Background: Quantifying the burden of multimorbidity for healthcare research using administrative data has been constrained. Existing measures incompletely capture chronic conditions of relevance and are narrowly focused on risk-adjustment for mortality, healthcare cost or utilization. Moreover, the measures have not undergone a rigorous review for how accurately the components, specifically the International Classification of Diseases, Ninth Revision (ICD-9) codes, represent the chronic conditions that comprise the measures. We performed a comprehensive, structured literature review of research studies on the accuracy of ICD-9 codes validated using external sources across an inventory of 81 chronic conditions. The conditions as a weighted measure set have previously been demonstrated to impact not only mortality but also physical and mental health-related quality of life. Methods: For each of 81 conditions we performed a structured literature search with the goal to identify 1) studies that externally validate ICD-9 codes mapped to each chronic condition against an external source of data, and 2) the accuracy of ICD-9 codes reported in the identified validation studies. The primary measure of accuracy was the positive predictive value (PPV). We also reported negative predictive value (NPV), sensitivity, specificity, and kappa statistics when available. We searched PubMed and Google Scholar for studies published before June 2019. Results: We identified studies with validation statistics of ICD-9 codes for 51 (64%) of 81 conditions. Most of the studies (47/51 or 92%) used medical chart review as the external reference standard. Of the validated using medical chart review, the median (range) of mean PPVs was 85% (39-100%) and NPVs was 91% (41-100%). Most conditions had at least one validation study reporting PPV ≥70%. Conclusions: To help facilitate the use of patient-centered measures of multimorbidity in administrative data, this review provides the accuracy of ICD-9 codes for chronic conditions that impact a universally valued patientcentered outcome: health-related quality of life. These findings will assist health services studies that measure chronic disease burden and risk-adjust for comorbidity and multimorbidity using patient-centered outcomes in administrative data.

Recent findings have suggested an association between pubic hair grooming and self-reported history of sexually transmitted infection (STI), specifically gonococcal infection (GC), chlamydial infection (CT), or human immunodeficiency virus (HIV). We evaluated the association between self-reported extreme grooming and laboratory-confirmed prevalence of GC/CT. Between April 2017 and April 2018, we enrolled English-speaking, adult, female students at a large, Midwestern university who presented on-campus for STI testing. Participants completed a questionnaire on demographics and sexual and grooming behaviors, which was linked to their GC/CT test results based on nucleic acid amplification testing. We defined extreme grooming as removal of all pubic hair either at least weekly in the past 12 months or ≥6 times in the past 30 days. We used two separate logistic regression models to determine whether odds of GC/CT varied by extreme groomer status for either time interval. In the study sample of 214 women, prevalence of GC/CT was 9.8%. Nearly all participants (98.1%) reported ever grooming; 53.6% were extreme groomers in the past year and 18% in the past month. Extreme grooming was not associated with prevalent GC/CT in the past year (odds ratio [OR] = 0.8; 95% confidence interval [CI]: 0.3–1.9; adjusted OR = 0.7; 95% CI: 0.3–2.0) or in the past month (OR = 0.5; 95% CI: 0.1–2.0; aOR = 0.4; 95% CI: 0.1–1.9). Pubic hair grooming was common among female university students attending for STI testing. Findings do not support pubic hair grooming as an STI risk factor in this population.

Background Given increasing numbers of people experiencing transitions in health insurance due to declines in employer-sponsored insurance and changes in health policy, the understanding and application of health insurance terms and concepts (health insurance literacy) may be important for navigating use of health care. The study objective was to systematically review evidence on the relationship between health insurance literacy and health care utilization. Methods Medline, SCOPUS, Web of Science, CINAHL, PsychInfo, Cochrane Library, and reference lists of published literature were searched in August 2019. Quantitative, qualitative, and intervention studies that assessed the association of health insurance literacy as the exposure and health care utilization as the outcome were identified, without language or date restrictions. Outcomes were independently assessed by 2–3 reviewers. Results Twenty-one studies including a total of 62,416 subjects met inclusion criteria: three interventional trials, two mixed-methods studies, and sixteen cross-sectional studies. Ten of thirteen preventive care studies suggested that higher health insurance literacy was associated with greater utilization of primary care and other preventive services. Eight of nine studies of care avoidance demonstrated that individuals with lower health insurance literacy were more likely to delay or avoid care. A few studies had mixed results regarding the utilization of emergency department, inpatient, and surgical care. Discussion The emerging literature in this area suggests that health insurance literacy is an important factor that can enable effective utilization of health care, including primary care and preventive services. However, the literature is limited by a paucity of studies using validated tools that broadly measure health insurance literacy (rather than testing knowledge of specific covered services). Improving health insurance literacy of the general public and increasing plain language communication of health insurance plan features at the point of health care navigation may encourage more effective and cost-conscious utilization. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-06819-0.

IMPORTANCE As US adults approach Medicare eligibility at age 65 years, they face important decisions about health care and employment. Recent legislative, regulatory, and legal challenges to the Affordable Care Act may add new uncertainties to this decision-making. OBJECTIVE To understand adults' perspectives on health insurance, health care, and employment near retirement. DESIGN, SETTING, AND PARTICIPANTS In October 2018, a cross-sectional online survey study of community-dwelling US adults aged 50 to 64 years was conducted with Ipsos KnowledgePanel, a nationally representative internet survey panel (completion rate, 62%). The initial data analysis was conducted from November 2018 to March 2019, and additional analyses were conducted in November 2019. MAIN OUTCOMES AND MEASURES Confidence in affording health insurance, keeping a job or delaying retirement to have employer-sponsored health insurance, concerns about potential changes to health insurance associated with changes in federal policies, and avoidance of medical care or medication because of cost. RESULTS Among 1028 respondents aged 50 to 64 years (mean [SD] age, 57.0 [4.2] years), 51.8% (95% CI, 48.6%-55.0%) were female, 40.4% (95% CI, 37.2%-43.7%) had a high school education or less, 65.2% (95% CI, 62.1%-68.3%) were employed, and 34.8% (95% CI, 31.7%-37.9%) were retired or not working. Approximately one-fourth of respondents (27.4%; 95% CI, 24.6%-30.4%) had little to no confidence in being able to afford health insurance over the next year, and nearly one-half (44.6%; 95% CI, 41.4%-47.8%) had little to no confidence in their ability to afford health insurance when they retire; 14.1% (95% CI, 12.0%-16.5%) reported keeping a job and 11.4% (95% CI, 9.6%-13.6%) reported delaying or considering delaying retirement to have employer-sponsored health insurance. Most respondents (67.7%; 95% CI, 64.6%-70.6%) were very or somewhat concerned about potential changes to their health insurance associated with changes in federal policies. In the past year, 13.2% (95% CI, 11.2%-15.5%) of respondents did not get medical care and 11.9% (95% CI, 9.9%-14.1%) avoided filling a prescription medication because of cost. After adjusting for demographic and health characteristics, individuals with low confidence in health insurance affordability during either the next year or retirement were significantly more likely than those with higher confidence to avoid medical care (adjusted odds ratio, 2.89; 95% CI, 1.86-4.49; P < .001) and to avoid filling a prescription medication (adjusted odds ratio, 2.87; 95% CI, 1.71-4.80; P < .001) because of cost concerns. CONCLUSIONS AND RELEVANCE Many adults aged 50 to 64 years worry about their ability to afford health insurance during retirement and about potential future changes to their health (continued)

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