A case study on variations in network structure and cross-sector alignment in two local systems serving pregnant and parenting women in recovery.

OBJECTIVE: To describe network structure and alignment across organizations in healthcare, public health, and social services sectors that serve pregnant and parenting women with substance use disorder (SUD) in an urban and a rural community. DATA SOURCES AND STUDY SETTINGS: Two community networks, one urban and one rural with each including a residential substance use treatment program, in Kentucky during 2021. STUDY DESIGN: Social network analysis measured system collaboration and cross-sector alignment between healthcare, public health, and social services organizations, applying the Framework for Aligning Sectors. To understand the alignment and structure of each network, we measured network density overall and between sectors, network centralization, and each organization's degree centrality and effective size. DATA COLLECTION/EXTRACTION METHODS: Computer-assisted telephone interviews were conducted to document alignment around shared purpose, data, financing, and governance. PRINCIPAL FINDINGS: On average, overall and cross-sector network densities in both communities were similar. However, alignment was highest for data sharing and financing in the urban community and for shared purpose and governance in the rural community. Cross-sector partnerships involving healthcare organizations were more prevalent in the rural county (44% vs. 38% for healthcare/public health, 44% vs. 29% for healthcare/social services), but more prevalent for those involving public health/social services organizations in the urban county (42% vs. 24%). A single healthcare organization had the highest degree centrality (Mdn [IQR] = 26 [26-9.5]) and effective size (Mdn [IQR] = 15.9 [20.6-8.7]) within the rural county. Social services organizations held more central positions in the urban county (degree centrality Mdn [IQR] = 13 [14.8-9.5]; effective size Mdn [IQR] = 10.4 [11.4-7.9]). CONCLUSIONS: Cross-sector alignment may strengthen local capacity for comprehensive SUD care for pregnant and parenting women. Healthcare organizations are key players in cross-sector partnerships in the rural community, where one healthcare facility holds the central brokerage role. In contrast, public health agencies are key to cross-sector collaboration with social services in the urban community.

Health Differs by Foster Care Eligibility: A Nine-Year Retrospective Observational Study Among Medicaid-Enrolled Children.

OBJECTIVE: This study sought to determine the prevalence and rates of physical, behavioral, and chronic health conditions among Medicaid-enrolled Colorado children by foster care eligibility codes over 9 years. METHODS: This retrospective, population-based study used Colorado's Medicaid administrative data for all enrolled children, aged <19 years old, from July 2011 to August 2020 to determine the period prevalence and rates of physical, behavioral, and chronic health conditions. We identified children in foster care by Medicaid eligibility codes and used the Pediatric Medical Complexity Algorithm version 3.0 to describe health condition outcomes. We report frequencies and percentages by foster care eligibility status, birth year cohort, and sex. RESULTS: Among 1,084,026 children, we identified 34,971 children in the foster cohort. Rates of physical (1105.0 per 100,000 person-months (PMs)) and behavioral health conditions (583.6 per 100,000 PMs) were two to threefold higher among the foster cohort than peers (physical 685.1 per 100,000 PMs; behavioral 212.2 per 100,000 PMs). By birth cohort, rates of behavioral health conditions among children in foster care were up to 8 times greater than peers. The foster cohort had greater prevalence of chronic conditions with (55.2%) and without (38.6%) behavioral health inclusion. CONCLUSIONS: This study provides a broader health assessment among Medicaid-enrolled children and finds condition disparities concentrated among youth in foster care. A more complete understanding of health problems among children in foster care is critical for health, child welfare, and Medicaid systems to improve health outcomes through coordinated and evidence-based interventions, programs, and policies.

Residence in urban or rural counties in relation to opioid overdose mortality among Kentucky hospitalizations before and during the COVID-19 pandemic.

BACKGROUND: At the beginning of the opioid overdose epidemic, overdose mortality rates were higher in urban than in rural areas. We examined the association between residence in an urban or rural county and subsequent opioid overdose mortality in Kentucky, a state highly impacted by the opioid epidemic, and whether this was modified by the COVID-19 pandemic. METHODS: We captured hospitalizations in Kentucky from 2016 to 2020, involving an opioid using ICD-10-CM codes T40.0-T40.4 and T40.6. Patient's county was classified as urban or rural based on the NCHS Urban-Rural Classification Scheme. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of opioid overdose mortality, adjusted for demographics, hospitalization severity, and zip code SES. We assessed effect modification by the COVID-19 pandemic. RESULTS: Overall, patients living in urban counties had 46% higher odds of opioid overdose death than patients residing in rural counties (adjusted OR=1.46; 95% CI=1.22, 1.74). Before the pandemic, patients in urban counties had 63% increased odds of opioid overdose death (adjusted OR=1.63; 95% CI=1.34, 1.97); however, during the COVID-19 pandemic, patients in urban and rural counties became more similar in regard to opioid overdose mortality (adjusted OR=0.72; 95% CI=0.45, 1.16; p-value for interaction =0.02). CONCLUSION: Before the pandemic, living in urban counties was associated with higher opioid overdose mortality among Kentucky hospitalizations; however, during the COVID-19 pandemic, opioid overdose mortality in rural areas increased, approaching rates in urban areas. COVID-19 posed social, economic, and healthcare challenges that may be contributing to worsening mortality trends affecting both urban and rural patients.

Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children.

To examine further racial and ethnic variations in antibiotic prescribing to children, we used the Child Opportunity Index. Black children were less likely to be prescribed an antibiotic. Low- and moderate-opportunity areas were associated with greater rates of antibiotic prescribing, after adjusting for race and other factors.

A social network analysis of interorganisational collaboration: Efforts to improve social connectedness.

The Covid-19 pandemic has challenged public health practitioners and clinicians at multiple levels to intentionally consider the impact of social isolation on health outcomes. Many community-based programmes design interventions to address tangible challenges within the social determinants of health, such as asset insecurity or food insecurity, to address health inequities. The growing need to address social isolation within marginalised communities also requires organisations to collaborate and create community partnerships that strengthen their own social integration within the community. The present research reports on the results of a Social Network Analysis (SNA) of community programmes within three southern U.S. cities and their local collaborations to address social isolation. After interviewing representatives of 46 community organisations, it was found that social service organisations that also offer public health services play a central role in community efforts to improve social isolation. The participating organisations primarily collaborate through referrals and information sharing, and report inadequate resources. With a growing recognition that social services and supports play a considerable role in addressing health inequities, this study provides evidence of opportunities for interorganisational collaboration to promote individual and community health.

Behavioral Parent Training for Families With Young Deaf or Hard of Hearing Children Followed in Hearing Health Care.

PURPOSE: It is well established that individuals with a communication disability, including being deaf or hard of hearing (DHH), experience inequities in health services and outcomes. These inequities extend to DHH children's access to psychosocial evidence-based interventions (EBIs). Behavioral parent training is an EBI that can be used to improve caregiver and child outcomes. Despite being supported by decades of effectiveness research, this EBI is rarely accessed by, or studied with, caregivers of DHH children. The purpose of this article is to describe a program of stakeholder-engaged research adapting and assessing behavioral parent training with caregivers of young DHH children followed in hearing health care, aimed at reducing inequities in access to this EBI. METHOD: The first section briefly summarizes the literature on disruptive behavior problems in young children, with a focus on preschool-age DHH children. The evidence base for behavioral parent training is described. Next, the gaps in knowledge and practice regarding disruptive behaviors among DHH children are highlighted, and the potential integration of behavioral parent training into the standard of care for this population is proposed. CONCLUSIONS: Young DHH children who use hearing aids and/or cochlear implants experience disruptive behavior problems at rates at least as high as typically hearing children, but their access to EBIs is limited, and behavioral parent training programs tailored to this population have not been rigorously tested. Caregivers and hearing health care service providers affirm the potential benefits of behavioral parent training and were partners in adapting this EBI. This research highlights several principles and approaches essential for reducing inequities and improving the quality of life not only for DHH children and their families but also for individuals with communication disabilities more broadly: engagement of key stakeholders in research, collaboration across disciplines, and using implementation science methods and models to design for implementation, dissemination, and sustainment. Presentation Video: https://doi.org/10.23641/asha.21215900.

Examination of U.S. national rates of emergency department visits and hospitalizations for depression and suicidal behaviors after the release of the 13 Reasons Why Netflix series by demographic characteristics.

BACKGROUND: To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents. METHODS: Data from the 2016 to 2018 Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2018 was used to determine the presentation in both settings for depression and suicidal thoughts and behavior. This was compared to predictive modeling for presentations in the same time frame. RESULTS: Following the release of 13 Reasons Why both hospital admissions and presentations to the Emergency Department (ED) increased for complaints of worsening depression or suicidal thoughts and behavior. This was more pronounced for youth aged 10-17 years, Black race, and female sex. There were no significant findings, overall, for females 6-9 years, but in-patient visits for depression increased in May 2017 for Black females 6-9 years. Males 6-9 years had higher rates of ED visits for depression and both ED and in-patient visits for suicidal behaviors. LIMITATIONS: Secondary data analyses have known limitations including inability to track over time, inclusion of only visit-level data, and failure to collect variables of interest. CONCLUSIONS: The series 13 Reasons Why was likely associated with exacerbations of both depressive illnesses and suicidal behavior in youth, particularly for female and Black youth from 10 to 17 years. This study adds to known concerns regarding the role of media in influencing suicidal behavioral in vulnerable children and has important implications for youth monitoring and parent and youth education. More research is needed to identify specific targets for prevention.

Communities Helping the Hearing of Infants by Reaching Parents (CHHIRP) through patient navigation: a hybrid implementation effectiveness stepped wedge trial protocol.

INTRODUCTION: As the most common neonatal sensory disorder in the USA, infant hearing loss has an incidence of 1.7 per 1000 births. The consequences of delayed diagnosis and failure to obtain timely intervention include significant communication impairment and negative socioeconomic effects. Early Hearing Detection and Intervention (EHDI) national standards dictate that all infants should be screened and diagnosed by 3 months of age and there is a need for interventions that promote adherence to timely diagnosis. Patient navigation (PN) has been shown to be efficacious to decrease non-adherence with infant hearing diagnostic care; however, PN has yet to be tested in diverse communities or implemented into real-world settings. METHODS AND ANALYSIS: The proposed research is a community-engaged, type 1 hybrid effectiveness-implementation trial of a PN intervention aimed at decreasing infant hearing diagnosis non-adherence after failed newborn hearing screening, delivered in state-funded EHDI clinics. Guided by our community advisory board and partners, we aim to (1) test the effectiveness of PN to decrease non-adherence to receipt of infant hearing diagnosis within 3 months after birth using a stepped-wedge trial design, (2) investigate implementation outcomes and factors influencing implementation and (3) determine the cost-effectiveness of PN from the perspective of third-party payers. The study will be conducted from April 2019 until March 2024. ETHICS AND DISSEMINATION: This protocol was approved by the University of Kentucky Institutional Review Board. Although all research involving human subjects contains some risk, there are no known serious risks anticipated from participating in this study. We will seek to disseminate our results in a systematic fashion to patients, key stakeholder, policymakers and the scientific community. Our results will impact the field by partnering with communities to inform the scale-up of this innovative patient supportive intervention to create efficient and effective EHDI programmes and maximise public health impact. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov (Pre-results phase): NCT03875339.

Study Protocol: Type 1 Hybrid Effectiveness-Implementation Trial of a Behavioral Parent Training Intervention for Parents of Young Children Who Are Deaf or Hard of Hearing.

PURPOSE: Children who are deaf or hard of hearing (DHH) and who use hearing aids or cochlear implants are more likely than their peers with typical hearing to exhibit behavior problems. Although multiple evidence-based interventions for child behavior problems exist, they are rarely delivered to children who are DHH, and no rigorous randomized controlled trials have been conducted to determine their effects with this population. This protocol describes a study aiming to test the effectiveness of an evidence-based behavioral parent training intervention adapted for parents of young children who are DHH and simultaneously to assess key implementation outcomes and multilevel contextual factors influencing implementation. METHOD: The protocol for a Type 1 hybrid effectiveness-implementation trial of a behavioral parent training intervention for parents of young children who are DHH is presented, including details of the study design, participants, assessments, and analyses. Using a stakeholder-engaged, mixed-methods approach, we will test the effects of the intervention versus treatment as usual on parenting behaviors, child behaviors, and a range of secondary effectiveness outcomes, including adherence to using hearing aids and cochlear implants as well as measures of child speech and language. We will assess the acceptability, feasibility, fidelity, and costs of the intervention from the perspectives of peer coaches who deliver the intervention, hearing health care clinicians (including audiologists and speech-language pathologists), and administrators of programs serving young children who are DHH. CONCLUSIONS: Results of this trial will inform future efforts to close the gap between prevalence of behavioral problems in young children who are DHH and access to and use of evidence-based interventions to prevent and treat them. If effective, this intervention could be widely implemented using strategies informed by the findings of this study to benefit young children who are DHH and followed in hearing health care and their families.

Antipsychotic Medications for Low-Income Preschoolers: Long Duration and Psychotropic Medication Polypharmacy.

OBJECTIVE: This study aimed to evaluate prescribing patterns of antipsychotic medication and factors that predict duration of use among low-income, preschool-age children. METHODS: State Medicaid claims from 2012 to 2017 were used to identify antipsychotic medication use for children <6 years old. ICD-9 and ICD-10 codes were used to describe child diagnoses. Descriptive and multivariable analyses were used to determine patterns of antipsychotic medication use and factors that predicted duration of use. RESULTS: In 2012, 316 children <6 years of age started an antipsychotic medication in a southeastern state. Most were non-Hispanic White (N=202, 64%) and boys (N=231, 73%). Diagnoses included attention-deficit hyperactivity disorder (N=288, 91%), neurodevelopmental disorders (N=208, 66%), anxiety and trauma-related diagnoses (N=202, 64%), and autism spectrum disorders (ASDs) (N=137, 43%). The mean±SD duration of exposure to antipsychotic medication for children in the cohort was 2.6±1.7 years, but 86 children (27%) had >4 years of exposure. Almost one-third (N=97, 31%) received polypharmacy of four or more medication classes, and 42% (N=131) received metabolic screening. Being male, being in foster care, and having a diagnosis of ASD or disruptive mood dysregulation disorder were significantly associated with duration of use of antipsychotic medications; race-ethnicity was not significantly associated with duration of use. Emergency department visits (N=277, 88%) and inpatient hospitalizations (N=107, 34%) were observed during the study period. CONCLUSIONS: Many preschoolers received antipsychotic medications for substantial periods. Further research is needed to identify evidence-based practices to reduce medication use and improve outcomes.

Oral health-related quality of life in US adults with type 2 diabetes.

OBJECTIVES: The objective of this study was to analyze factors associated with oral health-related quality of life (OHRQoL) between type 2 diabetes mellitus (T2DM) and nondiabetic US adults. METHODS: The study sample included 2945 participants (aged ≥20) selected from National Health and Nutrition Examination Survey (NHANES) 2003-2004 that represented 130,689,262 million persons in a probability weighted sample. Oral health outcomes were measured by the NHANES version of Oral Health Impact Profile (OHIP) for OHRQoL and summarized as additive scores (OHIP-ADD) and as prevalence of negative impacts (OHIP-SC). Multiple logistic regression models used dichotomous outcome variables OHIP-ADD and OHIP-SC. The cut-off values for poor OHRQoL were heuristically defined as OHIP-ADD ≥6 and as OHIP-SC > 0. RESULTS: Poor OHRQoL was significantly (p < 0.0001) predicted by T2DM (ORSC-controlled  = 1.43, ORSC-uncontrolled  = 1.73), obesity (ORSC  = 1.24), untreated dental caries (ORSC  = 1.79), periodontal disease (ORADD  = 1.07), evaluated unmet denture need (ORSC  = 1.72), low income (ORADD  = 1.22), smoking (ORSC-former-smoker  = 1.04, ORSC-current-smoker  = 1.99), African-American (ORSC  = 1.19), and female (ORSC  = 1.66) in both logistic regression models. In contrast, protective factors significantly (p < 0.0001) associated with poor OHRQoL were private dental insurance (ORSC  = 0.81), college education (ORSC  = 0.85), and annual dental prophylaxis (ORSC  = 0.83), after adjustment for covariates. CONCLUSIONS: This study showed that private insurance coverage and annual prophylaxis are associated with better average OHRQoL among individuals with T2DM. Improved OHRQoL may be associated with glycaemia control, decreased BMI, and smoking cessation. The highest odds for poor OHRQoL were found among US adults with T2DM with uncontrolled HbA1c, untreated dental caries, and current smoking.

Antibiotic prescribing to Kentucky Medicaid children, 2012-2017: Prescribing is higher in rural areas.

PURPOSE: Antibiotic resistance is a major public health threat. Antibiotic use is the main driver of resistance, with children and the state of Kentucky having particularly high rates of outpatient antibiotic prescribing. The purpose of this study was to describe patient and provider characteristics associated with pediatric antibiotic use in Kentucky Medicaid children. METHODS: We used Medicaid prescription claims data from 2012 to 2017 to describe patterns of pediatric antibiotic receipt in Kentucky. Patient and provider variables were analyzed to identify variations in prescribing. FINDINGS: Children who were female, less than 2 years old, White, and living in a rural area had consistently higher rates of antibiotic prescriptions. There was significant geographic variability in prescribing, with children in Eastern Kentucky receiving more than 3 courses of antibiotics a year. Most antibiotic prescriptions for children were written by general practitioners and nurse practitioners rather than pediatricians. CONCLUSION: These findings support the need for extensive antibiotic stewardship efforts inclusive of rural outpatient practices.

Cost Utility Analysis of Costal Cartilage Autografts and Human Cadaveric Allografts in Rhinoplasty.

BACKGROUND: Human cadaveric allograft (HCA) and costal cartilage autograft (CCA) have been described for reconstruction during rhinoplasty. Neither are ideal due to infection, resorption, and donor site morbidity. The clear superiority of 1 graft over the other has not yet been demonstrated. This study assesses comparative costs associated with current grafting materials to better explore the cost ceiling for a theoretical tissue engineered implant. MATERIALS AND METHODS: A cost utility analysis was performed. Initial procedure costs include physician fees (CPT 30420), hospital outpatient prospective payments, ambulatory surgical center payments, and fees for the following: rib graft (CPT 20910), hospital observation, and DRG (155) for inpatient admission. Additional costs for revision procedure, included the following fees: physician (CPT 30345), rib graft, hospital outpatient prospective payment, and ambulatory surgical center payments. Total costs under each scenario were calculated with and without the revision procedure. Comparison of total costs for each potential outcome to the estimated health utility value allowed for comparison across rhinoplasty subgroups. RESULTS: The mean cost of primary outpatient rhinoplasty using HCA and CCA were $8075 and $8342 respectively. Revision outpatient rhinoplasty averaged $7447 and increased to $8228 if costal cartilage harvest was required. Hospital admission increased the cost of primary rhinoplasty with CCA to $8609 for observational admission and to $13653 for 1 day inpatient admission. Revision CCA rhinoplasty with an inpatient admission complicated by pneumothorax increased costs to $21 099. CONCLUSION: Cost of rhinoplasty without hospitalization was similar between HCA and CCA and this cost represents the lower limit of a practical cost for an engineered graft. Considering complications such as need for revision or for admission after CCA due to surgical morbidity, the upper limit of cost for an engineered implant would approximately double.

High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid.

BACKGROUND: The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits. METHODS: A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration. RESULTS: High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015-2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate. CONCLUSIONS: Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.

Disparities in ADHD Diagnosis and Treatment by Race/Ethnicity in Youth Receiving Kentucky Medicaid in 2017.

Background: Kentucky has among the highest rate of attention deficit/hyperactivity disorder (ADHD) and stimulant use in the United States. Little is known about this use by race/ethnicity and geography. This article describes patterns of diagnosis of ADHD and receipt of stimulants and psychosocial interventions for children aged 6-17 years receiving Kentucky Medicaid in 2017 and identifies factors associated with diagnosis and treatment. Methods: Using Medicaid claims, children with and without ADHD (ICD-10 codes F90.0, F90.1, F90.2, F90.8, and F90.9) were compared and predictors of diagnosis and treatment type were examined. Psychosocial interventions were defined as having at least one relevant CPT code. Chi-squared tests and logistic regression models were used for univariate and multivariable analysis, respectively. Results: The rates of ADHD, stimulant use, and psychosocial interventions in our study population exceeded the national average (14% vs 9%; 75% vs 65.5%; and 51% vs 46.5%, respectively). The distributions varied by sex, race/ethnicity, sex among race/ethnicities, and population density. In general, race/ethnicity predicted ADHD diagnosis, stimulant use, and receipt of psychosocial interventions with non-Hispanic White children being more likely to receive diagnosis and medication, but less likely to receive psychosocial therapy than other children. Differences were also shown for rural compared with urban residence, sex, and sex within racial/ethnic groups. Conclusions: Diagnosis and treatment modalities differed for children by race/ethnicity, population density, and sex. More data are needed to better understand whether differences are due to provider bias, child characteristics, or cultural variations impacting the utilization of different treatment options.

Cefdinir Use in the Kentucky Medicaid Population: A Priority for Outpatient Antimicrobial Stewardship.

Cefdinir is frequently prescribed for pediatric infections despite lack of first-line indications. We reviewed Kentucky Medicaid claims from 2012 through 2016. Cefdinir prescriptions and spending significantly increased over the study period. Upper respiratory infections accounted for the majority of use. Inappropriate cefdinir use should be a priority for stewardship efforts.

Epidemiology of Treatment for Preschoolers on Kentucky Medicaid Diagnosed with Attention-Deficit/Hyperactivity Disorder.

Objectives: The National Survey of Children's Health reported a concerning increase in children 2-5 years being diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2016. Concerns include both the increase in diagnosing and potential deviations from published guidelines for the treatment of ADHD in preschoolers. The present study aims to describe the epidemiology and factors associated with receiving the diagnosis and treatment types for low-income preschoolers. Methods: Using Kentucky Medicaid claims from 2012 to 2017, a retrospective cohort study of children 2-5 years of age (n = 337,631) with a diagnosis of ADHD (n = 11,712) was completed. Trends in demographics, comorbidities, and treatment and provider types are presented. Multinomial logistic regression was used to determine predictors of receipt of the diagnosis and treatment type (a stimulant only, an alpha-2 agonist [A2A] only, both, or neither) based on nonmissing 2017 data (n = 2394). Results: The number of children in the cohort diagnosed with ADHD and receiving a stimulant decreased from 2012 to 2017, but the use of A2As increased. Primary care physicians were the most frequent prescribers of both medications. The adjusted odds ratios (AORs) of receipt of an A2A alone, stimulant alone, or both medications over receiving no ADHD medication were associated with specific demographics and comorbid conditions for each medication regimen. Race/ethnicity is associated with receiving the diagnosis of ADHD and treatment with A2A. Comorbid mental health conditions and provider type are associated with treatment type. Conclusion: Use of stimulants for preschoolers in Kentucky has decreased and A2A use has increased since 2012. Continued vigilance and long-term follow-up of preschoolers with ADHD are warranted. The appropriateness of the diagnosis and treatment type could not be determined.

Assessing the Healthy People 2020 Objective to Expand Early Treatment Receipt Among a National Sample of Children with Autism Spectrum Disorder.

OBJECTIVE: To assess the progress of the Healthy People 2020 (HP2020) objective to increase the proportion of children with autism spectrum disorder (ASD) who receive treatment by 48 months old and to examine the relationship between predisposing, enabling, and need factors and age of initial treatment receipt. METHOD: We used data from the National Survey of Children's Health, 2016 to 2017, a nationally representative study of US children. Our sample included children aged 3 to 17 years old with ASD who received treatment (N = 1333). We conducted χ goodness of fit tests and logistic regression. RESULTS: The HP2020 objective to enroll 57.6% of 8-year-old children with ASD in treatment by 48 months old was not met (40.9%). Among 3- to 5-year-old children with ASD, the proportion who received treatment by 48 months old was more than double that of 8-year-old children (88.3%). We detected social inequities and significant differences by provider type and state mandate. CONCLUSION: Research with larger samples is needed to continue tracking progress. If the goal continues not to be met, work will be required to explain stagnation and to inform additional targeted efforts to reduce the age of initial treatment.

Trends in diagnosis of bipolar and disruptive mood dysregulation disorders in children and youth.

OBJECTIVE: Rates of pediatric bipolar disorders have increased and some are concerned about diagnostic accuracy. Disruptive mood dysregulation disorder (DMDD) was added to the DSM-5 in 2013. The purpose of this study was to assess diagnostic trends of bipolar disorders and DMDD and to identify predictors of receiving the DMDD diagnosis since implementation of DSM-5. METHOD: Kentucky Medicaid claims from 2012-2017 for children under 18 years (N = 814,919; 2012 n = 473,389; 2013 n = 470,918; 2014 n = 499,094; 2015 n = 517,199; 2016 n = 529,048; 2017 n = 535,814) were used. Logistic regression was used to identify predictors of a diagnosis of DMDD in 2015-2017 for a sub-sample (n = 5,071). RESULTS: The use of DMDD rose after 2013 and mood disorder NOS decreased steadily through 2017. This decrease was seen when there was a diagnosis of bipolar and oppositional defiant disorder (ODD) combined with mood disorder NOS. A diagnosis of only mood disorder NOS in 2012 did not predict DMDD in 2015-2017, but the same diagnosis in 2013 was predictive (OR 2.14, p = 0.049). The reverse is true for a diagnosis of only ADHD in 2013, which did not predict DMDD in later years, but its presence in 2012 was predictive (OR 1.36, p = 0.010). CONCLUSIONS: DMDD increased after 2013, and this was associated with a diagnosis of mood disorder NOS, ADHD, as well as with bipolar disorders comorbid with ODD. Given the complexity of comorbid diagnoses, DMDD may be more accurate in classifying some children. Administrative claims data have limitations, which are discussed; and the data represent only children living in Kentucky.

A relational perspective on care coordination.

BACKGROUND: Care coordination occurs largely through care coordinators' interactions with patients and community partners to identify and address patients' individual needs. More frequent and higher-quality communication with each may enhance care coordination effectiveness. PURPOSE: The purpose of this study was to understand (a) how care coordinator perceptions of interactions with patients and community partners, respectively, compared to each other group's perceptions of their interactions with care coordinators and (2) whether these dynamics between care coordinators and community partners changed over time. METHODOLOGY: The research context was a comparative case study of provider-based care coordination projects funded through the Texas 1115(a) Medicaid waiver. The Relational Coordination instrument was administered through (a) two waves of in-person interviews with care coordinators (2014-2015 and 2015-2016) at a total of 10 sites across the state, (b) a single 2016 phone survey with 159 patients at nine of those sites, and (c) phone surveys with representatives of the community resources that care coordinators had identified as key partners in 2014-2015 and again in 2015-2016. RESULTS: Care coordinators reported more frequently needing both patients and community partners than either other group reported relative to care coordinators. Frequency of need and mutual influence with community partners increased in the first 2 years of the care coordination programs' implementation. The perceived quality of interactions between care coordinators and both patients and community partners was positive, but with room for improvement. CONCLUSION: Care coordination may entail limited interactions with patients and community partners, especially at program inception. As care coordination programs mature, interactions may become more frequent and influence with partners may expand. PRACTICE IMPLICATIONS: Decision makers should support care coordinators in improving the quality of their communication with both patients and community partners, as well as allow time for these relationships to develop.