Public Health Interventions and Overdose-Related Outcomes Among Persons With Opioid Use Disorder.

Importance: Given the high number of opioid overdose deaths in the US and the complex epidemiology of opioid use disorder (OUD), systems models can serve as a tool to identify opportunities for public health interventions. Objective: To estimate the projected 3-year association between public health interventions and opioid overdose-related outcomes among persons with OUD. Design, Setting, and Participants: This decision analytical model used a simulation model of the estimated US population aged 12 years and older with OUD that was developed and analyzed between January 2019 and December 2023. The model was parameterized and calibrated using 2019 to 2020 data and used to estimate the relative change in outcomes associated with simulated public health interventions implemented between 2021 and 2023. Main Outcomes and Measures: Projected OUD and medications for OUD (MOUD) prevalence in 2023 and number of nonfatal and fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. Results: In a baseline scenario assuming parameters calibrated using 2019 to 2020 data remained constant, the model projected more than 16 million persons with OUD not receiving MOUD treatment and nearly 1.7 million persons receiving MOUD treatment in 2023. Additionally, the model projected over 5 million nonfatal and over 145 000 fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. When simulating combinations of interventions that involved reducing overdose rates by 50%, the model projected decreases of up to 35.2% in nonfatal and 36.6% in fatal opioid-involved overdoses among persons with OUD. Interventions specific to persons with OUD not currently receiving MOUD treatment demonstrated the greatest reduction in numbers of nonfatal and fatal overdoses. Combinations of interventions that increased MOUD initiation and decreased OUD recurrence were projected to reduce OUD prevalence by up to 23.4%, increase MOUD prevalence by up to 137.1%, and reduce nonfatal and fatal opioid-involved overdoses among persons with OUD by 6.7% and 3.5%, respectively. Conclusions and Relevance: In this decision analytical model study of persons with OUD, findings suggested that expansion of evidence-based interventions that directly reduce the risk of overdose fatality among persons with OUD, such as through harm reduction efforts, could engender the highest reductions in fatal overdoses in the short-term. Interventions aimed at increasing MOUD initiation and retention of persons in treatment projected considerable improvement in MOUD and OUD prevalence but could require a longer time horizon for substantial reductions in opioid-involved overdoses.

Systematic Review of Per Person Violence Costs.

INTRODUCTION: Data on the long-term and comprehensive cost of violence are essential for informed decision making regarding the future benefits of resources directed toward violence prevention. This review aimed to summarize original per-person estimates of the attributable cost of interpersonal violence to support public health economic research and decision making. METHODS: In 2023, English-language peer-reviewed journal articles published in 2000-2022 with a focus on high-income countries reporting original per-person average cost of violence estimates were identified using index terms in multiple databases. Study contents, including violence type (e.g., adverse childhood experiences), timeline and payer cost perspective (e.g., hospitalization event-only healthcare payer cost), and associated per-person cost estimates, were summarized. Costs were in 2022 U.S. dollars. RESULTS: Per-person cost estimates related to adverse childhood experiences, community violence, sexual violence, intimate partner violence, homicide, firearm violence, youth violence, workplace violence, and bullying from 73 studies (majority focusing on the U.S.) were summarized. For example, among 23 studies with a focus on adverse childhood experiences, monetary estimates ranged from $390 for adverse childhood experience-related annual healthcare out-of-pocket costs per U.S. adult with ≥3 adverse childhood experiences to $20.2 million for the lifetime societal economic burden of a U.S. child maltreatment fatality. CONCLUSIONS: This review provides a descriptive summary of available per-person cost of violence estimates. Results can help public health professionals to describe the economic burden of violence, identify the best available estimate for a particular public health question, and address data gaps. Ultimately, understanding the long-term and comprehensive cost of violence is necessary to anticipate the economic benefits of prevention.

Costs of Implementing Teen Dating Violence and Youth Violence Prevention Strategies: Evidence From 5 CDC-Funded Local Health Departments.

OBJECTIVES: In 2016, the Centers for Disease Control and Prevention supported 5 local health departments (LHDs) to implement teen dating violence and youth violence primary prevention strategies across multiple levels of the social-ecological model and build capacity for the expansion of such prevention efforts at the local level. The objective of this study was to estimate the total cost of implementing primary prevention strategies for all LHDs across 3 years of program implementation. METHODS: We used a microcosting analytic approach to identify resources and compute costs for all prevention strategies implemented by LHDs. We computed the total program cost, total and average cost per strategy by social-ecological model level, and average cost of implementation per participant served by the program. All costs were inflated via the monthly Consumer Price Index and reported in August 2020 dollars. RESULTS: For 3 years of program implementation, the total estimated cost of implementing teen dating violence and youth violence primary prevention strategies was >$7.1 million across all 5 LHDs. The largest shares of program-related costs were program staff (55.9%-57.0%) and contracts (22.4%-25.5%). Among prevention strategies, the largest share of total costs was for strategies implemented at the community level of the social-ecological model (42.8%). CONCLUSIONS: The findings from this analysis provide a first look at the total costs of implementing comprehensive teen dating violence and youth violence primary prevention strategies and serve as a foundation for investments in local violence prevention funding for young people.

Simulation Models for Suicide Prevention: A Survey of the State-of-the-Art.

Suicide is a leading cause of death and a global public health problem, representing more than one in every 100 deaths in 2019. Modeling and Simulation (M&S) is widely used to address public health problems, and numerous simulation models have investigated the complex, dependent, and dynamic risk factors contributing to suicide. However, no review has been dedicated to these models, which prevents modelers from effectively learning from each other and raises the risk of redundant efforts. To guide the development of future models, in this paper we perform the first scoping review of simulation models for suicide prevention. Examining ten articles, we focus on three practical questions. First, which interventions are supported by previous models? We found that four groups of models collectively support 53 interventions. We examined these interventions through the lens of global recommendations for suicide prevention, highlighting future areas for model development. Second, what are the obstacles preventing model application? We noted the absence of cost effectiveness in all models reviewed, meaning that certain simulated interventions may be infeasible. Moreover, we found that most models do not account for different effects of suicide prevention interventions across demographic groups. Third, how much confidence can we place in the models? We evaluated models according to four best practices for simulation, leading to nuanced findings that, despite their current limitations, the current simulation models are powerful tools for understanding the complexity of suicide and evaluating suicide prevention interventions.

A systems science approach to identifying data gaps in national data sources on adolescent suicidal ideation and suicide attempt in the United States.

BACKGROUND: Suicide is currently the second leading cause of death among adolescents ages 10-14, and third leading cause of death among adolescents ages 15-19 in the United States (U.S). Although we have numerous U.S. based surveillance systems and survey data sources, the coverage offered by these data with regard to the complexity of youth suicide had yet to be examined. The recent release of a comprehensive systems map for adolescent suicide provides an opportunity to contrast the content of surveillance systems and surveys with the mechanisms listed in the map. OBJECTIVE: To inform existing data collection efforts and advance future research on the risk and protective factors relevant to adolescent suicide. METHODS: We examined data from U.S. based surveillance systems and nationally-representative surveys that included (1) observations for an adolescent population and (2) questions or indicators in the data that identified suicidal ideation or suicide attempt. Using thematic analysis, we evaluated the codebooks and data dictionaries for each source to match questions or indicators to suicide-related risk and protective factors identified through a recently published suicide systems map. We used descriptive analysis to summarize where data were available or missing and categorized data gaps by social-ecological level. RESULTS: Approximately 1-of-5 of the suicide-related risk and protective factors identified in the systems map had no supporting data, in any of the considered data sources. All sources cover less than half the factors, except the Adolescent Brain Cognitive Development Study (ABCD), which covers nearly 70% of factors. CONCLUSIONS: Examining gaps in suicide research can help focus future data collection efforts in suicide prevention. Our analysis precisely identified where data is missing and also revealed that missing data affects some aspects of suicide research (e.g., distal factors at the community and societal level) more than others (e.g., proximal factors about individual characteristics). In sum, our analysis highlights limitations in current suicide-related data availability and provides new opportunities to identify and expand current data collection efforts.

Circumstances Contributing to Suicide Among U.S. Adolescents Aged 10-19 Years With and Without a Known Mental Health Condition: National Violent Death Reporting System, 2013-2018.

PURPOSE: Suicide is the second leading cause of death for adolescents in the United States; however, suicide is preventable and a better understanding of circumstances that contribute to death can inform prevention efforts. While the association between adolescent suicide and mental health is well established, multiple circumstances contribute to suicide risk. This study examines characteristics of adolescents who died by suicide and differences in circumstances between those with and without known mental health conditions at the time of death. METHODS: Logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals of circumstances contributing to suicide between decedents with and without known mental health conditions using data from the 2013 to 2018 National Violent Death Reporting System (analyzed in 2021). RESULTS: Decedents with a known mental health condition were 1.2-1.8 times more likely to experience problematic alcohol misuse, substance misuse, family and other nonintimate relationship problems, and school problems; however, there were no significant differences between those with and without a known mental health condition for the preceding circumstances of arguments or conflicts, criminal or legal problems, or any crisis occurring within the two weeks prior to death. DISCUSSION: A comprehensive suicide prevention approach can address not only mental health conditions as a risk factor but also life stressors and other crises experienced among adolescents without known mental health conditions.

WISQARS Cost of Injury for public health research and practice.

AIM: Since 2011 the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System (WISQARS) has demonstrated per-injury average and population total medical and non-medical costs of injuries by type (such as unintentional cut/pierce) in the USA. This article describes the impact of data and methods changes in the newest version of WISQARS Cost of Injury. METHODS: Data sources and methods were compared for the legacy version of the WISQARS Cost of Injury website (available 2011-2021; most recent prior update was published in 2014 with 2010 injury incidence and costs) and the new version (published 2021; 2015-present injury incidence and costs). Cost data sources were updated for the new website and the basis for medical costs and non-fatal injury work loss costs changed from mathematical modelling (combined estimates from multiple data sources) in the legacy website to statistical modelling of actual injury-related medical and work loss financial transactions in the new website. Monetary valuation of non-medical costs for injury deaths changed from lost employment income and household work in the legacy website to value of statistical life. Quality of life loss costs were added for non-fatal injuries. Per-injury average medical and non-medical costs by injury type (mechanism and intent) and total population injury costs were compared for years 2010 (legacy website data) and 2020 (new website data) to illustrate the impact of data and methods changes on reported costs in the context of changed annual injury incidence. RESULTS: Owing to more comprehensive cost capture yielding higher per-injury average costs for most injury types-including those with high incidence in 2020 such as unintentional poisoning and unintentional falls-reported total US medical and non-medical injury costs were substantially higher in 2020 (US$4.6 trillion) compared with 2010 (US$693 billion) (both 2020 USD). CONCLUSIONS AND RELEVANCE: New data and methods increased the injury costs reported in WISQARS Cost of Injury. Researchers and public health professionals can use this information to proficiently communicate the burden of injuries and violence in terms of economic cost.

Pathways to suicide or collections of vicious cycles? Understanding the complexity of suicide through causal mapping.

Suicide is the second leading cause of death among youth ages 10-19 in the USA. While suicide has long been recognized as a multifactorial issue, there is limited understanding regarding the complexities linking adverse childhood experiences (ACEs) to suicide ideation, attempt, and fatality among youth. In this paper, we develop a map of these complex linkages to provide a decision support tool regarding key issues in policymaking and intervention design, such as identifying multiple feedback loops (e.g., involving intergenerational effects) or comprehensively examining the rippling effects of an intervention. We use the methodology of systems mapping to structure the complex interrelationships of suicide and ACEs based on the perceptions of fifteen subject matter experts. Specifically, systems mapping allows us to gain insight into the feedback loops and potential emergent properties of ACEs and youth suicide. We describe our methodology and the results of fifteen one-on-one interviews, which are transformed into individual maps that are then aggregated and simplified to produce our final causal map. Our map is the largest to date on ACEs and suicide among youth, totaling 361 concepts and 946 interrelationships. Using a previously developed open-source software to navigate the map, we are able to explore how trauma may be perpetuated through familial, social, and historical concepts. In particular, we identify connections and pathways between ACEs and youth suicide that have not been identified in prior research, and which are of particular interest for youth suicide prevention efforts.

Injury Prevention Activities in US Schools, School Health Policies and Practices Survey 2014.

BACKGROUND: Exposure to injury and violence early in life increases the risk of experiencing injury and violence later in life. In 2019, the top 3 leading causes of death among 15- to 18-year-olds in the United States were unintentional injury, suicide, and homicide. This study examines the extent to which schools promote injury and violence prevention. METHODS: This study examined injury- and violence-related school policies and practices using nationally representative data from the 2014 School Health Policies and Practices Study. The social ecological model served as the theoretical framework to identify level of impact. RESULTS: For many injury-related topics, more than 75% of schools nationwide had relevant policies and practices to address those topics. However, this study showed differences in schools' injury-related policies and practices by urbanicity. CONCLUSIONS: Understanding and identifying gaps in school policies and practices is essential for reducing and preventing the injury and violence children experience. Collecting data on school policies and practices allows for better monitoring and evaluation to determine which are efficacious and aligned with the best available evidence.

Modeling the Transmission of COVID-19: Impact of Mitigation Strategies in Prekindergarten-Grade 12 Public Schools, United States, 2021.

BACKGROUND: Schools are an integral part of the community; however, congregate settings facilitate transmission of SARS-CoV-2, presenting a challenge to school administrators to provide a safe, in-school environment for students and staff. METHODS: We adapted the Centers for Disease Control and Prevention's COVIDTracer Advanced tool to model the transmission of SARS-CoV-2 in a school of 596 individuals. We estimate possible reductions in cases and hospitalizations among this population using a scenario-based analysis that accounts for (a) the risk of importation of infection from the community; (b) adherence to key Centers for Disease Control and Prevention-recommended mitigation strategies: mask wearing, cleaning and disinfection, hand hygiene, and social distancing; and (c) the effectiveness of contact tracing interventions at limiting onward transmission. RESULTS: Low impact and effectiveness of mitigation strategies (net effectiveness: 27%) result in approximately 40% of exposed staff and students becoming COVID-19 cases. When the net effectiveness of mitigation strategies was 69% or greater, in-school transmission was mostly prevented, yet importation of cases from the surrounding community could result in nearly 20% of the school's population becoming infected within 180 days. The combined effects of mitigation strategies and contact tracing were able to prevent most onward transmission. Hospitalizations were low among children and adults (<0.5% of the school population) across all scenarios examined. CONCLUSIONS: Based on our model, layering mitigation strategies and contact tracing can limit the number of cases that may occur from transmission in schools. Schools in communities with substantial levels of community spread will need to be more vigilant to ensure adherence of mitigation strategies to minimize transmission. Our results show that for school administrators, teachers, and parents to provide the safest environment, it is important to utilize multiple mitigation strategies and contract tracing that reduce SARS CoV-2 transmission by at least 69%. This will require training, reinforcement, and vigilance to ensure that the highest level of adherence is maintained over the entire school term.

The Impact of Covid-19 State Closure Orders on Consumer Spending, Employment, and Business Revenue.

CONTEXT: In response to the COVID-19 pandemic, states across the United States implemented various strategies to mitigate transmission of SARS-CoV-2 (the virus that causes COVID-19). OBJECTIVE: To examine the effect of COVID-19-related state closures on consumer spending, business revenue, and employment, while controlling for changes in COVID-19 incidence and death. DESIGN: The analysis estimated a difference-in-difference model, utilizing temporal and geographic variation in state closure orders to analyze their impact on the economy, while controlling for COVID-19 incidence and death. PARTICIPANTS: State-level data on economic outcomes from the Opportunity Insights data tracker and COVID-19 cases and death data from usafacts.org. INTERVENTIONS: The mitigation strategy analyzed within this study was COVID-19-related state closure orders. Data on these orders were obtained from state government Web sites containing executive or administrative orders. MAIN OUTCOME MEASURES: Outcomes include state-level estimates of consumer spending, business revenue, and employment levels. RESULTS: Analyses showed that although state closures led to a decrease in consumer spending, business revenue, and employment, they accounted for only a small portion of the observed decreases in these outcomes over the first wave of COVID-19. CONCLUSIONS: The impact of COVID-19 on economic activity likely reflects a combination of factors, in addition to state closures, such as individuals' perceptions of risk related to COVID-19 incidence, which may play significant roles in impacting economic activity.

Reported History of Traumatic Brain Injury Among Suicide Decedents: National Violent Death Reporting System, 2003-2017.

INTRODUCTION: Traumatic brain injury is a major cause of death and disability in the U.S., and research shows that individuals who suffer traumatic brain injury have an increased risk for suicide. This study examines the characteristics of suicide decedents with a documented traumatic brain injury history using a database containing circumstantial data on suicides and examines the differences in traumatic brain injury‒ and nontraumatic brain injury‒related suicides within the general population and within individuals with a history of military service. METHODS: Logistic regression models estimated AORs and 95% CIs of suicide among those with and without a previous traumatic brain injury using data from the 2003-2017 National Violent Death Reporting System (analyzed in 2020). RESULTS: From 2003 to 2017, a total of 203,157 suicide decedents were identified, and 993 had a documented traumatic brain injury before suicide. Among those with a documented traumatic brain injury, a higher percentage were White non-Hispanic. Firearm injuries were the most common method of suicide for both groups. Poisoning was more common among decedents with a previous traumatic brain injury than among those without. Male individuals, those who were single, and those who served in the military were 1.4 times more likely to have a documented traumatic brain injury history before the suicide. Almost 1 in 5 suicides (18.9%) documenting traumatic brain injury occurred among individuals with a history of military service. CONCLUSIONS: Comprehensive suicide prevention approaches are imperative. Healthcare providers can play a role in assessing and identifying patients at increased risk of suicide, including those who have experienced falls or injuries that often result in traumatic brain injury, and provide tailored interventions or referrals.

Mapping the Complexity of Suicide by Combining Participatory Modeling and Network Science.

Suicide rates are steadily increasing among youth in the USA. Although several theories and frameworks of suicide have been developed, they do not account for some of the features that define suicide as a complex problem, such as a large number of interrelationships and cycles. In this paper, we create the first c omprehensive m ap o f a dverse c hildhood experiences (ACEs) and suicide for youth, by combining a participatory approach (involving 15 subject-matter experts) and network science. This results in a map of 946 edges and 361 concepts, in which we identify ACEs to be the most important factor (per degree centrality). The map is openly shared with the community to support further network analyses (e.g., decomposition into clusters). Similarly to the high-impact Foresight Map developed in the context of obesity, the largest map on suicide and ACEs to date presented in this paper can start a discussion at the crossroad of suicide research and network science, thus bringing new means to address a complex public health challenge.

The economic burden of opioid use disorder and fatal opioid overdose in the United States, 2017.

BACKGROUND: The United States (U.S.) is experiencing an ongoing opioid crisis. Economic burden estimates that describe the impact of the crisis are needed when considering federal and state resources devoted to addressing overdoses. In this study, we estimate the societal costs for opioid use disorder and fatal overdose from all opioids in 2017. METHODS: We estimated costs of fatal overdose from all opioids and opioid use disorder based on the incidence of overdose deaths and the prevalence of past-year opioid use disorder for 2017. Incidence of fatal opioid overdose was obtained from the National Vital Statistics System; prevalence of past-year opioid use disorder was estimated from the National Survey of Drug Use and Health. Costs were estimated for health care, criminal justice and lost productivity. Costs for the reduced quality of life for opioid use disorder and life lost due to fatal opioid overdose were valued using U.S. Department of Health and Human Services guidelines for valuing reductions in morbidity and mortality. RESULTS: Costs for opioid use disorder and fatal opioid overdose in 2017 were estimated to be $1.02 trillion. The majority of the economic burden is due to reduced quality of life from opioid use disorder and the value of life lost due to fatal opioid overdose. CONCLUSIONS: These estimates can assist decision makers in understanding the magnitude of opioid use disorder and fatal overdose. Knowing the magnitude and distribution of the economic burden can inform public policy, clinical practice, research, and prevention and response activities.

Estimated Resource Costs for Implementation of CDC's Recommended COVID-19 Mitigation Strategies in Pre-Kindergarten through Grade 12 Public Schools - United States, 2020-21 School Year.

As school districts across the United States consider how to safely operate during the 2020-21 academic year, CDC recommends mitigation strategies that schools can adopt to reduce the risk for transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1). To identify the resources and costs needed to implement school-based mitigation strategies and provide schools and jurisdictions with information to aid resource allocation, a microcosting methodology was employed to estimate costs in three categories: materials and consumables, additional custodial staff members, and potential additional transportation. National average estimates, using the national pre-kindergarten through grade 12 (preK-12) public enrollment of 50,685,567 students, range between a mean of $55 (materials and consumables only) to $442 (all three categories) per student. State-by-state estimates of additional funds needed as a percentage of fiscal year 2018 student expenditures (2) range from an additional 0.3% (materials and consumables only) to 7.1% (all three categories); however, only seven states had a maximum estimate above 4.2%. These estimates, although not exhaustive, highlight the level of resources needed to ensure that schools reopen and remain open in the safest possible manner and offer administrators at schools and school districts and other decision-makers the cost information necessary to budget and prioritize school resources during the COVID-19 pandemic.

Tobacco 21 policies in California and Hawaii and sales of cigarette packs: a difference-in-differences analysis.

OBJECTIVE: To measure the association of raising the minimum legal age of tobacco sales to 21 years (T21) statewide with monthly sales of cigarette packs in California and Hawaii, the first two states to implement T21 statewide. METHODS: State monthly cigarette tax revenues from state departments of taxation were analysed for 11 states from January 2014 through December 2018 (n=660). Monthly cigarette packs sold were constructed using cigarette tax revenue and cigarette tax rate in each state. A difference-in-differences regression method was used to estimate the association of statewide T21 policies with monthly cigarette packs sold in California and Hawaii, separately, compared to the western states that did not implement such policies. Both models were controlled for year-month fixed effects, cigarette tax rates, smoke-free air laws, Medicaid coverage of smoking cessation, minimum legal sales ages for e-cigarettes and state marijuana laws, in addition to state demographic characteristics (sex, age, education, race/ethnicity and population size). FINDINGS: Implementation of T21 statewide was associated with a reduction of 9.41 (95% CI=-15.52 to -3.30) million monthly packs sold in California and 0.57 (95% CI=-0.83 to -0.30) million monthly packs sold in Hawaii, compared to regional states. These translate to a reduction of 13.1%-18.2%, respectively, in monthly packs sold relative to mean values before the implementation of T21. CONCLUSIONS: Raising the minimum legal age for tobacco sales to 21 years could reduce cigarette sales as part of a comprehensive tobacco control strategy that complements and builds on proven approaches to achieve this goal.

Assessing the implementation of a patient navigation intervention for colonoscopy screening.

BACKGROUND: A recent study demonstrated the effectiveness of the New Hampshire Colorectal Cancer Screening Program's (NHCRCSP) patient navigation (PN) program. The PN intervention was delivered by telephone with navigators following a rigorous, six-topic protocol to support low-income patients to complete colonoscopy screening. We applied the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework to examine implementation processes and consider potential scalability of this intervention. METHODS: A mixed-methods evaluation study was conducted including 1) a quasi-experimental, retrospective, comparison group study examining program effectiveness, 2) secondary analysis of NHCRCSP program data, and 3) a case study. Data for all navigated patients scheduled and notified of their colonoscopy test date between July 1, 2012 and September 30, 2013 (N = 443) were analyzed. Researchers were provided in-depth call details for 50 patients randomly selected from the group of 443. The case study included review of program documents, observations of navigators, and interviews with 27 individuals including staff, patients, and other stakeholders. RESULTS: Program reach was state-wide, with navigators serving patients from across the state. The program successfully recruited patients from the intended priority population who met the established age, income, and insurance eligibility guidelines. Analysis of the 443 NHCRCSP patients navigated during the study period demonstrated effectiveness with 97.3% completing colonoscopy, zero missed appointments (no-shows), and 0.7% late cancellations. Trained and supervised nurse navigators spent an average of 124.3 min delivering the six-topic PN protocol to patients. Navigators benefited from a real-time data system that allowed for patient tracking, communication across team members, and documentation of service delivery. Evaluators identified several factors supporting program maintenance including consistent funding support from CDC, a strong program infrastructure, and partnerships. CONCLUSIONS: Factors supporting implementation included funding for colonoscopies, use of registered nurses, a clinical champion, strong partnerships with primary care and endoscopy sites, fidelity to the PN protocol, significant intervention dose, and a real-time data system. Further study is needed to assess scalability to other locations.

Social and Physical Environmental Characteristics Associated With Adult Current Cigarette Smoking.

INTRODUCTION: Our objective was to identify social and physical environmental factors associated with current cigarette smoking among adults by metropolitan county in the United States. METHODS: We linked cigarette smoking data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS) Selected Metropolitan Area Risk Trends (SMART) data set to 7 social and physical environmental characteristics: county type (metropolitan designation), primary care physician density, income inequality, percentage of the population that was a racial/ethnic minority, violent crime rate, education, and percentage of county residents with low income and no health insurance, all obtained from several county data sets. Spatial regression and hierarchical logistic regression modeling were performed. RESULTS: Results showed that metropolitan counties with a high proportion of non-Hispanic white adults (P < .001), lower education levels (high school graduate or less) (P < .001), and high violent crime rates (P < .001) had a higher adult cigarette smoking prevalence than other metropolitan counties. Spatial models showed 63.3% of the variability in county cigarette smoking prevalence was explained by these 3 factors as well as county type (based on population size of the of metropolitan area), primary care physician density, and percentage of county residents with low income and no health insurance. At an individual level, results showed that as the density (population) of primary care physicians increased in a county, the odds of being a current smoker decreased (OR, 0.980; P = .02). CONCLUSION: We found a significant association between adult cigarette smoking and county social and physical environmental factors. These place-based factors, especially social environmental characteristics, may reveal tobacco-related disparities to be considered when developing strategies to reduce tobacco use.

Cost-effectiveness of a patient navigation intervention to increase colonoscopy screening among low-income adults in New Hampshire.

BACKGROUND: Colonoscopy is the most widely used colorectal cancer (CRC) screening test in the United States. Through the detection and removal of potentially precancerous polyps, it can prevent CRC. However, CRC screening remains low among adults who are recommended for screening. The New Hampshire Colorectal Cancer Screening Program implemented a patient navigation (PN) intervention to increase colonoscopy screening among low-income patients in health centers in New Hampshire. In the current study, the authors examined the cost-effectiveness of this intervention. METHODS: A decision tree model was constructed using Markov state transitions to calculate the costs and effectiveness associated with PN. Costs were calculated for the implementation of PN in a statewide public health program and in endoscopy centers. The main study outcome was colonoscopy screening completion. The main decision variable was the incremental cost-effectiveness ratio associated with the PN intervention compared with usual care. RESULTS: The average cost per screening with PN was $1089 (95% confidence interval, $1075-$1103) compared with $894 with usual care (95% confidence interval, $886-$908). Among patients who were navigated, approximately 96.2% completed colonoscopy screening compared with 69.3% of those receiving usual care (odds ratio, 11.2; P <. 001). The incremental cost-effectiveness ratio indicated that 1 additional screening completion cost approximately $725 in a public health program and $548 in an endoscopy center with PN compared with usual care, both of which are less than the average Medicare reimbursement of $737 for a colonoscopy procedure. CONCLUSIONS: PN was found to be cost-effective in increasing colonoscopy screening among low-income adults in the New Hampshire Colorectal Cancer Screening Program, even at the threshold of current Medicare reimbursement rates for colonoscopy. The results of the current study support the implementation of PN in statewide public health programs and endoscopy centers.

Increasing colonoscopy screening in disparate populations: Results from an evaluation of patient navigation in the New Hampshire Colorectal Cancer Screening Program.

BACKGROUND: To investigate uniformly successful results from a statewide program of patient navigation (PN) for colonoscopy, this comparison study evaluated the effectiveness of the PN intervention by comparing outcomes for navigated versus non-navigated patients in one of the community health clinics included in the statewide program. Outcomes measured included screening completion, adequacy of bowel preparation, missed appointments and cancellations, communication of test results, and consistency of follow-up recommendations with clinical guidelines. METHODS: The authors compared a subset of 131 patients who were navigated to a screening or surveillance colonoscopy with a similar subset of 75 non-navigated patients at one endoscopy clinic. The prevalence and prevalence odds ratios were computed to measure the association between PN and each study outcome measure. RESULTS: Patients in the PN intervention group were 11.2 times more likely to complete colonoscopy than control patients (96.2% vs 69.3%; P<.001), and were 5.9 times more likely to have adequate bowel preparation (P =.010). In addition, intervention patients had no missed appointments compared with 15.6% of control patients, and were 24.8 times more likely to not have a cancellation <24 hours before their appointment (P<.001). All navigated patients and their primary care providers received test results, and all follow-up recommendations were consistent with clinical guidelines compared with 82.4% of patients in the control group (P<.001). CONCLUSIONS: PN appears to be effective for improving colonoscopy screening completion and quality in the disparate populations most in need of intervention. To the best of our knowledge, the results of the current study demonstrate some of the strongest evidence for the effectiveness of PN to date, and highlight its value for public health. Cancer 2017;123:3356-66. © 2017 American Cancer Society.