Breastfeeding Initiation and Continuation Among Women with Substance and Tobacco Use During Pregnancy: Findings from the Pregnancy Risk Assessment Monitoring System 2016-2018.

Background and Aims: Substance and tobacco use is associated with poor maternal and child health outcomes. Although these have each been linked to lower breastfeeding rates when examined separately, studies have yet to examine how the combination of tobacco and other substance use influences breastfeeding initiation and continuation. The aim of this study was to examine how the combination of smoking tobacco and use of illicit substances influences the odds of breastfeeding initiation and continuation. Materials and Methods: This retrospective cohort study (n = 15,634) used survey data from the 2016-2018 Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System from eight US states to examine the association of tobacco and illicit substance use with breastfeeding initiation and continuation (≥6 weeks). The odds of breastfeeding initiation and continuation for individuals with and without prenatal tobacco and illicit substance use, adjusting for maternal and infant characteristics, were estimated using weighted, multivariable logistic regression models. Results: The combination of prenatal tobacco and illicit substance use was associated with a 42% reduction in the odds of initiating breastfeeding (adjusted odds ratio [aOR] 0.58 [95% confidence interval, CI 0.39-0.87]) and a 39% reduction in the odds of breastfeeding for at least 6 weeks (aOR 0.61 [95% CI 0.41-0.92]) when compared with those without tobacco and substance use. Conclusion: The odds of breastfeeding initiation and continuation are significantly lower among individuals with both prenatal tobacco and illicit substance use. Future studies are needed to identify barriers to breastfeeding within this population, to inform patient-centered interventions aimed at overcoming these barriers.

Alcohol Screening During US Primary Care Visits, 2014-2016.

BACKGROUND: Unhealthy alcohol use is a significant health issue for the US population. The US Preventive Services Task Force (USPSTF) recommends screening adults 18 years or older for unhealthy alcohol use during primary care visits. OBJECTIVES: To evaluate alcohol screening among ambulatory visits made by US adult primary care patients and identify characteristics predictive of alcohol screening. DESIGN: A series of cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) data collected from 2014 to 2016 was used to examine US primary care providers' use of alcohol screening questionnaires and delivery of counseling on alcohol use. PARTICIPANTS: A total of 19,213 visits made by patients aged 18 years or older to a US primary care physician trained in family medicine or internal medicine. MAIN MEASURES: Administration of a validated alcohol screening questionnaire and counseling/education on alcohol use. Variation in alcohol screening by patient demographic characteristics, reason for office visit, length of office visit, chronic medical conditions, evaluation by assigned primary care physician, new patient to practice, and region. KEY RESULTS: Alcohol screening with a validated questionnaire occurred during 2.6% (95% Cl: 0.9%, 4.3%) of visits. Alcohol counseling, provided either by the physician or by referral, was documented in 0.8% (95% Cl: 0.3%, 1.3%) of visits. Screening was significantly more likely if patients were seen by their assigned primary care physician (adjOR 4.38 (95% Cl: 1.41, 13.61)), a new patient to the practice (adjOR 4.18 (95% Cl: 2.30, 7.79)), or had several chronic medical conditions (adjOR 3.40 (95% Cl: 1.48, 7.78)). Patients' sex, race/ethnicity, age group, or length of appointment time was not associated with screening for unhealthy alcohol use. CONCLUSIONS: Screening for unhealthy alcohol use using a validated questionnaire is uncommonly performed during US primary care visits. Interventions or incentives may be needed to increase uptake of USPSTF alcohol screening recommendations.

Cancer Screening Among Women Prescribed Opioids: A National Study.

PURPOSE: Prior work suggests that there are competing demands between addressing pain and other issues in primary care, potentially lessening delivery of evidence-based cancer screening. We assessed the association between opioid therapy and cancer screening among women in a nationally representative US sample. METHODS: We conducted an observational analysis of the 2005-2015 Medical Expenditure Panel Surveys. We included all women aged ≥18 years without cancer and with opioid prescription and preventive care services data. Logistic regression analyses examined associations between receipt of opioid prescription (any vs none) and receipt of breast, cervical, and colorectal cancer screenings. Analyses were adjusted for sociodemographic characteristics, health status, health conditions, and usual source of care, as well as health care utilization. RESULTS: Of 53,982 participants, 15.8% reported ≥1 opioid prescription. Compared with women not prescribed opioids, those prescribed opioids were more likely to visit their doctor (median number of visits per year = 5, vs 1). Without adjustment for number of visits, women prescribed opioids were more likely to receive all 3 cancer screenings; the adjusted odds ratio for breast cancer screening was 1.26 (95% CI, 1.16-1.38), that for cervical cancer screening was 1.22 (95% CI, 1.13-1.33), and that for colorectal cancer screening was 1.22 (95% CI, 1.12-1.33). With adjustment for number of visits, adjusted odds ratios decreased (breast 1.07 [95% CI, 0.98-1.18]; cervical 1.01 [95% CI, 0.93-1.09]; colorectal 1.04 [95% CI, 0.95-1.14]). CONCLUSIONS: In a nationally representative sample, receipt of opioid prescriptions was not associated with less recommended cancer screenings. Rather, women receiving opioids had greater adjusted odds of receiving breast, cervical, and colorectal cancer screening, although the associations were attenuated by adjusting for their more frequent office visits relative to women not receiving opioids.

Patient Satisfaction with Clinicians and Short-Term Mortality in a US National Sample: the Roles of Morbidity and Gender.

BACKGROUND: In a prior study, we found patient satisfaction was associated with mortality. However, that study included few deaths, yielding wide confidence intervals, was criticized for possible morbidity under-adjustment, and lacked power to explore sociodemographic moderation. OBJECTIVE: To revisit the satisfaction-mortality association in a larger national sample, allowing more precise risk estimates, sequential morbidity adjustment, and exploration of sociodemographic moderation. DESIGN: Prospective cohort study. PARTICIPANTS: 2000-2015 Adult Medical Expenditures Panel Surveys (MEPS) respondents (N = 92,952), each enrolled for 2 consecutive years. MAIN MEASURES: We used five Consumer Assessment of Health Plans Survey (CAHPS) items to assess patients' year 1 satisfaction with their clinicians. Death during the 2 years of MEPS participation was determined by proxy report. We modeled the satisfaction-mortality association in sequential regressions: model 1 included sociodemographics, model 2 added health status (approximating recommended CAHPS adjustment), and model 3 added smoking status, disease burden, and healthcare utilization. KEY RESULTS: Satisfaction was not associated with mortality in model 1. In model 2, higher satisfaction was associated with higher mortality (hazard ratios [95% CIs] for 2nd, 3rd, and 4th (top) quartiles vs. 1st quartile: 1.28 (1.01, 1.62), P = 0.04; 1.43 (1.12, 1.82), P = 0.004; and 1.57 (1.25, 1.98), P < 0.001, respectively). The associations were not attenuated in model 3. There was a significant interaction between gender and satisfaction (F[3, 443] = 3.62, P = 0.01). The association between satisfaction and mortality was significant in women only, such that their mortality advantage over men was eliminated in the highest satisfaction quartile. CONCLUSIONS: The association of higher patient satisfaction with clinicians with higher short-term mortality was evident only after CAHPS-recommended adjustment, was not attenuated by further morbidity adjustment, and was evident in women but not men. The findings suggest that characteristics among women who are more satisfied with their clinicians may be associated with increased mortality risk.