigmoidoscopy (-1.1%, 95% CI -1.7 to -0.46, p?=?<0.001), or FOBT (-1.6%, 95% CI -3.2 to -0.03, p?=?0.046) post-ACA. For those aged 65-75, rates of colonoscopy (+2.3%, 95% CI -1.4 to 6.0, p?=?0.22), sigmoidoscopy (+0.34%, 95% CI 0.88 to 1.6, p?=?0.58) and FOBT (-0.65, 95% CI -4.1 to 2.8, p?=?0.72) did not increase. Among those aged 65-75 with Medicare and no additional insurance, the use of colonoscopy rose by 12.0% (95% CI 3.3 to 20.8, p?=?0.007). Among participants with Medicare living in poverty, colonoscopy use also increased (+5.7%, 95% CI 0.18 to 11.3, p?=?0.043).Eliminating cost-sharing for CRC screening has not resulted in changes in the use of CRC screening services for many Americans, although use may have increased in the post-ACA period among some Medicare beneficiaries.
| S-EPMC4762811 | biostudies-other
Project description:We examined the prevalence trends of non-human immunodeficiency virus (HIV) sexually transmitted infections (STI) and associated patient characteristics in U.S. ambulatory-care settings from 2005-2016. We conducted a retrospective repeated cross-sectional analysis using data from the National Ambulatory Medical Care Survey (NAMCS) for individuals aged 15-64 with a non-HIV STI-related visit. Data were combined into three periods (2005-2008, 2009-2012, and 2013-2016) to obtain reliable estimates. Logistic regression was used for analysis. A total of 19.5 million weighted, non-HIV STI-related ambulatory visits from 2005-2016 were identified. STI-related visits per 100,000 ambulatory care visits increased significantly over the study period: 206 (95% CI = 153-259), 343 (95% CI = 279-407), and 361 (95% CI = 277-446) in 2005-2008, 2009-2012, and 2013-2016, respectively (Ptrend = 0.003). These increases were mainly driven by increases in HPV-related visits (56 to 163 per 100,000 visits) from 2005-2008 to 2009-2012, followed by syphilis- or gonorrhea-related visits (30 to 67 per 100,000 visits) from 2009-2012 to 2013-2016. Higher odds of having STI-related visit were associated with younger age (aged 15-24: aOR = 4.45; 95% CI = 3.19-6.20 and aged 25-44: aOR = 3.59; 95% CI = 2.71-4.77) vs. 45-64-year-olds, Black race (aOR = 2.41; 95% CI = 1.78-3.25) vs. White, and HIV diagnosis (aOR = 10.60; 95% CI = 5.50-20.27) vs. no HIV diagnosis. STI-related office visits increased by over 75% from 2005-2016, and were largely driven by HPV-related STIs and syphilis- or gonorrhea-related STIs.
| S-EPMC8745575 | biostudies-literature
Project description:Many individuals remain sexually active into their eighth decade. Surveillance data suggest that rates of sexually transmitted infections in older patients are increasing. We compared demographics, risk behaviors, and predictors of acute infections in patients 50 years and older versus younger patients attending sexually transmitted disease clinics in Baltimore, Maryland. This was a retrospective study from a large electronic database of visits to two urban sexually transmitted disease clinics between 2005 and 2010. Proportions were compared using the Chi square test. Logistic regression was used to assess predictors of acute sexually transmitted infections in older versus younger groups. It was found that patients over 50 were more likely than younger patients to report never using condoms (32.6% [CI 0.31-0.34] versus 24.1% [CI 0.23-0.25]). The overall prevalence of acute sexually transmitted infections was 18.1% (CI 0.17-0.19) in older and 25.8% (CI 0.25-0.27) in younger patients. Older women were more likely to be diagnosed with trichomoniasis (21.5% [CI 18.6-24.5] versus 13.1% [CI 11.5-14.8]). Black race was predictive of having an acute sexually transmitted infections in younger men (OR 2.2 [CI 1.47-3.35]) and women (OR 2.7 [CI 1.34-5.30]) but not in older men (OR 1.2 [CI 0.79-1.73]) or women (OR 1.2 [CI 0.43-3.15]). Older age was associated with a decreased risk of acute STI diagnosis in younger men and older women only, while having had sex for money or drugs in the past month was predictive only in younger women. Reporting symptoms and increasing numbers of sexual partners in the last six months was predictive of acute sexually transmitted infection diagnosis in all age groups. Older patients seeking care at sexually transmitted disease clinics engage in important risk behaviors. Race, a factor predictive of acute sexually transmitted infections in younger patients is not a significant predictor of sexually transmitted infections in older persons.
| S-EPMC5554957 | biostudies-other
Project description:ObjectivesWe describe payor for contraceptive visits 2013-2014, before and after Medicaid expansion under the Affordable Care Act (ACA), in a large network of safety-net clinics. We estimate changes in the proportion of uninsured contraceptive visits and the independent associations of the ACA, Title X, and state family planning programs.MethodsOur sample included 237 safety net clinics in 11 states with a common electronic health record. We identified contraception-related visits among women aged 10-49 years using diagnosis and procedure codes. Our primary outcome was an indicator of an uninsured visit. We also assessed payor type (public/private). We included encounter, clinic, county, and state-level covariates. We used interrupted time series and logistic regression, and calculated multivariable absolute predicted probabilities.ResultsWe identified 162,666 contraceptive visits in 219 clinics. There was a significant decline in uninsured contraception-related visits in both Medicaid expansion and nonexpansion states, with a slightly greater decline in expansion states (difference-in-difference: -1.29 percentage points; confidence interval: -1.39 to -1.19). The gap in uninsured visits between expansion and nonexpansion states widened after ACA implementation (from 2.17 to 4.1 percentage points). The Title X program continues to fill gaps in insurance in Medicaid expansion states.ConclusionsUninsured contraceptive visits at safety net clinics decreased following Medicaid expansion under the ACA in both expansion and nonexpansion states. Overall, levels of uninsured visits are lower in expansion states. Title X continues to play an important role in access to care and coverage. In addition to protecting insurance gains under the ACA, Title X and state programs should continue to be a focus of research and advocacy.
| S-EPMC7148195 | biostudies-literature
Project description:To examine the sources of family income dynamics leading to movement into and out of Medicaid expansion and subsidy eligibility under the Affordable Care Act.Survey of Income and Program Participation (SIPP): 1996, 2001, 2004, 2008 panels.Considering four broad subsidy eligibility categories for monthly Modified Adjusted Gross Income (MAGI) (<138 percent of the Federal Poverty Level [FPL], 138-250 percent FPL, 250-400 percent FPL, and >400 percent FPL), I use duration analysis to examine determinants of movements between categories over the course of a year.Using detailed monthly data, I determine the members of tax-filing units and calculate an approximation of MAGI at the monthly level. The analysis sample is adults ages 22-64 years.Incomes are highly variable within a year, particularly at the lower end of the income distribution. Employment transitions, including transitions not involving a period of nonemployment, and family structure changes strongly predict sufficient income volatility to trigger a change in subsidy category.Income volatility arising from employment and family structure changes is likely to trigger changes in subsidy eligibility within the year, but the sources and effects of the volatility differ substantially depending on the individual's position in the income distribution.
| S-EPMC4256552 | biostudies-literature
Project description:Rapid HIV testing in high-risk populations can increase the number of persons who learn their HIV status and avoid spending clinic resources to locate persons identified as HIV infected.We determined the cost to sexually transmitted disease (STD) clinics of point-of-care rapid HIV testing using data from 7 public clinics that participated in a randomized trial of rapid testing with and without brief patient-centered risk reduction counseling in 2010. Costs included counselor and trainer time, supplies, and clinic overhead. We applied national labor rates and test costs. We calculated median clinic start-up costs and mean cost per patient tested, and projected incremental annual costs of implementing universal rapid HIV testing compared with current testing practices.Criteria for offering rapid HIV testing and methods for delivering nonrapid test results varied among clinics before the trial. Rapid HIV testing cost an average of US $22/patient without brief risk reduction counseling and US $46/patient with counseling in these 7 clinics. Median start-up costs per clinic were US $1100 and US $16,100 without and with counseling, respectively. Estimated incremental annual costs per clinic of implementing universal rapid HIV testing varied by whether or not brief counseling is conducted and by current clinic testing practices, ranging from a savings of US $19,500 to a cost of US $40,700 without counseling and a cost of US $98,000 to US $153,900 with counseling.Universal rapid HIV testing in STD clinics with same-day results can be implemented at relatively low cost to STD clinics, if brief risk reduction counseling is not offered.
| S-EPMC4373404 | biostudies-literature
Project description:Sexually transmitted disease (STD) prevention remains a public health priority. Simple, practical interventions to reduce STD incidence that can be easily and inexpensively administered in high-volume clinical settings are needed. We evaluated whether a brief video, which contained STD prevention messages targeted to all patients in the waiting room, reduced acquisition of new infections after that clinic visit.In a controlled trial among patients attending three publicly funded STD clinics (one in each of three US cities) from December 2003 to August 2005, all patients (n = 38,635) were systematically assigned to either a theory-based 23-min video depicting couples overcoming barriers to safer sexual behaviors, or the standard waiting room environment. Condition assignment alternated every 4 wk and was determined by which condition (intervention or control) was in place in the clinic waiting room during the patient's first visit within the study period. An intent-to-treat analysis was used to compare STD incidence between intervention and control patients. The primary endpoint was time to diagnosis of incident laboratory-confirmed infections (gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV), as identified through review of medical records and county STD surveillance registries. During 14.8 mo (average) of follow-up, 2,042 patients (5.3%) were diagnosed with incident STD (4.9%, intervention condition; 5.7%, control condition). In survival analysis, patients assigned to the intervention condition had significantly fewer STDs compared with the control condition (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84 to 0.99).Showing a brief video in STD clinic waiting rooms reduced new infections nearly 10% overall in three clinics. This simple, low-intensity intervention may be appropriate for adoption by clinics that serve similar patient populations.http://www.ClinicalTrials.gov (#NCT00137670).
| S-EPMC2504047 | biostudies-literature
Project description:ObjectiveTo estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on health care access and self-assessed health during the first 2 years of the Trump administration (2017 and 2018).Data sourceThe 2011-2018 waves of the Behavioral Risk Factor Surveillance System (BRFSS), with the sample restricted to nonelderly adults. The BRFSS is a commonly used data source in the ACA literature due to its large number of questions related to access and self-assessed health. In addition, it is large enough to precisely estimate the effects of state policy interventions, with over 300 000 observations per year.DesignWe estimate difference-in-difference-in-differences (DDD) models to separately identify the effects of the private and Medicaid expansion portions of the ACA using an identification strategy initially developed in Courtemanche et al (2017). The differences come from: (a) time, (b) state Medicaid expansion status, and (c) local area pre-2014 uninsured rates. We examine ten outcome variables, including four measures of access and six measures of self-assessed health. We also examine differences by income and race/ethnicity.Principal findingsDespite changes in ACA administration and the political debate surrounding the ACA during 2017 and 2018, including these fourth and fifth years of postreform data suggests continued gains in coverage. In addition, the improvements in reported excellent health that emerged with a lag after ACA implementation continued during 2017 and 2018.ConclusionsWhile gains in access and self-assessed health continued in the first 2 years of the Trump administration, the ongoing debate at both the federal and state level surrounding the future of the ACA suggests the need to continue monitoring how the law impacts these and many other important outcomes over time.
| S-EPMC7518825 | biostudies-literature
Project description:This paper investigates whether individuals are sufficiently informed to make reasonable choices in the health insurance exchanges established by the Affordable Care Act (ACA). We document knowledge of health reform, health insurance literacy, and expected changes in healthcare using a nationally representative survey of the US population in the 5 wk before the introduction of the exchanges, with special attention to subgroups most likely to be affected by the ACA. Results suggest that a substantial share of the population is unprepared to navigate the new exchanges. One-half of the respondents did not know about the exchanges, and 42% could not correctly describe a deductible. Those earning 100-250% of federal poverty level (FPL) correctly answered, on average, 4 out of 11 questions about health reform and 4.6 out of 7 questions about health insurance. This compares with 6.1 and 5.9 correct answers, respectively, for those in the top income category (400% of FPL or more). Even after controlling for potential confounders, a low-income person is 31% less likely to score above the median on ACA knowledge questions, and 54% less likely to score above the median on health insurance knowledge than a person in the top income category. Uninsured respondents scored lower on health insurance knowledge, but their knowledge of ACA is similar to the overall population. We propose that simplified options, decision aids, and health insurance product design to address the limited understanding of health insurance contracts will be crucial for ACA's success.
| S-EPMC3992693 | biostudies-literature
Project description:PurposeHealth insurance coverage affects a patient's ability to access optimal care, the percentage of insured patients on a clinic's panel has an impact on the clinic's ability to provide needed health care services, and there are racial and ethnic disparities in coverage in the United States. Thus, we aimed to assess changes in insurance coverage at community health center (CHC) visits after the Patient Protection and Affordable Care Act (ACA) Medicaid expansion by race and ethnicity.MethodsWe undertook a retrospective, observational study of visit payment type for CHC patients aged 19 to 64 years. We used electronic health record data from 10 states that expanded Medicaid and 6 states that did not, 359 CHCs, and 870,319 patients with more than 4 million visits. Our analyses included difference-in-difference (DD) and difference-in-difference-in-difference (DDD) estimates via generalized estimating equation models. The primary outcome was health insurance type at each visit (Medicaid-insured, uninsured, or privately insured).ResultsAfter the ACA was implemented, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the greatest increases in Medicaid-insured visit rates after ACA implementation in expansion states (rate ratio [RR] = 1.77; 95% CI, 1.56-2.02) and the largest gains in privately insured visit rates in nonexpansion states (RR = 3.63; 95% CI, 2.73-4.83). In expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (DD = 2.03; 95% CI, 1.53-2.70), and this relative change was more than 2 times greater in expansion states compared with nonexpansion states (DDD = 2.06; 95% CI, 1.52-2.78).ConclusionThe lower rates of uninsured visits for all racial and ethnic groups after ACA implementation suggest progress in expanding coverage to CHC patients; this progress, however, was not uniform when comparing expansion with nonexpansion states and among all racial and ethnic minority subgroups. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.
| S-EPMC5593726 | biostudies-literature