Access to on-campus contraception on college and university campuses in North Carolina.

BACKGROUND AND OBJECTIVE: Unintended pregnancies occur more frequently in college students and negatively affect health outcomes and educational attainment. This study examined access to on-campus contraceptives at all 4-year colleges and universities in North Carolina (NC). METHODS: This institutional review board-exempt study evaluated availability of on-campus contraceptives including condoms; hormonal contraceptives including pills, patches, and vaginal rings; medroxyprogesterone injections; implants; intrauterine devices; and emergency contraception via website review. Institutions were stratified by characteristics including size, location, type (e.g., public, private, religious affiliation, historically black colleges and universities, women's colleges), and presence of a student health pharmacy. Comparisons were made using chi-square test or Fisher's exact test. RESULTS: Fifty-four 4-year colleges and universities were identified. A plurality or the majority of schools were considered small (41%) and urban (48%) and had a religious affiliation (61%). Thirty-three percent of colleges and universities had an on-campus pharmacy. The most frequent contraceptives offered were condoms (43%), oral contraceptives (33%), and medroxyprogesterone injections (22%). Emergency contraception was available at approximately one-third of colleges and universities. Six percent of institutions provided a full range of contraceptive methods. Contraceptives were offered more frequently at large, public, urban institutions, whereas religious institutions and smaller institutions were less likely to offer contraceptives. CONCLUSION: Access to on-campus contraception for college students in NC is lacking, and the vast majority of institutions did not provide a full range of contraceptives. Policy measures, such as enhancing reproductive health services at student health centers or increasing contraception availability directly through pharmacies, are needed to improve access for college students.

Implementation of patient priorities-aligned care in a home-based primary care program.

BACKGROUND: Older adults may be limited in their ability to access care that meets their health goals owing to disease burden, financial instability, and psychosocial barriers. A home-based primary care (HBPC) program established in 2020 within a large family medicine practice uses the Patient Priorities Care (PPC) approach to identify and address patients' health priorities. When incorporated as part of the HBPC model of care, the PPC approach has the potential to enhance person-centered care for older adults in a way that best supports their health goals. OBJECTIVE: The objective of this study is to summarize common recommendations for alignment of care with patients' health outcome goals after implementation of the PPC approach in an HBPC population. METHODS: This retrospective study was exempt from review by an institutional review board. After enrollment in the HBPC program, patients participated in a PPC priorities identification conversation to identify their health outcome goals and care preferences. Through chart review, 2 researchers independently categorized these goals based on the set of values they most reflect: connecting, managing health, enjoying life, and functioning. Aspects of care in place before enrollment in HBPC were considered to determine any adjustments that needed to be made to align care with patients' identified priorities. RESULTS: The most common value associated with patients' most desired health outcome goal was functioning (n = 33, 66%). For secondary and tertiary health outcome goals, the most common value identified was managing health (secondary, n = 28, 56%; tertiary, n = 22, 44%). Common recommendations made to align care with patients' identified priorities included stopping potentially harmful medications, starting medications for untreated conditions, starting physical or occupational therapy, and adjusting medications. CONCLUSION: Through the PPC approach, patients' values were identified and care was assessed to aid in attainment of individualized health outcome goals and tailor care to What Matters most.

The Impact of Discharge Against Medical Advice on Readmission After Opioid Use Disorder-Associated Infective Endocarditis: a National Cohort Study.

BACKGROUND: Hospitalizations for infective endocarditis (IE) associated with opioid use disorder (O-IE) have increased in the USA and have been linked to high rates of discharge against medical advice (DAMA). DAMA represents a truncation of care for a severe infection, yet patient outcomes after DAMA are unknown. OBJECTIVE: This study aimed to assess readmissions following O-IE and quantify the impact of DAMA on outcomes. DESIGN: A retrospective study of a nationally representative dataset of persons' inpatient discharges in the USA in 2016 PARTICIPANTS: A total of 6018 weighted persons were discharged for O-IE, stratified by DAMA vs. other discharge statuses. Of these, 1331 (22%) were DAMA. MAIN MEASURES: The primary outcome of interest was 30-day readmission rates, stratified by discharge type. We also examined the total number of hospitalizations during the year and estimated the effect of DAMA on readmission. KEY RESULTS: Compared with non-DAMA, those experiencing DAMA were more commonly female, resided in metropolitan areas, lower income, and uninsured. Crude 30-day readmission following DAMA was 50%, compared with 21% for other discharge types. DAMA was strongly associated with readmission in an adjusted logistic regression model (OR 3.72, CI 3.02-4.60). Persons experiencing DAMA more commonly had ≥2 more hospitalizations during the period (31% vs. 18%, p<0.01), and were less frequently readmitted at the same hospital (49% vs 64%, p<0.01). CONCLUSIONS: DAMA occurs in nearly a quarter of patients hospitalized for O-IE and is strongly associated with short-term readmission. Interventions to address the root causes of premature discharges will enhance O-IE care, reduce hospitalizations and improve outcomes.

Clinical and economic implications of increasing access to herpes zoster vaccination rate in community pharmacies.

BACKGROUND: A community pharmacist plays an important role in providing vaccination to the general public in the United States. No economic models have been used to assess the impact of these services on public health and economic benefits. OBJECTIVE: This study aimed to estimate the clinical and economic implications of community pharmacy-based herpes zoster (HZ) vaccination services with a hypothetical scenario of nonpharmacy-based vaccination in the State of Utah. METHODS: A hybrid model of decision tree and Markov models was used to estimate lifetime cost and health outcomes. This open-cohort model was populated based on Utah population statistics and included a population of 50 years and older who were eligible for HZ vaccination between the years 2010 and 2020. Data were derived from the U.S. Bureau of Labor Statistics, the Utah Immunization Coverage Report, the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System, the CDC National Health Interview Survey, and existing literature. The analysis was performed from a societal perspective. A lifetime time horizon was used. The primary outcomes were the number of vaccination cases increased and the number of shingles and postherpetic neuralgia (PHN) cases averted. Total costs and quality-adjusted life-years (QALYs) were also estimated. RESULTS: Based on a cohort of 853,550 people eligible for HZ vaccination in Utah, an additional 11,576 individuals were vaccinated in the community pharmacy-based scenario compared with the nonpharmacy-based vaccination, resulting in 706 averted cases of shingles and 143 averted cases of PHN. Community pharmacy-based HZ vaccination was less costly (-$131,894) and gained more QALYs (52.2) compared with the nonpharmacy-based vaccination. A series of sensitivity analyses showed that the findings were robust. CONCLUSIONS: Community pharmacy-based HZ vaccination was less costly and gained more QALYs and was associated with improved other clinical outcomes in the State of Utah. This study might be used as a model for future evaluations of other community pharmacy-based vaccination programs in the United States.

Heritable Risk and Protective Genetic Components of Glaucoma Medication Non-Adherence.

Glaucoma is the leading cause of irreversible blindness, affecting 76 million globally. It is characterized by irreversible damage to the optic nerve. Pharmacotherapy manages intraocular pressure (IOP) and slows disease progression. However, non-adherence to glaucoma medications remains problematic, with 41-71% of patients being non-adherent to their prescribed medication. Despite substantial investment in research, clinical effort, and patient education protocols, non-adherence remains high. Therefore, we aimed to determine if there is a substantive genetic component behind patients' glaucoma medication non-adherence. We assessed glaucoma medication non-adherence with prescription refill data from the Marshfield Clinic Healthcare System's pharmacy dispensing database. Two standard measures were calculated: the medication possession ratio (MPR) and the proportion of days covered (PDC). Non-adherence on each metric was defined as less than 80% medication coverage over 12 months. Genotyping was done using the Illumina HumanCoreExome BeadChip in addition to exome sequencing on the 230 patients (1) to calculate the heritability of glaucoma medication non-adherence and (2) to identify SNPs and/or coding variants in genes associated with medication non-adherence. Ingenuity pathway analysis (IPA) was utilized to derive biological meaning from any significant genes in aggregate. Over 12 months, 59% of patients were found to be non-adherent as measured by the MPR80, and 67% were non-adherent as measured by the PDC80. Genome-wide complex trait analysis (GCTA) suggested that 57% (MPR80) and 48% (PDC80) of glaucoma medication non-adherence could be attributed to a genetic component. Missense mutations in TTC28, KIAA1731, ADAMTS5, OR2W3, OR10A6, SAXO2, KCTD18, CHCHD6, and UPK1A were all found to be significantly associated with glaucoma medication non-adherence by whole exome sequencing after Bonferroni correction (p < 10-3) (PDC80). While missense mutations in TINAG, CHCHD6, GSTZ1, and SEMA4G were found to be significantly associated with medication non-adherence by whole exome sequencing after Bonferroni correction (p < 10-3) (MPR80). The same coding SNP in CHCHD6 which functions in Alzheimer's disease pathophysiology was significant by both measures and increased risk for glaucoma medication non-adherence by three-fold (95% CI, 1.62-5.8). Although our study was underpowered for genome-wide significance, SNP rs6474264 within ZMAT4 (p = 5.54 × 10-6) was found to be nominally significant, with a decreased risk for glaucoma medication non-adherence (OR, 0.22; 95% CI, 0.11-0.42)). IPA demonstrated significant overlap, utilizing, both standard measures including opioid signaling, drug metabolism, and synaptogenesis signaling. CREB signaling in neurons (which is associated with enhancing the baseline firing rate for the formation of long-term potentiation in nerve fibers) was shown to have protective associations. Our results suggest a substantial heritable genetic component to glaucoma medication non-adherence (47-58%). This finding is in line with genetic studies of other conditions with a psychiatric component (e.g., post-traumatic stress disorder (PTSD) or alcohol dependence). Our findings suggest both risk and protective statistically significant genes/pathways underlying glaucoma medication non-adherence for the first time. Further studies investigating more diverse populations with larger sample sizes are needed to validate these findings.

BRCA testing and outcomes in women with breast cancer.

MAIN PURPOSE: Germline BRCA mutations (BRCAm) strongly influence the risk of developing breast cancer. This study aimed to understand the role of BRCAm testing in affected individuals and to assess its impact on the outcome of BRCAm carriers compared to non-carriers (BRCAwt) with breast cancer. RESEARCH QUESTION: The research question is "Does standard of care testing for BRCAm improve survival outcomes of breast cancer patients?" METHODS: In a single institution observational cohort study, demographic and clinical characteristics were compared between breast cancer patients with and without BRCAm. Frequency of BRCA testing was assessed. Survival outcomes were assessed by initial treatment setting stratified by BRCA status. RESULTS: Of 5712 identified women with breast cancer, 14.6% (n = 835) were tested for a BRCA mutation and had a documented result. The total number and proportion of women tested for a BRCAm increased between 2000 and 2014, resulting in an increased number of BRCAm carriers identified. However, the proportion of women who underwent testing and had a BRCAm decreased during the study period from 27.5% in 2000-2004 to 13.3% in 2010-2014. Disease-free survival was similar in the adjuvant and neoadjuvant treatment settings between BRCAm and BRCAwt patients. Progression-free survival on first line treatment and overall survival for patients with metastatic disease was also similar between BRCAm and BRCAwt patients. CONCLUSIONS: The proportion of women tested and the number of BRCAm identified increased during the study period despite a decreasing proportion of positive results among women tested.

Improving access to care through Advanced Practice Registered Nurses: Focus on perinatal patients with Opioid Use Disorder.

Perinatal substance use disorders, and all of the associated sequelae, continue to be a national health crisis that is further impacted by shifts in access to obstetrical care, particularly in rural areas. Opioid Use Disorder (OUD) specifically presents as a medical condition for which evidence-based guidelines support the use of medication treatment for opioid use disorder (MOUD) in the form of Methadone or Buprenorphine for both non-pregnant and pregnant women. However, the overall rates of access for those treatment modalities remain sparse. There is a public call to increase access to MOUD in the pregnant population affected by OUD. This article discusses the history of the Advanced Practice Registered Nurse (APRN) and how across legislative differences, these professionals are perfectly positioned to answer this call.

Unintentional Pediatric Poisoning Exposures in an Emergency Department: A Comparison of Poison Control Center Referrals and Caregiver Self-Referred Visits.

OBJECTIVES: The purpose of this study is to describe the demographics and clinical characteristics of patients referred to a pediatric emergency department (ED) for unintentional poisoning exposures by a poison control center (PCC) compared with patients/caregivers who self-refer. METHODS: The electronic data warehouse at a pediatric hospital was queried from October 1, 2014, to September 30, 2015, for unintentional poisoning-related ED visits and subsequent inpatient admissions. Eligible patients aged 18 years and younger were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes for pharmaceuticals, non-pharmaceuticalchemicals, fumes/vapors, foreign bodies, adverse food reactions, food poisoning, and bites/stings. Referral classification (PCC referral vs self-refer) was determined by PCC and hospital medical records.Descriptive statistics were used to characterize the patient demographics and ED visits by referral classification and age group. Simple and multiple logistic regression models examined the individual and combined impact of demographic and clinical characteristics on self-referral. RESULTS: Of the 705 patients identified, 84.4% presented as caregiver/self-referred compared with PCC-referred. As compared with those who self-referred, a higher percentage of patients who contacted the PCC before ED presentation were white (93.9% [89.4-98.2%] vs 83.8% [80.7-86.7%]) and had commercial insurance (62.7% [51.5-69.5%] vs 53.0% [48.9-57.0%]). Pharmaceutical (71.9%) and chemical (14.0%) exposures were the most common exposure types for PCC-referred patients whereas foreign bodies (54.3%) were the most common for self-referred patients. The largest predictors of self-referral were age, insurance, and exposure type. CONCLUSIONS: Among patients presenting at 1 pediatric ED, disparities with PCC utilization exist among age groups, racial identification, and poison exposure type. Educational outreach interventions are needed to ensure optimal use of the PCC services by patients, caregivers, and health care professionals.

Exploration of the STOP Act and Opioid Deaths in North Carolina, 2010-2018.

Objectives. To examine the impact of North Carolina's 2017 Strengthening Opioid Misuse Prevention (STOP) Act on opioid overdose deaths.Methods. We used quarterly data from the North Carolina Opioid Dashboard to conduct an interrupted time series analysis ranging from 2010 to 2018. Results were stratified by heroin-fentanyl deaths and other opioid deaths.Results. After the STOP Act, there was an initial rate increase of 0.60 opioid deaths per 100 000 population (95% confidence interval [CI] = 0.04, 1.15) and a decrease of 0.42 (95% CI = -0.56, -0.29) every quarter thereafter. Results differed by stratification.Conclusions. Our results suggest that North Carolina's STOP Act was associated with a reduction in opioid deaths in the year following enactment. The changes in opioid overdose death trends coinciding with the STOP Act were similar to outcomes seen with previous opioid policies.Public Health Implications. Future policies designed to reduce the availability of opioids may benefit from encouraging and increasing the availability of evidence-based treatment of opioid use disorder.

Poison-related visits in a pediatric emergency department: A retrospective analysis of patients who bypass poison control centers.

INTRODUCTION: Poison control centers (PCC) are an effective means to prevent unnecessary emergency department (ED) visits associated with poisoning exposures. However, not all patients with poison exposures utilize the PCC. The purpose of this study was to identify unintentional pediatric poisoning exposures presenting to a large US children's hospital that could have been managed onsite (i.e., at home) if consultation with a PCC had occurred prior to the ED visit. METHODS: Using ED encounters from a tertiary children's hospital, unintentional pharmaceutical, chemical, or fume exposures occurring between October 1, 2014 and September 30, 2015 were identified from ICD-9-CM billing codes. Two specialists in poison information reviewed the medical records of the identified patients who had no contact with the PCC and determined whether these encounters were preventable through PCC triage. Descriptive statistics examined the differences between the encounters. Data were analyzed in R v3.2.4 (Vienna, Austria) and SAS v9.4 (SAS Institute, Cary, NC). RESULTS: In the total study population (n = 231), 98 (42.4%) were PCC triaged and 133 (57.6%) were caregiver self-referred to the ED. For those who self-referred, 62 (46.6%) patients would have been recommended to be managed onsite instead of presenting at the ED for medical care. Analgesics and household cleaning products were the most common pharmaceutical and chemical exposures, respectively. CONCLUSIONS: Nearly half of ED visits for pediatric patients with unintentional poisoning exposures could have been avoided by contacting a PCC. Educational and self-efficacy-based interventions are needed to expand the public's use of PCC services.

Cost-effectiveness of early cancer surveillance for patients with Li-Fraumeni syndrome.

INTRODUCTION: Patients with germline TP53 pathogenic variants (Li-Fraumeni syndrome [LFS]) are at extremely high lifetime risk of developing cancer. Recent data suggest that tumor surveillance for patients with LFS may improve survival through early cancer detection. The objective of this study was to assess the cost-effectiveness of a cancer surveillance strategy for patients with LFS compared with those whose tumors present clinically. METHODS: A Markov decision analytic model was developed from a third-party payer perspective to estimate cost-effectiveness of routine cancer surveillance over a patient's lifetime. The model consisted of four possible health states: no cancer, cancer, post-cancer survivorship, and death. Model outcomes were costs (2015 United States Dollars [USD]), effectiveness (life years [LY] gained), and incremental cost-effectiveness ratio (ICER; change in cost/LY gained). One-way sensitivity analyses and probabilistic sensitivity analyses examined parameter uncertainty. RESULTS: The model showed a mean cost of $46 496 and $117 102 and yielded 23 and 27 LY for the nonsurveillance and surveillance strategies, respectively. The ICER for early cancer surveillance versus no surveillance was $17 125 per additional LY gained. At the commonly accepted willingness to pay threshold of $100 000/life-year gained, surveillance had a 98% probability of being the most cost-effective strategy for early cancer detection in this high-risk population. CONCLUSIONS: Presymptomatic cancer surveillance is cost-effective for patients with germline pathogenic variants in TP53. Lack of insurance coverage or reimbursement in this population may have significant consequences and leads to undetected cancers presenting in later stages of disease with worse clinical outcomes.

Payers' Perspectives on Pharmacist-Directed Care in a Community Pharmacy Setting.

Background: The United States is spending an increasing share of its national income on health care while American citizens are not receiving the commensurate benefit of longer, healthier lives. Pharmacists are in a position to provide high-quality care; however, a paucity of data exists on payers' perspectives on insurance reimbursement for pharmacist-provided, community-delivered clinical services. Objective: To understand payers' perspectives toward pharmacist-provided community-delivered advanced clinical services. Methods: A 15-minute online survey was administered to determine payers' preferences and attitudes of impact about care being provided in a community pharmacy setting by a pharmacist. Results: The study recruited 50 payers from a diverse set of US organizations. The likelihood for reimbursement for a suite of pharmacist-provided, community-delivered clinical services was likely/very likely (66%), neutral (22%), and unlikely/very unlikely (12%). Pharmacists were viewed positively by payers for the provision of these services. Payers think that more clinical services should be offered in the community pharmacy. Trust in pharmacist-provided information services on general health and medications, and pharmacist competency were strongly positive. Conclusions and Relevance: A quantitative assessment of payer attitudes for pharmacist-provided, community-delivered advanced clinical practice was positive. Payers were positive about pharmacist contributions to the provision of heath and medication information. Continued development and deployment of advanced clinical services at the community pharmacy appears to be a financially viable model.

Impact of a guideline-based best practice alert on pneumococcal vaccination rates in adults in a primary care setting.

BACKGROUND: Despite the high burden of pneumococcal disease, pneumococcal vaccine coverage continues to fall short of Healthy People 2020 goals. A quasi-experimental design was used to investigate the impact of pneumococcal-specific best-practice alerts (BPAs) with and without workflow redesign compared to health maintenance notifications only, on pneumococcal vaccination rates in at-risk and high-risk adults, and on series completion in immunocompetent adults aged 65+ years. METHODS: This retrospective study used electronic health record and administrative data to identify pneumococcal vaccinations using cross sectional and historical cohorts of adults age 19+ years from 2013 to 2017 who attended clinics associated with the University of Utah Health. Difference-in-differences (DD) analyses was used to assess the impact of interventions across three observation periods (Baseline, Interim, and Follow Up). Adherence to the 2-dose vaccination schedule in older adults was measured through a longitudinal analysis. RESULTS: In DD analyses, implementing both workflow redesign and the BPA raised the vaccination rate by 8 percentage points (pp) (P < 0.001) and implementing the BPA only raised the rate by 7 pp. (P < 0.001) among at-risk adults age 19-64 years, relative to implementing health maintenance notifications (i.e., usual care) only in comparison clinics. In high-risk adults age 19-64 years, the BPA with or without workflow redesign did not significantly affect vaccination rates from baseline to follow up relative to health maintenance notifications. Per DD analyses, the effect of the BPA was mixed in immunocompetent and immunocompromised adults age 65+ years. However, immunocompetent older adults attending a clinic that implemented the BPA plus health maintenance notifications and workflow redesign (all 3 interventions) had 1.94 times higher odds (Odds ratio (OR) 1.94; P = 0.0003, 95% CI 1.24, 3.01) to receive the second pneumococcal dose than patients attending a usual practice clinic (i.e., no intervention). CONCLUSIONS: A pneumococcal BPA tool that reflects current guidelines implemented with and without workflow redesign improved vaccination rates for at-risk adults age 19-64 years and increased the likelihood of adults aged 65+ to complete the recommended 2-dose series. However, in other adult patient groups, the BPA was not consistently associated with improvements in pneumococcal vaccination rates.

Pharmacist-prescribed hormonal contraception: A review of the current landscape.

OBJECTIVE: The objective of this article is to review the current supply-side, demand-side, and regulatory landscape of pharmacist-prescribed hormonal contraception (HC) in the United States. SUMMARY: Pharmacists appear to be supportive of pharmacist-prescribed HC. However, support does not necessarily indicate likelihood to implement the practice, even when reimbursement mechanisms exist. The likelihood of implementation can be increased with education and training of HC prescribing. Previous investigations suggest that women broadly support accessing contraception within a pharmacy. Expanded access, where available, can improve rates of use and adherence. Women at higher risk for unintended pregnancy, such as younger women and women without health insurance, are likely to use the pharmacy to procure HC. Despite a willingness to pay for HC consultations with pharmacists, costs can remain a significant barrier for many women. CONCLUSIONS: Expanding access to HC through pharmacist-prescriptive authority could help curb the rates of unintended pregnancy in the United States. Pharmacists are well positioned for such a role; however, significant barriers for pharmacists and patients remain. Examination of current implementation methods will assist policy makers in overcoming these barriers.

Cost-Sharing Requirements for the Herpes Zoster Vaccine in Adults Aged 60.

Background: Rates of zoster vaccination in US adults aged 60+ were approximately 30.6% in 2015. Out-of-pocket cost-sharing has been identified as a major barrier to vaccination for patients. To date, herpes zoster vaccine cost-sharing requirements for adults aged 60 to 64 has not been described. Objective: Compare the cost-sharing requirements for zoster vaccination in adults aged 60 to 64 and adults aged 65+. Methods: A retrospective cohort design examined pharmacy claims for zoster vaccination from the Utah All Payer Claims Database for adults aged 60+. Descriptive statistics and a 2-part cost model compared cost-sharing requirements for adults aged 60 to 64 and adults 65+. Results: Of the 30 293 zoster vaccine claims, 13 398 (45.8%) had no cost-sharing, 1716 (5.9%) had low cost-sharing (defined as $1 to less than $30), and 14 133 (48.3%) had high cost-sharing (defined as $30 or more). In the cost models, adults aged 65+ had higher odds of any cost-sharing (odds ratio = 39.86) and 29% higher cost-sharing as compared with adults aged 60 to 64. Conclusions: Adults aged 60 to 64 encounter lower cost-sharing requirements than adults aged 65+. Providers should be cognizant of this dynamic and encourage zoster vaccination prior to the age of 65.

Cost-effectiveness of emergency contraception options over 1 year.

BACKGROUND: The copper intrauterine device is the most effective form of emergency contraception and can also provide long-term contraception. The levonorgestrel intrauterine device has also been studied in combination with oral levonorgestrel for women seeking emergency contraception. However, intrauterine devices have higher up-front costs than oral methods, such as ulipristal acetate and levonorgestrel. Health care payers and decision makers (eg, health care insurers, government programs) with financial constraints must determine if the increased effectiveness of intrauterine device emergency contraception methods are worth the additional costs. OBJECTIVE: We sought to compare the cost-effectiveness of 4 emergency contraception strategies-ulipristal acetate, oral levonorgestrel, copper intrauterine device, and oral levonorgestrel plus same-day levonorgestrel intrauterine device-over 1 year from a US payer perspective. STUDY DESIGN: Costs (2017 US dollars) and pregnancies were estimated over 1 year using a Markov model of 1000 women seeking emergency contraception. Every 28-day cycle, the model estimated the predicted number of pregnancy outcomes (ie, live birth, ectopic pregnancy, spontaneous abortion, or induced abortion) resulting from emergency contraception failure and subsequent contraception use. Model inputs were derived from published literature and national sources. An emergency contraception strategy was considered cost-effective if the incremental cost-effectiveness ratio (ie, the cost to prevent 1 additional pregnancy) was less than the weighted average cost of pregnancy outcomes in the United States ($5167). The incremental cost-effectiveness ratios and probability of being the most cost-effective emergency contraception strategy were calculated from 1000 probabilistic model iterations. One-way sensitivity analyses were used to examine uncertainty in the cost of emergency contraception, subsequent contraception, and pregnancy outcomes as well as the model probabilities. RESULTS: In 1000 women seeking emergency contraception, the model estimated direct medical costs of $1,228,000 and 137 unintended pregnancies with ulipristal acetate, compared to $1,279,000 and 150 unintended pregnancies with oral levonorgestrel, $1,376,000 and 61 unintended pregnancies with copper intrauterine devices, and $1,558,000 and 63 unintended pregnancies with oral levonorgestrel plus same-day levonorgestrel intrauterine device. The copper intrauterine device was the most cost-effective emergency contraception strategy in the majority (63.9%) of model iterations and, compared to ulipristal acetate, cost $1957 per additional pregnancy prevented. Model estimates were most sensitive to changes in the cost of the copper intrauterine device (with higher copper intrauterine device costs, oral levonorgestrel plus same-day levonorgestrel intrauterine device became the most cost-effective option) and the cost of a live birth (with lower-cost births, ulipristal acetate became the most cost-effective option). When the proportion of obese women in the population increased, the copper intrauterine device became even more most cost-effective. CONCLUSION: Over 1 year, the copper intrauterine device is currently the most cost-effective emergency contraception option. Policy makers and health care insurance companies should consider the potential for long-term savings when women seeking emergency contraception can promptly obtain whatever contraceptive best meets their personal preferences and needs; this will require removing barriers and promoting access to intrauterine devices at emergency contraception visits.

The impact of exposure to antidepressant medications during pregnancy on neonatal outcomes: a review of retrospective database cohort studies.

INTRODUCTION: Concerns with prescription antidepressant use in pregnant women have instigated the examination of potential associations between fetal exposure to antidepressant medication and outcomes including preterm delivery, congenital malformations, perinatal and post-natal adverse events, persistent pulmonary hypertension, and mortality. The retrospective cohort model is an often utilized study design. The objective of this review is to evaluate the literature on antidepressant use in pregnancy conducted as retrospective cohorts in national/regional medical, or claims databases that assess neonatal and infant outcomes for agreement between studies, ultimately providing a methodological and outcomes summary for future scientific endeavors. METHODS: PubMed was searched for literature relating to antidepressant use and infant outcomes from the earliest available date through July 15, 2016. Studies with a retrospective cohort design and conducted in national/regional medical or claims databases were included. Searched outcomes included preterm delivery, congenital malformations, low birth weight, small for gestational age, persistent pulmonary hypertension of the newborn, and other select adverse events comprising low Apgar score (5 min), convulsions/seizures, respiratory distress/problems, fetal mortality, and infant mortality. RESULTS: Of the 784 studies identified, 36 retrospective cohort studies met eligibility criteria. An increase in preterm delivery and respiratory distress/problems and no increase in congenital malformation or fetal and infant death were associated with prenatal use of prescription antidepressants by majority consensus (at least 2/3 [67%] of studies). CONCLUSIONS: While consensus indicates that perinatal prescription antidepressant use has consequences for the fetus and infant, there are notable inconsistencies in the literature. More investigations that address prenatal exposure to depression and other important covariates are needed.

The value of a poison control center in preventing unnecessary ED visits and hospital charges: A multi-year analysis.

OBJECTIVE: The purpose of this study is to determine the economic value of the Utah Poison Control Center (UPCC) by examining its contribution to the reduction of unnecessary emergency department (ED) visits and associated charges across multiple years. METHODS: A multi-year (2009-2014) analysis of cross-sectional data was performed. Callers were asked what they would do for a poison emergency if the UPCC was not available. Healthcare charges for ED visits averted were calculated according to insurance status using charges obtained from a statewide database. RESULTS: Of the 10,656 survey attempts, 5018 were completed. Over 30,000 cases were managed on-site each year. Using the proportion of callers who noted they would call 911, visit an ED, or call a physician's office, between 20.0 and 24.2 thousand ED visits were potentially prevented each year of the survey. Between $16.6 and $24.4 million dollars in unnecessary healthcare charges were potentially averted annually. CONCLUSIONS: Compared to the cost of operation, the service UPCC provides demonstrates economic value by reducing ED visits and associated charges. As the majority of patients have private insurance, the largest benefit falls to private payers.