Prenatal opioid use as a predictor of postpartum suicide attempts among reproductive-age women enrolled in Oregon Medicaid.

BACKGROUND: The rates of suicide and opioid use disorder (OUD) among pregnant and postpartum women continue to increase. This research characterized OUD and suicide attempts among Medicaid-enrolled perinatal women and examined prenatal OUD diagnosis as a marker for postpartum suicide attempts. METHODS: Data from Oregon birth certificates, Medicaid eligibility and claims files, and hospital discharge records were linked and analyzed. The sample included Oregon Medicaid women aged 15-44 who became pregnant and gave live births between January 2008 and January 2016 (N = 61,481). Key measures included indicators of suicide attempts (separately for any means and opioid poisoning) and OUD diagnosis, separately assessed during pregnancy and the one-year postpartum period. Probit regression was used to examine the overall relationship between prenatal OUD diagnosis and postpartum suicide attempts. A simultaneous equations model was employed to explore the link between prenatal OUD diagnosis and postpartum suicide attempts, mediated by postpartum OUD diagnosis. RESULTS: Thirty-three prenatal suicide attempts by any means were identified. Postpartum suicide attempts were more frequent with 58 attempts, corresponding to a rate of 94.3 attempts per 100,000. Of these attempts, 79% (46 attempts) involved opioid poisoning. A total of 1,799 unique women (4.6% of the sample) were diagnosed with OUD either during pregnancy or one-year postpartum with 53% receiving the diagnosis postpartum. Postpartum suicide attempts by opioid poisoning increased from 55.5 per 100,000 in 2009 to 105.1 per 100,000 in 2016. The rate of prenatal OUD also almost doubled over the same period. Prenatal OUD diagnosis was associated with a 0.15%-point increase in the probability of suicide attempts by opioid poisoning within the first year postpartum. This increase reflects a three-fold increase compared to the rate for women without a prenatal OUD diagnosis. A prenatal OUD diagnosis was significantly associated with an elevated risk of postpartum suicide attempts by opioid poisoning via a postpartum OUD diagnosis. CONCLUSIONS: The risk of suicide attempt by opioid poisoning is elevated for Medicaid-enrolled reproductive-age women during pregnancy and postpartum. Women diagnosed with prenatal OUD may face an increased risk of postpartum suicides attempts involving opioid poisoning.

Postpartum Medicaid coverage and outpatient care utilization among low-income birthing individuals in Oregon: impact of Medicaid expansion.

Objective: This study examined the effect of Medicaid expansion in Oregon on duration of Medicaid enrollment and outpatient care utilization for low-income individuals during the postpartum period. Methods: We linked Oregon birth certificates, Medicaid enrollment files, and claims to identify postpartum individuals (N = 73,669) who gave birth between 2011 and 2015. We created one pre-Medicaid expansion (2011-2012) and two post-expansion (2014-2015) cohorts (i.e., previously covered and newly covered by Medicaid). We used ordinary least squares and negative binomial regression models to examine changes in postpartum coverage duration and number of outpatient visits within a year of delivery for the post-expansion cohorts compared to the pre-expansion cohort. We examined monthly and overall changes in outpatient utilization during 0-2 months, 3-6 months, and 7-12 months after delivery. Results: Postpartum coverage duration increased by 3.14 months and 2.78 months for the post-Medicaid expansion previously enrolled and newly enrolled cohorts (p < 0.001), respectively. Overall outpatient care utilization increased by 0.06, 0.19, and 0.34 visits per person for the previously covered cohort and 0.12, 0.13, and 0.26 visits per person for newly covered cohort during 0-2 months, 3-6 months, and 7-12 months, respectively. Monthly change in utilization increased by 0.006 (0-2 months) and 0.004 (3-6 months) visits per person for post-Medicaid previously enrolled cohort and decreased by 0.003 (0-2 months) and 0.02 (7-12 months) visits per person among newly enrolled cohort. Conclusion: Medicaid expansion increased insurance coverage duration and outpatient care utilization during postpartum period in Oregon, potentially contributing to reductions in pregnancy-related mortality and morbidities among birthing individuals.

Use of Sexual and Reproductive Health Services Among Women Living in Rural and Urban Oregon: Impact of the Affordable Care Act Medicaid Expansion.

Objectives: We compared the use of sexual and reproductive health (SRH) services for Medicaid-enrolled women of reproductive age (WRA) living in Oregon by urban/rural status and examined the effect of the Affordable Care Act (ACA) Medicaid expansion on the use of SRH services for these women. Methods: We linked Oregon Medicaid enrollment files and claims for the years 2008-2016 to identify 392,111 WRA. Outcome measures included receipt of five key SRH services. The main independent variables were urban/rural status (urban, large rural cities, and small rural towns) and an indicator for the post-Medicaid expansion time period (2014-2016). We performed (conditional) fixed-effects logistic regression and multiple-group interrupted time-series analyses. Results: Women living in small rural towns were less likely than women living in urban areas to receive well-woman visits (odds ratio [OR] = 0.87; 95% confidence interval [95% CI] [0.80-0.94]), sexually transmitted infection (STI) screening (OR = 0.81; 95% CI [0.72-0.90]), and pap tests (OR = 0.91; 95% CI [0.84-0.99]). Women living in large rural cities were less likely than women living in urban areas to receive STI screening (OR = 0.91; 95% CI [0.84-0.98]). Following the implementation of ACA Medicaid expansion, the average number of all five SRH services increased for all women. With the exception of contraceptive services, the average number of SRH services examined increased more for urban women than for women living in small rural towns. Conclusions: Although Medicaid expansion contributed to increased use of SRH services for all WRA, the policy was unsuccessful in reducing disparities in access to SRH services for WRA living in rural areas compared with urban areas.

A Reduction in Health Care Expenditures Linked to Mental Health Service Use Among Adults With Chronic Physical Conditions.

OBJECTIVE: The aim was to examine the impact of receipt of mental health services on health care expenditures for U.S. adults with major chronic physical conditions. METHODS: Medical Expenditure Panel Survey data for 2004-2014 were analyzed for adults ages ≥18 with at least one of six chronic physical conditions (cardiovascular diseases, cancer, diabetes, emphysema, asthma, and arthritis) who were followed up for 2 years (N=33,419). Outcomes included overall health care spending and expenditure by service type (inpatient services, outpatient services, emergency department visits, office-based physician visits, and prescribed medication). A difference-in-differences model compared a change in health care costs in the subsequent year for those who did and did not receive mental health services in the preceding year. RESULTS: On average, the increase in overall health care expenditure in the subsequent year among adults receiving mental health services in the preceding year was smaller by 12.6 percentage points (p<0.05) than for those who did not receive such services. The difference was equivalent to $1,146 in 2014 constant U.S. dollars (p=0.05). Medication treatment alone did not have a meaningful effect on overall costs. The combination of psychotherapy and medication was associated with a per-capita reduction in overall health care expenditure of 21.7 percentage points, or $2,690 (p<0.01). The combination was also associated with reduced costs for office-based visits (p<0.05) and medication (p<0.05). CONCLUSIONS: Receipt of mental health services was associated with a reduction in overall health care costs, particularly for office-based visits and prescribed medication, among adults with chronic physical conditions.

Postpartum Care Utilization Among Women with Medicaid-Funded Live Births in Oregon.

INTRODUCTION: Postpartum care is an important strategy for preventing and managing chronic disease in women with pregnancy complications (i.e., gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP)). METHODS: Using a population-based, cohort study among Oregon women with Medicaid-financed deliveries (2009-2012), we examined Medicaid-financed postpartum care (postpartum visits, contraceptive services, and routine preventive health services) among women who retained Medicaid coverage for at least 90 days after delivery (n = 74,933). We estimated postpartum care overall and among women with and without GDM and/or HDP using two different definitions: 1) excluding care provided on the day of delivery, and 2) including care on the day of delivery. Pearson chi-square tests were used to assess differential distributions in postpartum care by pregnancy complications (p < .05), and generalized estimating equations were used to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS: Of Oregon women who retained coverage through 90 days after delivery, 56.6-78.1% (based on the two definitions) received any postpartum care, including postpartum visits (26.5%-71.8%), contraceptive services (30.7-35.6%), or other routine preventive health services (38.5-39.1%). Excluding day of delivery services, the odds of receiving any postpartum care (aOR 1.26, 95% CI 1.08-1.47) or routine preventive services (aOR 1.32, 95% CI 1.14-1.53) were meaningfully higher among women with GDM and HDP (reference = neither). DISCUSSION: Medicaid-financed postpartum care in Oregon was underutilized, it varied by pregnancy complications, and needs improvement. Postpartum care is important for all women and especially those with GDM or HDP, who may require chronic disease risk assessment, management, and referrals.

Determinants of Boarding of Patients with Severe Mental Illness in Hospital Emergency Departments.

BACKGROUND: Boarding of patients in hospital emergency departments (EDs) occurs routinely across the U.S. ED patients with behavioral health conditions are more likely to be boarded than other patients. However, the existing literature on ED boarding of psychiatric patients remains largely descriptive and has not empirically related mental health system capacity to psychiatric boarding. Nor does it show how the mental health system could better address the needs of populations at the highest risk of ED boarding. AIMS OF THE STUDY: We examined extent and determinants of "boarding" of patients with severe mental illness (SMI) in hospital emergency departments (ED) and tested whether greater mental health system capacity may mitigate the degree of ED boarding. METHODS: We linked Oregon's ED Information Exchange, hospital discharge, and Medicaid data to analyze encounters in Oregon hospital EDs from October 2014 through September 2015 by 7,103 persons aged 15 to 64 with SMI (N = 34,207). We additionally utilized Medicaid claims for years 2010-2015 to identify Medicaid beneficiaries with SMI. Boarding was defined as an ED stay over six hours. We estimated a recursive simultaneous-equation model to test the pathway that mental health system capacity affects ED boarding via psychiatric visits. RESULTS: Psychiatric visits were more likely to be boarded than non-psychiatric visits (30.2% vs. 7.4%). Severe psychiatric visits were 1.4 times more likely to be boarded than non-severe psychiatric visits. Thirty-four percent of psychiatric visits by children were boarded compared to 29.6% for adults. Statistical analysis found that psychiatric visit, substance abuse, younger age, black race and urban residence corresponded with an elevated risk of boarding. Discharge destinations such as psychiatric facility and acute care hospitals also corresponded with a higher probability of ED boarding. Greater supply of mental health resources in a county, both inpatient and intensive community-based, corresponded with a reduced risk of ED boarding via fewer psychiatric ED visits. DISCUSSION: Psychiatric visit, severity of psychiatric diagnosis, substance abuse, and discharge destinations are among important predictors of psychiatric ED boarding by persons with SMI. A greater capacity of inpatient and intensive community mental health systems may lead to a reduction in psychiatric ED visits by persons with SMI and thereby decrease the extent of psychiatric ED boarding. IMPLICATIONS FOR HEALTH POLICIES: Continued investment in mental health system resources may reduce psychiatric ED visits and mitigate the psychiatric ED boarding problem.

Coordinated Care Organizations and mortality among low-income infants in Oregon.

OBJECTIVE: To examine the impact of Oregon's Coordinated Care Organizations (CCOs), an accountable care model for Oregon Medicaid enrollees implemented in 2012, on neonatal and infant mortality. DATA SOURCES: Oregon birth certificates linked with death certificates, and Medicaid/CCO enrollment files for years 2008-2016. STUDY DESIGN: The sample consisted of the pre-CCO birth cohort of 135 753 infants (August 2008-July 2011) and the post-CCO birth cohort of 148 650 infants (August 2012-December 2015). We used a difference-in-differences probit model to estimate the difference in mortality between infants enrolled in Medicaid and infants who were not enrolled. We examined heterogeneous effects of CCOs for preterm and full-term infants and the impact of CCOs over the implementation timeline. All models were adjusted for maternal and infant characteristics and secular time trends. PRINCIPAL FINDINGS: The CCO model was associated with a 56 percent reduction in infant mortality compared to the pre-CCO level (-0.20 percentage points [95% CI: -0.35; -0.05]), and also with a greater reduction in infant mortality among preterm infants compared to full-term infants. The impact on mortality grew in magnitude over the postimplementation timeline. CONCLUSIONS: The CCO model contributed to a reduction in mortality within the first year of birth among infants enrolled in Medicaid.