Importance Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. Objective To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. Design, Setting, and Participants In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type. Exposures Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively. Main Outcomes and Measures Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. Results More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types). Conclusions and Relevance Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.

中文翻译：

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2019-2021 年 COVID-19 大流行期间美国门诊护理模式的趋势。


重要性 在大流行初期美国门诊护理减少后，目前尚不清楚各种保险类型和服务的护理是否始终恢复到预期水平。目的 评估具有 Medicaid 或 Medicare-Medicaid 双重资格的患者恢复使用门诊护理的比率是否显着低于拥有商业保险、Medicare Advantage 或 Medicare 按服务收费保险的患者。设计、设置和参与者在这项回顾性队列研究中，研究了 2019 年 1 月 1 日至 2021 年 2 月 28 日的门诊护理服务模式，使用 Milliman MedInsight 研究数据库合并了来自多个美国付款人的索赔数据。使用双重差分设计，估计了大流行期间的利用率与未发生大流行时的预期比率的差异程度。将 2020 年 1 月至 2 月以及大流行期间随后每个 2 个月时间范围内的利用率变化与去年相应月份的变化进行了比较。使用每月使用计数的年龄和性别调整泊松回归模型，抵消总患者月数并按服务和保险类型分​​层。具有 Medicaid 或 Medicare-Medicaid 双重资格的患者与分别拥有商业保险、Medicare Advantage 或 Medicare 按服务收费保险的患者进行比较。主要成果和措施 每 100 人 6 项服务的利用率：急诊室、办公室和紧急护理、行为健康、结肠镜检查、乳房 X 光检查、避孕咨询或艾滋病毒筛查。结果 超过 1,450 万美国成年人被纳入其中（平均年龄 52.7 岁；54.9% 为女性）。 在 2020 年 3 月至 4 月期间，6 种门诊服务的综合使用率下降至预期率的 67.0%（95% CI，66.9%-67.1%），但恢复至 96.7%（95% CI，96.6%-96.8%） ）到 2020 年 11 月至 12 月时间范围内的预期利率。在 2021 年 1 月至 2 月期间的第二波 COVID-19 浪潮中，总体利用率再次下降至预期率的 86.2%（95% CI，86.1%-86.3%），结肠镜检查仍保持在 65.0%（95% CI，64.1） %-65.9%），乳房X光检查为预期率的79.2%（95% CI，78.5%-79.8%）。到 2021 年 1 月至 2 月的时间范围内，总体利用率恢复到预期水平，如下：享受医疗补助的患者为 78.4%（95% CI，78.2%-78.7%），医疗保险-医疗补助双重资格为 73.3%（95% CI，72.8） %-73.8%），商业为 90.7%（95% CI，90.5%-90.9%），Medicare Advantage 为 83.2%（95% CI，81.7%-82.2%），Medicare 按服务收费为 82.0%（ 95% CI，81.7%-82.2%；P < .001；分别将具有医疗补助和医疗保险-医疗补助双重资格的患者与其他每种保险类型的预期利用率进行比较。结论和相关性 2020 年 3 月至 2021 年 2 月期间，6 种门诊护理服务的总使用量在之前因 COVID-19 大流行爆发后使用量下降之后有所增加。然而，具有医疗补助或医疗保险-医疗补助双重资格的参与者使用这些门诊护理服务的增长率明显低于商业保险、医疗保险优势或医疗保险按服务收费保险的参与者。