Lessons Learned from Remote Assessment of Mother-Infant Interactions Among Women with Postpartum Depression.

Purpose: The COVID-19 pandemic posed challenges to measuring mother-infant interactions, a critical outcome for many interventions to support mothers with postpartum depression symptoms and their new infants. The current study describes the process and lessons learned from implementing a remote assessment of mother-infant interactions during the pandemic. Description: At the onset of the COVID-19 pandemic, we pivoted from in-person to using two different strategies to remotely assess mother-infant interactions: (1) participants independently recorded and uploaded videos of free-play with their child; and (2) research team conducted a live-video recording of the free-play. Assessment: We found initial barriers including technical and video quality issues but overall, a remote option could increase enrollment and retention rates in a sample of postpartum women across various racial/ethnic groups and economic levels. Conclusion: Our experiences in conducting remote assessments with postpartum women add to growing evidence for the feasibility and validity of remote visits. This showed how our methods can be implemented in future research and in practice with postpartum mothers and their infants.

Association Between Medicaid Waivers and Medicaid Disenrollment Among Autistic Adolescents During the Transition to Adulthood.

This cohort study examines whether Medicaid waivers were associated with a reduced risk of Medicaid disenrollment among autistic adolescents who are transitioning to adulthood.

Large and small financial incentives may motivate COVID-19 vaccination: A randomized, controlled survey experiment.

INTRODUCTION: Experts continue to debate how to increase COVID-19 vaccination rates. Some experts advocate for financial incentives. Others argue that financial incentives, especially large ones, will have counterproductive psychological effects, reducing the percent of people who want to vaccinate. Among a racially and ethnically diverse U.S. sample of lower income adults, for whom vaccine uptake has lagged compared with higher income adults, we empirically examine such claims about relatively large and small guaranteed cash payments. METHODS: In 2021, we conducted a randomized, controlled experiment among U.S. residents with incomes below $80,000 who reported being unvaccinated against COVID-19. Study participants were randomized to one of four study arms. In two arms, respondents first learned about a policy proposal to pay $1,000 or $200 to those who received COVID-19 vaccination and were then asked if, given that policy, they would want to vaccinate. In the two other arms, respondents received either an educational message about this vaccine or received no vaccine information and were then asked if they wanted to vaccinate for COVID-19. The primary analyses estimated and compared the overall percentage in each study arm that reported wanting to vaccinate for COVID-19. In other analyses, we estimated and compared these percentages for subgroups of interest, including gender, race/ethnicity, and education. MAIN RESULTS: Among 2,290 unvaccinated adults, 79.7% (95%CI, 76.4-83.0%) of those who learned about the proposed $1,000 payment wanted to get vaccinated, compared with 58.9% (95%CI, 54.8-63.0%) in the control condition without vaccine information, a difference of 20 percentage points. Among those who learned of the proposed $200 payment, 74.8% (95% CI, 71.3-78.4%) wanted to vaccinate. Among those who learned only about the safety and efficacy of COVID-19 vaccines, 68.9% (95% CI, 65.1-72.7%) wanted to vaccinate. Findings were consistent across various subgroups. DISCUSSION: Despite several study limitations, the results do not support concerns that the financial incentive policies aimed to increase COVID-19 vaccination would have counterproductive effects. Instead, those who learned about a policy with a large or small financial incentive were more likely than those in the control condition to report that they would want to vaccinate. The positive effects extended to subgroups that have been less likely to vaccinate, including younger adults, those with less education, and racial and ethnic minorities. Financial incentives of $1,000 performed similarly to those offering only $200.

Ho'ouna Pono implementation: applying concept mapping to a culturally grounded substance use prevention curriculum in rural Hawai'i schools.

BACKGROUND: Despite their potential to ameliorate health disparities and address youth substance use, prevention programs have been poorly disseminated and implemented across Hawai'i, which begs the question: Why are effective prevention programs not being used in communities most in need of them? Implementing and sustaining culturally grounded prevention programs is critical to address equitable healthcare and minimize health disparities in communities. The field of implementation science provides frameworks, theories, and methods to examine factors associated with community adoption of these programs. METHOD: Our project applies concept mapping methods to a culturally grounded youth drug prevention program with state level educational leadership in rural Hawai'i schools. The goal is to integrate barrier and facilitator salience collected through teacher and school staff surveys and specific implementation strategies to regionally tailored implementation plans on Hawai'i island. This protocol paper describes the concept mapping steps and how they will be applied in public and public-charter schools. DISCUSSION: Improving prevention program implementation in rural schools can result in sustained support for populations that need it most. The project will integrate implementation science and culturally grounded methods in rural Hawai'i, where most youth are of Native Hawaiian and Pacific Islander descent. This project addresses health disparities among Native Hawaiian and Pacific Islander youth and provides actionable plans for rural Hawai'i communities to implement effective prevention programming.

Making Progress Monitoring Easier and More Motivating: Developing a Client Data Collection App Incorporating User-Centered Design and Behavioral Economics Insights.

Data collection is an important component of evidence-based behavioral interventions for children with autism, but many one-to-one aides (i.e., behavioral support staff) do not systemically collect quantitative data that are necessary for best-practice client progress monitoring. Data collection of clients' behaviors often involves labor-intensive pen-and-paper practices. In addition, the solitary nature of one-to-one work limits opportunities for timely supervisor feedback, potentially reducing motivation to collect data. We incorporated principles from behavioral economics and user-centered design to develop a phone-based application, Footsteps, to address these challenges. We interviewed nine one-to-one aides working with children with autism and seven supervisors to ask for their app development ideas. We then developed the Footsteps app prototype and tested the prototype with 10 one-to-one aides and supervisors through three testing cycles. At each cycle, one-to-one aides rated app usability. Participants provided 76 discrete suggestions for improvement, including 29 new app features (e.g., behavior timer), 20 feature modifications (e.g., numeric type-in option for behavior frequency), four flow modifications (e.g., deleting a redundant form), and 23 out-of-scope suggestions. Of the participants that tested the app, 90% rated usability as good or excellent. Results support continuing to develop Footsteps and testing its impact in a clinical trial.

The Association of the Medicaid 1915(c) Home and Community-Based Services Waivers with Emergency Department Utilization among Youth with Autism Spectrum Disorder.

Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.

The implementation of opioid prescribing report cards in Medicaid managed care: a community quality collaborative.

Philadelphia, Pennsylvania, is an urban epicenter of the opioid epidemic, and inappropriate opioid prescribing remains a top concern. To help address this issue, the Philadelphia Medicaid Opioid Prescribing Initiative, a type of community quality collaborative, mailed thousands of local Medicaid providers an individualized prescribing report card in 2017 and 2018. The report card featured details of providers' opioid prescribing, including peer comparison measures and inappropriate prescribing measures like concomitant opioid and benzodiazepine prescribing. This case study describes the unique process of developing and distributing the opioid prescribing report cards, with a particular focus on the role of Medicaid managed care organizations. Using Medicaid pharmacy claims, the extensive variation in prescribing measures within and across specialties is also illustrated. The report card's implementation points to the potential value of collaborations between public health departments and Medicaid managed care organizations and can provide insight for other locally grown policies.

Insights from Behavioral Economics: A Case of Delayed Diagnosis of Autism Spectrum Disorder.

ABSTRACT: We present the case of a child of color diagnosed with autism spectrum disorder (ASD) at 67 months of age. Drawing from behavioral economics, we used this case to explore errors in decision-making by clinicians and family members and structural factors that may have delayed ASD diagnosis well beyond the national average.

Immunomodulatory Medication Use in Newly Diagnosed Youth With Systemic Lupus Erythematosus.

OBJECTIVE: To examine glucocorticoid-sparing immunomodulatory medication use in youth with systemic lupus erythematosus (SLE) during their first year of care. METHODS: We conducted a retrospective cohort study using administrative claims for 2000 to 2013 from Clinformatics DataMart for youth ages 10-24 years with an incident diagnosis of SLE (≥3 International Classification of Diseases, Ninth Revision codes for SLE [710.0], each >30 days apart). We determined the proportion of subjects filling a prescription for immunomodulatory medications within 12 months of the first SLE code (index date). We used multivariable regression to examine associations between demographic/disease factors and time to prescription fill in the first year, and also between prescription fill at any time after the index date. RESULTS: We identified 532 youth with an incident SLE diagnosis, of which 413 (78%) had a glucocorticoid-sparing immunomodulatory prescription fill in the first year. Prescriptions for hydroxychloroquine and immunosuppressants were filled in the first year by 366 youth (69%) and by 182 (34%), respectively. Those with adult-onset (versus childhood-onset) disease were less likely to fill an immunomodulatory medication by 12 months. No other statistically significant associations were found, although there was increasing likelihood of immunomodulatory medication fills with each subsequent calendar year. CONCLUSION: Among youth with newly diagnosed SLE, hydroxychloroquine use is prevalent although not universal, and prescription immunosuppressant use is notably low during the first year of care. Further research is needed to identify factors contributing to suboptimal immunomodulatory medication use during the first year of care.

Understanding Racial and Ethnic Disparities in Autism-Related Service Use Among Medicaid-Enrolled Children.

Racial and ethnic disparities in the use of nine common autism-related services among Medicaid-enrolled children with autism spectrum disorder (ASD) were examined, distinguishing between school and other community-based outpatient settings. Using 2012 Medicaid Analytic Extract data, we identified 117,848 continuously enrolled children with ASD. Several racial and ethnic disparities were found, varying by geography. Black, Asian, and Native American/Pacific Islanders received fewer outpatient services compared with white children, but there was no disparity for Latinx children. Black and Asian children received more school-based services than white children. Disparities in case management/care coordination services were largest and present in each minority group. Geographic variation in receipt of services suggests targets for policy intervention to improve access for minorities with ASD.

Traveling Without a Map: An Incomplete History of the Road to Implementation Science and Where We May Go from Here.

This editorial provides a brief history of mental health services research over the last 30 years and how findings from large-scale studies shocked the field and led to the lines of inquiry culminating in current implementation science research. I review the manuscripts published in this special issue of Administration and Policy in Mental Health in light of that history and usethese studies as a way to assess the state of the field. Finally, I present five takeaways extracted from these articles that may be useful in considering future directions for implementation research.

Effect of Outpatient Service Utilization on Hospitalizations and Emergency Visits Among Youths With Autism Spectrum Disorder.

OBJECTIVE: Psychiatric hospitalizations and emergency department (ED) visits occur more frequently for youths with autism spectrum disorder (ASD). One mechanism that may reduce the likelihood of these events is utilization of home and community-based care. Using commercial claims data and a rigorous analytical framework, this retrospective study examined whether spending on outpatient services for ASD, including occupational, physical, and speech therapies and other behavioral interventions, reduced the likelihood of psychiatric hospitalizations and ED visits. METHODS: The study sample was composed of >100,000 children and young adults with ASD and commercial insurance from every state between 2008 and 2012. The authors estimated maximum-likelihood complementary log-log link survival models with robust standard errors. The outcomes of interest were a hospitalization or an ED visit with an associated psychiatric diagnosis code (ICD-9-CM 290 through 319) in a given week. RESULTS: An increase of $125 in weekly spending on ASD-specific outpatient services in the 7 to 14 weeks prior to a given week reduced the likelihood of a psychiatric hospitalization in that week by 2%. ASD-specific outpatient spending during the 6 weeks prior to a psychiatric hospitalization did not decrease risk of hospitalization. Spending on ASD-specific outpatient services did not reduce the likelihood of a psychiatric ED visit. CONCLUSIONS: The financial burden associated with ASD is extensive, and psychiatric hospitalizations remain the most expensive type of care, costing more than $4,000 per week on average. Identifying the mechanisms by which psychiatric hospitalizations occur may reduce the likelihood of these events.

The effect of Medicaid waivers on ameliorating racial/ethnic disparities among children with autism.

OBJECTIVE: To examine the effects of Medicaid Home and Community-based Services (HCBS) waivers on reducing racial/ethnic disparities in unmet need for services among families of children with autism spectrum disorder (ASD). DATA SOURCES: Data from the 2003, 2007, and 2011 waves of the National Survey of Children's Health and the 2005 and 2010 waves of the National Survey of Children with Special Health Care Needs were used. Data on waiver characteristics were collected from source materials that were submitted in support of each state's waiver application. Waiver characteristics were combined to create a single waiver generosity variable. STUDY DESIGN: Quasi-difference-in-difference-in-difference models were used to determine the effect of waiver generosity on racial/ethnic disparities in unmet need among children with ASD. PRINCIPAL FINDINGS: Increased waiver generosity was associated with significantly reduced odds of having unmet need for black children with ASD compared with white children with ASD. Unmet needs among black children with ASD were roughly cut in half, a 13 percentage point decrease, with the implementation of an average generosity waiver. No significant differences were seen for Hispanic ethnicity. CONCLUSION: These findings suggest that Medicaid HCBS waivers have the potential to ameliorate disparities in unmet need among children with ASD. Future policy development should focus on replicating the most effective characteristics of these waivers.

Insurance Mandates and Out-of-Pocket Spending for Children With Autism Spectrum Disorder.

BACKGROUND: The health care costs associated with treating autism spectrum disorder (ASD) in children can be substantial. State-level mandates that require insurers to cover ASD-specific services may lessen the financial burden families face by shifting health care spending to insurers. METHODS: We estimated the effects of ASD mandates on out-of-pocket spending, insurer spending, and the share of total spending paid out of pocket for ASD-specific services. We used administrative claims data from 2008 to 2012 from 3 commercial insurers, and took a difference-in-differences approach in which children who were subject to mandates were compared with children who were not. Because mandates have heterogeneous effects based on the extent of children's service use, we performed subsample analyses by calculating quintiles based on average monthly total spending on ASD-specific services. The sample included 106 977 children with ASD across 50 states. RESULTS: Mandates increased out-of-pocket spending but decreased the share of spending paid out of pocket for ASD-specific services on average. The effects were driven largely by children in the highest-spending quintile, who experienced an average increase of $35 per month in out-of-pocket spending (P < .001) and a 4 percentage point decline in the share of spending paid out of pocket (P < .001). CONCLUSIONS: ASD mandates shifted health care spending for ASD-specific services from families to insurers. However, families in the highest-spending quintile still spent an average of >$200 per month out of pocket on these services. To help ease their financial burden, policies in which children with higher service use are targeted may be warranted.

Effects of State Autism Mandate Age Caps on Health Service Use and Spending Among Adolescents.

OBJECTIVE: Many states with mandates requiring commercial insurers to cover autism spectrum disorder (ASD) health services specify upper age limits above which coverage is no longer mandated. It is unknown what effects these age caps have on health service use and spending among adolescents who have exceeded the age cap. METHOD: Using administrative claims data from 3 national commercial insurers, a difference-in-differences approach was used to estimate effects of age caps on health service use and spending among adolescents with ASD. Statistical models compared changes in use and spending between those above versus below the age cap among individuals eligible versus ineligible for mandated coverage. The analytic sample included data from 2008 through 2012 on 7,845 individuals (151,976 person-months) ages 10 to 21 years in 11 states imposing mandate age caps going into effect during adolescence. RESULTS: Age caps were associated with 4.2 percentage point (95% CI = -7.0, -1.5) lower probability of any ASD-specific service use in a month and $69 less (95% CI = -112, -$26) in average monthly spending on ASD-specific services than would have been expected given concomitant pre-post age cap differences among individuals in the same states who were never eligible for mandate-covered services. In addition, age caps were associated with $99 (95% CI = -$168, -$30) lower average monthly spending on all health care services. CONCLUSION: Insurance mandates that include age caps going into effect during adolescence reduce health service use and spending among individuals with ASD during a critical phase of the life course.

The Differential Effects of Insurance Mandates on Health Care Spending for Children's Autism Spectrum Disorder.

OBJECTIVES: There is substantial variation in treatment intensity among children with autism spectrum disorder (ASD). This study asks whether policies that target health care utilization for ASD affect children differentially based on this variation. Specifically, we examine the impact of state-level insurance mandates that require commercial insurers to cover certain treatments for ASD for any fully-insured plan. METHODS: Using insurance claims between 2008 and 2012 from three national insurers, we used a difference-in-differences approach to compare children with ASD who were subject to mandates to children with ASD who were not. To allow for differential effects, we estimated quantile regressions that evaluate the impact of mandates across the spending distributions of three outcomes: (1) monthly spending on ASD-specific outpatient services; (2) monthly spending on ASD-specific inpatient services; and (3) quarterly spending on psychotropic medications. RESULTS: The change in spending on ASD-specific outpatient services attributable to mandates varied based on the child's level of spending. For those children with ASD who were subject to the mandate, monthly spending for a child in the 95th percentile of the ASD-specific outpatient spending distribution increased by $1460 (P<0.001). In contrast, the effect was only $2 per month for a child in the fifth percentile (P<0.001). Mandates did not significantly affect spending on ASD-specific inpatient services or psychotropic medications. CONCLUSIONS: State-level insurance mandates have larger effects for those children with higher levels of spending. To the extent that spending approximates treatment intensity and the underlying severity of ASD, these results suggest that mandates target children with greater service needs.

Relationship Between Pregnancy Complications and Psychiatric Disorders: A Population-Based Study With a Matched Control Group.

OBJECTIVES: This study sought to identify whether pregnancy complications differ between women with and without a psychiatric disorder diagnosis prior to pregnancy. METHODS: Women who gave birth between 2007 and 2009 in Pennsylvania and were enrolled in Medicaid from one year prior to their pregnancy until their delivery were included (N=9,930); those with psychiatric disorders were compared with a matched control group (N=4,965 for each). Logistic regression analysis estimated the odds of having a pregnancy complication among those with a psychiatric diagnosis prior to pregnancy, adjusting for demographic characteristics and chronic general medical conditions. RESULTS: Compared with the control group, women with a psychiatric disorder prior to pregnancy had greater odds of having at least one pregnancy complication (odds ratio=1.48, 95% confidence interval=1.37-1.61). Compared with the control group, their odds of antepartum hemorrhage were 1.50 times higher, their odds of preterm labor were 1.45 times higher, and their odds of preterm birth were 1.61 times higher. CONCLUSIONS: Women with psychiatric disorders prior to pregnancy were more likely to experience pregnancy complications, including pregnancy hemorrhage, preterm labor, and preterm birth, after the analysis controlled for age, race-ethnicity, and chronic illness status before and during pregnancy. The finding of an association between psychiatric disorders and a higher complication risk suggests the importance of population-based preconception interventions for women with psychiatric disorders and prenatal monitoring to reduce the risk of pregnancy complications in this group.