Publications by authors named "Asheley C Skinner"

50 Publications

Predictors and Patterns of Physical Activity From Transportation Among United States Youth, 2007-2016.

J Adolesc Health 2021 May 3. Epub 2021 May 3.

Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.

Purpose: Physical activity is strongly associated with health benefits in youth, although wide disparities in physical activity persist across sex, race/ethnicity, and income. Active transportation is an important source of youth physical activity. We aimed to describe active transportation patterns for United States adolescents and young adults ages 12-25 years across sociodemographic and weight status characteristics.

Methods: Cross-sectional secondary data analyses were based on self-reported transportation-related physical activity using the National Health and Nutrition Examination Survey, 2007-2016.

Results: Of the sample (n = 8,680; population represented, N = 57,768,628), 4,300 (49.5%) were adolescents (12-17 y), and 4,380 (50.4%) were young adults (18-25 y). Male adolescents were more likely to participate in any (risk ratio [RR] = 1.3; 95% confidence interval [CI], 1.16-1.40) and daily (RR = 1.3; 95% CI, 1.06-1.63) active transportation than females. Black (RR = 1.1; 95% CI, 1.01-1.31) and Hispanic (RR = 1.2; 95% CI, 1.05-1.31) adolescents were more likely to engage in any active transportation than whites. Young adult males were more likely to participate in any (RR = 1.3; 95% CI, 1.20-1.50) and daily (RR = 1.3; 95% CI, 1.08-1.55) active transportation than females. Young adults with a lower family income, and both adolescents and young adults with a lower household education, were more likely to engage in any and daily active transportation. We also observed an inverse relationship between weight class and active transportation participation.

Conclusion: Active transportation was higher in males, minority, and lower income youth. Our study findings provide evidence for physical activity interventions, suggesting active transportation is a feasible target for low-income and minority youth to reduce physical activity disparities and support optimal health.
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http://dx.doi.org/10.1016/j.jadohealth.2021.03.028DOI Listing
May 2021

Weight-Related Behaviors of Children with Obesity during the COVID-19 Pandemic.

Child Obes 2021 Apr 26. Epub 2021 Apr 26.

Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.

During the coronavirus disease 2019 (COVID-19) pandemic, children and families have had to adapt their daily lives. The purpose of this study was to describe changes in the weight-related behaviors of children with obesity after the onset of the COVID-19 pandemic. Semistructured interviews ( = 51) were conducted from April to June 2020 with parents of children with obesity. Families were participants in a randomized trial testing a clinic-community pediatric obesity treatment model. During interviews, families described their experience during the COVID-19 pandemic, with a particular emphasis on children's diet, physical activity, sleep, and screen time behaviors. Rapid qualitative analysis methods were used to identify themes around changes in children's weight-related behaviors. The mean child age was 9.7 (±2.8) years and the majority of children were Black (46%) or Hispanic (39%) and from low-income families (62%). Most parent participants were mothers (88%). There were differences in the perceived physical activity level of children, with some parents attributing increases in activity or maintenance of activity level to increased outdoor time, whereas others reported a decline due to lack of outdoor time, school, and structured activities. Key dietary changes included increased snacking and more meals prepared and consumed at home. There was a shift in sleep schedules with children going to bed and waking up later and an increase in leisure-based screen time. Parents played a role in promoting activity and managing children's screen time. The COVID-19 pandemic has created unique lifestyle challenges and opportunities for lifestyle modification. Clinical Trials ID: NCT03339440.
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http://dx.doi.org/10.1089/chi.2021.0038DOI Listing
April 2021

Prevalence of food insecurity among students attending four Historically Black Colleges and Universities.

J Am Coll Health 2021 Mar 24:1-7. Epub 2021 Mar 24.

Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.

This study examined the prevalence of food insecurity (FI) among students attending Historically Black Colleges and Universities (HBCUs) in the Southeastern United States. Students attending four HBCUs ( = 351) completed an anonymous Web-based survey. Food insecurity was assessed using the 2-item Hunger Vital Sign Tool. Summary statistics were used to quantify FI experiences. Logistic regression was conducted to determine if student demographic characteristics were significantly associated with FI outcomes. Nearly 3 in 4 students (72.9%) reported some level of FI in the past year. Students representing all levels of postsecondary education reported FI. Meal plan participation did not prevent FI. Students attending HBCUs experience FI at levels that exceed estimates reported among students attending predominantly White institutions. More work is needed to understand the lived experience of food-insecure HBCU students as a means to ensure institution-level food policies support student academic success and wellbeing.
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http://dx.doi.org/10.1080/07448481.2021.1877144DOI Listing
March 2021

The association between neighborhood quality, youth physical fitness, and modifiable cardiovascular disease risk factors.

Ann Epidemiol 2021 05 14;57:30-39. Epub 2021 Feb 14.

Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Department of Family Medicine & Community Health, Duke University School of Medicine, Durham, NC. Electronic address:

Purpose: Striking disparities persist in cardiovascular disease risk factors among minority youth. We examined the association between multiple indicators of neighborhood quality and minority youth fitness.

Methods: The primary exposure was the Child Opportunity Index (COI), a measure comprised of indicators that facilitate healthy child development. Outcome data were drawn from the 2018-2019 Fit2Play Study (Miami-Dade County, FL). Hotspot analysis evaluated COI spatial clustering. Generalized linear mixed models examined cross-sectional COI-fitness associations.

Results: The sample included 725 youth (53% Black, 43% Hispanic; 5-17 years). Significant neighborhood quality spatial clusters were identified (Gi* = -4.85 to 5.36). Adjusting for sociodemographics, walkability was associated with lower percentiles in body mass index (BMI) and diastolic blood pressure percentiles (DBP) (β = -5.25, 95% CI: -8.88, -1.62 and β = -3.95, 95% CI: -7.02, -0.89, respectively) for all, lower skinfold thickness (β = -4.83, 95% CI: -9.97, 0.31 and higher sit-ups (β = 1.67, 95% CI: -0.17, 3.50) among girls, and lower systolic blood pressure percentiles (SBP) (β = -4.75, 95% CI: -8.99, -0.52) among boys. Greenspace was associated with higher BMI (β = 6.17, 95% CI: 2.47, 9.87), SBP (β = 3.47, 95% CI: -0.05, 6.99), and DBP (β = 4.11, 95% CI: 1.08, 7.13).

Conclusions: COI indicators were positively associated with youth fitness. Disparities in youth cardiovascular disease risk may be modifiable through community interventions and built environment initiatives targeting select neighborhood factors.
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http://dx.doi.org/10.1016/j.annepidem.2021.02.004DOI Listing
May 2021

The Dose-Response Relationship Between Physical Activity and Cardiometabolic Health in Adolescents.

Am J Prev Med 2021 01;60(1):95-103

Duke Clinical Research Institute, Durham, North Carolina; Duke Center for Childhood Obesity Research, Duke University School of Medicine, Durham, North Carolina; Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Duke Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina.

Introduction: This study examines the dose-response relationship between moderate-to-vigorous physical activity and cardiometabolic measures in adolescents.

Methods: Cross-sectional spline analyses were performed using 2003-2016 National Health and Nutrition Examination Survey data among adolescents (aged 12-19 years, N=9,195) on objectively measured (2003-2006) and self-reported (2007-2016) weekly mean minutes of moderate-to-vigorous physical activity and cardiometabolic measures (systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein, BMI, and cardiorespiratory fitness). Inflection points were determined for nonlinear relationships.

Results: For objective moderate-to-vigorous physical activity, female adolescents had significant nonlinear associations with inflection points at 90 minutes/week for BMI percentile and systolic blood pressure. Male adolescents had inflection points at 150 weekly minutes of objective activity for BMI percentile and cardiorespiratory fitness. BMI percentile was about 7% lower for female and male adolescents at 150 weekly minutes of objectively measured moderate-to-vigorous physical activity than at 0 minutes. For self-reported moderate-to-vigorous physical activity, inflection points were at 375 minutes/week (diastolic blood pressure for female adolescents) and 500 minutes/week (systolic blood pressure for male adolescents).

Conclusions: Among several significant dose-response relationships between physical activity and cardiometabolic health in adolescents, consistent and often nonlinear relationships were identified for BMI, with inflection points at 90-150 minutes of objective moderate-to-vigorous physical activity. Notable differences in associations and linearity were identified by sex and physical activity measure (objective or self-reported). These results support calls for any increase in physical activity among adolescents and suggest that recommendations closer to the adult guidelines of 150 weekly minutes of physical activity may be health promoting and more attainable for youth than the current recommendation of 420 weekly minutes.
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http://dx.doi.org/10.1016/j.amepre.2020.06.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769140PMC
January 2021

Critically Evaluating Youth Body Mass Index Trajectories: Implications for Health Versus Stigma.

Am J Public Health 2020 11;110(11):1599-1600

The authors are with the Department of Population Health Sciences, Duke University School of Medicine, Durham, NC. Emily M. D'Agostino is also with the Department of Family Medicine and Community Health, Duke University School of Medicine.

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http://dx.doi.org/10.2105/AJPH.2020.305928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542281PMC
November 2020

The association between the supply of select nonpharmacologic providers for pain and use of nonpharmacologic pain management services and initial opioid prescribing patterns for Medicare beneficiaries with persistent musculoskeletal pain.

Health Serv Res 2021 Apr 1;56(2):275-288. Epub 2020 Oct 1.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA.

Objective: To test the relationship between the supply of select nonpharmacologic providers (physical therapy (PT) and mental health (MH)) and use of nonpharmacologic services among older adults with a persistent musculoskeletal pain (MSP) episode.

Data Sources/study Setting: Claims data from a 5 percent random sample of Medicare beneficiaries enrolled fee-for-service (2007-2014) and the Area Health Resource File (AHRF).

Study Design: This retrospective study used generalized estimating equations to estimate the association between the county nonpharmacologic provider supply and individual service use with opioid prescriptions filled during Phase 1 (first three months of an episode) and Phase 2 (three months following Phase 1).

Data Collection/extraction Methods: We identified beneficiaries (>65 years) with ≥2 MSP diagnoses ≥90 days apart and no opioid prescription six months before the first pain diagnosis (N = 69 456). Beneficiaries' county characteristics were assigned using the AHRF.

Principal Findings: About 13.9 percent of beneficiaries used PT, 1.8 percent used MH services, and 10.7 percent had an opioid prescription during the first three months of a persistent MSP episode. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT/10 000 people/county [aOR: 0.98, 95% CI: 0.97-1.00] was associated with lower odds of filling an opioid prescription in Phase 1. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT use in Phase 1 [aOR: 0.62, 95% CI: 0.58-0.67] were associated with lower odds of filling an opioid prescription in Phase 2. The associations between the supply of providers and nonpharmacologic service use in Phase 1 and Phase 1 opioid prescriptions significantly differed by metropolitan and rural counties (P-value: .019).

Conclusions: Limited access to nonpharmacologic services is associated with opioid prescriptions at the onset of a persistent MSP episode. Initiating PT at the onset of an episode may reduce future opioid use. Strategies for engaging beneficiaries in nonpharmacologic services should be tailored for metropolitan and rural counties.
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http://dx.doi.org/10.1111/1475-6773.13561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969208PMC
April 2021

Effects of Breastfeeding, Formula Feeding, and Complementary Feeding on Rapid Weight Gain in the First Year of Life.

Acad Pediatr 2021 03 19;21(2):288-296. Epub 2020 Sep 19.

Division of Primary Care Pediatrics and Duke Center for Childhood Obesity Research, Department of Pediatrics, Duke University School of Medicine (CT Wood and EM Perrin), Durham, NC.

Objective: To determine whether proportion of breast versus formula feeding and timing of complementary food introduction affect the odds of rapid gain in weight status in a diverse sample of infants.

Methods: Using data from Greenlight Intervention Study, we analyzed the effects of type of milk feeding (breastfeeding, formula, or mixed feeding) from the 2- to 6-month well visits, and the introduction of complementary foods before 4 months on rapid increase in weight-for-age z-score (WAZ) and weight-for-length z-score (WLZ) before 12 months using multivariable logistic regression models.

Results: Of the 865 infants enrolled, 469 had complete data on all variables of interest, and 41% and 33% of those infants had rapid increases in WAZ and WLZ, respectively. Odds of rapid increase in WAZ remained lowest for infants breastfeeding from 2 to 6 months (adjusted odds ratio [aOR] 0.34; 95% confidence interval [CI]: 0.17, 0.69) when compared to infants who were formula-fed. Adjusted for feeding, introduction of complementary foods after 4 months was associated with decreased odds of rapid increase in WLZ (aOR 0.64; 95% CI: 0.42, 0.96).

Conclusions: Feeding typified by predominant breastfeeding and delaying introduction of complementary foods after 4 months reduces the odds of rapid increases in WAZ and WLZ in the first year of life.
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http://dx.doi.org/10.1016/j.acap.2020.09.009DOI Listing
March 2021

Changes in the Recreational Built Environment and Youth Body Mass Index.

Acad Pediatr 2021 Jan-Feb;21(1):76-83. Epub 2020 Sep 8.

Duke Center for Childhood Obesity Research (MJ White, J Howard, AC Skinner, and EM Perrin), Duke University School of Medicine, Durham, NC; Department of Pediatrics (MJ White, J Howard, and EM Perrin), Duke University School of Medicine, Durham, NC.

Objective: Many cities have implemented programs to improve the recreational built environment. We evaluated whether neighborhood recreational built environmental changes are associated with change in body mass index (BMI).

Methods: We performed a longitudinal assessment of association between the recreational built environment and BMI percent of 95th percentile (BMIp95). Patient data from 2012 to 2017 were collected from electronic medical records including height, weight, sex, race/ethnicity, insurance type, and address. BMIp95 was calculated. Environmental data including sidewalks, trails, Healthy Mile Trails, and parks were collected. Patients' neighborhood environments were characterized using proximity of features from home address. Multilevel linear regressions with multiple encounters per patient estimated effects of recreational features on BMIp95 and stratified models estimated effect differences.

Results: Of 8282 total patients, 27.7% were non-Hispanic White, half were insured by Medicaid, and 29.5% changed residence. Median BMIp95 was 86.3%. A decrease in BMIp95 was associated with park proximity in the full cohort (-2.85; 95% CI [confidence interval]: -5.47, -0.24; P = .032), children with obesity at baseline (-6.50; 95% CI: -12.36, -0.64; P = .030) and privately insured children (-4.77; 95% CI: -9.14, -0.40; P = .032). Healthy Mile Trails were associated with an increase in BMIp95 among children without obesity (1.00; 95% CI 0.11, 1.89; P = .027) and children living in higher income areas (6.43; 95% CI: 0.23, 12.64; P = .042).

Conclusions: Differences in effect indicate that built environment changes may improve or exacerbate disparities. Improving obesity disparities may require addressing family-level barriers to the use of recreational features in addition to proximity.
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http://dx.doi.org/10.1016/j.acap.2020.09.004DOI Listing
September 2020

Flattening the (BMI) Curve: Timing of Child Obesity Onset and Cardiovascular Risk.

Pediatrics 2020 08 6;146(2). Epub 2020 Jul 6.

Departments of Pediatrics and Population Health Sciences, School of Medicine, Duke University and Duke Clinical Research Institute, Duke Center for Childhood Obesity Research, Durham, North Carolina.

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http://dx.doi.org/10.1542/peds.2020-1353DOI Listing
August 2020

Rationale and design of "Hearts & Parks": study protocol for a pragmatic randomized clinical trial of an integrated clinic-community intervention to treat pediatric obesity.

BMC Pediatr 2020 06 26;20(1):308. Epub 2020 Jun 26.

Duke Clinical Research Institute, Duke University, Durham, NC, 27710, USA.

Background: The prevalence of child and adolescent obesity and severe obesity continues to increase despite decades of policy and research aimed at prevention. Obesity strongly predicts cardiovascular and metabolic disease risk; both begin in childhood. Children who receive intensive behavioral interventions can reduce body mass index (BMI) and reverse disease risk. However, delivering these interventions with fidelity at scale remains a challenge. Clinic-community partnerships offer a promising strategy to provide high-quality clinical care and deliver behavioral treatment in local park and recreation settings. The Hearts & Parks study has three broad objectives: (1) evaluate the effectiveness of the clinic-community model for the treatment of child obesity, (2) define microbiome and metabolomic signatures of obesity and response to lifestyle change, and (3) inform the implementation of similar models in clinical systems.

Methods: Methods are designed for a pragmatic randomized, controlled clinical trial (n = 270) to test the effectiveness of an integrated clinic-community child obesity intervention as compared with usual care. We are powered to detect a difference in body mass index (BMI) between groups at 6 months, with follow up to 12 months. Secondary outcomes include changes in biomarkers for cardiovascular disease, psychosocial risk, and quality of life. Through collection of biospecimens (serum and stool), additional exploratory outcomes include microbiome and metabolomics biomarkers of response to lifestyle modification.

Discussion: We present the study design, enrollment strategy, and intervention details for a randomized clinical trial to measure the effectiveness of a clinic-community child obesity treatment intervention. This study will inform a critical area in child obesity and cardiovascular risk research-defining outcomes, implementation feasibility, and identifying potential molecular mechanisms of treatment response.

Clinical Trial Registration: NCT03339440 .
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http://dx.doi.org/10.1186/s12887-020-02190-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318397PMC
June 2020

The Dose-Response Relationship Between Physical Activity and Cardiometabolic Health in Young Adults.

J Adolesc Health 2020 08 19;67(2):201-208. Epub 2020 Jun 19.

Duke Clinical Research Institute, Durham, North Carolina; Duke Center for Childhood Obesity Research, Duke University School of Medicine, Durham, North Carolina; Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Children's Health and Discovery Institute, Duke University School of Medicine, Durham, North Carolina. Electronic address:

Purpose: Guidelines recommend 150 minutes of weekly moderate-to-vigorous physical activity (MVPA) for all adults, although physical activity level correlation with cardiometabolic health is not well characterized for young adults. We determined the dose-response relationship of MVPA on measures of cardiometabolic health in young adults.

Methods: We examined young adults (aged 20-29 years; N = 5,395, 47.9% female) in the 2003-2016 National Health and Nutrition Examination Survey. Exposures were objective (accelerometer based) and self-reported weekly mean minutes of MVPA. Cardiometabolic outcome measures were body mass index (BMI), high-density lipoprotein (HDL), total cholesterol, systolic blood pressure, and diastolic blood pressure. The dose-response relationships were assessed with unadjusted spline analyses. Sex-stratified outcomes were modeled using multivariable linear regression with mean estimated change presented for 150-minute dose increases of MVPA.

Results: Among females, associations between objective activity and cardiometabolic measures were all linear. Compared with no activity, 150 minutes of objective activity was associated with a lower BMI (-1.37 kg/m) and total cholesterol (-4.89 mg/dL), whereas 150 minutes of self-reported activity was associated with a higher HDL (1 mg/dL) and lower diastolic blood pressure (-.42 mm Hg). Among males, an inflection point was identified in the dose-response curves for objective activity with BMI around 100 minutes. Compared with no activity, 150 self-reported minutes was associated with lower BMI (-.26 kg/m), higher HDL (.52 mg/dL), and lower total cholesterol (-1.35 mg/dL).

Conclusions: The dose-response relationships between physical activity and cardiometabolic markers in young adults were predominantly linear, supporting public health calls for any increase in physical activity in this population.
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http://dx.doi.org/10.1016/j.jadohealth.2020.04.021DOI Listing
August 2020

Using geographic information systems to characterize food environments around historically black colleges and universities: Implications for nutrition interventions.

J Am Coll Health 2020 Jun 22:1-6. Epub 2020 Jun 22.

Nicholas School of the Environment, Division of Environmental Sciences & Policy, Duke University, Durham, North Carolina, USA.

Objective: To understand the distribution of healthy and unhealthy food stores near historically black colleges and universities (HBCUs). Using ArcGIS Pros network analysis tools and ReferenceUSA database, this study characterized the healthy (favorable) and unhealthy (unfavorable) retail food stores within a 5-mile radius, 15-min driving, and 15-min walking distance from each HBCU in North Carolina. Most retail food stores within a 5-mile buffer radius of the 10 HBCUs in North Carolina were unfavorable. Within 15-min driving from each HBCU, 1082 stores (76.0%) were unfavorable food stores, while 332 (24.0%) were favorable. Additionally, there were four favorable and 35 unfavorable retail food stores within the 15-min walking distance of each HBCU. Favorable food retail stores around HBCUs in North Carolina are limited. Researchers, policy makers, and community stakeholders should work together to improve food environments surrounding HBCUs.
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http://dx.doi.org/10.1080/07448481.2020.1767113DOI Listing
June 2020

Food insecurity is associated with increased weight loss attempts in children and adolescents.

Pediatr Obes 2021 01 18;16(1):e12691. Epub 2020 Jun 18.

Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Household food insecurity (HFI) has been associated with adverse childhood outcomes and shares many common risk factors with obesity. Half of adolescents with overweight or obesity are actively attempting to lose weight. We aim to evaluate whether HFI is associated with weight loss attempts and unhealthy weight loss control practices in children. We examined cross-sectional data of children ages 8 to 15 years old from the National Health and Nutrition Examination Survey. Attempted weight loss was more common among children with very low food security (OR 1.50, 95% CI 1.09, 2.07). Children with a healthy weight with very low food security had increased odds of attempting weight loss (OR 1.51, 95% CI 1.00, 2.26) but there was no association in children with overweight or obesity. Very low food security was also associated with unhealthy weight control practices (OR: 1.42, 95% CI: 1.04, 1.93). Physicians should counsel all children and adolescents on healthy and unhealthy weight loss behaviours, regardless of weight or food security status.
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http://dx.doi.org/10.1111/ijpo.12691DOI Listing
January 2021

The Association Between the Supply of Nonpharmacologic Providers, Use of Nonpharmacologic Pain Treatments, and High-risk Opioid Prescription Patterns Among Medicare Beneficiaries With Persistent Musculoskeletal Pain.

Med Care 2020 05;58(5):433-444

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill.

Background: Opioids are prescribed more frequently than nonpharmacologic treatments for persistent musculoskeletal pain (MSP). We estimate the association between the supply of physical therapy (PT) and mental health (MH) providers and early nonpharmacologic service use with high-risk opioid prescriptions among Medicare beneficiaries with persistent MSP.

Research Design: We retrospectively studied Medicare beneficiaries (>65 y) enrolled in Fee-for-Service and Part D (2007-2014) with a new persistent MSP episode and no opioid prescription during the prior 6 months. Independent variables were nonpharmacologic provider supply per capita and early nonpharmacologic service use (any use during first 3 mo). One year outcomes were long-term opioid use (LTOU) (≥90 days' supply) and high daily dose (HDD) (≥50 mg morphine equivalent). We used multinomial regression and generalized estimating equations and present adjusted odds ratios (aORs).

Results: About 2.4% of beneficiaries had LTOU; 11.9% had HDD. The supply of MH providers was not associated with LTOU and HDD. Each additional PT/10,000 people/county was associated with greater odds of LTOU [aOR: 1.06; 95% confidence interval (CI), 1.01-1.11). Early MH use was associated with lower odds of a low-risk opioid use (aOR: 0.81; 95% CI, 0.68-0.96), but greater odds of LTOU (aOR: 1.93; 95% CI, 1.28-2.90). Among beneficiaries with an opioid prescription, early PT was associated with lower odds of LTOU (aOR: 0.75; 95% CI, 0.64-0.89), but greater odds of HDD (aOR: 1.25; 95% CI, 1.15-1.36).

Conclusions: The benefits of nonpharmacologic services on opioid use may be limited. Research on effective delivery of nonpharmacologic services to reduce high-risk opioid use for older adults with MSP is needed.
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http://dx.doi.org/10.1097/MLR.0000000000001299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451631PMC
May 2020

Prevalence of hyperfiltration among US youth/young adults with overweight and obesity: A population-based association study.

Obes Sci Pract 2019 Dec 22;5(6):570-580. Epub 2019 Aug 22.

Department of Population Health Sciences and Duke Clinical Research Institute Duke University School of Medicine Durham North Carolina USA.

Objective: Determine prevalence of hyperfiltration (high estimated glomerular filtration rate "GFR" >95th percentile for age/sex) among youth and association with BMI classification.

Methods: With the use of 1999 to 2016 National Health and Nutrition Examination Survey data from 12- to 29-year-olds, data for serum creatinine and thresholds for high GFR were normed using a metabolically healthy subsample (no albuminuria, healthy weights, normal blood pressures, blood glucoses, lipids, and liver enzymes). Logistic regression examined the association of BMI classification (healthy weight, overweight, and obesity classes 1-3) with hyperfiltration (GFR > 95th percentile for age/sex), adjusted for diabetes and other covariates.

Results: Of 12- to 29-year-olds ( = 18 698), 27.4% ( = 5493) met criteria for entry into the "healthy subsample" and contributed data to derive normative values for serum creatinine/hyperfiltration thresholds. In the full sample, hyperfiltration prevalence in 12- to 29-year-olds classified as healthy-weight, overweight, and obesity classes 1 to 3 was 4.9%, 4.7%, 6.5%, 8.7%, and 11.8%, respectively ( < .001). In multivariable analysis, obesity classes 2 and 3 were associated with greater likelihood of hyperfiltration (adjusted ORs for class 2: 1.5, 95% CI, 1.1-2.1; and for class 3, 2.1, 95% CI, 1.5-2.9). Diabetes also was associated with hyperfiltration (AOR, 4.0; 95% CI, 2.2-7.4).

Conclusion: Obesity classes 2 to 3 are associated with hyperfiltration in youth. Age/sex-specific norms for creatinine and hyperfiltration thresholds may aid recognition of kidney dysfunction early.
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http://dx.doi.org/10.1002/osp4.365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6934429PMC
December 2019

Long-term opioid therapy definitions and predictors: A systematic review.

Pharmacoepidemiol Drug Saf 2020 03 18;29(3):252-269. Epub 2019 Dec 18.

Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA.

Purpose: This review sought to (a) describe definitions of long-term opioid therapy (LTOT) outcome measures, and (b) identify the predictors associated with the transition from short-term opioid use to LTOT for opioid-naïve individuals.

Methods: We conducted a systematic review of the peer-reviewed literature (January 2007 to July 2018). We included studies examining opioid use for more than 30 days. We classified operationalization of LTOT based on criteria used in the definitions. We extracted LTOT predictors from multivariate models in studies of opioid-naïve individuals.

Results: The search retrieved 5,221 studies, and 34 studies were included. We extracted 41 unique variations of LTOT definitions. About 36% of definitions required a cumulative duration of opioid use of 3 months. Only 17% of definitions considered consecutive observation periods, 27% used days' supply, and no definitions considered dose. We extracted 76 unique predictors of LTOT from seven studies of opioid-naïve patients. Common predictors included pre-existing comorbidities (21.1%), non-opioid prescription medication use (13.2%), substance use disorders (10.5%), and mental health disorders (10.5%).

Conclusions: Most LTOT definitions aligned with the chronic pain definition (pain more than 3 months), and used cumulative duration of opioid use as a criterion, although most did not account for consistent use. Definitions were varied and rarely accounted for prescription characteristics, such as days' supply. Predictors of LTOT were similar to known risk factors of opioid abuse, misuse, and overdose. As LTOT becomes a central component of quality improvement efforts, researchers should incorporate criteria to identify consistent opioid use to build the evidence for safe and appropriate use of prescription opioids.
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http://dx.doi.org/10.1002/pds.4929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058495PMC
March 2020

Using Telehealth to Disseminate Primary, Secondary, and Tertiary CVD Interventions to Rural Populations.

Curr Hypertens Rep 2019 11 7;21(12):92. Epub 2019 Nov 7.

Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Suite 210, Durham, NC, 27701, USA.

Purpose Of Review: This study aims to review the evidence on telehealth interventions in rural communities that use primary, secondary, or tertiary strategies for the prevention and management of cardiovascular disease (CVD).

Recent Findings: Studies focused on the reduction of CVD risk factors and mitigation of disease progression among rural populations using telehealth are limited in number but appear to be increasing in the last 5 years. These studies suggest primary-, secondary-, and tertiary-level interventions can impact CVD risk and management. The current review found more studies addressing primary CVD intervention strategies, although the evidence for efficacy at all intervention levels is in the early stages. Leveraging prevention strategies via telehealth may be an effective vehicle to facilitate improved CVD outcomes among populations traditionally marginalized by geographic location.
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http://dx.doi.org/10.1007/s11906-019-0998-8DOI Listing
November 2019

Kinship Care and Foster Care: A Comparison of Out-of-Home Placement From the Perspective of Child Abuse Experts in North Carolina.

N C Med J 2019 Nov-Dec;80(6):325-331

associate professor, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina.

Children may be placed in either kinship or foster care, forms of out-of-home placement (OHP), if maltreatment is suspected. The American Academy of Pediatrics has identified them as children with special health needs requiring elevated care. While North Carolina has increased support for foster care, it is unclear whether similar support exists for kinship care. Child abuse medical providers (CAMPs) were interviewed regarding their understanding and assessment of the state of the kinship care system in North Carolina, and how it can be improved. CAMPs were individually interviewed using a semi-structured, open-ended question guide to assess their perspectives on kinship versus foster care in North Carolina. Data were coded, and the analysis was conducted in an inductive manner, allowing themes and then recommendations to emerge from interviews. The following three themes were identified: 1) providers have a foundational understanding of the kinship care system, marked by knowledge gaps; 2) children in kinship care and foster care have equivalent, elevated health needs, but children in kinship care do not receive the same level of care; 3) individual and structural changes have to be made to the interprofessional teams working within the OHP system. The study sample was small, including eight CAMPs who had relatively homogenous demographic characteristics. CAMPs typically see the worst cases of maltreatment, which may bias responses. Additionally, the majority of children in kinship care are unknown to CAMPs and may not be fully represented in responses. CAMPs' responses were summarized into a set of recommendations targeting four different components of the OHP team: the general interprofessional team, policymakers and state leaders, medical providers, and social workers.
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http://dx.doi.org/10.18043/ncm.80.6.325DOI Listing
November 2019

Body Mass Index Change Between Referral to and Enrollment in Pediatric Weight Management.

Clin Pediatr (Phila) 2020 01 28;59(1):70-74. Epub 2019 Oct 28.

Department of Pediatrics, Duke Center for Childhood Obesity Research, Duke University, Durham, NC, USA.

This study describes changes in body mass index score (BMI) and percent of 95th percentile (P95) between referral to pediatric weight management (PWM) and initial PWM visit. We conducted a prospective cohort analysis among subjects (n = 77) aged 5 to 11 years referred to PWM and compared height and weight at time of referral versus initial PWM visit. Mean BMI decreased by 0.05, and P95 decreased by 1.48 across all age groups (both < .01) from time of referral to initial visit. Children 5 to 8 years old experienced a greater BMI change than older children (-0.07 vs -0.02; < .05). Interval BMI change was greater for non-Hispanic White and Hispanic children compared with non-Hispanic Blacks (-0.10 vs -0.01; < .001). There were no subgroup differences in P95. Interval BMI changes between referral and treatment approach half the effect reported by some PWM programs. Referral to PWM may motivate pretreatment lifestyle changes in some patients.
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http://dx.doi.org/10.1177/0009922819884587DOI Listing
January 2020

The lock-in loophole: Using mixed methods to explain patient circumvention of a Medicaid opioid restriction program.

Subst Abus 2020 23;41(4):510-518. Epub 2019 Oct 23.

Department of Pharmacy Sciences, Creighton University School of Pharmacy and Health Professions, Creighton University, Omaha, Nebraska, USA.

Background: Lock-in programs are proliferating among private and public payers to restrict access to controlled substance prescriptions and enhance care coordination for patients exhibiting high-risk use of, primarily, opioids. Patients enrolled in lock-in programs are required to seek opioids from a designated provider and pharmacy for insurance coverage of their opioid and benzodiazepine prescriptions. Lock-in program restrictions are often circumvented by patients through out-of-pocket cash purchases of opioid prescriptions, undermining the program's intended function. This study sought to construct and explain trajectories of Medicaid-covered and cash pay opioid prescription fills among adults enrolled in an opioid lock-in program. : We used sequential explanatory mixed methods, which involved a quantitative retrospective cohort analysis of opioid fill trajectories using North Carolina Medicaid administrative claims data linked with state prescription drug monitoring program data, followed by qualitative semi-structured interviews with North Carolina pharmacists. The quantitative component included adults enrolled in the North Carolina Medicaid lock-in program between 10/1/2010-3/31/2012. The qualitative component included a maximum variation sample of community pharmacists in North Carolina delivering care to lock-in patients. Quantitative outcomes included group-based trajectories of monthly Medicaid-covered and cash pay opioid prescription fills six months before and after LIP enrollment, and qualitative analyses generated themes explaining observed trajectories. : Two-thirds of subjects exhibited reduced Medicaid-covered opioid prescription fills and no increase in cash pay fills after lock-in enrollment, with one-third exhibiting increased cash pay fills after lock-in. Pharmacists attributed increases in cash pay fills primarily to illicit behaviors, while some cash pay behavior likely reflected new unintended barriers to care. : Lock-in programs appear to reduce prescription opioid use for most enrolled patients. However, lock-in programs may have limited capacity to deter illicit behaviors among patients intent on abusing, misusing, or diverting these medications and may introduce new access barriers to necessary care for some.
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http://dx.doi.org/10.1080/08897077.2019.1674239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7176522PMC
October 2019

Characteristics of New Opioid Use Among Medicare Beneficiaries: Identifying High-Risk Patterns.

J Manag Care Spec Pharm 2019 Sep;25(9):966-972

Department of Population Health Sciences, Duke University School of Medicine, and Duke Clinical Research Institute, Duke University, Durham, North Carolina.

Background: Opioid prescription patterns, including long-term use, multiple prescribers, and high opioid doses, increase the risk for adverse outcomes; however, previous research in older adult populations has primarily described opioid dose patterns using average daily dose measures or using very high thresholds (i.e., > 100 morphine milligram equivalents [MME] per day).

Objective: To describe prescription patterns by peak dose among older adults who have newly initiated opioid use in 2014 and describe long-term opioid use and the use of multiple pharmacies and prescribers among those with peak opioid doses over 50 and over 90 MME per day.

Methods: This was a retrospective cohort study of Medicare Part D prescription claims data (5% sample) for beneficiaries aged 65 years and older who were prescribed ≥ 1 opioid prescription in 2014 and did not have an opioid prescription in the preceding 180 days. Within a 1-year period of follow-up, we used prescription claims to characterize individuals' opioid exposure, measuring long-term opioid use (≥ 90 days of continuous opioid supply), unique opioid prescribers, and unique opioid-dispensing pharmacies. Peak MME was defined as the maximum daily MME received across all overlapping opioid prescriptions in the observation period.

Results: 144,127 beneficiaries without an opioid prescription in the previous 6 months filled ≥ 1 opioid prescription in 2014. During the 1-year follow-up period, 6.5% of beneficiaries transitioned to long-term opioid use; 39.5% received opioid prescriptions from > 1 prescriber; 18.1% filled opioid prescriptions from > 1 pharmacy; and 21.8% had a peak MME of 50-89. Among the 28.1% of beneficiaries exposed to a peak MME > 50, 8.6% developed long-term opioid use; 7.0% had 3 or more opioid dispensing pharmacies; and 28.0% had 3 or more opioid prescribers. Among the 6.2% of beneficiaries exposed to a peak MME ≥ 90, 18.5% developed long-term opioid use; 13.0% had 3 or more opioid dispensing pharmacies; and 39.6% had 3 or more opioid prescribers.

Conclusions: High doses of opioids were prescribed for about one quarter (28%) of Medicare beneficiaries with new opioid use in 2014. Having multiple opioid prescribers or multiple opioid dispensing pharmacies was common, especially among those prescribed higher doses. These prescription patterns can be particularly helpful to identify older adults with increased opioid-related risk.

Disclosures: No funding supported this study. Raman reports research grants from GlaxoSmithKline not related to this study. Roberts was supported by a CTSA grant from NCATS awarded to the University of Kansas Medical Center for Frontiers: The Heartland Institute for Clinical and Translational Research (#KL2TR000119). The other authors have no potential conflicts to report.
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http://dx.doi.org/10.18553/jmcp.2019.25.9.966DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7121919PMC
September 2019

Health Care Utilization and Comorbidity History of North Carolina Medicaid Beneficiaries in a Controlled Substance "Lock-in" Program.

N C Med J 2019 May-Jun;80(3):135-142

assistant professor, Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Medicaid "lock-in" programs (MLIPs) are a widely used strategy for addressing potential misuse of prescription drugs among beneficiary populations. However, little is known about the health care needs and attributes of beneficiaries selected into these programs. Our goal was to understand the characteristics of those eligible, enrolled, and retained in a state MLIP. Demographics, comorbidities, and health care utilization were extracted from Medicaid claims from June 2009 through June 2013. Beneficiaries enrolled in North Carolina's MLIP were compared to those who were MLIP-eligible, but not enrolled. Among enrolled beneficiaries, those completing the 12-month MLIP were compared to those who exited prior to 12 months. Compared to beneficiaries who were eligible for, but not enrolled in the MLIP (N = 11,983), enrolled beneficiaries (N = 5,424) were more likely to have: 1) substance use (23% versus 14%) and mental health disorders, 2) obtained controlled substances from multiple pharmacies, and 3) visited more emergency departments (mean: 8.3 versus 4.2 in the year prior to enrollment). One-third (N = 1,776) of those enrolled in the MLIP exited the program prior to completion. Accurate information on unique prescribers visited by beneficiaries was unavailable. Time enrolled in Medicaid differed for beneficiaries, which may have led to underestimation of covariate prevalence. North Carolina's MLIP appears to be successful in identifying subpopulations that may benefit from provision and coordination of services, such as substance abuse and mental health services. However, there are challenges in retaining this population for the entire MLIP duration.
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http://dx.doi.org/10.18043/ncm.80.3.135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482144PMC
August 2019

Adolescent and Young Adult Recreational, Occupational, and Transportation Activity: Activity Recommendation and Weight Status Relationships.

J Adolesc Health 2019 07 1;65(1):147-154. Epub 2019 Apr 1.

Duke Center for Childhood Obesity Research, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Division of Primary Care, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Duke Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina. Electronic address:

Purpose: Physical activity can occur in many settings, or domains, including recreation, occupation, and transportation. We described patterns of adolescent and young adult (YA) activity in each domain, and the extent that accounting for different domains impacts activity recommendation adherence. We also examined activity domain associations with weight status.

Methods: We examined physical activity among 11,157 adolescents and YAs in recreational, occupational, and transportation domains in the 2007-2016 National Health and Nutrition Examination Survey. We calculated proportions meeting weekly activity recommendations (adolescents: 420 minutes; YAs: 150 minutes) by domain. We compared adjusted odds of performing any activity in each domain by weight status. All estimates are weighted and stratified by age (adolescents: 12-19 years; YAs: 20-29 years) and sex.

Results: Most adolescents (90.9%) and YAs (86.7%) reported activity in at least one domain. Recreational activity accounted for an average of 60.2% (adolescents) and 42.5% (YAs) of an individual's total activity. Approximately half of YAs (50.2%) reported any occupational activity, which accounted for 44.6% (males) and 37.4% (females) of total activity minutes. Transportation accounted for 18.1% (adolescents) and 16.2% (YAs) of total activity. Activity recommendation adherence estimates increased when adding domains: recreation alone (34.9% adolescents, 45.6% YAs); recreation and occupation (47.2% adolescents, 68.7% YAs); and recreation, occupation, and transportation (53.5% adolescents, 74.7% YAs). Weight status was generally not associated with activity domains.

Conclusions: Adolescents and YAs accumulate substantial occupational and some transportation-related physical activity, resulting in more youth meeting activity recommendations when accounting for these activity domains than recreation alone.
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http://dx.doi.org/10.1016/j.jadohealth.2019.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589358PMC
July 2019

Evaluation of a Medicaid Lock-in Program: Increased Use of Opioid Use Disorder Treatment but No Impact on Opioid Overdose Risk.

Med Care 2019 03;57(3):213-217

Duke Clinical Research Institute, Durham, NC.

Background: "Lock-in" programs (LIPs) identify beneficiaries demonstrating potential overutilization of opioids, and other controlled substances, and restrict their access to these medications. LIPs are expanding to address the opioid crisis and could be an effective tool for connecting people to opioid use disorder treatment. We examined the immediate and sustained effects of a Medicaid LIP on overdose risk and use of medication-assisted treatment (MAT) for opioid use disorder.

Methods: We analyzed North Carolina Medicaid claims from July 2009 through June 2013. We estimated daily risk differences and ratios of MAT use and overdose during lock-in and following release from the program, compared with periods before program enrollment.

Results: The daily probability of MAT use during lock-in and following release was greater, when compared with a period just before LIP enrollment [daily risk ratios: 1.50, 95% confidence interval (CI): 1.18-1.91; 2.27, 95% CI: 1.07-4.80; respectively]. Beneficiaries' average overdose risk while enrolled in the program and following release was similar to their risk just before enrollment (daily risk ratios: 1.01, 95% CI: 0.79-1.28; 1.12, 95% CI: 0.82-1.54; respectively).

Discussion: North Carolina's Medicaid LIP was associated with increased use of MAT during enrollment, and this increase was sustained in the year following release from the program. However, we did not observe parallel reductions in overdose risk during lock-in and following release. Identifying facilitators of MAT access and use among this population, as well as potential barriers to overdose reduction are important next steps to ensuring effective LIP design.
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http://dx.doi.org/10.1097/MLR.0000000000001058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083172PMC
March 2019

Improving Timeliness of Medical Evaluations for Children Entering Foster Care.

Pediatrics 2018 12 16;142(6). Epub 2018 Nov 16.

Department of Pediatrics, Duke Children's Primary Care, Duke University Medical Center, Durham, North Carolina.

Background And Objectives: The American Academy of Pediatrics (AAP) recommends children in foster care (FC) have an initial medical evaluation within 3 days of custody initiation; however, this vulnerable population often suffers from disjointed care. Our aim was to improve the mean time to initial foster care evaluation (TIE) from 32 to <7 days within 12 months for children in FC in Durham County, North Carolina.

Methods: This study was a time series, quality improvement project used to target interventions within an academic clinic and a community agency. Interventions were tested through multiple plan-do-study-act cycles. Control charts of the primary outcome, the TIE, were constructed. Charts were annotated with the dates of interventions, including workshops, performance feedback, integration of state forms, identification of appointments, development of an urgent appointment pathway, and empowerment of the scheduler.

Results: The mean TIE improved from 32 to 9 days within 12 months. Significant improvement in the following 2 process measures contributed to this: the time from custody initiation to the referral date improved from an average of 10 to 3 days, and the time from referral date to the initial evaluation improved from an average of 22 to 6 days.

Conclusions: Improvement interventions and increased collaboration between medical and child welfare agencies can result in significant improvement of the TIE. However, despite improvement efforts, challenges remain in meeting the AAP 3-day TIE recommendation. We recommend further assessment of the AAP guideline as it relates to implementation feasibility and health outcomes of children in FC.
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http://dx.doi.org/10.1542/peds.2018-0725DOI Listing
December 2018

Trajectories of dispensed prescription opioids among beneficiaries enrolled in a Medicaid controlled substance "lock-in" program.

Pharmacoepidemiol Drug Saf 2019 01 26;28(1):16-24. Epub 2018 Apr 26.

Duke Clinical Research Institute, Durham, NC, USA.

Purpose: "Lock-in" programs (LIPs) are used by health insurers to address potential substance (eg, opioid) misuse among beneficiaries. We sought to (1) examine heterogeneity in trajectories of dispensed opioids (in average daily morphine milligram equivalents (MMEs)) over time: prior to, during, and following release from a LIP, and (2) assess associations between trajectory patterns and beneficiary characteristics.

Methods: Medicaid claims were linked to Prescription Drug Monitoring Program records for a cohort of beneficiaries enrolled in the North Carolina Medicaid LIP (n = 2701). Using latent class growth analyses, we estimated trajectories of average daily MMEs of opioids dispensed to beneficiaries across specific time periods of interest.

Results: Five trajectory patterns appeared to sufficiently describe underlying heterogeneity. Starting values and slopes varied across the 5 trajectory groups, which followed these overall patterns: (1) start at a high level of MMEs, end at a high level of MMEs (13.1% of cohort); (2) start medium, end medium (13.2%); (3) start medium, end low (21.5%); (4) start low, end medium (22.6%); and (5) start low, end low (29.6%). We observed strong associations between patterns and beneficiaries' demographics, substance use-related characteristics, comorbid conditions, and healthcare utilization.

Conclusions: In its current form, the Medicaid LIP appeared to have limited impact on beneficiaries' opioid trajectories. However, strong associations between trajectory patterns and beneficiary characteristics provide insight into potential LIP design modifications that might improve program impact (eg, LIP integration of substance use disorder assessment and referral to treatment, assessment and support for alternate pain therapies).
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http://dx.doi.org/10.1002/pds.4445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482140PMC
January 2019

Etiology and Resource Use of Fever of Unknown Origin in Hospitalized Children.

Hosp Pediatr 2018 03;8(3):135-140

Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine and North Carolina Children's Hospital, Chapel Hill, North Carolina.

Background: Fever of unknown origin (FUO) is a well-known pediatric presentation. The primary studies determining the causes of prolonged fever in children were performed 4 decades ago, before major advances in laboratory and diagnostic testing. Given that the distribution of diagnosed causes of adult FUO has changed in recent decades, we hypothesized that the etiology of FUO in children has concordantly changed and also may be impacted by a definition that includes a shorter required duration of fever.

Methods: A single-center, retrospective review of patients 6 months to 18 years of age admitted to the North Carolina Children's Hospital from January 1, 2002, to December 21, 2012, with an diagnosis of fever, a documented fever duration >7 days before admission, and a previous physician evaluation of each patient's illness.

Results: A total of 1164 patients were identified, and of these, 102 met our inclusion criteria for FUO. Etiologic categories included "infectious" (42 out of 102 patients), "autoimmune" (28 out of 102 patients), "oncologic" (18 out of 102 patients), and "other" or "unknown" (14 out of 102 patients). Several clinical factors were statistically and significantly different between etiologic categories, including fever length, laboratory values, imaging performed, length of stay, and hospital costs.

Conclusions: Unlike adult studies, the categorical distribution of diagnoses for pediatric FUO has marginally shifted compared to previously reported pediatric studies. Patients hospitalized with FUO undergo prolonged hospital stays and have high hospital costs. Additional study is needed to improve the recognition, treatment, and expense of diagnosis of prolonged fever in children.
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http://dx.doi.org/10.1542/hpeds.2017-0098DOI Listing
March 2018

Understanding the Relationship Between Male Gender Socialization and Gender-Based Violence Among Refugees in Sub-Saharan Africa.

Trauma Violence Abuse 2019 12 29;20(5):638-652. Epub 2017 Aug 29.

Department of Health Policy and Management, University of North Carolina, Chapel Hill, NC, USA.

Gender-based violence (GBV) in humanitarian emergencies is progressively recognized as a global public health problem. Detrimental gender norms influence male perpetrated GBV against women, and social and structural contexts of forced migration and camp resettlement contribute to problematic gender norm development. The review sought to elucidate the dynamics that link gender socialization among male youth in sub-Saharan Africa with violent sexual behaviors. Two concepts were explored: (1) male gender socialization in sub-Saharan Africa related to GBV perpetration patterns and (2) the effect of forced migration on male socialization and GBV. We reviewed articles using a standard systematic review methodology, searching academic databases for peer-reviewed articles, and contacting experts for gray literature. Our initial search identified 210 articles. We manually reviewed these, and 19 met the review inclusion criteria. We identified 20 variables from the first concept and 18 variables from the second. GBV perpetration by male youth is positively associated with social pressures as well as cultural and religious beliefs. Amid forced migration, personal, societal, and cultural preexisting gender inequalities are often amplified to encourage GBV perpetration. The literature revealed aspects of culture, language, role modeling, religion, and the context of violence as important factors that shape young men's perspectives regarding the opposite sex and gender relations as well as sexual desires and dominance. Overall, though, literature focusing on male socialization and GBV prevention is limited. We made recommendations for future studies among refugee male youth in order to better understand these relationships.
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http://dx.doi.org/10.1177/1524838017727009DOI Listing
December 2019