Trauma Exposure and Suicidality in a Pediatric Emergency Psychiatric Population.

OBJECTIVES: The increasing rates of depression and suicidality in children and adolescents are reflected in the increasing number of mental health-related visits to emergency departments. Despite the high rates of traumatic exposure experienced by high-acuity children and adolescents and a known link to suicidal ideation, the systematic review of trauma history is not a consistent part of emergency department assessments for suicide ideation or attempt. In the present study, we examined the prevalence of suicidality as well as traumatic exposures in children and adolescents presenting to a dedicated pediatric psychiatric emergency department. METHODS: Suicide ideation, suicide attempts, and trauma exposure history were identified through a retrospective chart review of youth (n = 861) who presented to a dedicated child psychiatric emergency department during a 1-year period. Bivariate analyses comparing demographic and trauma history for children with and without suicidality and a multivariable logistic regression were performed. RESULTS: Childhood adversity was common, with 52% of youth reporting at least one type of trauma exposure. Emotional abuse, physical abuse, and sexual abuse/assault were associated with suicidality. Any trauma exposure and the total number of different trauma exposures were associated with reported suicide attempt. After adjusting for sociodemographic characteristics, children who reported a history of emotional abuse had 3.2-fold increased odds of attempted suicide. Children who reported a history of being a victim of bullying had 1.9-fold increased odds of current suicidal ideation. CONCLUSIONS: Traumatic experiences were common in youth presenting with suicidality. Traumatic experiences are frequently underrecognized in treatment settings because they are not part of routine evaluations and are often overlooked when trauma-related symptoms are not the presenting problem. Addressing traumatic experiences underlying depression and suicidal ideation is a necessary step in effective treatment. Emergency departments need to implement routine screening for traumatic exposures in children presenting with suicidal ideation or attempt.

Friendly Faces: Characteristics of Children and Adolescents With Repeat Visits to a Specialized Child Psychiatric Emergency Program.

OBJECTIVES: Pediatric mental health emergency department (ED) visits continue to rise with 19% to 62% of youth presenting to the ED ultimately returning for a mental health-related complaint. To better understand the needs of children returning to the ED, this study examines the clinical, demographic, and environmental factors associated with revisits to a dedicated child psychiatric ED. METHODS: Clinical factors, home environment, and mental health service utilization of 885 children presenting to a dedicated child psychiatric ED over a 1-year period were abstracted by retrospective chart review. Bivariate analyses comparing demographic and clinical characteristics for children with and without revisits and a multivariable logistic regression were performed. RESULTS: Of the children presenting to the ED, 186 (21.0%) had at least 1 revisit in the subsequent 180 days. Thirty-one percent of initial visits presented as urgent, 55% presented as emergent. Children presenting with more severe symptoms at their initial visit were more likely to return within 6 months. Female gender, suicidal and disruptive behavioral symptomatology, and a diagnosis of oppositional defiant disorder were associated with repeat visits. Children with mental health system involvement were more likely to have revisits than those who were "treatment naive." CONCLUSIONS: Revisits to the ED are driven by both clinical factors, including severity and psychosocial complexity, and barriers to accessing services. Addressing the problem of return ED visits will require the development of a robust mental health service system that is accessible to children and families of all socioeconomic levels.

Do Subspecialists Ask About and Refer Families with Psychosocial Concerns? A Comparison with General Pediatricians.

Objectives Calls for pediatricians to tend to children's psychosocial concerns have existed for decades because they are known to negatively impact child health. Children with chronic illnesses frequently have child- and family-level psychosocial concerns that complicate the care provided by their pediatric subspecialists. This study compares pediatricians who exclusively practice general pediatrics with subspecialists regarding their inquiring/screening and referring for psychosocial concerns. Physician and practice characteristics associated with these behaviors were examined. Methods We conducted a cross-sectional study using the 2013 American Academy of Pediatrics Periodic Survey of Fellows. Respondents included 304 pediatricians who exclusively practice general pediatrics and 147 subspecialists. The primary analysis compared the current practices of generalists vs. subspecialists with regard to inquiring/screening and referring children with 10 different psychosocial concerns. Covariates included socio-demographics, practice characteristics, and training experiences. Weighted univariate, bivariate and multivariable analyses were performed. Results Less than half of all pediatricians in the sample reported routinely inquiring/screening for most psychosocial concerns, and 2/3 of subspecialists failed to routinely inquire/screen for most of these conditions. Pediatricians who practice general pediatrics exclusively were more likely to inquire/screen (incident rate ratio (IRR) 1.41, p < .05) and refer (IRR 1.59, p < .001) for a greater number of psychosocial concerns than subspecialists, after adjusting for provider and practice characteristics. Having attended a child or adolescent mental health (MH) lecture/conference in the past 2 years was also related to inquiring/screening (IRR 1.24, p < .05). Conclusions Pediatricians infrequently inquire/screen and refer psychosocial concerns, with subspecialists addressing these concerns even less frequently.

Diagnostic Efficiency of Caregiver Report on the SCARED for Identifying Youth Anxiety Disorders in Outpatient Settings.

This study investigated the diagnostic and clinical utility of the parent-rated Screen for Child Anxiety Related Emotional Disorders (SCARED-P) for detecting youth anxiety disorders. Youth ages 6 to 12 years, 11 months were recruited from 9 outpatient mental health clinics (N = 707). Consensus diagnoses were based on semistructured interviews (Schedule for Affective Disorders and Schizophrenia for School-Age Children) with youth and caregivers; 31% were diagnosed with at least one anxiety disorder. Caregivers completed the SCARED-P to describe youth anxiety levels. SCARED-P scores were not considered during the consensus diagnoses. Areas under the curve (AUCs) from receiver operating characteristic analyses and diagnostic likelihood ratios (DLRs) quantified performance of the SCARED-P total score and subscale scores (generalized anxiety disorder and separation anxiety disorder). SCARED-P total scores had variable efficiency (AUCs = .69-.88), and Generalized Anxiety Disorder and Separation Anxiety subscale scores were excellent (AUCs = .86-.89) for identifying specific anxiety disorders. Optimal subscale cutoff scores were computed to help rule in (DLRs = 2.7-5.4) or rule out (DLRs < 1.0) anxiety disorders among youth. Results suggest that the Generalized Anxiety Disorder and Separation Anxiety SCARED-P subscales accurately identify their respective matched diagnoses. DLRs may aid clinicians in screening for youth anxiety disorders and improve accuracy of diagnosis.

Advanced sleep phase in adolescents born preterm.

The objective of this article is to evaluate whether sleep patterns and quality differed between adolescents born preterm and term, and to further explore whether differences in sleep patterns were explained by differences in mediating factors such as mood, behavior, or socioeconomic status. Five hundred and one 16- to 19-year-old children in the longitudinal Cleveland Children's Sleep and Health Study cohort underwent overnight polysomnography (PSG), wore wrist actigraphs, and completed sleep logs for 1 week. The modified Epworth Sleepiness Scale, the Adolescent Sleep Hygiene Scale, and the Adolescent Sleep-Wake Scale were used to further assess sleep. Adolescents born preterm demonstrated significantly (p < .05) earlier bed and wake times and sleep midpoints (approximately 22 min after adjusting for demographic and psychosocial factors) by actigraphy. They also had significantly fewer arousals (by PSG), and reported being more rested and alert in the morning, as well as less sleepiness and fatigue. These findings support a growing body of evidence that perinatal factors may influence sleep phenotypes later in life. These factors may reflect developmental influences, as well as the influence of parenting styles on children's sleep.

Educating health care professionals on human trafficking.

BACKGROUND: The US Department of State estimates that there are between 4 and 27 million individuals worldwide in some form of modern slavery. Recent studies have demonstrated that 28% to 50% of trafficking victims in the United States encountered health care professionals while in captivity, but were not identified and recognized. This study aimed to determine whether an educational presentation increased emergency department (ED) providers' recognition of human trafficking (HT) victims and knowledge of resources to manage cases of HT. METHODS: The 20 largest San Francisco Bay Area EDs were randomized into intervention (10 EDs) or delayed intervention comparison groups (10 EDs) to receive a standardized educational presentation containing the following: background about HT, relevance of HT to health care, clinical signs in potential victims, and referral options for potential victims. Participants in the delayed intervention group completed a pretest in the period the immediate intervention group received the educational presentation, and all participants were assessed immediately before (pretest) and after (posttest) the intervention. The intervention effect was tested by comparing the pre-post change in the intervention group to the change in 2 pretests in the delayed intervention group adjusted for the effect of clustering within EDs. The 4 primary outcomes were importance of knowledge of HT to the participant's profession (5-point Likert scale), self-rated knowledge of HT (5-point Likert scale), knowledge of who to call for potential HT victims (yes/no), and suspecting that a patient was a victim of HT (yes/no). FINDINGS: There were 258 study participants from 14 EDs; 141 from 8 EDs in the intervention group and 117 from 7 EDs in the delayed intervention comparison group, of which 20 served as the delayed intervention comparison group. Participants in the intervention group reported greater increases in their level of knowledge about HT versus those in the delayed intervention comparison group (1.42 vs -0.15; adjusted difference = 1.57 [95% confidence interval, 1.02-2.12]; P < 0.001). Pretest ratings of the importance of knowledge about HT to the participant's profession were high in both groups and there was no intervention effect (0.31 vs 0.55; -0.24 [-0.90-0.42], P = 0.49). Knowing who to call for potential HT victims increased from 7.2% to 59% in the intervention group and was unchanged (15%) in the delayed intervention comparison group (61.4% [28.5%-94.4%]; P < 0.01). The proportion of participants who suspected their patient was a victim of HT increased from 17% to 38% in the intervention group and remained unchanged (10%) in the delayed intervention comparison group (20.9 [8.6%-33.1%]; P < 0.01). INTERPRETATION: A brief educational intervention increased ED provider knowledge and self-reported recognition of HT victims.

Screening for symptoms of postpartum traumatic stress in a sample of mothers with preterm infants.

There are no established screening criteria to help identify mothers of premature infants who are at risk for symptoms of emotional distress. The current study, using data obtained from recruitment and screening in preparation for a randomized controlled trial, aimed to identify potential risk factors associated with symptoms of depression, anxiety and posttraumatic stress in a sample of mothers with premature infants hospitalized in a neonatal intensive care unit. One hundred, thirty-five mothers of preterm infants born at 26-34 weeks of gestation completed three self-report measures: the Stanford Acute Stress Reaction Questionnaire, the Beck Depression Inventory (2nd ed.), and the Beck Anxiety Inventory to determine their eligibility for inclusion in a treatment intervention study based on clinical cut-off scores for each measure. Maternal sociodemographic measures, including race, ethnicity, age, maternal pregnancy history, and measures of infant medical severity were not helpful in differentiating mothers who screened positive on one or more of the measures from those who screened negative. Programs to screen parents of premature infants for the presence of symptoms of posttraumatic stress, anxiety, and depression will need to adopt universal screening rather than profiling of potential high risk parents based on their sociodemographic characteristics or measures of their infant's medical severity.

Psychometric properties of the Adolescent Sleep Hygiene Scale.

This study evaluated the psychometric properties of the Adolescent Sleep Hygiene Scale (ASHS), a self-report measure assessing sleep practices theoretically important for optimal sleep. Data were collected on a community sample of 514 adolescents (16-19; 17.7 ± 0.4 years; 50% female) participating in the late adolescent examination of a longitudinal study on sleep and health. Sleep hygiene and daytime sleepiness were obtained from adolescent reports, behavior from caretaker reports, and sleep-wake estimation on weekdays from wrist actigraphy. Confirmatory factor analysis indicated the empirical and conceptually based factor structure were similar for six of the eight proposed sleep hygiene domains. Internal consistency of the revised scale (ASHSr) was α = 0.84; subscale alphas were: physiological: α = 0.60; behavioural arousal: α = 0.62; cognitive/emotional: α = 0.81; sleep environment: α = 0.61; sleep stability: α = 0.68; daytime sleep: α = 0.78. Sleep hygiene scores were associated positively with sleep duration (r = 0.16) and sleep efficiency (r = 0.12) and negatively with daytime sleepiness (r = -0.26). Results of extreme-groups analyses comparing ASHSr scores in the lowest and highest quintile provided further evidence for concurrent validity. Correlations between sleep hygiene scores and caretaker reports of school competence, internalizing and externalizing behaviours provided support for convergent validity. These findings indicate that the ASHSr has satisfactory psychometric properties for a research instrument and is a useful research tool for assessing sleep hygiene in adolescents.

Parental coping in the neonatal intensive care unit.

Fifty-six mothers of premature infants who participated in a study to reduce symptoms of posttraumatic stress disorder (PTSD) completed the Brief COPE, a self-report inventory of coping mechanisms, the Stanford Acute Stress Reaction Questionnaire to assess acute stress disorder (ASD) and the Davidson Trauma Scale to assess PTSD. 18 % of mothers had baseline ASD while 30 % of mothers met the criteria for PTSD at the 1-month follow-up. Dysfunctional coping as measured by the Brief COPE was positively associated with elevated risk of PTSD in these mothers (RR = 1.09, 95 % CI 1.02-1.15; p = .008). Maternal education was positively associated with PTSD; each year increase in education was associated with a 17 % increase in the relative risk of PTSD at 1 month follow-up (RR = 1.17, 95 % CI 1.02-1.35; p = .03). Results suggest that dysfunctional coping is an important issue to consider in the development of PTSD in parents of premature infants.

Costs Associated With Progression of Mildly Reduced Kidney Function Among Medicare Advantage Enrollees.

Rationale & Objective: The prevalence of early chronic kidney disease (CKD) in older adults has increased in the past 2 decades, yet CKD disease progression, overall, is variable. It is unclear whether health care costs differ by progression trajectory. The purpose of this study was to estimate the trajectories of CKD progression and examine Medicare Advantage (MA) health care costs of each trajectory over a 3-year period in a large cohort of MA enrollees with mildly reduced kidney function. Study Design: Cohort study. Setting & Population: 421,187 MA enrollees with stage G2 CKD in 2014-2017. Outcomes: We identified 5 trajectories of kidney function over time. Model Perspective & Timeframe: Mean total health care costs for each of the trajectories were described in each of the following 3 years from a payer perspective: 1 year before and 2 years after the index date establishing stage G2 CKD (study entry). Results: The mean estimated glomerular filtration rate (eGFR) at study entry was 75.9 mL/min/1.73 m2 and the median (interquartile range) follow-up period was 2.6 (1.6, 3.7) years. The cohort had a mean age of 72.6 years and had predominantly female participants (57.2%), and White (71.2%). We identified the following 5 distinct trajectories of kidney function: a stable eGFR (22.3%); slow eGFR decline with a mean eGFR at study entry of 78.6 (30.2%); slow eGFR decline with an eGFR at study entry of 70.9 (28.4%); steep eGFR decline (16.3%); and accelerated eGFR decline (2.8%). Mean costs of enrollees with accelerated eGFR decline were double the MA enrollees' mean costs in each of the other 4 trajectories in every year ($27,738 vs $13,498 for a stable eGFR 1 year after study entry). Limitations: Results may not generalized beyond MA and a lack of albumin values. Conclusions: The small fraction of MA enrollees with accelerated eGFR decline has disproportionately higher costs than other enrollees with mildly reduced kidney function.

Fulfillment and Validity of the Kidney Health Evaluation Measure for People with Diabetes.

Objective: To evaluate the fulfillment and validity of the kidney health evaluation for people with diabetes (KED) Healthcare Effectiveness Data Information Set (HEDIS) measure. Patients and Methods: Optum Labs Data Warehouse (OLDW) was used to identify the nationally distributed US population aged 18 years and older, with diabetes, between January 1, 2017, and December 31, 2017. The OLDW includes deidentified medical, pharmacy, laboratory, and electronic health record (EHR) data. The KED fulfillment was defined in 2017 as both estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio testing within the measurement year. The KED validity was assessed using bivariate analyses of KED fulfillment with diabetes care measures in 2017 and chronic kidney disease (CKD) diagnosis and evidence-based kidney protective interventions in 2018. Results: Among eligible 5,635,619 Medicare fee-for-service beneficiaries, 736,875 Medicare advantage (MA) beneficiaries, and 660,987 commercial patients, KED fulfillment was 32.2%, 38.7%, and 37.7%, respectively. Albuminuria testing limited KED fulfillment with urinary albumin-creatinine ratio testing (<40%) and eGFR testing (>90%). The KED fulfillment was positively associated with receipt of diabetes care in 2017, CKD diagnosis in 2018, and evidence-based kidney protective interventions in 2018. The KED fulfillment trended lower for Black race, Medicare-Medicaid dual eligibility status, low neighborhood income, and low education status. Conclusion: Less than 40% of adults with diabetes received guideline-recommended testing for CKD in 2017. Routine KED was associated with diabetes care and evidence-based CKD interventions. Increasing guideline-recommended testing for CKD among people with diabetes should lead to timely and equitable CKD detection and treatment.

Sleep-disordered breathing is associated with asthma severity in children.

OBJECTIVE: To examine the relationships among obesity, sleep-disordered breathing (SDB, defined as intermittent nocturnal hypoxia and habitual snoring), and asthma severity in children. We hypothesized that obesity and SDB are associated with severe asthma at a 1- year follow-up. STUDY DESIGN: Children aged 4-18 years were recruited sequentially from a specialty asthma clinic and underwent physiological, anthropometric, and biochemical assessment at enrollment. Asthma severity was determined after 1 year of follow-up and guideline-based treatment, using a composite measure of level of controller medication, symptom burden, and health care utilization. Multivariate logistic regression was used to examine adjusted associations of SDB and obesity with asthma severity at 12-month follow-up. RESULTS: Among 108 subjects (mean age, 9.1±3.4 years; 45.4% African-American; 67.6% male), obesity and SDB were common, affecting 42.6% and 29.6% of subjects, respectively. After adjusting for obesity, race, and sex, children with SDB had a 3.62-fold increased odds of having severe asthma at follow-up (95% CI, 1.26-10.40). Obesity was not associated with asthma severity. CONCLUSION: SDB is a modifiable risk factor for severe asthma after 1 year of specialty asthma care. Further studies are needed to determine whether treating SDB improves asthma morbidity.

Association of short and long sleep durations with insulin sensitivity in adolescents.

OBJECTIVE: To characterize the relationship between insulin sensitivity, assessed with the homeostasis model of insulin (HOMA), and objective measurements of sleep duration in adolescents. STUDY DESIGN: We conducted a cross-sectional analysis from two examinations conducted in the Cleveland Children's Sleep and Health Cohort (n = 387; 43% minorities). Biochemical and anthropometry measurements were made in a clinical research unit. Sleep duration was measured with actigraphy. RESULTS: Decreased sleep duration was associated with increased adiposity and minority race. Sleep duration had a quadratic "u-shape" association with HOMA. When adjusted for age, sex, race, preterm status, and activity, adolescents who slept 7.75 hours had the lowest predicted HOMA (1.96, 95% confidence interval [CI], 1.82-2.10), and adolescents who slept 5.0 hours or 10.5 hours had HOMA indices that were approximately 20% higher (2.36; 95% CI, 1.94-2.86; and 2.41; 95% CI, 1.93-3.01, respectively). After adjusting for adiposity, the association between shorter sleep and HOMA was appreciably attenuated, but the association with longer sleep persisted. CONCLUSIONS: Shorter and longer sleep durations are associated with decreased insulin sensitivity in adolescents. Although the association between shorter sleep duration with insulin sensitivity likely is explained by the association between short sleep duration and obesity, the association between longer sleep and insulin sensitivity is independent of obesity.

Brief cognitive-behavioral intervention for maternal depression and trauma in the neonatal intensive care unit: a pilot study.

Parents of hospitalized premature infants are at risk for developing psychological symptoms. This randomized controlled pilot study examined the effectiveness of a brief cognitive-behavioral intervention in reducing traumatic and depressive symptoms in mothers 1 month after their infant's discharge from the hospital. Fifty-six mothers were randomly assigned to the intervention or control group. Results showed that mothers experienced high levels of symptoms initially and at follow-up. At follow-up, there was a trend for mothers in the intervention group to report lower levels of depression (p = .06; Cohen's f = .318), but levels of traumatic symptoms were similar for both groups. Brief psychological interventions may reduce depressive symptoms in this population. Estimates of the effect sizes can be used to inform future intervention studies.

Teaching physicians to assess suicidal youth presenting to the emergency department.

OBJECTIVES: The objective of this study was to determine whether a 5-module self-paced computerized educational program improves residents' skills in assessing and managing youth presenting to the emergency department in acute psychiatric distress. METHODS: The evaluation used a quasi-experimental posttest-only design assessing both knowledge of the educational context of the program and self-rated pretest knowledge of program content with 32 residents recruited from 1 medical center in Cleveland, Ohio. RESULTS: About half of the respondents were female (48%); almost two thirds were white (65%), and few were trained in psychiatric assessment of children/adolescents. On average, residents had significantly higher scores on the posttest compared with the self-rated pretest (6.4 ± 1.1 vs 3.8 ± 2.3; P < 0.001), an effect size of 1.32. Residents responded positively to the modules and rated them highly on educational content (4.2 ± 0.5 on a 5-point scale) and satisfaction with clinical applicability (8.2 ± 1.2 on a 10-point scale) and found the program easy to navigate (8.5 ± 1.9 on a 10-point scale). CONCLUSIONS: A brief, self-administered, Web-based training program shows promise for improving residents' knowledge about suicidal behaviors in youth.

Chronic Kidney Disease Testing Among Primary Care Patients With Type 2 Diabetes Across 24 U.S. Health Care Organizations.

OBJECTIVE: Clinical guidelines for people with diabetes recommend chronic kidney disease (CKD) testing at least annually using estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (uACR). We aimed to understand CKD testing among people with type 2 diabetes in the U.S. RESEARCH DESIGN AND METHODS: Electronic health record data were analyzed from 513,165 adults with type 2 diabetes receiving primary care from 24 health care organizations and 1,164 clinical practice sites. We assessed the percentage of patients with both one or more eGFRs and one or more uACRs and each test individually in the 1, 2, and 3 years ending September 2019 by health care organization and clinical practice site. Elevated albuminuria was defined as uACR ≥30 mg/g. RESULTS: The 1-year median testing rate across organizations was 51.6% for both uACR and eGFR, 89.5% for eGFR, and 52.9% for uACR. uACR testing varied (10th-90th percentile) from 44.7 to 63.3% across organizations and from 13.3 to 75.4% across sites. Over 3 years, the median testing rate for uACR across organizations was 73.7%. Overall, the prevalence of detected elevated albuminuria was 15%. The average prevalence of detected elevated albuminuria increased linearly with uACR testing rates at sites, with estimated prevalence of 6%, 15%, and 30% at uACR testing rates of 20%, 50%, and 100%, respectively. CONCLUSIONS: While eGFR testing rates are uniformly high among people with type 2 diabetes, testing rates for uACR are suboptimal and highly variable across and within the organizations examined. Guideline-recommended uACR testing should increase detection of CKD.

The association of sleep duration with adolescents' fat and carbohydrate consumption.

STUDY OBJECTIVES: To investigate the relation between sleep duration and energy consumption in an adolescent cohort. DESIGN: Cross-sectional. SETTING: Free-living environment. PARTICIPANTS: Two hundred forty adolescents (mean age 17.7 +/- 0.4 years). MEASUREMENTS AND RESULTS: Daily 24-hour food-recall questionnaires and wrist-actigraphy measurements of sleep duration were employed to test the hypothesis that shorter weekday sleep duration (< 8 h) is associated with altered nutrient intake. Nutrition parameters included total calories, calories from meals and snacks, and proportions of caloric intake from fat and carbohydrates. Compared with adolescents sleeping 8 or more hours on average on weekdays, those sleeping less than 8 hours consumed a higher proportion of calories from fats (35.9% +/- 6.7% vs 33.2% +/- 6.9%; mean +/- SD; P = 0.004) and a lower proportion of calories from carbohydrates (49.6% +/- 8.2% vs 53.3% +/- 8.3%; P = 0.001). After adjusting for potential confounders, shorter sleep duration was significantly associated with an average daily increase of calories consumed from fat of 2.2 percentage points and an average daily decrease in percentage of calories from carbohydrates of 3.0 percentage points. In unadjusted analyses, shorter sleep duration was also associated with a 2.1-fold increased odds (95% confidence interval: 1.03, 4.44) of daily consuming 475 or more kcal from snacks. CONCLUSION: Quantitative measures of macronutrient intake in adolescents were associated with objectively measured sleep duration. Short sleep duration may increase obesity risk by causing small changes in eating patterns that cumulatively alter energy balance.

Access to and Engagement in Substance Use Disorder Treatment Over Time.

OBJECTIVE: This study evaluated whether access to and engagement in substance use disorder treatment has improved from 2010 to 2016. METHODS: Data submitted by commercial and Medicaid health plans, representing over 163 million beneficiaries from 2010 to 2016, were analyzed. RESULTS: For commercial plans, identification increased (from 1.0% to 1.6%, p<0.001), the initiation rate declined (from 41.9% to 33.7%, p<0.001), and the engagement rate also declined (from 15.8% to 12.1%, p<0.001). The decline in the initiation and engagement rates could not be explained by the increasing identification rates. For Medicaid plans, the identification rate increased (from 3.3% to 6.7%, p<0.001), and the initiation and engagement rates were unchanged. CONCLUSIONS: Although an increasing proportion of health plan members are being identified with substance use disorders, the majority of these individuals are not engaging in treatment.

Sleep quality and elevated blood pressure in adolescents.

BACKGROUND: We assessed whether insufficient sleep is associated with prehypertension in healthy adolescents. METHODS AND RESULTS: We undertook a cross-sectional analysis of 238 adolescents, all without sleep apnea or severe comorbidities. Participants underwent multiple-day wrist actigraphy at home to provide objective estimates of sleep patterns. In a clinical research facility, overnight polysomnography, anthropometry, and 9 blood pressure measurements over 2 days were made. Exposures were actigraphy-defined low weekday sleep efficiency, an objective measure of sleep quality (low sleep efficiency < or =85%), and short sleep duration (< or =6.5 hours). The main outcome was prehypertension (> or =90th percentile for age, sex, and height), with systolic and diastolic blood pressures as continuous measures as secondary outcomes. Prehypertension, low sleep efficiency, and short sleep duration occurred in 14%, 26%, and 11% of the sample, respectively. In unadjusted analyses, the odds of prehypertension increased 4.5-fold (95% CI, 2.1 to 9.7) in adolescents with low sleep efficiency and 2.8-fold (95% CI, 1.1 to 7.3) in those with short sleep. In analyses adjusted for sex, body mass index percentile, and socioeconomic status, the odds of prehypertension increased 3.5-fold (95% CI, 1.5. 8.0) for low sleep efficiency and 2.5-fold (95% CI, 0.9 to 6.9) for short sleep. Adjusted analyses showed that adolescents with low sleep efficiency had on average a 4.0+/-1.2-mm Hg higher systolic blood pressure than other children (P<0.01). CONCLUSIONS: Poor sleep quality is associated with prehypertension in healthy adolescents. Associations are not explained by socioeconomic status, obesity, sleep apnea, or known comorbidities, suggesting that inadequate sleep quality is associated with elevated blood pressure.

Sleep duration and biomarkers of inflammation.

INTRODUCTION: Extremes of sleep duration have been associated with adverse health outcomes. The mechanism is unclear but may be related to increased inflammation. We sought to assess the association between sleep duration and inflammatory biomarkers. METHODS: A total of 614 individuals from the Cleveland Family Study completed questionnaires about sleep habits and underwent polysomnography. A morning fasting blood sample was assayed for 5 inflammatory cytokines. RESULTS: In this cohort, mean (SD) habitual sleep duration based on self-report was 7.6 (1.6) h and mean sleep duration by polysomnography (PSG) on the night prior to blood sampling was 6.2 (1.3) h. After adjusting for obesity and apnea severity, each additional hour of habitual sleep duration was associated with an 8% increase in C-reactive protein (CRP) levels (P=0.004) and 7% increase in interleukin-6 (IL-6) levels (P=0.0003). These associations were independent of self-reported sleepiness. In contrast, PSG sleep duration was inversely associated with tumor necrosis factor alpha (TNFa) levels. For each hour reduction in sleep, TNFalpha levels increased by 8% on average (P=0.02). Sleep duration was not associated with IL-1 or IL-10. CONCLUSIONS: Increases in habitual sleep durations are associated with elevations in CRP and IL-6 while reduced PSG sleep duration is associated with elevated TNFa levels. Activation of pro-inflammatory pathways may represent a mechanism by which extreme sleep habits affect health.