Publications by authors named "Derek S Brown"

76 Publications

Implementation of a Scalable Family-Based Behavioral Treatment for Childhood Obesity Delivered through Primary Care Clinics: Description of the Missouri Childhood Obesity Research Demonstration Study Protocol.

Child Obes 2021 09;17(S1):S39-S47

Pennington Biomedical Research Center, Baton Rouge, LA, USA.

Significant gaps exist in access to evidence-based pediatric weight management interventions, especially for low-income families who are disproportionately affected by obesity. As a part of the Centers for Disease Control and Prevention's Childhood Obesity Research Demonstration project (CORD 3.0), the Missouri team (MO-CORD) aims to increase access to and dissemination of an efficacious pediatric obesity treatment, specifically family-based behavioral treatment (FBT), for low-income families. The implementation pilot study is a multisite matched-comparison group pilot of packaged FBT in pediatric clinics for low-income children with obesity, of ages 5 to 12 years old. The study is implemented in two Missouri pediatric primary care clinical sites, Freeman Health System Pediatric Clinics (rural Joplin) and Children's Mercy Hospital Pediatric Clinics (urban Kansas City). The design focuses on pragmatism through utilization of PRECIS (Pragmatic Explanatory Continuum Indicator Summary) domains, such as open eligibility criteria, limited follow-up intensity, reliance on medical records for creating a usual care comparison group data, and unobtrusive measurement of participant and provider adherence. The evaluation focuses on effectiveness as well as implementation outcomes and barriers to inform implementation scale up. Findings from this study will advance both science and practice by providing novel and immediately useful information to families, health care providers, health care organizations, payers, and other state Medicaid plans by developing and optimizing evidence-based pediatric weight management treatment for implementation and dissemination in health systems to address health disparities among low-income populations most affected by overweight and obesity.
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http://dx.doi.org/10.1089/chi.2021.0175DOI Listing
September 2021

Association of Medicaid expansion under the Affordable Care Act with access to elective spine surgical care.

J Neurosurg Spine 2021 Sep 24:1-9. Epub 2021 Sep 24.

1Department of Neurological Surgery.

Objective: The Affordable Care Act expanded Medicaid eligibility in many states, improving access to some forms of elective healthcare in the United States. Whether this effort increased access to elective spine surgical care is unknown. This study's objective was to evaluate the impact of Medicaid expansion under the Affordable Care Act on the volume and payer mix of elective spine surgery in the United States.

Methods: This study evaluated elective spine surgical procedures performed from 2011 to 2016 and included in the all-payer State Inpatient Databases of 10 states that expanded Medicaid access in 2014, as well as 4 states that did not expand Medicaid access. Adult patients aged 18-64 years who underwent elective spine surgery were included. The authors used a quasi-experimental difference-in-difference design to evaluate the impact of Medicaid expansion on hospital procedure volume and payer mix, independent of time-dependent trends. Subgroup analysis was conducted that stratified results according to cervical fusion, thoracolumbar fusion, and noninstrumented surgery.

Results: The authors identified 218,648 surgical procedures performed in 10 Medicaid expansion states and 118,693 procedures performed in 4 nonexpansion states. Medicaid expansion was associated with a 17% (95% CI 2%-35%, p = 0.03) increase in mean hospital spine surgical volume and a 23% (95% CI -0.3% to 52%, p = 0.054) increase in Medicaid volume. Privately insured surgical volumes did not change significantly (incidence rate ratio 1.13, 95% CI -5% to 34%, p = 0.18). The increase in Medicaid volume led to a shift in payer mix, with the proportion of Medicaid patients increasing by 6.0 percentage points (95% CI 4.1-7.0, p < 0.001) and the proportion of private payers decreasing by 6.7 percentage points (95% CI 4.5-8.8, p < 0.001). Although the magnitude of effects varied, these trends were similar across procedure subgroups.

Conclusions: Medicaid expansion under the Affordable Care Act was associated with an economically and statistically significant increase in spine surgery volume and the proportion of surgical patients with Medicaid insurance, indicating improved access to care.
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http://dx.doi.org/10.3171/2021.3.SPINE2122DOI Listing
September 2021

Association of Child Maltreatment With Risk of Death During Childhood in South Australia.

JAMA Netw Open 2021 Jun 1;4(6):e2113221. Epub 2021 Jun 1.

Health Economics and Social Policy Group, Australian Centre for Precision Health, University of South Australia, Adelaide, South Australia, Australia.

Importance: Child maltreatment is a prominent public health concern affecting 20% to 50% of children worldwide. Consequences for mental and physical health have been reported, but population-level estimates of risk of death during childhood that are adjusted for confounders have not been published to date.

Objective: To estimate the association of documented child protection concerns regarding maltreatment with risk of death from infancy to 16 years of age.

Design, Setting, And Participants: This case-control study was nested in a population birth cohort of 608 547 persons born in South Australia, Australia. Case children were those who died between 1 month and 16 years of age (with the death registered by May 31, 2019). Control children were randomly selected individuals from the same population who were alive at the age at which the case child died, matched 5:1 for age, sex, and Aboriginal status. Data were analyzed from January 2019 to March 2021.

Exposure: Children were assigned to 1 of 4 child protection concern categories (child protection system notification[s] only, investigation[s] [not substantiated], substantiated maltreatment, and ever placed in out-of-home care) based on administrative data from the South Australia Department for Child Protection or were classified as unexposed.

Main Outcomes And Measures: Mortality rate ratios for death before 16 years of age, by child protection concern category, were estimated using conditional logistic regression, adjusted for birth outcomes, maternal attributes, and area-based socioeconomic status. Patterns of cause of death were compared for children with vs without child protection concerns.

Results: Of 606 665 children included in the study, 1635 were case children (57.9% male [when sex was known]; mean [SD] age, 3.59 [4.56] years) and 8175 were control children (57.7% male; mean [SD] age, 3.59 [4.56] years [age censored at the time of death of the matched control child]). Compared with children with no child protection system contact, adjusted mortality rate ratios among children who died before 16 years of age were 2.69 (95% CI, 2.05-3.54) for children with child protection system notification(s) only; 3.16 (95% CI, 2.25-4.43) for children with investigation(s) (not substantiated); 2.93 (95% CI, 1.95-4.40) with substantiated maltreatment; and 3.79 (95% CI, 2.46-5.85) for children ever placed in out-of-home care. External causes represented 136 of 314 deaths (43.3%) among children with a documented child protection concern and 288 of 1306 deaths (22.1%) among other children. Deaths from assault or self-harm were most overrepresented, accounting for 11.1% of deaths in children with child protection concerns but just 0.8% of deaths among other children.

Conclusions And Relevance: In this case-control study, children with documented child protection concerns, who were known to child protection agencies and were typically seen by clinicians and other service providers, had a higher risk of death compared with children with no child protection service contact. These findings suggest the need for a more comprehensive service response for children with protection concerns.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.13221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193432PMC
June 2021

Social Needs, Chronic Conditions, and Health Care Utilization among Medicaid Beneficiaries.

Popul Health Manag 2021 May 14. Epub 2021 May 14.

Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, USA.

Health care organizations are increasingly assessing patients' social needs (eg, food, utilities, transportation) using various measures and methods. Prior studies have assessed social needs at the point of care and many studies have focused on correlates of 1 specific need (eg, food). This comprehensive study examined multiple social needs and medical and pharmacy claims data. Medicaid beneficiaries in Louisiana (n = 10,275) completed a self-report assessment of 10 social needs during July 2018 to June 2019. Chronic health conditions, unique medications, and health care utilization were coded from claims data. The sample was predominantly female (72%), Black (45%) or White (32%), had a mean age of 42 years, and at least 1 social need (55%). In bivariate analyses, having greater social needs was associated with greater comorbidity across conditions, and each social need was consistently associated with mental health and substance use disorders. In multivariable logistic analyses, having ≥2 social needs was positively associated with emergency department (ED) visits (OR = 1.39, CI = 1.23 - 1.57) and negatively associated with wellness visits (OR = 0.87, CI = 0.77 - 0.98), inpatient visits (OR = 0.87, CI = 0.76 - 0.99), and 30-day rehospitalization (OR = 0.66, CI = 0.50 - 0.87). Findings highlight the greater concomitant risk of social needs, mental health, and substance use. Admission policies may reduce the impact of social needs on hospitalization. Chronic disease management programs offered by health plans may benefit from systematically assessing and addressing social needs outside point-of-care interactions to impact health outcomes and ED utilization. Behavioral health care management programs would benefit from integrating interventions for multiple social needs.
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http://dx.doi.org/10.1089/pop.2021.0065DOI Listing
May 2021

Intergenerational transmission of child maltreatment in South Australia, 1986-2017: a retrospective cohort study.

Lancet Public Health 2021 07 30;6(7):e450-e461. Epub 2021 Apr 30.

Australian Centre for Precision Health, Cancer Research Institute, University of South Australia, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, SA, Australia.

Background: The extent of intergenerational transmission of child maltreatment is unclear due to methodological limitations in previous studies. In this study, we aimed to examine factors associated with intergenerational transmission of child maltreatment and quantify its extent in a population sample over a 30-year period in South Australia.

Methods: In this retrospective cohort study, we used linked administrative data from the South Australian Birth Registry to identify dyads of mothers and their children both born in South Australia between July 1, 1986, and June 30, 2017. Three child protection system (CPS) outcomes (any CPS involvement, substantiated maltreatment, and time spent in out-of-home care) were computed from data obtained from the South Australian Department for Child Protection. Multivariable Cox regression models were used to estimate hazard ratios (HRs) for child CPS outcomes according to their mother's CPS exposure.

Findings: 38 556 unique mother-child dyads were included. 458 (2·0%) of 23 437 children whose mothers had no CPS involvement in childhood had a substantiated report of maltreatment and 127 (0·5%) spent time in out-of-home care. By comparison, 970 (22·1%) of 4382 children whose mothers experienced substantiated maltreatment in childhood had substantiated maltreatment and 469 (10·7%) spent time in out-of-home care. After adjusting for potential confounders, children of mothers with any CPS involvement in childhood had an increased risk of CPS contact compared with children whose mothers had no CPS involvement; this risk was greatest for children of mothers who had both substantiated maltreatment and spent time in out-of-home care (HR 6·25 [95% CI 5·59-6·98] for any CPS involvement, 13·69 [10·08-16·92] for substantiated maltreatment, and 25·78 [18·23-36·45] for any time in out-of-home care). Risks of child CPS outcomes were substantially increased for children of mothers who had a first CPS notification under the age of 1 year or who had any CPS notification at age 13-17 years.

Interpretation: Children are at high risk of maltreatment if their mother experienced maltreatment as a child. Assisting survivors of childhood maltreatment, particularly female survivors, provides a crucial intervention opportunity to help prevent further child abuse and neglect.

Funding: Australian National Health and Medical Research Council; Channel 7 Children's Research Foundation.
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http://dx.doi.org/10.1016/S2468-2667(21)00024-4DOI Listing
July 2021

Associations among social needs, health and healthcare utilization, and desire for navigation services among US Medicaid beneficiaries with type 2 diabetes.

Health Soc Care Community 2021 Mar 11. Epub 2021 Mar 11.

Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA.

The purpose of this study was to better understand the number and types of social needs experienced by Medicaid beneficiaries with type 2 diabetes, and how their social needs are associated with key health indicators. Also examined were factors that influence patients' interest in navigation services for health and social needs to inform future interventions and service delivery. The study expands upon prior research, much of which has focused on only one social need (e.g., food insecurity) or one health outcome. The hypothesis was that among individuals with type 2 diabetes, those with a greater number of social needs would report more health-related problems and be more interested in receiving social needs navigation services. Participants completed a cross-sectional survey by phone (n = 95) or online (n = 14). Most (85%) reported having at least one social need (M = 2.5, SD = 2.2), most commonly not having enough money for unexpected expenses (68%) or necessities like food, shelter and clothing (31%), medical costs (24%), and utilities (23%). Results supported our comprehensive conceptual model. Having more social needs was associated with greater perceived stress, diabetes distress, problems with sleep and executive and cognitive functioning, less frequent diabetes self-care activities, more days of poor mental health and activity limitations, worse self-reported health and more hospitalisations. Number of social needs also was positively associated with interest in having a social needs navigator. Social needs were not associated with days of poor physical health, BMI, self-reported A1C or smoking status. Social needs were associated with a wide range of indicators of poor health and well-being. Participants with the greatest social need burden were most open to intervention.
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http://dx.doi.org/10.1111/hsc.13296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8433262PMC
March 2021

Child Maltreatment and Mortality in Young Adults.

Pediatrics 2021 01 14;147(1). Epub 2020 Dec 14.

Health Economics and Social Policy Group, Australian Centre for Precision Health, University of South Australia, Adelaide, South Australia, Australia.

Background: Child maltreatment (CM) is a global public health issue, with reported impacts on health and social outcomes. Evidence on mortality is lacking. In this study, we aimed to estimate the impact of CM on death rates in persons 16 to 33 years.

Methods: A retrospective cohort study of all persons born in South Australia 1986 to 2003 using linked administrative data. CM exposure was based on child protection service (CPS) contact: unexposed, no CPS contact before 16 years, and 7 exposed groups. Deaths were observed until May 31, 2019 and plotted from 16 years. Adjusted hazard ratios (aHRs) by CPS category were estimated using Cox proportional hazards models, adjusting for child and maternal characteristics. Incident rate ratios (IRRs) were derived for major causes of death, with and without CPS contact.

Results: The cohort included 331 254 persons, 20% with CPS contact. Persons with a child protection matter notification and nonsubstantiated or substantiated investigation had more than twice the death rate compared with persons with no CPS contact: aHR = 2.09 (95% confidence interval [CI] = 1.62-2.70) to aHR = 2.61 (95% CI = 1.99-3.43). Relative to no CPS contact, persons ever placed in out-of-home care had the highest mortality if first placed in care aged ≥3 years (aHR = 4.67 [95% CI = 3.52-6.20]); aHR was 1.75(95% CI = 0.98-3.14) if first placed in care aged <3 years. The largest differential cause-specific mortality (any contact versus no CPS contact) was death from poisonings, alcohol, and/or other substances (IRR = 4.82 [95% CI = 3.31-7.01]) and from suicide (IRR = 2.82 [95% CI = 2.15-3.68]).

Conclusions: CM is a major underlying cause of potentially avoidable deaths in early adulthood. Clinical and family-based support for children and families in which CM is occurring must be a priority to protect children from imminent risk of harm and early death as young adults.
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http://dx.doi.org/10.1542/peds.2020-023416DOI Listing
January 2021

Preferences for Accessing Electronic Health Records for Research Purposes: Views of Parents Who Have a Child With a Known or Suspected Genetic Condition.

Value Health 2020 12 26;23(12):1639-1652. Epub 2020 Oct 26.

RTI International, Research Triangle Park, NC, USA.

Objectives: The purpose of this study was to examine parental preferences for researchers accessing their child's electronic health record across 3 groups: those with a child with (1) a known genetic condition (fragile X syndrome FXS), (2) a suspected genetic condition (autism spectrum disorder [ASD]), and (3) no known genetic condition (typically developing).

Methods: After extensive formative work, a discrete choice experiment was designed consisting of 5 attributes, each with 2 or 3 levels, including (1) type of researcher, (2) the use of personally identifiable information, (3) the use of sensitive information, (4) personal importance of research, and (5) return of results. Stratified mixed logit and latent class conditional logit models were examined.

Results: Parents of children with FXS or ASD had relatively higher preferences for research conducted by nonprofits than parents of typically developing children. Parents of children with ASD also preferred research using non-identifiable and nonsensitive information. Parents of children with FXS or ASD also had preferences for research that was personally important and returned either summary or individual results. Although a few child and family characteristics were related to preferences, they did not overall define the subgroups of parents.

Conclusions: Although electronic health record preference research has been conducted with the general public, this is the first study to examine the opinions of parents who have a child with a known or suspected genetic condition. These parents were open to studies using their child's electronic health record because they may have more to gain from this type of research.
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http://dx.doi.org/10.1016/j.jval.2020.06.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7701359PMC
December 2020

Using discrete choice experiments to design interventions for heterogeneous preferences: protocol for a pragmatic randomised controlled trial of a preference-informed, heterogeneity-focused, HIV testing offer for high-risk populations.

BMJ Open 2020 11 6;10(11):e039313. Epub 2020 Nov 6.

Duke Global Health Institute, Duke University, Durham, North Carolina, USA.

Introduction: Approximately one million undiagnosed persons living with HIV in Southern and Eastern Africa need to test for HIV. Novel approaches are necessary to identify HIV testing options that match the heterogeneous testing preferences of high-risk populations. This pragmatic randomised controlled trial (PRCT) will evaluate the efficacy of a preference-informed, heterogeneity-focused HIV counselling and testing (HCT) offer, for improving rates of HIV testing in two high-risk populations.

Methods And Analysis: The study will be conducted in Moshi, Tanzania. The PRCT will randomise 600 female barworkers and 600 male Kilimanjaro mountain porters across three study arms. All participants will receive an HIV testing offer comprised of four preference-informed testing options, including one 'common' option-comprising features that are commonly available in the area and, on average, most preferred among study participants-and three options that are specific to the study arm. Options will be identified using mixed logit and latent class analyses of data from a discrete choice experiment (DCE). Participants in Arm 1 will be offered the common option and three 'targeted' options that are predicted to be more preferred than the common option and combine features widely available in the study area. Participants in Arm 2 will be offered the common option and three 'enhanced' options, which also include HCT features that are not yet widely available in the study area. Participants in Arm 3, an active control arm, will be offered the common option and three predicted 'less preferred' options. The primary outcome will be uptake of HIV testing.

Ethics And Dissemination: Ethical approval was obtained from the Duke University Health System IRB, the University of South Carolina IRB, the Ethics Review Committee at Kilimanjaro Christian Medical University College, Tanzania's National Institute for Medical Research, and the Tanzania Food & Drugs Authority (now Tanzania Medicines & Medical Devices Authority). Findings will be published in peer-reviewed journals. The use of rigorous DCE methods for the preference-based design and tailoring of interventions could lead to novel policy options and implementation science approaches.

Trial Registration Number: NCT02714140.
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http://dx.doi.org/10.1136/bmjopen-2020-039313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7651730PMC
November 2020

Unmet Need for Total Joint Arthroplasty in Medicaid Beneficiaries After Affordable Care Act Expansion.

J Bone Joint Surg Am 2020 Sep;102(17):1495-1500

Department of Orthopaedic Surgery (C.J.D., P.C., and K.Y.), Division of Public Health Sciences, Department of Surgery (C.J.D., A.R.B., D.S.B., and M.A.O.), and Division of Infectious Diseases, Department of Medicine (M.K. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri.

Background: The utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) increased after Medicaid expansion under the U.S. Affordable Care Act (ACA), suggesting a potential unmet need for THA and TKA. We examined the timing of THA and TKA in patients after obtaining Medicaid expansion insurance coverage. We hypothesized that patients with Medicaid expansion insurance would undergo a surgical procedure sooner than patients in traditional Medicaid populations.

Methods: We used administrative data from a Medicaid managed care company to determine the timing of primary THA and TKA in patients who were 18 to 64 years of age in 4 states with Medicaid expansion (Illinois, Ohio, Oregon, and Washington) and 4 states without Medicaid expansion (Louisiana, Mississippi, Texas, and Wisconsin) from 2008 to 2015. The insurance types were Medicaid expansion, Medicaid plans for Supplemental Security Income (SSI), or Temporary Assistance for Needy Families (TANF). Roughly, these 3 groups correspond to relatively healthy childless adults, relatively unhealthy disabled adults, and parents of children with Medicaid insurance. The main outcome measure was time from enrollment to the surgical procedure. The primary exposure of interest was insurance type. We used a generalized linear regression model to adjust for patient age, sex, social deprivation, surgeon supply and reimbursement, and state-level Medicaid enrollment.

Results: In the unadjusted analysis of 4,117 patients, there was a significantly shorter time from enrollment to THA and TKA for the expansion group (median, 7.5 months) relative to the SSI group (median, 16.1 months; p < 0.0001) and the TANF group (median, 12.2 months; p < 0.0001). In the adjusted analysis, the time from enrollment to THA and TKA was significantly shorter in the expansion group (β, -1.21 [95% confidence interval (CI), -1.35 to -1.07]; p < 0.001) compared with the TANF group (β, -0.27 [95% CI, -0.38 to -0.17]; p < 0.001) and the SSI group (reference). Compared with the SSI group, these coefficients are equivalent to a 70% shorter time to the surgical procedure in the expansion group and a 24% shorter time to the surgical procedure in the TANF group.

Conclusions: Our findings suggest an unmet need for THA and TKA among newly enrolled Medicaid expansion beneficiaries. This need should be considered by surgeons, hospitals, and policymakers in ensuring access to care. Furthermore, consideration should be given to existing insurance-based disparities in access to orthopaedic care, as these may be exacerbated by an increased demand for THA and TKA from Medicaid expansion beneficiaries.
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http://dx.doi.org/10.2106/JBJS.20.00125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8313181PMC
September 2020

Heterogeneous Patient Preferences for Modern Antiretroviral Therapy: Results of a Discrete Choice Experiment.

Value Health 2020 07 18;23(7):851-861. Epub 2020 Jul 18.

Duke Global Health Institute, Duke University, Durham, NC, USA. Electronic address:

Objective: Limited data describe patient preferences for the growing number of antiretroviral therapies (ARTs). We quantified preferences for key characteristics of modern ART deemed relevant to shared decision making.

Methods: A discrete choice experiment survey elicited preferences for ART characteristics, including dosing (frequency and number of pills), administration characteristics (pill size and meal requirement), most bothersome side effect (from diarrhea, sleep disturbance, headaches, dizziness/difficulty thinking, depression, or jaundice), and most bothersome long-term effect (from increased risk of heart attacks, bone fractures, renal dysfunction, hypercholesterolemia, or hyperglycemia). Between March and August 2017, the discrete choice experiment was fielded to 403 treatment-experienced persons living with human immunodeficiency virus (HIV), enrolled from 2 infectious diseases clinics in the southern United States and a national online panel. Participants completed 16 choice tasks, each comparing 3 treatment options. Preferences were analyzed using mixed and latent class logit models.

Results: Most participants were male (68%) and older (interquartile range: 42-58 years), and had substantial treatment experience (interquartile range: 7-21 years). In mixed logit analyses, all attributes were associated with preferences. Side and long-term effects were most important, with evidence of substantial preference heterogeneity. Latent class analysis identified 5 preference classes. For classes 1 (40%), 2 (24%), and 3 (21%), side effects were most important, followed by long-term effects. For class 4 (10%), dosing was most important. Class 5 (4%) was largely indifferent to ART characteristics.

Conclusion: Overall, treatment-experienced persons living with HIV valued minimizing side effects and long-term toxicities over dosing and administration characteristics. Preferences varied widely, highlighting the need to elicit individual patient preferences in models of shared antiretroviral decision making.
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http://dx.doi.org/10.1016/j.jval.2020.03.007DOI Listing
July 2020

Hospitalizations among children involved in the child protection system: A long-term birth cohort study from infancy to adulthood using administrative data.

Child Abuse Negl 2020 09 8;107:104518. Epub 2020 Jul 8.

Australian Centre for Precision Health, University of South Australia, Adelaide, South Australia, Australia.

Background: Despite considerable health consequences of child abuse and neglect, there is limited evidence on hospitalizations in this population.

Objectives: To describe frequency and reasons for hospitalization by lifetime child protection system (CPS) involvement.

Participants: 608,540 children born from January 1, 1986 to June 30, 2017 in South Australia, Australia METHODS: Using linked administrative data on CPS involvement and hospitalizations, we descriptively examined cumulative incidence, cumulative count and reasons for hospitalization from infancy to early adulthood by CPS involvement.

Results: By 16.5 years of age, cumulative incidence of ever-being hospitalized was 58% (95% CI 58-58) for children with no CPS involvement and significantly higher (72% (95% CI 71-73) to 88% (95% CI 86-90), P < 0.001) among those with different levels of CPS involvement. Cumulative mean counts of hospitalizations were highest at every age for those placed in out-of-home-care (reaching 7.7 by 16.5 years), almost four times higher than for children with no CPS involvement (2.0 by 16.5 years). Most frequent reasons for hospitalizations were similar across CPS involvement in the early years. From adolescence through early adulthood, mental health, and 'injury, poisoning or toxic effects of drugs' were frequent reasons for hospitalization among individuals with CPS involvement.

Conclusions: This study highlights the vulnerability of children who have been maltreated, or are at risk of maltreatment, and the urgency of implementing effective preventive strategies early in life including consideration of adequate responses of child protection services. Frequent hospitalizations for mental health and injury confirms the potentially preventable nature of these hospitalizations.
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http://dx.doi.org/10.1016/j.chiabu.2020.104518DOI Listing
September 2020

School Absenteeism Associated With Child Protection System Involvement, Maltreatment Type, and Time in Out-of-Home Care.

Child Maltreat 2020 11 13;25(4):433-445. Epub 2020 Mar 13.

Australian Centre for Precision Health, Cancer Research Institute, School of Health Sciences, 1067University of South Australia, Adelaide, South Australia, Australia.

Greater school absenteeism is associated with numerous negative educational outcomes. We used a retrospective cohort design with linked administrative data on 296,422 children to examine the relationship between school absenteeism and child protection system (CPS) involvement. Children with substantiated maltreatment had 4.1 times more unexplained and problem absences than children with no CPS involvement. In multivariate analyses, children with substantiated maltreatment had significantly greater "chronic" truancy ( = 3.41) and less "acceptable" levels of absences ( = 0.74) compared to children with no CPS involvement. Greater absenteeism was seen for children with substantiated neglect and who had their first CPS notification earlier in life. Being in out-of-home care for 3+ years was a protective factor for children who had a CPS notification before age 5. Additional adversities had a strong additive effect with CPS involvement on absenteeism and chronic truancy. This study demonstrates the potential scope for reducing problem absenteeism and helps inform the public debate regarding how the type and timing of CPS involvement might ameliorate or exacerbate harm for children.
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http://dx.doi.org/10.1177/1077559520907682DOI Listing
November 2020

Impact of the affordable care act dependent coverage provision on young adult cancer patient insurance coverage by sociodemographic and economic characteristics.

Cancer Causes Control 2020 Jan 6;31(1):33-42. Epub 2019 Nov 6.

Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA.

Purpose: To evaluate the impact of the Affordable Care Act Dependent Care Provision by sociodemographic and economic characteristics in young adult cancer patients.

Methods: The National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) 18 database were queried for young adult cancer cases diagnosed during 2007-2014. Using a difference-in-differences approach, we examined insurance coverage in different subgroups of policy-eligible 19-25 year-olds versus policy-ineligible 27-29 year-olds from the pre- (2007-2009) to post- (2011-2014) Dependent Care Provision period.

Results: Across subgroups and study populations, insurance coverage increased significantly following the Provision enactment in the policy-eligible versus policy-ineligible group across most subgroups (range in NCDB: 1.83 to 6.38% for low and mid-low education areas, respectively; range in SEER: 1.43 to 6.18 for Non-Hispanic Others and Hispanics, respectively). Heterogenous impacts were observed by sex with a larger impact in males (NCDB: 5.14%, 95% CI 3.59-6.69; SEER: 4.46, 2.12-6.8) than females (NCDB: 2.51%, 95% CI 1.39-3.62; SEER: 2.50, 0.82-4.18). We observed no other statistical evidence for Dependent Care Provision subgroup heterogeneity except for a smaller impact in individuals from low education areas in NCDB.

Conclusions: Our results indicate a positive Dependent Care Provision impact on insurance coverage in young adults with cancer across subgroups, with evidence for a smaller impact in females relative to males and in low relative to high education areas.
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http://dx.doi.org/10.1007/s10552-019-01246-3DOI Listing
January 2020

Lifetime risk of child protection system involvement in South Australia for Aboriginal and non-Aboriginal children, 1986-2017 using linked administrative data.

Child Abuse Negl 2019 11 26;97:104145. Epub 2019 Aug 26.

Australian Centre for Precision Health, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.

Background: Child protection services exist to reduce potential harms from child maltreatment. Many jurisdictions produce annual data on child protection system (CPS) involvement, leaving a gap in knowledge of lifetime involvement.

Objective: To describe lifetime involvement in CPS, by type of contact.

Participants: All 608,547 children born in South Australia (SA), Australia between 1986 and 2017.

Methods: A retrospective cohort design using linked administrative data to report cumulative incidence of CPS involvement from birth to age <18 (or June30 2017) by Aboriginal status. CPS involvement was categorised into notifications (3 levels), investigations, substantiations and out-of-home care (OOHC). Cumulative incidence curves were derived for 5 birth cohorts.

Results: Across childhood (to age <18 years), substantiated maltreatment was experienced by 3.2-3.6% of non-Aboriginal and 19-25% of Aboriginal children, 7 times reported annual substantiation rates. For most CPS categories CPS involvement increased until 2010, and was occurring earlier in life. By age 3, 0.5% of non-Aboriginal and 4.5% of Aboriginal children born 1986-1991 were the subject of a substantiation compared with 1.9% and 15% of non-Aboriginal and Aboriginal children, respectively, born 2010-2017. Incidence rates beyond age 3 were similar. OOHC contact was similar across cohorts, with ˜1.5% of non-Aboriginal and 12.7% of Aboriginal children ever-placed in care.

Conclusions: Data linkage is an essential tool for understanding life course involvement with the CPS and describing trends not observable from annual snapshots. Such information is critical for burden of disease estimates, informing policy and monitoring CPS performance.
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http://dx.doi.org/10.1016/j.chiabu.2019.104145DOI Listing
November 2019

A comparison of buprenorphine and psychosocial treatment outcomes in psychosocial and medical settings.

J Subst Abuse Treat 2019 09 15;104:135-143. Epub 2019 Jun 15.

Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, Box 8134, St. Louis, MO 63110, United States of America. Electronic address:

Background: Facing an epidemic of opioid-related mortality, many government health departments, insurers, and treatment providers have attempted to expand patient access to buprenorphine in psychosocial substance use disorder (SUD) programs and medical settings.

Methods: With Missouri Medicaid data from 2008 to 2015, we used Cox proportional hazard models to estimate the relative hazards for treatment attrition and SUD-related emergency department (ED) visits or hospitalizations associated with buprenorphine in psychosocial SUD programs and medical settings. We also tested the association of buprenorphine with hours of psychosocial treatment during the first 30 days of psychosocial SUD treatment. The analytic sample included claims from 7606 individuals with an OUD diagnosis.

Results: Compared to psychosocial treatment without buprenorphine (PSY), the addition of buprenorphine (PSY-B) was associated with a significantly reduced hazard for treatment attrition (adjusted hazard ratio: 0.67, 95% CI: 0.62-0.71). Among buprenorphine episodes, office-based (B-OBOT), outpatient hospital (B-OPH), and no documented setting (B-PHA) were associated with reduced hazards for treatment attrition when compared to the psychosocial SUD setting (B-PSY) (adjusted hazard ratios: 0.27, 95% CI: 0.24-0.31; 0.46, 95% CI: 0.39-0.54; 0.70, 95% CI: 0.61-0.81). Compared to B-PSY, B-OBOT and B-PHA were associated with significantly reduced hazards for a SUD-related ED visits or hospitalization (adjusted hazard ratios: 0.59, 95% CI: 0.41-0.85; 0.53, 95% CI: 0.36-0.78). There was no significant difference between B-PSY and B-OPH or B-PSY and PSY in hazard for an SUD-related ED visit or hospitalization.

Conclusions: Our findings support the conclusion that adding buprenorphine to Medicaid-covered psychosocial SUD treatment reduces patient attrition and SUD-related ED visits or hospitalizations but that buprenorphine treatment in office-based medical settings is even more effective in reducing these negative outcomes. Policy-makers should consider ways to expand buprenorphine access in all settings, but particularly in office-based medical settings. Buprenorphine treatment in an unbilled setting was associated with an increased hazard for patient attrition when compared to treatment in billed medical settings, indicating the importance of Medicaid-covered provider visits for patient retention.
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http://dx.doi.org/10.1016/j.jsat.2019.06.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075557PMC
September 2019

Support Tools for Preference-Sensitive Decisions in Healthcare: Where Are We? Where Do We Go? How Do We Get There?

Patient 2019 10;12(5):439-443

Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1007/s40271-019-00372-zDOI Listing
October 2019

Scaling Up Housing Services Within the Child Welfare System: Policy Insights From Simulation Modeling.

Child Maltreat 2020 02 16;25(1):51-60. Epub 2019 May 16.

Brown School, Washington University, St. Louis, MO, USA.

Objectives: Housing insecurity and homelessness contribute to risk of maltreatment among one in five of the nearly 3.5 million children annually investigated for maltreatment in the United States. The Family Unification Program (FUP)-a federal initiative-connects inadequately housed families involved in child welfare with long-term rental subsidies to avoid foster placement. However, FUP remains understudied and underutilized with funding levels that serve only a fraction of eligible households. The present study uses system dynamics modeling to inform decision-making by testing policies for scaling FUP.

Method: Simulations model delivery of FUP within child welfare from a feedback perspective. Calibrated on national data, models replicate trends in child welfare involvement from 2013 through 2016, and analyses forecast rates through 2019. Experiments test policies that enhance FUP. Outcomes track system-wide rates of family separation and returns on investment of expanded housing interventions.

Results: Dramatic expansions of FUP benefit more families and improve marginal return on investment. Yet, scale-up fails to reduce system-wide rates of family separation or generates substantial cost-savings.

Conclusions: Simulations demonstrate structural challenges for scaling FUP. Constant demand for affordable housing constrains sustainable improvements in child protection. Child welfare responses to homelessness require innovations that reduce demand for housing services through prevention and earlier intervention.
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http://dx.doi.org/10.1177/1077559519846431DOI Listing
February 2020

Impacts of the Affordable Care Act Dependent Coverage Provision on Young Adults With Cancer.

Am J Prev Med 2019 05 19;56(5):716-726. Epub 2019 Mar 19.

Siteman Cancer Center, Washington University in St. Louis, St. Louis, Missouri; Brown School, Washington University in St. Louis, St. Louis, Missouri. Electronic address:

Introduction: Evidence through 2012 suggests that the 2010 Affordable Care Act Dependent Coverage Provision, extending dependent insurance coverage eligibility to age 26years, increased young adult insurance coverage and decreased cancer diagnosis stage in young adult cancer patients. This study examines Dependent Coverage Provision-associated changes in insurance coverage and diagnosis stage through 2014 in young adult cancer patients.

Methods: Using a quasi-experimental study design, analyses were conducted in 2017-2018 using 2007 to 2014 data from the Surveillance, Epidemiology, and End Results (SEER) 18 and the National Cancer Database (NCDB). Using difference-in-differences analyses applied to linear probability models, changes in the percentage of policy-eligible individuals aged 19-25years versus ineligible individuals aged 27-29years who were insured (excluding Medicaid) and diagnosed at early (Stages 0 and 1) or late (Stage 4) stages following Dependent Coverage Provision enactment were estimated.

Results: A total of 36,901 and 92,358 young adults were included from SEER and NCDB. Consistent increases in the percentage insured (SEER: 3.45 percentage points, 95% CI=2.04, 4.87; NCDB: 3.72 percentage points, 95% CI=2.80, 4.64); variable increases in early-stage diagnoses (2.25 percentage points, 95% CI=0.40, 4.10; 0.69 percentage points, 95% CI= -0.65, 2.02); and decreases in late-stage diagnoses (-1.74 percentage points, 95% CI= -3.10, -0.38; -0.58 percentage points, 95% CI= -1.46, 0.30) were observed in young adults aged 19-25 versus 27-29years.

Conclusions: These results provide clear evidence for a Dependent Coverage Provision-associated impact on insurance coverage in young adult cancer patients; however, clear impacts on diagnosis stage are less evident.
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http://dx.doi.org/10.1016/j.amepre.2018.12.011DOI Listing
May 2019

Two-State Comparison of Total Joint Arthroplasty Utilization Following Medicaid Expansion.

J Arthroplasty 2019 04 22;34(4):619-625.e1. Epub 2018 Dec 22.

Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO; Division of Infectious Diseases, Department of Medicine, Center for Administrative Data Research, Washington University School of Medicine, St. Louis, MO.

Background: Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid).

Methods: Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois' Medicaid expansion date: January 1, 2014).

Results: The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012).

Conclusion: Our study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures.
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http://dx.doi.org/10.1016/j.arth.2018.12.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6430692PMC
April 2019

The affordable care act and insurance coverage for persons with diabetes in the United States.

J Hosp Manag Health Policy 2018 Apr 26;2. Epub 2018 Apr 26.

Brown School, Washington University in St. Louis, St. Louis, MO, USA.

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http://dx.doi.org/10.21037/jhmhp.2018.04.07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6117109PMC
April 2018

Homelessness in the child welfare system: A randomized controlled trial to assess the impact of housing subsidies on foster care placements and costs.

Child Abuse Negl 2018 09 17;83:52-61. Epub 2018 Jul 17.

Washington University in St. Louis, 1 Brookings Drive, St. Louis, MO 63130, USA.

Inadequate housing and homelessness among families represent a substantial challenge for child and adolescent well-being. Child welfare services confront housing that threatens placement into foster care with little resources and evidence to guide practice. The present study provides the first rigorous test of the Family Unification Program (FUP) - a federal program that offers housing subsidies for inadequately housed families under investigation for child maltreatment. A randomized controlled trial assesses program impact on foster care placement and costs. The experiment referred intact child welfare-involved families whose inadequate housing threatened foster placement in Chicago, IL to FUP plus housing advocacy (n = 89 families with 257 children) or housing advocacy alone (n = 89 families with 257 children). Families were referred from 2011 to 2013, and administrative data recorded dates and costs of foster placements over a 3-year follow-up. Intent-to-treat analyses suggested families randomly assigned for FUP exhibited slower increases in rates of foster placement following housing intervention compared with families referred for housing advocacy alone. The program generates average savings of nearly $500 per family per year to the foster care system. Housing subsidies provide the foster care system small but significant benefits for keeping homeless families together. Findings inform the design of a coordinated child welfare response to housing insecurity.
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http://dx.doi.org/10.1016/j.chiabu.2018.07.014DOI Listing
September 2018

Colorectal Cancer Screening: Preferences, Past Behavior, and Future Intentions.

Patient 2018 12;11(6):599-611

RTI Health Solutions, RTI International, 200 Park Offices Drive, PO Box 12194, Research Triangle Park, NC, 27709-2194, USA.

Background: Screening rates for colorectal cancer are below the Healthy People 2020 goal. There are several colorectal cancer screening tests that differ in terms of accuracy, recommended frequency, and administration. In this article, we compare how a set of personal characteristics correlates with preferences for colorectal cancer screening test attributes, past colorectal cancer screening behavior, and future colorectal cancer screening intentions.

Methods: We conducted a discrete-choice experiment survey to assess relative preferences for attributes of colorectal cancer screening tests among adults aged 50-75 years in USA. We used a latent class logit model to identify classes of preferences and calculated willingness to pay for changes in test attributes. A set of personal characteristics were included in the latent class analysis and analyses of self-reported past screening behavior and self-assessed likelihood of future colorectal cancer screening.

Results: Latent class analysis identified three types of respondents. Class 1 valued test accuracy, class 2 valued removing polyps and avoiding discomfort, and class 3 valued cost. Having had a prior colonoscopy and a higher income were predictors of the likelihood of future screening and membership in classes 1 and 2. Health insurance and a self-reported higher risk of developing colorectal cancer were associated with prior screening and higher future screening intentions, but not class membership.

Conclusion: We identified distinct classes of preferences focusing on different test features and personal characteristics associated with reported behavior and intentions. Healthcare providers should engage in a careful assessment of patient preferences when recommending colorectal cancer test options to encourage colorectal cancer screening uptake.
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http://dx.doi.org/10.1007/s40271-018-0308-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6226356PMC
December 2018

The economic burden of child sexual abuse in the United States.

Child Abuse Negl 2018 05 20;79:413-422. Epub 2018 Mar 20.

Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA.

The present study provides an estimate of the U.S. economic impact of child sexual abuse (CSA). Costs of CSA were measured from the societal perspective and include health care costs, productivity losses, child welfare costs, violence/crime costs, special education costs, and suicide death costs. We separately estimated quality-adjusted life year (QALY) losses. For each category, we used the best available secondary data to develop cost per case estimates. All costs were estimated in U.S. dollars and adjusted to the reference year 2015. Estimating 20 new cases of fatal and 40,387 new substantiated cases of nonfatal CSA that occurred in 2015, the lifetime economic burden of CSA is approximately $9.3 billion, the lifetime cost for victims of fatal CSA per female and male victim is on average $1,128,334 and $1,482,933, respectively, and the average lifetime cost for victims of nonfatal CSA is of $282,734 per female victim. For male victims of nonfatal CSA, there was insufficient information on productivity losses, contributing to a lower average estimated lifetime cost of $74,691 per male victim. If we included QALYs, these costs would increase by approximately $40,000 per victim. With the exception of male productivity losses, all estimates were based on robust, replicable incidence-based costing methods. The availability of accurate, up-to-date estimates should contribute to policy analysis, facilitate comparisons with other public health problems, and support future economic evaluations of CSA-specific policy and practice. In particular, we hope the availability of credible and contemporary estimates will support increased attention to primary prevention of CSA.
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http://dx.doi.org/10.1016/j.chiabu.2018.02.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542279PMC
May 2018

Health Preference Research: An Overview.

Patient 2017 08;10(4):507-510

Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Discovery Bldg., Ste. 358, Columbia, SC, 290208, USA.

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http://dx.doi.org/10.1007/s40271-017-0253-9DOI Listing
August 2017

Health Valuation: Demonstrating the Value of Health and Lifespan.

Patient 2017 08;10(4):515-517

Washington University in St. Louis, Brown School, Campus Box 1196, One Brookings Drive, St. Louis, Missouri, 63130, USA.

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http://dx.doi.org/10.1007/s40271-017-0252-xDOI Listing
August 2017

Preferences for Health Interventions: Improving Uptake, Adherence, and Efficiency.

Patient 2017 08;10(4):511-514

Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University, Durham, NC, USA.

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http://dx.doi.org/10.1007/s40271-017-0251-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5534371PMC
August 2017

Can Medicaid Claims Validly Ascertain Foster Care Status?

Child Maltreat 2017 08 7;22(3):227-235. Epub 2017 Jun 7.

3 RTI International, Research Triangle Park, Durham, NC, USA.

Medicaid claims have been used to identify populations of children in foster care in the current literature; however, the ability of such an approach to validly ascertain a foster care population is unknown. This study linked children in the National Survey of Child and Adolescent Well-Being-I to their Medicaid claims from 36 states using their Social Security numbers. Using this match, we examined discordance between caregiver report of foster care placement and the foster care eligibility code contained in the child's Medicaid claims. Only 73% of youth placed in foster care for at least a year displayed a Medicaid code for foster care eligibility. Half of all youth coming into contact with child welfare displayed discordance between caregiver report and Medicaid claims. Children with emergency department utilization, and those in primary care case management health insurance arrangements, had the highest odds of accurate ascertainment. The use of Medicaid claims to identify a cohort of children in foster care results in high rates of underascertainment. Supplementing administrative data with survey data is one way to enhance validity of ascertainment.
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http://dx.doi.org/10.1177/1077559517712261DOI Listing
August 2017

Morbid Obesity and Use of Second Generation Antipsychotics among Adolescents in Foster Care: Evidence from Medicaid.

Child Youth Serv Rev 2016 Aug 30;67:27-31. Epub 2016 May 30.

Washington University in St. Louis, Campus Box 1196, Goldfarb Hall, Room 229C, One Brookings Drive, St. Louis, MO 63130, United States.

Background: Many adolescents enter foster care with high body mass index (BMI), and patterns of treatment further exacerbate the risk of morbid obesity. A principal risk factor for such exacerbation is the use of second generation antipsychotics (SGAs). We examine the association between receiving a morbid obesity diagnosis and SGA prescriptions among adolescents in foster care.

Methods: We analyzed claims from 36 states' Medicaid Analytic Extract (MAX) files for 2000 through 2003. Obesity diagnoses were ascertained through a primary or secondary diagnosis claim of morbid obesity. Covariates included gender, race/ethnicity. age, insurance status, state obesity rate, and state fixed effects. We calculated relative risks of a diagnosis based upon four SGAs (clozapine, olanzapine, quetiapine, and risperidone) associated with obesity and a polypharmacy indicator.

Results: Of the 1,261,806 foster care adolescent-years in the MAX files, 6,517 were diagnosed with morbid obesity, an annual prevalence of 0.5%. The risk of a morbid obesity diagnosis is much higher for female and non-white adolescents. The risk increases with age. Quetiapine and clozapine increased the risk of a morbid obesity diagnosis more than 2.5 times, and two or more psychotropic drugs (polypharmacy) increased the risk fivefold.

Conclusions: Adolescents in foster care are much more likely to be on SGA medications, and therefore may be more susceptible to weight gain and obesity. Given that SGA prescribing for younger populations has only expanded since these data were released, our study may actually understate the magnitude of the problem. Care is needed when prescribing SGAs for foster care adolescents.
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http://dx.doi.org/10.1016/j.childyouth.2016.05.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5157933PMC
August 2016

Who Wants Long-Term Care Insurance? A Stated Preference Survey of Attitudes, Beliefs, and Characteristics.

Inquiry 2016 16;53. Epub 2016 Aug 16.

RTI International, Research Triangle Park, NC, USA.

Approximately half of people turning 65 years between 2015 and 2019 are projected to need long-term support and services. Yet the long-term care insurance (LTCI) market is depressed, with only 7.4 million people owning policies. The objective of this study was to provide an analysis of potential LTCI purchasers. We investigate (1) who wants to purchase LTCI, (2) what are the attitudes and beliefs among those who have a preference for LTCI, and (3) who would prefer a law mandating the purchase of LTCI and how that view relates to willingness to purchase LTC. We combine a discrete choice experiment with a survey on attitudes toward LTCI. We estimate odds ratio for choosing a plan based on sociodemographic characteristics, attitudes, and beliefs. Our sample consists of a population of 12 936 people who completed an Internet panel survey. Female respondents were substantially less likely to choose an LTCI plan (OR = 0.74). Income and assets over $100 000 were strong predictors of LTCI uptake (OR = 1.27 and OR = 1.48, respectively). Having adult children live close by was not associated with preference for LTCI. People who support almost any government intervention are more likely to purchase private insurance (OR = 1.12-1.33). Minorities expressed a preference for mandatory enrollment relative to whites. There is a relationship between attitudes toward long-term care financing reform and preference for LTCI, but it is not limited to supporters of private sector initiatives. While support for mandatory LTCI is low overall, it is strongest among racial/ethnic minorities and people with health problems, who potentially have the most to gain.
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http://dx.doi.org/10.1177/0046958016663728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5812045PMC
May 2017
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