Evaluating participant engagement in a preconception cohort study in relation to the Dobbs decision.

BACKGROUND: On June 24th, 2022, the United States (US) Supreme Court's ruling in Dobbs v. Jackson, et al. (hereafter, the Dobbs decision) removed federal-level protections for induced abortion, sparking concerns about reproductive rights and health privacy. Although other pregnancy outcomes (e.g. spontaneous abortion, ectopic pregnancy) are not explicit targets of post-Dobbs abortion bans, study participants may be worried about how their reproductive health data are used by researchers in the post-Dobbs era. OBJECTIVE: To evaluate the extent to which the Dobbs decision influenced participant's engagement in a preconception cohort study. METHODS: We leveraged data spanning 20 weeks before and after the Dobbs decision (4 February 2022, to 11 November 2022) from US participants in Pregnancy Study Online (PRESTO), an internet-based prospective preconception cohort study of couples attempting conception. We categorised participants' state-level abortion access by residential location: banned or restricted rights; limited access; and protected rights. We evaluated three participant engagement outcomes: follow-up questionnaire completion; report of a pregnancy; and clicking on the invitation link for a fertility-tracking app. We fit separate linear regression models and restricted cubic splines to compare outcome prevalence before and after the Dobbs decision by state-level abortion category. RESULTS: A total of 585 newly enrolled participants and 1247 already-enrolled participants received 2802 invitations to complete a follow-up questionnaire. In states with limited or protected abortion rights, we observed little change in participant engagement. In states with banned or restricted abortion rights, however, we observed a 27.12 percentage point reduction (95% confidence interval -43.68, -10.51) in the prevalence of clicking on the invitation link for the fertility-tracking app comparing the post- versus pre-Dobbs periods. CONCLUSIONS: There was some evidence of reduced participant engagement after the Dobbs decision in states with banned or restricted abortion rights, indicating potentially deleterious effects on the conduct of reproductive health studies.

Neighborhood socioeconomic deprivation, healthcare access, and 30-day mortality and readmission after sepsis or critical illness: findings from a nationwide study.

BACKGROUND: To determine if neighborhood socioeconomic deprivation independently predicts 30-day mortality and readmission for patients with sepsis or critical illness after adjusting for individual poverty, demographics, comorbidity burden, access to healthcare, and characteristics of treating healthcare facilities. METHODS: We performed a nationwide study of United States Medicare beneficiaries from 2017 to 2019. We identified hospitalized patients with severe sepsis and patients requiring prolonged mechanical ventilation, tracheostomy, or extracorporeal membrane oxygenation (ECMO) through Diagnosis Related Groups (DRGs). We estimated the association between neighborhood socioeconomic deprivation, measured by the Area Deprivation Index (ADI), and 30-day mortality and unplanned readmission using logistic regression models with restricted cubic splines. We sequentially adjusted for demographics, individual poverty, and medical comorbidities, access to healthcare services; and characteristics of treating healthcare facilities. RESULTS: A total of 1,526,405 admissions were included in the mortality analysis and 1,354,548 were included in the readmission analysis. After full adjustment, 30-day mortality for patients was higher for those from most-deprived neighborhoods (ADI 100) compared to least deprived neighborhoods (ADI 1) for patients with severe sepsis (OR 1.35 95% [CI 1.29-1.42]) or with prolonged mechanical ventilation with or without sepsis (OR 1.42 [95% CI 1.31, 1.54]). This association was linear and dose dependent. However, neighborhood socioeconomic deprivation was not associated with 30-day unplanned readmission for patients with severe sepsis and was inversely associated with readmission for patients requiring prolonged mechanical ventilation with or without sepsis. CONCLUSIONS: A strong association between neighborhood socioeconomic deprivation and 30-day mortality for critically ill patients is not explained by differences in individual poverty, demographics, measured baseline medical risk, access to healthcare resources, or characteristics of treating hospitals.

Characteristics of an Outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury-North Carolina, 2019.

BACKGROUND In August 2019, the North Carolina Division of Public Health (NCDPH) began investigating e-cigarette, or vaping, product use-associated lung injury (EVALI) cases as part of a national response. We describe clinical, epidemiologic, and laboratory findings of North Carolina EVALI patients.METHODS NCDPH requested that physicians report cases of respiratory illness or bilateral pulmonary infiltrates or opacities in patients who reported using e-cigarette, or vaping, products and had no infection or alternative plausible diagnoses. We reviewed medical records, interviewed patients, and tested vaping products for substances.RESULTS During August 13, 2019-February 18, 2020, 78 EVALI cases were reported in North Carolina. Median age of cases was 24 years (range: 13-72 years); 49 (63%) patients were male. Symptoms included cough (n = 70; 90%), shortness of breath (n = 66; 85%), and gastrointestinal symptoms (n = 63; 81%). Seventy-five patients (96%) were hospitalized, 32 (41%) required intensive care, and 12 (16%) required mechanical ventilation; none died. Among 20 patients interviewed, most reported using tetrahydrocannabinol (THC) (n = 16; 80%) or nicotine-containing products (n = 14; 70%). All obtained THC-containing products from informal sources, such as family, friends, or dealers, as THC is illegal in North Carolina. Among 82 products tested, 74 (90%) contained THC, cannabidiol, or cannabinol; 54 (66%) contained vitamin E acetate.LIMITATIONS In North Carolina, EVALI is not reportable by law, and THC is illegal. Thus, cases and exposures are likely underreported.CONCLUSIONS THC-containing products, particularly those containing vitamin E acetate, are associated with EVALI. Persons should not use these products, particularly from informal sources. Continued communication of health risks to persons who use e-cigarette, or vaping, products is essential.

Incorporating Acute Conditions into Risk-Adjustment for Provider Profiling: The Case of the US News and World Report Best Hospitals Rankings Methodology.

Several years ago, the US News and World Report changed their risk-adjustment methodology, now relying almost exclusively on chronic conditions for risk adjustment. The impacts of adding selected acute conditions like pneumonia, sepsis, and electrolyte disorders ("augmented") to their current risk models ("base") for 4 specialties-cardiology, neurology, oncology, and pulmonology-on estimates of hospital performance are reported here. In the augmented models, many acute conditions were associated with substantial risks of mortality. Compared to the base models, the discrimination and calibration of the augmented models for all specialties were improved. While estimated hospital performance was highly correlated between the 2 models, the inclusion of acute conditions in risk-adjustment models meaningfully improved the predictive ability of those models and had noticeable effects on hospital performance estimates. Measures or conditions that address disease severity should always be included when risk-adjusting hospitalization outcomes, especially if the goal is provider profiling.

Neighborhood Socioeconomic Disadvantage and 30-Day Outcomes for Common Cardiovascular Conditions.

BACKGROUND: Understanding the relationship between neighborhood environment and cardiovascular outcomes is important to achieve health equity and implement effective quality strategies. We conducted a population-based cohort study to determine the association of neighborhood socioeconomic deprivation and 30-day mortality and readmission rate for patients admitted with common cardiovascular conditions. METHODS AND RESULTS: We examined claims data from fee-for-service Medicare beneficiaries aged ≥65 years between 2017 and 2019 admitted for heart failure, valvular heart disease, ischemic heart disease, or cardiac arrhythmias. The primary exposure was the Area Deprivation Index; outcomes were 30-day all-cause death and unplanned readmission. More than 2 million admissions were included. After sequential adjustment for patient characteristics (demographics, dual eligibility, comorbidities), area health care resources (primary care clinicians, specialists, and hospital beds per capita), and admitting hospital characteristics (ownership, size, teaching status), there was a dose-dependent association between neighborhood socioeconomic deprivation and 30-day mortality rate for all conditions. In the fully adjusted model for death, estimated effect sizes of residence in the most disadvantaged versus least disadvantaged neighborhoods ranged from adjusted odds ratio 1.29 (95% CI, 1.22-1.36) for the heart failure group to adjusted odds ratio 1.63 (95% CI, 1.36-1.95) for the valvular heart disease group. Neighborhood deprivation was associated with increased adjusted 30-day readmission rates, with estimated effect sizes from adjusted odds ratio 1.09 (95% CI, 1.05-1.14) for heart failure to adjusted odds ratio 1.19 (95% CI, 1.13-1.26) for arrhythmia. CONCLUSIONS: Neighborhood socioeconomic disadvantage was associated with 30-day mortality rate and readmission for patients admitted with common cardiovascular conditions independent of individual demographics, socioeconomic status, medical risk, care access, or admitting hospital characteristics.

Neighborhood Socioeconomic Disadvantage, Healthcare Access, and Outcomes of Hospitalizations for Common Pulmonary Conditions: A National Study of Medicare Beneficiaries.

Rationale: Understanding how systemic forces and environmental exposures impact patient outcomes is critical to advancing health equity and improving population health for patients with pulmonary disease. This relationship has not yet been assessed at the population level nationally. Objectives: To determine whether neighborhood socioeconomic deprivation is independently associated with 30-day mortality and readmission for hospitalized patients with pulmonary conditions, after controlling for demographics, access to healthcare resources, and characteristics of admitting healthcare facilities. Methods: This was a retrospective, population-level cohort study of 100% of United States nationwide Medicare inpatient and outpatient claims from 2016-2019. Patients were admitted for one of four pulmonary conditions (pulmonary infections, chronic lower respiratory disease, pulmonary embolism, and pleural and interstitial lung diseases), defined by diagnosis-related group. The primary exposure was neighborhood socioeconomic deprivation, measured by the area deprivation index. The main outcomes were 30-day mortality and 30-day unplanned readmission, defined by Centers for Medicare and Medicaid Services methodologies. Generalized estimating equations were used to estimate logistic regression models for the primary outcomes, addressing clustering by hospital. A sequential adjustment strategy was first adjusted for age, legal sex, Medicare-Medicaid dual eligibility, and comorbidity burden, then adjusted for metrics of access to healthcare resources, and finally adjusted for characteristics of the admitting healthcare facility. Results: After full adjustment, patients from low socioeconomic status neighborhoods had greater 30-day mortality after admission for pulmonary embolism (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.13-1.40), respiratory infections (OR, 1.20; 95% CI, 1.16-1.25), chronic lower respiratory disease (OR, 1.31; 95% CI, 1.22-1.41), and interstitial lung disease (OR, 1.15; 95% CI, 1.04-1.27) when compared to patients from the highest SES neighborhoods. Low neighborhood socioeconomic status was also associated with 30-day readmission for all groups except the interstitial lung disease group. Conclusions: Neighborhood socioeconomic deprivation may be a key factor driving poor health outcomes for patients with pulmonary diseases.

Association Between Neighborhood Socioeconomic Status and 30-Day Mortality and Readmission for Patients With Common Neurologic Conditions.

BACKGROUND AND OBJECTIVES: Patients of low individual socioeconomic status (SES) are at a greater risk of unfavorable health outcomes. However, the association between neighborhood socioeconomic deprivation and health outcomes for patients with neurologic disorders has not been studied at the population level. Our objective was to determine the association between neighborhood socioeconomic deprivation and 30-day mortality and readmission after hospitalization for various neurologic conditions. METHODS: This was a retrospective study of nationwide Medicare claims from 2017 to 2019. We included patients older than 65 years hospitalized for the following broad categories based on diagnosis-related groups (DRGs): multiple sclerosis and cerebellar ataxia (DRG 058-060); stroke (061-072); degenerative nervous system disorders (056-057); epilepsy (100-101); traumatic coma (082-087), and nontraumatic coma (080-081). The exposure of interest was neighborhood SES, measured by the area deprivation index (ADI), which uses socioeconomic indicators, such as educational attainment, unemployment, infrastructure access, and income, to estimate area-level socioeconomic deprivation at the level of census block groups. Patients were grouped into high, middle, and low neighborhood-level SES based on ADI percentiles. Adjustment covariates included age, comorbidity burden, race/ethnicity, individual SES, and sex. RESULTS: After exclusions, 905,784 patients were included in the mortality analysis and 915,993 were included in the readmission analysis. After adjustment for age, sex, race/ethnicity, comorbidity burden, and individual SES, patients from low SES neighborhoods had higher 30-day mortality rates compared with patients from high SES neighborhoods for all disease categories except for multiple sclerosis: magnitudes of the effect ranged from an adjusted odds ratio of 2.46 (95% CI 1.60-3.78) for the nontraumatic coma group to 1.23 (95% CI 1.19-1.28) for the stroke group. After adjustment, no significant differences in readmission rates were observed for any of the groups. DISCUSSION: Neighborhood SES is strongly associated with 30-day mortality for many common neurologic conditions even after accounting for baseline comorbidity burden and individual SES. Strategies to improve health equity should explicitly consider the effect of neighborhood environments on health outcomes.

Impact of the COVID-19 Pandemic on Pediatric Preventive Health Care Among North Carolina Children Enrolled in Medicaid.

BACKGROUND: Children enrolled in private insurance had reduced preventive health care during the coronavirus disease 2019 (COVID-19) pandemic. However, the impact of the pandemic on children enrolled in Medicaid has been minimally described. METHODS: We used an administrative claims database from North Carolina Medicaid to evaluate the rates of well-child visits and immunization administration for children ≤14 months of age, and used a quasi-Poisson regression model to estimate the rate ratio (RR) of each outcome during the pandemic period (3/15/2020 through 3/15/2021) compared with the pre-pandemic period (3/15/2019 through 3/14/2020). RESULTS: We included 83 442 children during the pre-pandemic period and 96 634 children during the pandemic period. During the pre-pandemic period, 405 295 well-child visits and 715 100 immunization administrations were billed; during the pandemic period, 287 285 well-child visits and 457 144 immunization administrations were billed. The rates of well-child visits (RR 0.64; 95% CI, 0.64-0.64) and vaccine administration (RR 0.55; 95% CI, 0.55-0.55) were lower during the pandemic compared with the pre-pandemic period. CONCLUSIONS: The rates of well-child visits and immunization administrations among North Carolina children enrolled in public insurance substantially decreased during the first year of the COVID-19 pandemic.

Life expectancy and voting patterns in the 2020 U.S. presidential election.

INTRODUCTION: In the 2016 U.S. Presidential election, voters in communities with recent stagnation or decline in life expectancy were more likely to vote for the Republican candidate than in prior Presidential elections. We aimed to assess the association between change in life expectancy and voting patterns in the 2020 Presidential election. METHODS: With data on county-level life expectancy from the Institute for Health Metrics and Evaluation and voting data from a GitHub repository of results scraped from news outlets, we used weighted multivariable linear regression to estimate the association between the change in life expectancy from 1980 to 2014 and the proportion of votes for the Republican candidate and change in the proportion of votes cast for the Republican candidate in the 2020 Presidential election. RESULTS: Among 3110 U.S counties and Washington, D.C., change in life expectancy at the county level was negatively associated with Republican share of the vote in the 2020 Presidential election (parameter estimate -7.2, 95% confidence interval, -7.8 to -6.6). With the inclusion of state, sociodemographic, and economic variables in the model, the association was attenuated (parameter estimate -0.8; 95% CI, -1.5 to -0.2). County-level change in life expectancy was positively associated with change in Republican vote share 0.29 percentage points (95% CI, 0.23 to 0.36). The association was attenuated when state, sociodemographic, and economic variables were added (parameter estimate 0.24; 95% CI, 0.15 to 0.33). CONCLUSION: Counties with a less positive trajectory in life expectancy were more likely to vote for the Republican candidate in the 2020 U.S. Presidential election, but the Republican candidate's share improved in some counties that experienced marked gains in life expectancy. Associations were moderated by demographic, social and economic factors.