Valuing the cross-sector benefits from improving youth health to drive investment in place-based preventive interventions in the US: A simulation modeling study.

Healthcare payment reform has not produced incentives for investing in place-based, or population-level, upstream preventive interventions. This article uses economic modeling to estimate the long-term benefits to different sectors associated with improvements in population health indicators in childhood. This information can motivate policymakers to invest in prevention and provide guidance for cross-sector contracting to align incentives for implementing place-based preventive interventions. A benefit-cost model developed by the Washington State Institute for Public Policy was used to estimate total and sector-specific benefits expected from improvements to nine different population health indicators at ages 17 and 18. The magnitudes of improvement used in the model were comparable to those that could be achieved by high-quality implementation of evidence-based population-level preventive interventions. Benefits accruing throughout the lifecycle and over a ten-year time horizon were modelled. Intervention effect sizes of 0.10 and 0.20 demonstrated substantial long-term benefits for eight of the nine outcomes measured. At an effect size of 0.10, the median lifecycle benefit per participant across the ten indicators was $3080 (ranged: $93 to $14,220). The median over a 10-year time horizon was $242 (range: $14 to $1357). Benefits at effect sizes of 0.20 were approximately double. Policymakers may be able to build will for additional investment based on these cross-sector returns and communities may be able to capture these cross-sector benefits through contracting to better align incentives for implementing and sustaining place-based preventive interventions.

Mental Health-related Utilization of Emergency Departments During Pregnancy in the U.S., 2016-2019.

INTRODUCTION: Mental health conditions are a leading comorbidity of pregnancy, but little is known about the use of emergency departments (EDs) for mental health-related care during pregnancy. This study aims to describe both the characteristics of pregnant women who receive mental health-related care in hospital EDs in the United States and the most common mental health diagnoses, types of medications, and mental health services that these women receive. METHODS: Pooled, cross-sectional data from the National Hospital Ambulatory Medical Care Survey (2016-2019) were used. Pregnant patients were identified based on diagnosis and reason for visit codes. Weighted descriptive analyses were performed to describe characteristics of pregnant women, services offered, and medications received for mental health-related visits. RESULTS: Mental health-related visits comprised 6.2% of all ED visits during pregnancy. History of depression was significantly higher in pregnant patients with mental health-related visits compared to those pregnant patients presenting for other reasons. The most common diagnoses for pregnant patients with mental health-related visits were substance use disorders (30.7%), anxiety-related disorders (19.1%), and depressive disorders (14.6%). Anxiolytics and antidepressants were the most common pharmacotherapies given. Few women saw a mental health provider during their visit (6.7%), while most were referred to an outside clinic for follow-up (55.0%). DISCUSSION: Many pregnant women seek care from EDs for mental health-related reasons. It remains important to train health care professionals who treat pregnant women in EDs how to deliver effective treatments, particularly for substance use disorders and anxiety. SIGNIFICANCE: Many pregnant patients receive care in emergency departments during pregnancy. Despite mental health conditions being a leading comorbidity of pregnancy, little is known about the use of emergency departments for mental health-related reasons during pregnancy. This study is the first to analyze a representative sample of emergency department visits by pregnant women in the United States between 2016 and 2019 and report on mental health-related visits. Among pregnant women seen in the ED for mental health-related reasons, the most common diagnoses were substance use disorders, anxiety-related disorders, and depressive disorders, but few saw a mental health provider during their visit.

Caring for Children of Incarcerated Parents.

By age 18, one in fourteen American children has had a parent incarcerated. Although children from all backgrounds experience parental incarceration, racial and ethnic minority groups and those living in poverty are disproportionately affected. Parental incarceration is an adverse childhood experience that can negatively affect health and well-being over the life course. However, resilient children of incarcerated parents can flourish despite profound adversity. Pediatric providers should create safe, inclusive medical homes that foster sensitive disclosures and discussions about parental incarceration. If pediatric providers identify parental incarceration, they should promote foundational relationships and family resilience (including relationships with incarcerated parents when appropriate) and consider referrals to mental health specialists and specialized programs for children of incarcerated parents. Pediatric providers are also uniquely positioned to advocate for partnerships and policies that support children of incarcerated parents.

"Prevention of opioid use disorder: the HOME (housing, opportunities, motivation and engagement) feasibility study".

Young adults experiencing homelessness are at high risk of opioid and other substance use, poor mental health outcomes, exposure to trauma, and other risks. Providing access to stable housing has the potential to act as a powerful preventive intervention, but supportive housing programs have been studied most often among chronically homeless adults or adults with serious mental illness. The Housing First model, which does not precondition supportive housing on sobriety, may reduce drug use in homeless adults. In the present study, we piloted an adapted model of Housing First plus prevention services that was tailored to the needs of young adults (18-24 years) experiencing homelessness in the USA. Preventive services were added to the Housing First model and included youth-centered advocacy services, motivational interviewing, and HIV risk prevention services. This model was piloted in a single-arm study (n = 21) to assess the feasibility, acceptability, and initial efficacy of a Housing First model over a 6-month period in preparation for a larger randomized trial. We use repeated measures ANOVA to test for changes in alcohol and drug use (percent days of use; alcohol or drug use consequences), housing stability, social network support, and cognitive distortions over 6 months of follow-up. A total of 17 youth completed the study (85% retention), and a high proportion of youth were stably housed at 6-month follow-up. Participation in intervention services was high with an average of 13.57 sessions for advocacy, 1.33 for MI, and 0.76 for HIV prevention. Alcohol use did not change significantly over time. However, drug use, drug use consequences, and cognitive distortions, and the size of youths' social networks that were drug using individuals decreased significantly. The Housing First model appeared to be feasible to deliver, and youth engaged in the supportive intervention services. The study demonstrates the potential for an adapted Housing First model to be delivered to youth experiencing homelessness and may improve outcomes, opening the way for larger randomized trials of the intervention.

Promoting Children's Mental, Emotional, and Behavioral (MEB) Health in All Public Systems, Post-COVID-19.

The COVID-19 pandemic exacerbates the mental, emotional, and behavioral (MEB) health problems of children and adolescents in the United States (U.S.). A collective and coordinated national economic and social reconstruction effort aimed at shoring up services to promote children's MEB, like the Marshall Plan that helped rebuild Europe post-World War II, has been proposed to buttress against the expected retrenchment. The plan prioritizes children's well-being as a social objective. We propose strategically reconstructing the public safety-net systems serving youth, including early education, maternal and child health, child welfare, corrections, and mental health. That plan called for a concentrated focus on coalition-building and contracting by state mental health systems to establish a foundation for an improved health system. This paper offers a complementary set of suggestions for the four non-mental health systems mentioned above by recommending actionable steps based on scientific evidence to support improved services for children at risk for MEB problems. For each system we describe examples of evidence-informed services, policies or programs that (1) prevent disabilities and promote health, (2) protect and preserve families and neighborhoods, and (3) provide quality care. Prioritizing the promotion of children's MEB health by all state systems can shape U.S. children's health and well-being for generations to come.

'Home is where the health is': Housing quality and adult health outcomes in the Survey of Income and Program Participation.

Nearly a quarter of the homes in the United States were considered unhealthy or inadequate, but whether these housing characteristics have direct effects on health or whether they are driven by other contextual housing and neighborhood characteristics remains unclear. The purpose of this study was to quantify the independent associations between poor housing quality and adult health outcomes, adjusting for socioeconomic factors (e.g. income to poverty ratio, food insecurity) and other contextual housing characteristics (e.g. rental status, number of people per household, unsafe neighborhood). Using in-person household interview data from wave 1 of the 2014 Survey of Income and Program Participation (SIPP), a secondary analysis was performed using a series of logistic regression models. The 2014 SIPP sample is a multistage stratified sample of 53,070 housing units designed to represent the civilian, noninstitutionalized population of the United States (N = 55,281 adults ages 18 and older). Our results indicate that each additional poor housing characteristic was associated with poorer health status (OR: 1.17, CI [1.11, 1.23]), higher medical utilization (OR: 1.11 CI: [1.06, 1.16]), and a higher likelihood of hospitalization (OR: 1.07, CI [1.02, 1.12]). Non-housing-related government assistance, food security, and safe neighborhoods only partially explained associations between housing quality and health outcomes. Evaluating current local, state, and federal policy on housing quality standards may help determine if these standards decrease the number of Americans residing in inadequate homes or result in improvements in health and reductions in healthcare costs. Simply put, the home is where [we suggest] the health is.

Trends Over Time and Jurisdiction Variability in Supplemental Security Income and State Supplementary Payment Programs for Children With Disabilities.

CONTEXT: Nearly 1.2 million children with disabilities received federally administered Supplemental Security Income (SSI) payments in 2017. Based on a robust review of research and evaluation evidence and microsimulations, The National Academies of Sciences, Engineering, and Medicine committee identified modifications to SSI (ie, increasing the federal SSI benefit maximum by one-third or two-thirds) as 1 of 10 strategies that could reduce the US child poverty rate, improving child health and well-being on a population level. OBJECTIVE: Describing the availability and amount of SSI and State Supplementary Payment (SSP) program benefits to support families of children with disabilities may be a first step toward evaluating The National Academies of Sciences, Engineering, and Medicine-proposed modification to SSI as a potential poverty alleviation and health improvement tool for children with disabilities and their families. DESIGN: We used public health law research methods to characterize the laws (statutes and state agency regulations) governing the federal SSI program and SSP programs in the 50 states and District of Columbia from January 1, 1996, through November 1, 2018. RESULTS: The number of jurisdictions offering supplementary payments (SSP) was relatively stable between 1996 and 2018. In 2018, 23 US jurisdictions legally mandated that SSP programs were available for children. Among the states with SSP payment amounts in their codified laws, SSP monthly benefit amounts ranged from $8 to $64.35 in 1996 and $3.13 to $60.43 in 2018. CONCLUSION: Our initial exploration of SSI-related policies as a tool for improving the economic stability of children with disabilities and their families suggests that current SSPs, in combination with SSI, would not rise to the level of SSI increases proposed by The National Academies of Sciences, Engineering, and Medicine. Understanding more about how SSI and SSP reach children and work in combination with other federal and state income security programs may help identify policies and strategies that better support children with disabilities in low-income households.

Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings.

OBJECTIVES: To examine patient- and provider-level factors associated with receiving attention-deficit/hyperactivity disorder (ADHD) medication treatment in a community care setting. We hypothesized that the likelihood of ADHD medication receipt would be lower in groups with specific patient sociodemographic (eg, female sex, race other than white) and clinical (eg, comorbid conditions) characteristics as well as physician characteristics (eg, older age, more years since completing training). STUDY DESIGN: A retrospective cohort study was conducted with 577 children (mean age, 7.8 years; 70% male) presenting for ADHD to 50 community-based practices. The bivariate relationship between each patient- and physician-level predictor and whether the child was prescribed ADHD medication was assessed. A multivariable model predicting ADHD medication prescription was conducted using predictors with significant (P < .05) bivariate associations. RESULTS: Sixty-nine percent of children were prescribed ADHD medication in the year after initial presentation for ADHD-related concerns. Eleven of 31 predictors demonstrated a significant (P < .05) bivariate relationship with medication prescription. In the multivariable model, being male (OR, 1.34; 95% CI, 1.01-1.78; P = .02), living in a neighborhood with higher medical expenditures (OR, 1.11 for every $100 increase; 95% CI, 1.03-1.21; P = .005), and higher scores on parent inattention ratings (OR, 1.06; 95% CI, 1.03-1.10; P < .0001) increased the likelihood of ADHD medication prescription. CONCLUSIONS: We found that some children, based on sociodemographic and clinical characteristics, are less likely to receive an ADHD medication prescription. An important next step will be to examine the source and reasons for these disparities in an effort to develop strategies for minimizing treatment barriers.

Factors Affecting Emergency Department Computed Tomography Use in Children.

BACKGROUND: Variability in computed tomography (CT) use during pediatric emergency department (ED) visits has been reported. Our objective was to identify patient and hospital characteristics associated with CT use during pediatric ED visits. METHODS: Patients <18 y treated and released from EDs in the 2006-2012 Nationwide Emergency Department Sample were included. Associations were evaluated between pediatric CT scan rate and patient/hospital factors using logistic mixed effects models. Independent predictors of being a high outlier (having a pediatric CT scan rate in the top 10%) were also evaluated using logistic regression models. RESULTS: There were 1543 EDs and 20,703,273 visits included. CT scans were prescribed in 4.7% of pediatric ED visits; the highest 10% of EDs prescribed CT scans in >7.63% of all pediatric visits. In multivariable analysis, older age, male gender, private insurance, higher zip code level median income, and higher injury severity were all associated with an increased probability of receiving a CT scan (all P < 0.001). The chance of receiving a CT scan also varied by diagnosis and was independently associated with geographic location and annual pediatric ED volume. Rates of CT use increased with increasing pediatric volume up to approximately 5400 annual pediatric visits, and then decreased with volume >5400 annual visits. CONCLUSIONS: Several patient-level and ED-level characteristics, including annual pediatric volume, are associated with the probability of a child having a CT scan during an ED visit. Future work should focus on determining drivers behind these associations to develop intervention strategies to decrease pediatric CT use.

Social determinants of health priorities of state Medicaid programs.

BACKGROUND: Growing understanding of the influence of social determinants of health (SDH) on healthcare costs and outcomes for low income populations is leading State Medicaid agencies to consider incorporating SDH into their program design. This paper explores states' current approaches to SDH. METHODS: A mixed-methods approach combined a web-based survey sent through the Medicaid Medical Director Network (MMDN) listserv and semi-structured interviews conducted at the MMDN Annual Meeting in November 2017. RESULTS: Seventeen MMDs responded to the survey and 14 participated in an interview. More than half reported current collection of SDH data and all had intentions for future collection. Most commonly reported SDH screening topics were housing instability and food insecurity. In-depth interviews underscored barriers to optimal SDH approaches. CONCLUSION: These results demonstrate that Medicaid leaders recognize the importance of SDH in improving health, health equity, and healthcare costs for the Medicaid population but challenges for sustainable implementation remain.