Updated core competencies in pharmacoepidemiology to inform contemporary curricula and training for academia, government, and industry.

PURPOSE: The first paper to specify the core content of pharmacoepidemiology as a profession was published by an ISPE (International Society for Pharmacoepidemiology) workgroup in 2012 (Jones JK et al. PDS 2012; 21[7]:677-689). Due to the broader and evolving scope of pharmacoepidemiology, ISPE considers it important to proactively identify, update and expand the list of core competencies to inform curricula of education programs; thus, better positioning pharmacoepidemiologists across academic, government (including regulatory), and industry positions. The aim of this project was to update the list of core competencies in pharmacoepidemiology. METHODS: To ensure applicability of findings to multiple areas, a working group was established consisting of ISPE members with positions in academia, industry, government, and other settings. All competencies outlined by Jones et al. were extracted from the initial manuscript and presented to the working group for review. Expert-based judgments were collated and used to identify consensus. It was noted that some competencies could contribute to multiple groups and could be directly or indirectly related to a group. RESULTS: Five core domains were proposed: (1) Epidemiology, (2) Clinical Pharmacology, (3) Regulatory Science, (4) Statistics and data science, and (5) Communication and other professional skills. In total, 55 individual competencies were proposed, of which 25 were new competencies. No competencies from the original work were dropped but aggregation or amendments were made where considered necessary. CONCLUSIONS: While many core competencies in pharmacoepidemiology have remained the same over the past 10 years, there have also been several updates to reflect new and emerging concepts in the field.

Trajectories of Pre-Exposure Prophylaxis (PrEP) Adherence Among Commercially Insured Individuals.

We used group-based trajectory models to identify four distinct trajectory patterns of adherence to pre-exposure prophylaxis (PrEP) among 20,696 users. Only 44.5% were consistently PrEP adherent, with younger age, being female, or having substance use disorder or depression associated with early discontinuation. Public health efforts are needed to improve PrEP adherence.

Using Joinpoint regression for drug utilization research: Tutorial and case study of prescription opioid use in the United States.

PURPOSE: Drug utilization researchers are often interested in evaluating prescribing and medication use patterns and trends over a specified period of time. Joinpoint regression is a useful methodology to identify any deviations in secular trends without a preconceived notion of where these break points might occur. This article provides a tutorial on the use of joinpoint regression, within Joinpoint software, for the analysis of drug utilization data. METHODS: The statistical considerations for whether a joinpoint regression analytical technique is a suitable approach are discussed. Then, we offer a tutorial as an introduction on conducting joinpoint regression (within Joinpoint software) through a step-by-step application, which is a case study developed using opioid prescribing data from the United States. Data were obtained from public files available through the Centers for Disease Control and Prevention from 2006 to 2018. The tutorial provides parameters and sample data needed to replicate the case study and it concludes with general considerations for the reporting of results using joinpoint regression in drug utilization research. RESULTS: The case study evaluated the trend of opioid prescribing in the United States from 2006 to 2018, where time points of significant variation (one in 2012 and another in 2016) are detected and interpreted. CONCLUSIONS: Joinpoint regression is a helpful methodology for drug utilization for the purposes of conducting descriptive analyses. This tool also assists with corroborating assumptions and identifying parameters for fitting other models such as interrupted time series. The technique and accompanying software are user-friendly; however, researchers interested in using joinpoint regression should exercise caution and follow best practices for correct measurement of drug utilization.

Partnering with recovery community centers to build recovery capital by improving access to reproductive health.

BACKGROUND: People with substance use disorders (SUD), especially opioid use disorder (OUD) have the highest rates of unintended pregnancies (80-95%) and report unmet reproductive health needs. Women of childbearing age have some of the highest death rates from opioids and are notably rising the most rapidly, and when pregnancy does occur overdose is one of the leading causes of maternal mortality. There are numerous gender-based health disparities and social determinants of health shaped by the distribution of power and privilege that influence the risk trajectories of people who can get pregnant or are pregnant with a substance use disorder (SUD). PURPOSE: The purpose of this paper is to describe how reproductive health is essential to recovery and building recovery capital for people who can get pregnant, (1) introduce a pilot implementation science study working with trained peer support coaches to promote reproductive autonomy in the community, and (2) make policy and advocacy recommendations relevant to the new reproductive health landscape in the United States. We will also describe the adaptation and feasibility of the initial pilot study where we partnered with a recovery community center to train peer recovery coaches to provide low barrier resources (contraception, pregnancy tests and prenatal vitamins) and referrals to health care. METHODS: This initiative is the merging of best practices in recovery and community-based global reproductive health, to empower people with SUD who can get pregnant in an implementation science framework. The pilot study will last 3 months in each city and aims to (1) assess and describe the effectiveness of the training of local peer recovery coaches on the link between recovery capital and reproductive health, and (2) assess the feasibility, acceptability, appropriateness, scalability, sustainability, and uptake and reach of low barrier reproductive health resources (pregnancy tests, prenatal vitamins, and emergency contraception). In this paper we are only reporting the initial findings regarding adaptation and feasibility. FINDINGS: Informed by qualitative interviews with stakeholders and participants, the method of contraception was adapted from injectable to emergency to meet the needs and context of the community with SUD. Early outcomes such as uptake and acceptability indicate that this is a feasible model with peer recovery coaches and recovery community centers, with the greatest uptake of emergency contraception and pregnancy tests. CONCLUSION: Considering recent policies limiting access to reproductive health, innovative community-based solutions are needed to engage and empower people who can get pregnant or are pregnant while in active drug use and in recovery. Providing low barrier reproductive health items by people with lived experience with SUD can serve as a valuable harm reduction model and improve recovery capital. CLINICAL RELEVANCE: This is the first study to propose a methodology and context to implement a community-based study merging best practices in recovery with those in reproductive health with the potential to improve recovery capital and maternal/child health trajectories for people with SUD.

Prescription Patterns of Adjuvant Pain Medications Following an Opioid Supply Restriction Law: An Interrupted Time Series Analysis.

BACKGROUND: Florida House Bill 21 (HB21) was implemented in July 2018 to limit prescriptions of Schedule II opioids for acute pain patients, but it is unclear whether such restrictions have a collateral influence on the utilization of commonly prescribed adjuvant pain medications. OBJECTIVE: The objective of this study was to assess whether this law was associated with a change in use patterns of gabapentinoids, benzodiazepines, and muscle relaxants. METHODS: We obtained prescription claims for medications dispensed from January 1, 2015, to June 31, 2019, from a health plan serving a large Florida employer. Interrupted time series analyses were conducted to compare pre-HB21 and post-HB21 implementation changes in the mean monthly number of users and prescriptions for gabapentinoids, benzodiazepines, and muscle relaxants. RESULTS: There was a 6% immediate increase (relative risk: 1.06; 95% confidence interval: 1.02, 1.11) in the monthly proportion of gabapentinoid users, and an 11% immediate increase in the monthly proportion of gabapentinoids prescriptions (relative risk: 1.11; 95% confidence interval: 1.04, 1.18) per 1000 patients following law implementation. However, after the law, we observed a significant reduction in trend for the monthly proportion of muscle relaxants and benzodiazepine users. CONCLUSIONS: An increased number of patients and prescriptions were observed for gabapentinoids, while fewer patients received benzodiazepines and muscle relaxants after HB21. In previous studies, opioid prescription restriction laws are shown to reduce opioids, but this work suggests that these laws may also have unintended consequences for the use of adjunctive medications that were not intended to be affected.

Changes in Prescribing by Provider Type Following a State Prescription Opioid Restriction Law.

BACKGROUND: Many states have implemented opioid days' supply restriction policies, leading to reductions in opioid prescribing. Although research within certain provider types exist, no study has evaluated a restriction policy by various provider types. OBJECTIVE: To evaluate changes in opioid utilization following a days' supply restriction policy stratified by provider type: surgery, emergency medicine, primary care, specialty care, and dentistry. DESIGN: Interrupted time series (ITS) PARTICIPANTS: Opioid prescription claims of patients in a private health plan serving a large Florida employer from 1/1/2015 to 3/31/2019. Provider types were determined using the Healthcare Provider Taxonomy Code associated with the national provider identifier (NPI). INTERVENTIONS: Florida's opioid restriction policy implemented on July 1, 2018. MAIN MEASURES: Changes in mean morphine milligram equivalent (MMEs), mean days' supply, and mean number of units dispensed per opioid prescription before and after policy implementation. KEY RESULTS: There were 10,583 opioid initial prescriptions dispensed. Treating providers were classified as surgery (16.4%; n = 1732), emergency care (14.3%; n = 1516), primary care (21.2%; n = 2241), specialty care (11.4%; n = 1207), and dentistry providers (23.7%; n = 2511). Significant reductions in mean days' supply were observed across most provider types ranging from 14% reduction for dentistry providers to 41% reduction for specialty care providers. Significant changes were observed for emergency care and specialty care providers with a 30% (p = 0.001)and 29% (p < 0.001) reduction in mean MME, respectively, and a 27% (p = 0.040) reduction in mean number of units dispensed in emergency care providers, after implementation. Pre-implementation trends in opioid prescribing varied by provider type impacting the effects of the opioid days' supply restriction policy. CONCLUSIONS: Pre-policy opioid prescribing varied by provider type with a differential impact on mean MMEs, mean days' supply, and mean number of units dispensed per prescription following implementation.

The U.S. COVID-19 County Policy Database: a novel resource to support pandemic-related research.

BACKGROUND: It is increasingly recognized that policies have played a role in both alleviating and exacerbating the health and economic consequences of the COVID-19 pandemic. There has been limited systematic evaluation of variation in U.S. local COVID-19-related policies. This study introduces the U.S. COVID-19 County Policy (UCCP) Database, whose objective is to systematically gather, characterize, and assess variation in U.S. county-level COVID-19-related policies. METHODS: In January-March 2021, we collected an initial wave of cross-sectional data from government and media websites for 171 counties in 7 states on 22 county-level COVID-19-related policies within 3 policy domains that are likely to affect health: (1) containment/closure, (2) economic support, and (3) public health. We characterized the presence and comprehensiveness of policies using univariate analyses. We also examined the correlation of policies with one another using bivariate Spearman's correlations. Finally, we examined geographical variation in policies across and within states. RESULTS: There was substantial variation in the presence and comprehensiveness of county policies during January-March 2021. For containment and closure policies, the percent of counties with no restrictions ranged from 0% (for public events) to more than half for public transportation (67.8%), hair salons (52.6%), and religious gatherings (52.0%). For economic policies, 76.6% of counties had housing support, while 64.9% had utility relief. For public health policies, most were comprehensive, with 70.8% of counties having coordinated public information campaigns, and 66.7% requiring masks outside the home at all times. Correlations between containment and closure policies tended to be positive and moderate (i.e., coefficients 0.4-0.59). There was variation within and across states in the number and comprehensiveness of policies. CONCLUSIONS: This study introduces the UCCP Database, presenting granular data on local governments' responses to the COVID-19 pandemic. We documented substantial variation within and across states on a wide range of policies at a single point in time. By making these data publicly available, this study supports future research that can leverage this database to examine how policies contributed to and continue to influence pandemic-related health and socioeconomic outcomes and disparities. The UCCP database is available online and will include additional time points for 2020-2021 and additional counties nationwide.

Co-utilization of opioids and nonbenzodiazepine hypnotic drugs in U.S. ambulatory care visits, 2006-2016.

OBJECTIVE(S): This study aimed to characterize the co-utilization of non-benzodiazepine sedative 'Z'-drugs with opioids at ambulatory care visits in the United States. DESIGN: A cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2016 was completed. SETTING AND PARTICIPANTS: Ambulatory care visits in the United States involving adult patients with an opioid prescription were included in the analysis. OUTCOME MEASURES: The primary outcome was initiation or continuation of a Z-drug (zolpidem, eszopiclone, or zaleplon) in a patient visit in conjunction with an opioid medication. RESULTS: The authors analyzed 564,090,296 visits (weighted from a sample of 28,773) with a reported opioid prescription. Co-utilization of opioids with Z-drugs fluctuated during the study period beginning at 4.0% in 2006 (95% CI 2.2%-5.7%), 6.3% in 2012 (3.7%-8.9%), and 4.7% in 2016 (2.8%-6.5%). Among all opioid visits in the study period, co-utilization with a Z-drug was not significantly different among female patients compared with male patients (5.26% vs. 4.63%, P = 0.26). Among visits with concomitant opioid and Z-drugs, 7.0% reported new initiation of both medications in the same visit. CONCLUSION: At ambulatory care visits between 2006 and 2016, co-utilization of opioids and Z-drugs fluctuated with some differences by sex. Major regulatory advisories and policy changes during this period may have contributed to these varying rates of utilization. Additional work is needed to identify predictors of co-utilization and downstream consequences more widely.

Tobacco use and mental health disparities in LGB youth.

OBJECTIVE: In 2019, the Youth Risk Behavioral Survey (YRBS) collected sexual orientation data for the first time in Kentucky. Tobacco use behaviors and mental health status among Lesbian, Gay, and Bisexual (LGB) youth is infrequently documented in southern states such as Kentucky. This study aimed to analyze self-reported tobacco use and mental health in youth by sexual orientation. DESIGN: Cross-sectional survey. SAMPLE: All participants, aged 12-19, of the 2019 Kentucky YRBS that indicated a sexual orientation. MEASUREMENTS: Differences in response distributions for tobacco use and mental health measures were analyzed via chi square by sexual orientation, with additional stratification by sex. RESULTS: A total of n = 1996 respondents were 12.8% LGB-identified and 82.1% heterosexual-identified. No disparities between LGB and heterosexual youth were observed in tobacco-related behaviors for male students, but disparities were persistent for female students (p = .005 for "tried tobacco before age 13"; p = .007 for "current smoking", p = .012 for "ever smoked"). Mental health disparities between LGB and heterosexual youth were significant for males and females (p < .05, all mental health measures). CONCLUSIONS: Findings suggest that tobacco disparities in this most recent data are narrower than in previous years; however, mental health disparities persist between LGB and heterosexual youth in Kentucky.

A Pharmacoepidemiologic Approach to Evaluate Real-world Effectiveness of Hormonal Contraceptives in the Presence of Drug-drug Interactions.

BACKGROUND: Accurate estimation of conception is critical in the assessment of the effects of drugs used during pregnancy or to prevent pregnancy. In a novel application, we studied the effectiveness of oral contraceptives (OCs), where misclassification of conception relative to OC exposure may obscure effect estimates. METHODS: We studied OC failure, in a large claims database, among women who used antiepileptic drugs with metabolizing enzyme-inducing properties (carbamazepine or oxcarbazepine), which reduce OC's effectiveness or enzyme-neutral properties (lamotrigine or levetiracetam), with no expected impact on OC effectiveness. We compared conception rates in women 12-48 years of age concomitantly using OCs and enzyme-inducing drugs with rates in concomitant users of OCs and enzyme-neutral drugs. We measured conception with a validated algorithm that estimates gestational age based on pregnancy endpoints. We estimated relative and attributable risk using generalized estimating equation models after standardized mortality ratio weighting. RESULTS: We identified 89,777 concomitant use episodes with adjusted contraceptive failure rates of 1.6 (95% confidence interval (CI) = 1.4, 1.8) per 100 person-years among users of enzyme-neutral drugs and 18,964 episodes with a rate of 2.3 (1.9, 2.8) among users of enzyme-inducing drugs. The relative risk of conception for enzyme-inducing group was 1.4 (1.1, 1.8), and the rate difference was 0.7 (0.2, 1.2). CONCLUSIONS: OCs in combination with antiepileptic drugs that interact with metabolic enzymes were associated with increased contraceptive failure rates. Measurement of conception in claims data had adequate accuracy to uncover a strong drug-drug interaction, offering promise for broader application in comparative effectiveness studies on hormonal contraceptives to inform clinical and regulatory decisionmaking.

Cannabis use assessment and documentation in healthcare: Priorities for closing the gap.

Several factors, including the lack of a systematic cannabis use assessment within healthcare systems, have led to significant under-documentation of cannabis use and its correlates in medical records, the unpreparedness of clinicians, and poor quality of cannabis-related electronic health record data, limiting its utilization in research. Multiple steps are required to overcome the existing knowledge gaps and accommodate the health needs implied by the increasing cannabis use prevalence. These steps include (1) enhancing clinician and patient education on the importance of cannabis use assessment and documentation, (2) implementing a standardized approach for comprehensive cannabis use assessment within and across healthcare systems, (3) improving documentation of cannabis use and its correlates in medical records and electronic health records by building in prompts, (4) developing and validating reliable computable phenotypes of cannabis use, (5) conducting research utilizing electronic health data to study a wide array of related health outcomes, (6) and establishing evidence-based guidelines to inform clinical practices and policies. Integrating comprehensive cannabis use assessment and documentation within healthcare systems is necessary to enhance patient care and improve the quality of electronic health databases. Employing electronic health record data in cannabis-related research is crucial to accelerate research in light of the existing knowledge gaps on a wide array of health outcomes. Thus, improving and modernizing cannabis use assessment and documentation in healthcare is an integral step on which research conduct and evidence generation primarily rely.

Changes in Quantity of Opioids Dispensed following Florida's Restriction Law for Acute Pain Prescriptions.

OBJECTIVE: To assess the impact of Florida's 3-day opioid prescription supply law, effective July 2018, on opioids dispensed for acute pain patients. METHODS: Pharmacy claims from a health plan serving a large Florida employer from January 2015 through March 2019 were analyzed. We used an interrupted time series study design accounting for autocorrelation of trends before and after policy change. Acute pain patients met inclusion criteria if they had not received any opioid containing medications in the past 180 days. Patients could contribute to additional new use time if subsequent opioid claims occurred ≥180 days since the previous claim. Outcomes included mean number of units dispensed of the initial opioid prescription, mean morphine milligram equivalents (MMEs) per day of initial prescription by month, and mean total MMEs per initial prescription by month. RESULTS: A total of 8,375 enrollees had 10,583 unique opioid starts in the given timeframe. Following the policy, there was an immediate significant decrease in the units dispensed per prescription of 4.9 (95% confidence interval [CI] -8.95, -.82 units). Additionally, there was a significant immediate reduction in total MMEs dispensed per prescription of 25.6 (95% CI -44.76, -6.44 MMEs). CONCLUSIONS: Among a group of privately-insured plan enrollees in Florida, and as a result of the law, there were significant decreases in the number of units dispensed, and total MMEs of opioid prescriptions. The immediate reduction in new opioid utilization following policy implementation suggests effective policy; however, impacts on chronic pain patients were not assessed.

Effects of hydrocodone rescheduling on opioid use outcomes: A systematic review.

OBJECTIVE: To evaluate opioid prescribing, dispensing, and use in relation to hydrocodone-containing product (HCP) rescheduling. METHODS: Seven biomedical databases and grey literature sources were searched with keywords and database-specific controlled vocabulary relevant to HCP rescheduling for items published between January 2014 and July 2019. We included English-language quasi-experimental studies that assessed changes in HCP and other opioid prescribing, dispensing, utilization, and opioid-related health outcomes before and after HCP rescheduling. A data extraction sheet was created for this review. Two authors evaluated risk of bias for each included study. Two of 4 authors each independently extracted patient demographics and opioid-related outcomes from the included studies. Conflicts were resolved by a third author. RESULTS: All studies identified (n = 44) were quasi-experimental in design with 10 using an interrupted time series approach. A total of 24 studies reported a decrease in HCP prescribing by 3.1%-66.0%. Six studies reported a decrease in HCP days' supply or doses by 14.0%-80.8%. There was increased prescribing of oxycodone-containing products by 4.5%-13.9% in 5 studies, tramadol by 2.7%-53.0% in 9 studies, codeine-containing products by 0.8%-1352.9% in 8 studies). Five studies reported a decrease in morphine equivalents by at least 10%, whereas 2 studies reported an increase in morphine equivalents. Differences in populations, sample sizes, and approaches did not allow for a meta-analysis. Details regarding approach and findings were limited in published conference abstracts (n = 16). CONCLUSIONS: Hydrocodone rescheduling was associated with reductions in prescribing and use of HCPs but was also associated with increased prescribing and use of other opioids, both schedule II and nonschedule II.

Development and Validation of an Administrative Claims-based Measure for All-cause 30-day Risk-standardized Readmissions After Discharge From Inpatient Psychiatric Facilities.

OBJECTIVE: The objective of this study was to develop and test a measure that estimates unplanned, 30-day, all-cause risk-standardized readmission rates (RSRRs) after inpatient psychiatric facility (IPF) discharge. PARTICIPANTS: We established a retrospective cohort of adults with a principal diagnosis of psychiatric illness or dementia discharged from IPFs to nonacute care settings, using 2012-2013 Medicare fee-for-service claims data. MEASURES: All-cause unplanned readmissions within 3-30 days post-IPF discharge were assessed by constructing then validating a parsimonious logistic regression model of 56 risk factors (selected via empirical data, systematic literature review, clinical expert opinion) for readmission using bootstrapping. RSRRs were calculated from the ratio of predicted versus expected readmission rates for each IPF using hierarchical regression. Measure reliability and validity were assessed via multiple strategies. RESULTS: The measure development cohort included 716,174 admissions to 1679 IPFs and 149,475 (20.9%) readmissions. Most readmissions (>80%) had principal diagnoses of mood, schizoaffective or substance use disorders, delirium/dementia, infections or drug/substance poisoning. Facility RSRRs ranged from 11.0% to 35.4%. The risk adjustment model showed good calibration and moderate discrimination similar to other readmission risk models (c statistic 0.66). Sensitivity analyses solidified the risk modeling approach. The intraclass correlation coefficient of estimated IPF RSRRs was 0.78, indicating good reliability. The measure identified 8.3% of hospitals as having better and 13.4% as having worse RSRRs than the national readmission rate. CONCLUSIONS: The measure provides an assessment of facility-level quality and insight into risk factors useful for informing preventive interventions. The measure will be included in the Centers for Medicare and Medicaid Services (CMS) Inpatient Psychiatric Quality Reporting program in 2019.

Domperidone prescribing patterns in pediatric patients before and after safety warning in South Korea.

OBJECTIVE: In 2014, the Korean Ministry of Food and Drug Safety (MFDS) issued a safety warning to carefully consider adverse cardiac effects when prescribing domperidone for children. We conducted this study to compare the trends of domperidone prescription in pediatrics before and after the MFDS safety warning. MATERIALS: This study included patients < 18 years old who used national health insurance services within the year 2011 and the year 2016, sampled from Health Insurance Review Agency data. METHODS: We analyzed domperidone prescribing patterns including prescribed daily dosage, maximum period of continuous prescription, and number and types of co-prescribed medications and compared two different years pre and post safety warning. RESULTS: A total of 16,614 pediatric patients (1.74%) received domperidone prescriptions in 2011, and 11,317 patients (1.23%) in 2016. The probability of receiving at least one prescription in 2016 has been reduced by 30% compared to 2011. Gastritis was the most common indication in both years. The number of prescriptions containing a maximum daily dosage of over 30 mg was significantly lower in 2016. In the same time period, the number of cases with a maximum continuous prescription period of more than 7 days significantly decreased (p < 0.001). In addition, from 2011 to 2016, comorbid diseases of domperidone-treated patients were similar, but the number of co-prescriptions of interacting medication to domperidone decreased (p < 0.001). CONCLUSION: After the 2014 safety letter was released, the pattern of prescribing domperidone in pediatrics has enhanced drug safety for children in terms of frequency of prescriptions, maximum duration of domperidone use, and the prescription of drugs interacting with domperidone.

Impact of an on-site perinatal mood disorders clinic in the diagnosis and management of perinatal mood disorders.

Objectives To assess change in Edinburgh Postnatal Depression Scale (EPDS) scores in women treated at the Perinatal Mood Disorders Clinic (PMDC) as a measure of improvement in perinatal mood disorders (primary outcome), and treatment disposition at final visit. Methods Chart review was performed for all PMDC patients between March 1, 2017 and June 1, 2018 (n=120), as a self-controlled case series design. Two-tailed t-tests compared initial and final EPDS scores for all patients with >1 visit (n=64), where EPDS score of ≥13 indicated a positive screen for depression. A multivariable linear regression model with robust standard errors estimated the relationship between patient characteristics and final EPDS scores. Results Of 120 patients, n=56 had one visit and n=64 had >1 visit. Of these 64, mean final score (11.04) was lower than mean initial score (16.54; p<0.001). Additionally, certain patient characteristics were associated with higher final EPDS score, including history of mood disorder and treatment with both pharmacotherapy and psychotherapy. Conclusions Women treated at the PMDC showed improved EPDS scores when receiving at least two separate care visits. Therefore, the clinic may be filling a gap in access to timely care for women with perinatal mood disorders.

Assessing the utility of the Healthy Start Screen to predict an elevated Edinburgh Postnatal Depression Scale score.

Objective To examine the utility of the Healthy Start Screen (HSS), which is an assessment of health, environment, and behavioral risk factors offered to all pregnant women in the state of Florida, in identifying women at risk for developing postpartum depression (PPD). Methods The sample for this Institutional Review Board (IRB)-approved, retrospective study consisted of patients who presented to a women's clinic for a new prenatal visit. Those patients who completed both the HSS at their prenatal visit and the Edinburgh Postnatal Depression Scale (EPDS) at their postpartum visit were included. We focused on items 1-10 of the HSS, where patients could respond with either "yes" or "no", and identified a positive EPDS as any score greater than or equal to 12. Results Women who identified as feeling down, depressed or hopeless, feeling alone when facing problems, to having ever received mental health services, or to having any trouble paying bills were more likely to have an EPDS score greater than or equal to 12. Conclusion The HSS, currently mandated by the state of Florida to be offered to all pregnant women, is a useful tool for identifying women at increased risk of developing PPD.

Increased Tdap and Influenza Vaccination Acquisition Among Patients Participating in Group Prenatal Care.

CenteringPregnancy, an alternative to traditional prenatal care, offers additional time between clinicians and patients with the goal of increasing knowledge, understanding, and autonomy in pregnant participants. We investigated whether these women would be more likely to receive recommended Tdap and influenza vaccinations relative to others who received one-on-one traditional prenatal care. Our study employed a retrospective chart review of all women who participated in CenteringPregnancy group care compared to a group of matched women who received only traditional prenatal care at a large, quaternary care referral academic center. We extracted demographic and clinical characteristics from charts that included maternal age during pregnancy care and parity. Outcome variables of interest were influenza and Tdap vaccination status. Compared with traditional obstetrical care patients, women who participated in CenteringPregnancy were 1.7-2.7 times more likely to obtain the Tdap and influenza vaccines. These findings may be attributable to the increased opportunity for patient education and social support offered by the CenteringPregnancy model.

Mass Casualty Shooting Venues, Types of Firearms, and Age of Perpetrators in the United States, 1982-2018.

OBJECTIVES: To evaluate the association between mass casualty shooting venues, types of firearms, and the age of perpetrators in the United States. METHODS: We analyzed data on mass casualty (≥ 3 fatalities) shootings for August 1982 through February 14, 2018. We describe data overall, specifically by school venues and the weapons used. We categorized perpetrators by ages of younger than 18 years, 18 to 20 years, and 21 years and older. We described the number of victims (fatalities plus injuries) by medians and average per event. RESULTS: Of 97 events, the median perpetrator age was 35 years and 21 years for school shootings. Four of 16 school events were committed by those aged 18 to 20 years, and all of those events included long guns. Victims of perpetrators aged 18 to 20 years made up 9.0% of all victims and 31.1% of victims of school shootings. CONCLUSIONS: Persons aged 18 to 20 years perpetrated about 1 in 8 shootings, accounting for about 1 in 3 victims of school shootings. Public Health Implications. Legislation to prevent mass casualty events must be multifaceted, including age restrictions, restrictions on certain types of firearms, and improved resources for mental health, with particular emphasis on mental health and firearm restrictions for young adults.