Estimate of Care Non-Continuity Among Medicaid Beneficiaries Diagnosed with Congenital Heart Defects in Five Metropolitan Georgia Counties: 1999-2010 Open Access

Abstract

Purpose: Continuity in healthcare for individuals with a congenital heart defect (CHD) is an important public health issue. The aim of this study was to estimate the percentage of Georgia Medicaid beneficiaries diagnosed with a CHD sometime during 1999-2007 who also had a Medicaid-paid claim during 2008-2010. Medicaid claims paid during 2008-2010 were analyzed to determine the extent to which age, gender, and disease severity explain the likelihood of healthcare indicating their CHD.

Methods: Medicaid data were used to identify a CHD cohort, ages 9-62 years. Using multivariable logistic regression, odds ratios were calculated between age and having a Medicaid-paid claim during 2008-2010 and, among those with a claim, between age and having a CHD-related diagnosis on the claim.

Results: 5,944 patients had a CHD-related diagnosis on their Medicaid claim during 1999-2007; only 46% also had a Medicaid-paid claim during 2008-2010. After excluding those known to have left the catchment area, 52% had at least one Medicaid-paid claim; only 10% (522 of the 5,285) had a CHD-related diagnosis. Among 214 females less than 18 with a severe CHD classification, 115 (53%) had a Medicaid claim during 2008-2010, with 60% having a claim that included a CHD diagnosis. They were the most likely to have a Medicaid claim with a CHD diagnosis. With them as referent, males over 18 years regardless of CHD severity were less likely to have any Medicaid-paid claims during 2008-2010; further, among those with claims, almost every combination of age, sex, and CHD severity was less likely to have a Medicaid claim with a CHD diagnosis.

Conclusion: Among Medicaid patients in Georgia known to have CHD, during a three-year period surveillance of claims for CHD adolescents and adults, only 10% were identified by a Medicaid claim indicating CHD. As adolescents transition into adulthood, many no longer meet the requirements for Medicaid coverage in Georgia unless they are pregnant. Pregnant women with CHD need to be identified and referred for specialty care. Georgia needs to address implementing Medicaid expansion to cover individuals who otherwise may not be able to afford health coverage.

Table of Contents

CHAPTER I: BACKGROUND 1

Congenital Heart Defects (CHD) 1

Improved Longevity and Need for Population-based CHD Surveillance 1

Quebec's CHD Population-based Prevalence Estimates 2

CDC's First U.S. Pilot Project: Surveillance of CHD among Adolescents and Adults 3

Prevalence Estimates from First Pilot Project 4

Lifelong Care and Management of CHD 5

The Association of Diabetes and Congenital Heart Defects 6

Access to Care 7

Medicaid 8

Georgia Medicaid Eligibility 9

A Snapshot of Georgia Medicaid Beneficiaries 10

State Children's Health Insurance Program (SCHIP) 10

Georgia's PeachCare for Kids® 11

Medicaid and CHIP Coverage Gaps 11

Insurance Transition and Disparities 12

Medicaid and CHD 12

Transitioning Care from Adolescence to Adulthood 15

CHAPTER II: METHODS 17

Hypotheses 17

Study Design and Population 17

Data Management and IRB 19

Inclusion and Exclusion Criteria 19

Outcome Variables 19

Predictor Variables 20

Age 20

Race 20

Sex 21

CHD Severity 21

Statistical Analysis 21

CHAPTER III: MANUSCRIPT 24

Introduction 24

Methods 26

Study Design and Population 26

Case Definition and Exclusion Criteria 26

Predictor Variables 27

Directed Acyclic Graph (DAG) 27

Statistical Analysis 27

Results 29

Descriptive Statistics 29

Crude Model and Possible Confounders 31

Outcome 2- a CHD-Related Medicaid Claim during the 2008-2010 surveillance period 32

Final Adjusted Model Odds Ratio 33

Outcome 1- a Medicaid Claim during the 2008-2010 surveillance period 33

Outcome 2- a CHD-Related Medicaid Claim during the 2008-2010 surveillance period 33

Discussion 35

Strengths and Limitations 36

Conclusion 37

References 39

Tables 48

Table 1. Case Definition for Surveillance of CHD, Emory-CDC Pilot Project 48

Table 2a. Demographics for CHD Medicaid Patients^ by Catchment Area Residence and Healthcare Seeking Behavior in 2008-2010 49

Table 2b. Severity of CHD among Medicaid Patients* by Catchment Area Residence and Healthcare Seeking Behavior in 2008-2010 50

Table 2c. Severity of CHD by Age and Sex among Medicaid Patients* by Catchment Area Residence and Healthcare Seeking Behavior in 2008-2010 51

Table 3a. Demographics for CHD Medicaid Patients Residing Within the Catchment Area Who Sought Care in 2008-2010 With or Without a CHD Medicaid Claim in 2008-2010 52

Table 3b Severity of CHD among Medicaid Patients Residing Within the Catchment Area with a CHD Medicaid Claim during 1999-2007 and Sought Care in 2008-2010 53

Table 3c. Severity of CHD by Age and Sex among Medicaid Patients Residing Within the Catchment Area with a CHD Medicaid Claim during 1999-2007 and Sought Care in 2008-2010 54

Table 4. Crude Odds Ratios for Age Association with Each Outcome 55

Table 5. Adjusted Odds Ratio for Each Outcome 56

Supplementary Table 1. CHD-Diagnosed Patients Who Resided Within Catchment Area in 1999-2007 and Who Resided Within the Catchment Area and Sought Care Any Time during 2008-2010 57

Supplementary Table 2. CHD-Diagnosed Patients Who Reside Inside or Outside Catchment Area in 1999-2007 and Who Reside Within the Catchment Area and Sought Care Any Time during 2008-2010 59

Supplementary Table 3. Adjusted Odds Ratio for Each Outcome for the Main Effect Age 61

Figures 62

Figure 1. DAG 62

CHAPTER IV: EXTENDED ANALYSIS 63

Sensitivity Analyses 63

Final Adjusted Model Odds Ratio 63

CHAPTER V: Public Health Implications and Future Directions 65

APPENDICES 68

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Keyword	Adults Continuity of care Medicaid Adolescents Congenital Heart Defects
Committee Chair / Thesis Advisor	Hogue, Carol J, Emory University
Committee Members	Raskind-Hood, Cheryl, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs CDC

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