Publications

IMPORTANCE: Medicare Advantage (MA) plans use health care utilization management and other approaches that may be associated with different utilization patterns among beneficiaries from different racial and ethnic groups compared with traditional Medicare (TM).

OBJECTIVE: To measure the MA-TM utilization gap across racial and ethnic groups.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included Medicare beneficiaries 65 years or older continuously enrolled in MA and a 20% random sample of TM beneficiaries during 2021. TM beneficiaries were matched to MA beneficiaries by geographic location, age, and sex separately for Black, Hispanic, and White beneficiaries. Data analysis was conducted between August 2025 and January 2026.

EXPOSURE: MA vs TM enrollment.

MAIN OUTCOME AND MEASURES: Utilization rates per 1000 beneficiaries for 3 discretionary procedures (hip, knee replacement, and back surgery), 3 less discretionary cardiac procedures (cardiac catheterizations, percutaneous coronary interventions, and coronary artery bypass grafting), and 2 overall measures (emergency department visits and hospitalizations). MA utilization was measured using Healthcare Effectiveness Data and Information Set data; TM utilization measures were created following the exact same specifications.

RESULTS: The final matched samples included 4 366 556 MA beneficiaries (2 442 688 [56.0%] female; 1 254 260 [28.7%] aged 71-75 years; 2 84 774 [6.5%] Black, 226 798 [5.2%] Hispanic, and 3 854 984 [88.3%] White) and 4 366 556 TM beneficiaries (2 442 688 [56.0%] female; 1 254 260 [28.7%] aged 71-75 years; 284 774 [6.5%] Black, 226 798 [5.2%] Hispanic, and 3 854 984 [88.3%] White). The MA-TM gap was largest for White beneficiaries for discretionary procedures. For example, there were 2.51 fewer (95% CI, -2.52 to -2.49) knee replacements per 1000 beneficiaries for White beneficiaries in MA vs TM, 1.26 fewer (95% CI, -1.32 to -1.21) for Black compared with White beneficiaries (P < .001), and 0.60 fewer (95% CI, -0.66 to -0.55) for Hispanic compared with White beneficiaries (P < .001). Among Hispanic and White beneficiaries, rates of coronary artery bypass grafting were marginally higher in MA vs TM (1.84 [95% CI, 1.67 to 2.02] vs 1.41 [95% CI, 1.25 to 1.56] per 1000 beneficiaries [P < .001]; 2.22 [95% CI, 2.17 to 2.26] vs 2.12 [95% CI, 2.05 to 2.20] per 1000 beneficiaries [P = .004], respectively) but not significantly different among Black beneficiaries in MA vs TM (1.37 [95% CI, 1.23 to 1.52] vs 1.45 [95% CI, 0.69 to 2.20]; P = .44). Compared with White beneficiaries, the MA-TM gap was significantly different but of similar magnitude for Black (0.09 [95% CI, 0.08 to 0.10] vs -0.07 [95% CI, -0.15 to 0.00];P < .001) and Hispanic (0.09 [95% CI, 0.08 to 0.10] vs 0.44 [95% CI, -0.40 to 0.47]; P = .007) beneficiaries. Hospitalizations showed similar MA-TM gaps across race and ethnicity. Emergency department visit rates were lower in the MA group, with the greatest difference among Black beneficiaries.

CONCLUSIONS AND RELEVANCE: In this cohort study of MA and TM beneficiaries, exposure to MA was associated with a narrowing of utilization gaps for discretionary procedures with similar impacts on utilization across racial and ethnic groups for less discretionary procedures and overall utilization. Observed reductions in disparities in utilization possibly reflect reductions in discretionary use of procedures among White beneficiaries rather than increased access for Black and Hispanic beneficiaries.

OBJECTIVE: The COVID-19 pandemic exacerbated health disparities and increased alcohol use and its health consequences. Although prepandemic research identified racial and ethnic disparities in receipt of alcohol use disorder treatment, few studies have described postpandemic disparities or have assessed the role social determinants of health (SDOHs) may play in these inequities. The authors examined how rates of treatment for alcohol use disorder differ by race and ethnicity, SDOHs, and at the intersection of both.

METHODS: In this cross-sectional analysis, the authors used a nationally representative sample of 5,785 U.S. adults with past-year alcohol use disorder from the 2023 National Survey on Drug Use and Health (NSDUH). Multivariable logistic regression models were used to estimate the probability of any past-year alcohol use disorder treatment overall, by the intersection of race and ethnicity with 20 SDOH subcategories, and across treatment settings.

RESULTS: Only 9.6% of adults with alcohol use disorder in the NSDUH received any treatment in 2023. Compared with other racial and ethnic groups, non-Hispanic Black or African American adults had the lowest probability of receiving treatment for alcohol use disorder overall and in the stratified analyses of nine of 20 SDOH subcategories.

CONCLUSIONS: These findings highlight significant disparities in the receipt of treatment for alcohol use disorder among non-Hispanic Black or African American adults, generally concentrated within the more vulnerable SDOH categories. These results underscore a critical need for clinically and culturally nuanced policies and practices tailored to specific populations with health disparities.

RATIONALE: Sarcoidosis disproportionately affects U.S. military Veterans. Its rising incidence and prevalence among Veterans are higher than in civilians and vary by branch of service, suggesting a role for prior military exposures.

OBJECTIVES: To investigate whether estimated service-related exposure to inorganic dust is associated with increased risk of sarcoidosis.

METHODS: In a retrospective nested case-control study of Veterans enrolled in the Veterans Health Administration (VHA) who received VHA- or Medicare-covered care, sarcoidosis cases identified in electronic health records between 2002 and 2022 were each matched to five controls by propensity scores and incidence density sampling by calendar year. To estimate inorganic dust exposure, military occupational codes (MOCs) were linked to a job exposure matrix (JEM). Multivariable conditional logistic regression analyses were adjusted for demographics, geography, rurality, and service branch. The attributable fraction among the exposed was calculated. In secondary analyses, latency from service separation to diagnosis was assessed. In sensitivity analyses, exposure misclassification was assessed by using a modified JEM weighted for MOC coding precision and by examining only post-9/11 Veterans; service duration was also analyzed.

RESULTS: Among >16 million individuals evaluated, 3,019,636 Veterans had at least one MOC; 5,855 incident cases and 29,275 controls were analyzed. Inorganic dust exposure was associated with increased risk of sarcoidosis (conditional odds ratio [cOR]: 1.08; 95% confidence interval [CI], 1.003-1.170); the attributable fraction was 7.6%. Associations were stronger with a modified JEM score (cOR: 1.15; 95% CI 1.05-1.27) and when restricted to post-9/11 Veterans (cOR: 1.25; 95% CI 1.07-1.47). In latency analysis, sarcoidosis risk peaked 2-5 years post-service (cOR: 2.10; 95% CI: 1.20-3.58).

CONCLUSION: Occupational and environmental exposure to inorganic dust during military service was associated with increased risk of sarcoidosis among Veterans, carrying potential implications for prevention and surveillance.

The opioid crisis has remained a public health challenge in the US for more than two decades. After increasing from 2002 to 2012, opioid-related hospitalizations decreased from 2016 to 2019, but more recent trends are unknown. We sought to determine trends in incidence and outcomes of US opioid-related hospitalizations in recent years. We conducted a serial cross-sectional study of adult primary and secondary opioid-related hospitalizations, using the 2016-23 National Inpatient Survey and regression models, annual percent change, and z-tests to examine change during the study period. Measures included annual opioid-related hospitalizations, hospital stay outcomes, and sociodemographic characteristics. Among the 1.48 million opioid-related hospitalizations during 2016-23, survey-weighted to 7.42 million, 0.93 million were classified as primary and 6.49 million as secondary opioid-related hospitalizations. Hospitalizations decreased through 2023 for all groups except patients who were Hispanic or Native American, who reported Medicaid as their payer, or who were older than age sixty-five. The greatest decline occurred among people younger than age thirty-five. The proportion of hospitalizations ending in death and self-directed discharge increased by 0.58 percentage points and 2.68 percentage points, respectively. Overall, differential reductions in opioid-related hospitalizations and increasing mortality and self-directed discharge highlight opportunities for interventions.

OBJECTIVE: To investigate whether eligibility for Veterans Health Administration (VA)-purchased community care, which expanded Veterans' access to care outside VA, was associated with increased polypharmacy or potentially inappropriate medication use among older adult Veterans.

STUDY SETTING AND DESIGN: Regression discontinuity design, leveraging the distance threshold for community care eligibility (residing > 40 miles from the nearest VA facility with ≥ 1 or more full-time primary care physician), to examine the effects of community care eligibility on polypharmacy and potentially inappropriate medication use among Veterans aged ≥ 65 years.

DATA SOURCES AND ANALYTIC SAMPLE: VA pharmacy data for all prescriptions filled at VA facilities, VA Program Integrity Tool files for prescriptions paid by VA and filled in community pharmacies, and Medicare Part D data. Analyses included annual cross-sectional samples of Veterans 36-39 miles or 41-44 miles from their nearest VA facility during FY 2016-2019.

PRINCIPAL FINDINGS: The sample included 399,250 Veteran-year observations, of which 226,157 (56.6%) were 36-39 miles and 173,093 (43.4%) were 41-44 miles from the nearest eligible VA facility. Overall, we observed no discontinuities across the 40-mile threshold in the number of unique medications filled annually (-0.06 medications; 95% confidence interval [CI], -0.15 to 0.03). There were no discontinuities in proportions of Veterans filling ≥ 5 unique medications (-0.25 percentage points [pp]; 95% CI, -0.84 to 0.34), ≥ 10 medications (-0.55 pp.; 95% CI, -1.24 to 0.14), ≥ 1 medication on the Beers list (-0.02 pp.; 95% CI, -0.63 to 0.59), or ≥ 1 high-risk drug-drug interaction (-0.05 pp.; 95% CI, -0.17 to 0.07). Among Veterans with mental health conditions, exceeding the 40-mile threshold was associated with a higher likelihood of filling ≥ 10 unique medications annually (2.06 pp.; 95% CI, 0.42 to 3.70). We did not observe clinically or statistically significant discontinuities in other subgroups.

CONCLUSIONS: Overall, eligibility for VA-purchased community care was not associated with increased polypharmacy or potentially inappropriate medication use among older adult Veterans.

BACKGROUND: People with non-traumatic fractures typically qualify for antifracture medications to prevent recurrent fractures.

OBJECTIVE: To quantify the current osteoporosis care gap and determine factors that predict prescribing of antifracture medications following hospitalization for non-traumatic fracture.

DESIGN: Retrospective cohort study.

SETTING: Twenty hospitals from a large US health system.

PATIENTS: Patients aged 50 years and older presenting to the emergency department with a non-traumatic hip, pelvic, or vertebral fracture between 2017 and 2023.

MEASUREMENTS: In-hospital administration or outpatient prescription fill of antifracture medications within 180 days following hospital discharge. We estimated incident rate ratios (IRRs) using modified Poisson regression with robust standard errors to in order to determine factors associated with antifracture medication initiation.

RESULTS: The cohort included 9849 patients (median (IQR) age, 80 [70-87] years; 68% female) of which 9008 (91.4%) were antifracture medication naïve prior to hospital presentation. Of medication-naïve patients, 510 (5.7%) were prescribed antifracture medications, with 279 (3.1%) initiating treatment as an inpatient and 119 (1.3%) in the 180 days following discharge. Medication classes included bisphosphonate (N = 431, 85%), RANK ligand inhibitors and selective estrogen receptor modulators (N = 56, 11%), and anabolic therapies (N = 21, 4%). Female sex (IRR 1.93; 95% CI 1.41-2.64) and a pre-existing diagnosis of osteoporosis (IRR 1.76, 95% CI 1.47-2.11) were positively associated with medication receipt.

LIMITATIONS: Inability to measure reasons for treatment non-initiation.

CONCLUSIONS: This study found very few adults with a non-traumatic fracture received medical treatment for secondary osteoporosis fracture prevention. Expanded quality improvement efforts are needed to close the osteoporosis care gap.

Aggregated counts from electronic health records (EHRs) provide a rich source of real-world data for investigating critical medical conditions such as postpartum hemorrhage (PPH). We used the Evolve to Next-Gen Accrual to Clinical Trials (ENACT) network, a large, federated network of EHRs, to characterize national trends, risk factors, and comorbidities associated with PPH in a cohort of 705,120 women hospitalized for delivery from 2005 to 2022. During this period, there was a statistically significant increase in the incidence of PPH, consistent with previous studies. Asian women had the highest incidence of PPH (10.33%), followed by Black or African American (8.33%) and American Indian or Alaska Native (8.05%) women. In PPH deliveries, the top-ranked risk factor was severe eclampsia (18.51%), the top-ranked comorbidity was operative vaginal delivery (16.98%), and the commonest cause was uterine atony (83.06%). We demonstrated that a large federated EHR network such as ENACT can be used to generate population-level epidemiological findings, albeit with some limitations.