RESUMO
OBJECTIVE: The authors aimed to identify barriers to and strategies for supporting coordination between state agencies for intellectual and developmental disability (IDD) or mental health to meet the mental health needs of people with co-occurring IDD and mental health conditions. METHODS: Forty-nine employees of state agencies as well as advocacy and service delivery organizations across 11 U.S. states with separate IDD and mental health agencies were interviewed between April 2022 and April 2023. Data were analyzed with a thematic analysis approach. RESULTS: Interviewees reported that relationships between the IDD and mental health agencies have elements of both competition and coordination and that coordination primarily takes place in response to crisis events. Barriers to interagency coordination included a narrow focus on the populations targeted by each agency, within-state variation in agency structures, and a lack of knowledge about co-occurring IDD and mental health conditions. Interviewees also described both administrative (e.g., memorandums of understanding) and agency culture (e.g., focusing on whole-person care) strategies that are or could be used to improve coordination to provide mental health services for people with both IDD and a mental health condition. CONCLUSIONS: Strategies that support state agencies in moving away from crisis response toward a focus on whole-person care should be prioritized to support coordination of mental health services for individuals with co-occurring IDD and mental health conditions.
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Deficiências do Desenvolvimento , Deficiência Intelectual , Transtornos Mentais , Serviços de Saúde Mental , Humanos , Deficiência Intelectual/terapia , Deficiências do Desenvolvimento/terapia , Estados Unidos , Serviços de Saúde Mental/organização & administração , Transtornos Mentais/terapia , Transtornos Mentais/epidemiologia , Comorbidade , Relações Interinstitucionais , Pesquisa QualitativaRESUMO
OBJECTIVE: Federal loan repayment programs (LRPs) are one strategy to address the shortage of behavioral health providers. This scoping review aimed to identify and characterize the federal LRPs' impact on the U.S. behavioral health workforce. METHODS: A scoping review was conducted in accordance with JBI (formerly known as the Joanna Briggs Institute) methodology for scoping reviews. The authors searched the Ovid MEDLINE, Web of Science, APA PsycInfo, EconLit, PAIS Index, and Embase databases, and gray literature was also reviewed. Two coders screened each article's abstract and full text and extracted study data. Findings were narratively synthesized and conceptually organized. RESULTS: The full-text screening identified 17 articles that met eligibility criteria. Of these, eight were peer-reviewed studies, and all but one evaluated the National Health Service Corps (NHSC) LRP. Findings were conceptually organized into five categories: descriptive studies of NHSC behavioral health needs and the NHSC workforce (k=4); providers' perceptions of, and experiences with, the NHSC (k=2); associations between NHSC funding and the number of NHSC behavioral health providers (k=4); NHSC behavioral health workforce productivity and capacity (k=3); and federal LRP recruitment and retention (k=4). CONCLUSIONS: The literature on federal LRPs and their impact on the behavioral health workforce is relatively limited. Although federal LRPs are an important and effective tool to address the behavioral health workforce shortage, additional federal policy strategies are needed to attract and retain behavioral health providers and to diversify the behavioral health workforce.
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Mão de Obra em Saúde , Serviços de Saúde Mental , Humanos , Estados Unidos , Serviços de Saúde Mental/economia , Pessoal de Saúde , Apoio ao Desenvolvimento de Recursos Humanos/economia , Financiamento GovernamentalRESUMO
OBJECTIVE: The authors examined trends in opioid use disorder treatment and in-person and telehealth modalities before and after COVID-19 pandemic onset among patients who had received treatment prepandemic. METHODS: The sample included 13,113 adults with commercial insurance or Medicare Advantage and receiving opioid use disorder treatment between March 2018 and February 2019. Trends in opioid use disorder outpatient treatment, treatment with medications for opioid use disorder (MOUD), and in-person and telehealth modalities were examined 1 year before pandemic onset and 2 years after (March 2019-February 2022). RESULTS: From March 2019 to February 2022, the proportion of patients with opioid use disorder outpatient and MOUD visits declined by 2.8 and 0.3 percentage points, respectively. Prepandemic, 98.6% of outpatient visits were in person; after pandemic onset, at least 34.9% of patients received outpatient care via telehealth. CONCLUSIONS: Disruptions in opioid use disorder outpatient and MOUD treatments were marginal during the pandemic, possibly because of increased telehealth utilization.
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COVID-19 , Medicare Part C , Transtornos Relacionados ao Uso de Opioides , Telemedicina , Idoso , Estados Unidos/epidemiologia , Adulto , Humanos , Pacientes Ambulatoriais , Pandemias , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologiaRESUMO
OBJECTIVE: The authors explored potential unintended consequences of Medicare policy changes in response to the COVID-19 pandemic for beneficiaries with behavioral health care needs. METHODS: The authors collected policies relevant to mental health and substance use care. Informed by a literature review conducted in spring 2022, the authors convened a modified Delphi panel with 13 experts in June 2022. The authors assessed expert consensus through panelist surveys conducted before and after the panel convened. RESULTS: Two policies that had a risk for unintended consequences for those with behavioral health care needs were identified. Panelists identified a discharge planning waiver as likely to decrease care access, care quality, and desirable outcomes and HIPAA enforcement discretion as likely to increase access to care and desirable outcomes (with some mixed effects on other outcomes) for Medicare beneficiaries with mental illness or substance use disorders. CONCLUSIONS: Policies implemented quickly during the pandemic did not always account for unintended consequences for beneficiaries with behavioral health care needs.
Assuntos
COVID-19 , Transtornos Mentais , Transtornos Relacionados ao Uso de Substâncias , Idoso , Humanos , Estados Unidos/epidemiologia , Medicare , Pandemias/prevenção & controle , COVID-19/prevenção & controle , Transtornos Mentais/epidemiologia , Transtornos Mentais/terapia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Transtornos Relacionados ao Uso de Substâncias/psicologiaRESUMO
OBJECTIVE: State insurance departments enforce the federal Mental Health Parity and Addiction Equity Act (MHPAEA) for fully insured employer-sponsored health plans and plans on the individual marketplace. Variable enforcement among states may drive patients' difficulties in accessing behavioral health treatment. This study explored insurance commissioners' statutory capacity for enforcing the MHPAEA. METHODS: Legal mapping of insurance office powers and responsibilities was conducted for MHPAEA-enforcing states. Relevant state laws and regulations were gathered from the Westlaw database. Sections were coded in the categories commissioner selection, frequency of examinations, fines, licenses, subpoenas, investigations and hearings, rehabilitation or liquidation of insurers, and initiation of legal actions. RESULTS: The sample included 450 sections of states' codes and regulations. The 46 states that enforced the MHPAEA showed only small differences in the powers and responsibilities of insurance commissioners. CONCLUSIONS: Similarities across states in statutory capacity of commissioners suggest that it is not a primary source of variation in MHPAEA enforcement.
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Comportamento Aditivo , Equidade em Saúde , Serviços de Saúde Mental , Humanos , Estados Unidos , Saúde Mental , Comportamento Aditivo/terapia , Cobertura do Seguro , Seguro SaúdeRESUMO
CONTEXT: The Mental Health Parity and Addiction Equity Act (MHPAEA) requires coverage for mental health and substance use disorder (MH/SUD) benefits to be no more restrictive than for medical/surgical benefits in commercial health plans. State insurance departments oversee enforcement for certain plans. Insufficient enforcement is one potential source of continued MH/SUD treatment gaps among commercial insurance enrollees. This study explored state-level factors that may drive enforcement variation. METHODS: The authors conducted a four-state multiple-case study to explore factors influencing state insurance offices' enforcement of MHPAEA. They interviewed 21 individuals who represented state government offices, advocacy organizations, professional organizations, and a national insurer. Their analysis included a within-case content analysis and a cross-case framework analysis. FINDINGS: Common themes included insurance office relationships with other stakeholders, policy complexity, and political priority. Relationships between insurance offices and other stakeholders varied between states. MHPAEA complexity posed challenges for interpretation and application. Policy champions influenced enforcement via priorities of insurance commissioners, governors, and legislatures. Where enforcement of MHPAEA was not prioritized by any actors, there was minimal state enforcement. CONCLUSIONS: Within a state, enforcement of MHPAEA is influenced by insurance office relationships, legal interpretation, and political priorities. These unique state factors present significant challenges to uniform enforcement.
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Comportamento Aditivo , Serviços de Saúde Mental , Transtornos Relacionados ao Uso de Substâncias , Humanos , Estados Unidos , Saúde Mental , Seguro Saúde , Transtornos Relacionados ao Uso de Substâncias/terapia , Cobertura do SeguroRESUMO
BACKGROUND: Many states have adopted laws that limit the amount or duration of opioid prescriptions. These limits often focus on prescriptions for acute pain, but there may be unintended consequences for those diagnosed with chronic pain, including reduced opioid prescribing without substitution of appropriate non-opioid treatments. OBJECTIVE: To evaluate the effects of state opioid prescribing cap laws on opioid and non-opioid treatment among those diagnosed with chronic pain. DESIGN: We used a difference-in-differences approach that accounts for staggered policy adoption. Treated states included 32 states that implemented a prescribing cap law between 2017 and 2019. POPULATION: A total of 480,856 adults in the USA who were continuously enrolled in medical and pharmacy coverage from 2013 to 2019 and diagnosed with a chronic pain condition between 2013 and 2016. MAIN MEASURES: Among individuals with chronic pain in each state: proportion with at least one opioid prescription and with prescriptions of a specific duration or dose, average number of opioid prescriptions, average opioid prescription duration and dose, proportion with at least one non-opioid chronic pain prescription, average number of such prescriptions, proportion with at least one chronic pain procedure, and average number of such procedures. KEY RESULTS: State laws limiting opioid prescriptions were not associated with changes in opioid prescribing, non-opioid medication prescribing, or non-opioid chronic pain procedures among patients with chronic pain diagnoses. CONCLUSIONS: These findings do not support an association between state opioid prescribing cap laws and changes in the treatment of chronic non-cancer pain.
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Dor Crônica , Adulto , Humanos , Estados Unidos/epidemiologia , Dor Crônica/tratamento farmacológico , Dor Crônica/epidemiologia , Analgésicos Opioides/uso terapêutico , Padrões de Prática Médica , Prescrições de Medicamentos , Manejo da DorRESUMO
Policy Points Over the past several decades, states have adopted policies intended to address prenatal drug use. Many of these policies have utilized existing child welfare mechanisms despite potential adverse effects. Recent federal policy changes were intended to facilitate care for substance-exposed infants and their families, but state uptake has been incomplete. Using legal mapping and qualitative interviews, we examine the development of state child welfare laws related to substance use in pregnancy from 1974 to 2019, with a particular focus on laws adopted between 2009 and 2019. Our findings reveal policies that may disincentivize treatment-seeking and widespread implementation challenges, suggesting a need for new treatment-oriented policies and refined state and federal guidance. CONTEXT: Amid increasing drug use among pregnant individuals, legislators have pursued policies intended to reduce substance use during pregnancy. Many states have utilized child welfare mechanisms despite evidence that these policies might disincentivize treatment-seeking. Recent federal changes were intended to facilitate care for substance-exposed infants and their families, but implementation of these changes at the state level has been slowed and complicated by existing state policies. We seek to provide a timeline of state child welfare laws related to prenatal drug use and describe stakeholder perceptions of implementation. METHODS: We catalogued child welfare laws related to prenatal drug use, including laws that defined child abuse and neglect and established child welfare reporting standards, for all 50 states and the District of Columbia (DC), from 1974 to 2019. In the 19 states that changed relevant laws between 2009 and 2019, qualitative interviews were conducted with stakeholders to capture state-level perspectives on policy implementation. FINDINGS: Twenty-four states and DC have passed laws classifying prenatal drug use as child abuse or neglect. Thirty-seven states and DC mandate reporting of suspected prenatal drug use to the state. Qualitative findings suggested variation in implementation within and across states between 2009 and 2019 and revealed that implementation of changes to federal law during that decade, intended to encourage states to provide comprehensive social services and linkages to evidence-based care to drug-exposed infants and their families, has been complicated by existing policies and a lack of guidance for practitioners. CONCLUSIONS: Many states have enacted laws that may disincentivize treatment-seeking among pregnant people who use drugs and lead to family separation. To craft effective state laws and support their implementation, state policymakers and practitioners could benefit from a treatment-oriented approach to prenatal substance use and additional state and federal guidance.
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Proteção da Criança , Transtornos Relacionados ao Uso de Substâncias , Feminino , Humanos , Gravidez , Proteção da Criança/legislação & jurisprudência , Estados UnidosRESUMO
Recent clinical guidelines have emphasized non-opioid treatments in lieu of prescription opioids for chronic non-cancer pain, exempting cancer patients from these recommendations. In this study, we determine trends in opioid and non-opioid treatment among privately insured adults with chronic non-cancer pain (CNCP) or cancer. Using administrative claims data from IBM MarketScan Research Databases, we identified privately-insured adults who were continuously enrolled in insurance for at least one calendar year from 2012 to 2019. We identified individuals with CNCP diagnosis, defined as a diagnosis of arthritis, headache, low back pain, and/or neuropathic pain, and a individuals with cancer diagnosis in a calendar year. Outcomes included receipt of any opioid, non-opioid medication, or non-pharmacologic CNCP therapy and opioid prescribing volume, MME-per-day, and days' supply. Estimates were regression-adjusted for age, sex, and region. Between 2012 and 2019, the proportion of patients who received any opioid decreased across both groups (CNCP: 49.7 to 30.5%, p<0.01; cancer: 86.0 to 78.7%, p<0.01). Non-opioid pain medication receipt remained steady for individuals with CNCP (66.7 to 66.4%, p<0.01) and increased for individuals with cancer (74.4 to 78.8%, p<0.01), while non-pharmacologic therapy use rose among individuals with CNCP (62.4 to 66.1%, p<0.01). Among those prescribed opioids, there was a decrease in the receipt of at least one prescription with >90 MME/day (CNCP: 13.9% in 2012 to 4.9% in 2019, p<0.01; Cancer: 26.2% to 7.6%, p<0.01); >7 days of supply (CNCP: 56.3% to 30.7%, p <0.01; Cancer: 47.5% to 22.7%, p<0.01), the mean number of opioid prescriptions (CNCP: 5.2 to 3.9, p<0.01; Cancer: 4.0 to 2.7, p<0.01) and mean MME/day (CNCP: 49.9 to 38.0, p<0.01; Cancer: 62.4 to 44.7, p<0.01). Overall, from 2012-2019, opioid prescribing declined for CNCP and cancer, with larger reductions for patients with CNCP. For both groups, reductions in prescribed opioids outpaced increases in non-opioid alternatives.
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Dor do Câncer , Dor Crônica , Neoplasias , Adulto , Analgésicos Opioides/uso terapêutico , Dor do Câncer/tratamento farmacológico , Dor do Câncer/epidemiologia , Dor Crônica/tratamento farmacológico , Humanos , Seguro Saúde , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Padrões de Prática Médica , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Over the past decade, states have passed several laws on prenatal drug use, including "maltreatment laws" deeming prenatal drug use child maltreatment, "reporting laws" requiring providers to report prenatal drug use to Child Protective Services (CPS) and "criminalization laws" that criminalize prenatal drug use. METHOD: We examined the association between a 2012 Utah maltreatment law, a 2013 Alabama maltreatment and criminalization law, and a 2014 Maryland reporting law on the rate of infant CPS reports using 2010-2017 National Child Abuse and Neglect Data System data. We conducted an event study comparing CPS reporting pre/post law in each treatment state with reporting in a pool of control states over the same period. Regression models included state and year fixed effects and state-level demographics. We triangulated quantitative results with qualitative interviews of 11 state leaders whose professional responsibilities included implementation of the state law. RESULTS: We found no association between Alabama's simultaneous maltreatment and criminalization laws and infant reporting. Maryland's reporting law (28.2 fewer reports per 1000 infants, 95%CI: [-42.9, -13.6], 4-years post-law) and Utah's maltreatment laws (31.0 fewer CPS reports per 1000 infants, 95%CI: [-61.2, -0.8], 6-years post-law) were associated with declines in infant CPS reports. Qualitative results suggest that the reduced reporting associated with Maryland's reporting and Utah's maltreatment laws may be due to increased perceived stigma resulting from the law, and health providers' distrust of CPS and/or confusion about reporting to CPS. CONCLUSION: Future research should characterize differential policy implementation across states and counties and identify policy impacts on treatment seeking behavior.
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Serviços de Proteção Infantil , Transtornos Relacionados ao Uso de Substâncias , Alabama , Criança , Proteção da Criança , Feminino , Humanos , Lactente , Maryland/epidemiologia , Gravidez , Utah/epidemiologiaRESUMO
OBJECTIVE: To evaluate the effects of state opioid prescribing cap laws on opioid prescribing after surgery. DATA SOURCES: OptumLabs Data Warehouse administrative claims data covering all 50 states from July 2012 through June 2019. STUDY DESIGN: We included individuals from 20 states that had implemented prescribing cap laws without exemptions for postsurgical pain by June 2019 and individuals from 16 control states plus the District of Columbia. We used a difference-in-differences approach accounting for differential timing in law implementation across states to estimate the effects of state prescribing cap laws on postsurgical prescribing of opioids. Outcome measures included filling an opioid prescription within 30 days after surgery; filling opioid prescriptions of specific doses or durations; and the number, days' supply, daily dose, and pill quantity of opioid prescriptions. To assess the validity of the parallel counterfactual trends assumption, we examined differences in outcome trends between law-implementing and control states in the years preceding law implementation using an equivalence testing framework. DATA COLLECTION/EXTRACTION METHODS: We included the first surgery in the study period for opioid-naïve individuals undergoing one of eight common surgical procedures. PRINCIPAL FINDINGS: State prescribing cap laws were associated with 0.109 lower days' supply of postsurgical opioids on the log scale (95% Confidence Interval [CI]: -0.139, -0.080) but were not associated with the number (Average treatment effect on the treated [ATT]: -0.011; 95% CI: -0.043, 0.021) or daily dose of postsurgical opioid prescriptions (ATT: -0.013; 95% CI: -0.030, 0.005). The negative association observed between prescribing cap laws and the probability of filling a postsurgical opioid prescription (ATT: -0.041; 95% CI: -0.054, -0.028) was likely spurious, given differences between law-implementing and control states in the pre-law period. CONCLUSIONS: Prescribing cap laws appear to have minimal effects on postsurgical opioid prescribing.
Assuntos
Analgésicos Opioides , Padrões de Prática Médica , Analgésicos Opioides/uso terapêutico , District of Columbia , Prescrições de Medicamentos , HumanosRESUMO
Rapidly rising drug overdose rates in the United States during the past decade underscore the need to increase access to treatment among people with substance use disorders (SUDs). We analyzed trends in the use of treatment services among people with SUDs during the period 2010-19, using data from the National Survey on Drug Use and Health. Compared with 2013, outpatient visits for general health in the prior year increased 3.6 percentage points by the 2017-19 period. Use of any SUD treatment in the prior year remained unchanged, but treatment use among people involved in the criminal legal system increased by about 6.2 percentage points by the end of the study period. Among those receiving SUD treatment, there was a 14.9-percentage-point increase in having treatment paid for by Medicaid between 2010-13 and 2017-19. Although access to general medical care and insurance coverage have improved for people with SUD, our study findings underscore the importance of renewed efforts to increase the use of SUD treatment.
Assuntos
Transtornos Relacionados ao Uso de Substâncias , Humanos , Cobertura do Seguro , Medicaid , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados UnidosRESUMO
BACKGROUND: There is concern that state laws to curb opioid prescribing may adversely affect patients with chronic noncancer pain, but the laws' effects are unclear because of challenges in disentangling multiple laws implemented around the same time. OBJECTIVE: To study the association between state opioid prescribing cap laws, pill mill laws, and mandatory prescription drug monitoring program query or enrollment laws and trends in opioid and guideline-concordant nonopioid pain treatment among commercially insured adults, including a subgroup with chronic noncancer pain conditions. DESIGN: Thirteen treatment states that implemented a single law of interest in a 4-year period and unique groups of control states for each treatment state were identified. Augmented synthetic control analyses were used to estimate the association between each state law and outcomes. SETTING: United States, 2008 to 2019. PATIENTS: 7 694 514 commercially insured adults aged 18 years or older, including 1 976 355 diagnosed with arthritis, low back pain, headache, fibromyalgia, and/or neuropathic pain. MEASUREMENTS: Proportion of patients receiving any opioid prescription or guideline-concordant nonopioid pain treatment per month, and mean days' supply and morphine milligram equivalents (MME) of prescribed opioids per day, per patient, per month. RESULTS: Laws were associated with small-in-magnitude and non-statistically significant changes in outcomes, although CIs around some estimates were wide. For adults overall and those with chronic noncancer pain, the 13 state laws were each associated with a change of less than 1 percentage point in the proportion of patients receiving any opioid prescription and a change of less than 2 percentage points in the proportion receiving any guideline-concordant nonopioid treatment, per month. The laws were associated with a change of less than 1 in days' supply of opioid prescriptions and a change of less than 4 in average monthly MME per day per patient prescribed opioids. LIMITATIONS: Results may not be generalizable to non-commercially insured populations and were imprecise for some estimates. Use of claims data precluded assessment of the clinical appropriateness of pain treatments. CONCLUSION: This study did not identify changes in opioid prescribing or nonopioid pain treatment attributable to state laws. PRIMARY FUNDING SOURCE: National Institute on Drug Abuse.
Assuntos
Analgésicos não Narcóticos , Dor Crônica , Programas de Monitoramento de Prescrição de Medicamentos , Adulto , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Prescrições de Medicamentos , Humanos , Manejo da Dor , Padrões de Prática Médica , Estados UnidosRESUMO
INTRODUCTION: The U.S. Affordable Care Act Medicaid expansion, which allowed states to expand Medicaid coverage to low-income adults beginning in 2014, has reduced the risk factors for child neglect and physical abuse, including parental financial insecurity, substance use, and untreated mental illness. This study examines the associations between Medicaid expansion and the rates of overall, first-time, and repeat reports of child neglect and physical abuse incidents per 100,000 children aged 0-5, 6-12, and 13-17 years. METHODS: The 2008-2018 National Child Abuse and Neglect Data System was analyzed using an extension of the difference-in-differences approach that accounts for staggered policy implementation across time. Owing to evidence of nonparallel preperiod trends in the 6 states that expanded Medicaid from 2015 to 2017, the main analyses included 20 states that newly expanded Medicaid in 2014 and 18 states that did not expand Medicaid from 2008 to 2018. Analyses were conducted in 2020-2021. RESULTS: Medicaid expansion states were associated with reductions of 13.4% (95% CI= -24.2, -9.6), 14.8% (95% CI= -26.4, -1.4), and 16.0% (-27.6, -2.6) in the average rate of child neglect reports per 100,000 children aged 0-5, 6-12, and 13-17 years, per state-year, relative to control states. Expansion was associated with a 17.3% (95% CI= -28.9, -3.8) reduction in the rate of first-time neglect reports among children aged 0-5 years and with 16.6% (95% CI= -29.3, -1.6) and 18.7% (95% CI= -32.5, -2.1) reductions in the rates of repeat neglect reports among children aged 6-12 and 13-17 years, respectively. There were no statistically significant associations between Medicaid expansion and the rates of physical abuse among children in any age group. CONCLUSIONS: Insurance expansions for low-income adults may reduce child neglect.
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Maus-Tratos Infantis , Medicaid , Adulto , Criança , Acessibilidade aos Serviços de Saúde , Humanos , Cobertura do Seguro , Patient Protection and Affordable Care Act , Abuso Físico , Estados UnidosRESUMO
BACKGROUND: Cancer is the second leading cause of death for people with serious mental illness (SMI), such as schizophrenia and bipolar disorder. People with SMI receive cancer screenings at lower rates than the general population. AIMS: We sought to identify factors associated with cancer screening in a publicly insured population with SMI and stratified by race, a factor itself linked with differential rates of cancer screening. MATERIALS AND METHODS: We used Maryland Medicaid administrative claims data (2010-2018) to examine screening rates for cervical cancer (N = 40,622), breast cancer (N = 9818), colorectal cancer (N = 19,306), and prostate cancer (N = 4887) among eligible Black and white enrollees with SMI. We examined individual-level socio-demographic and clinical factors, including co-occurring substance use disorder, medical comorbidities, psychiatric diagnosis, obstetric-gynecologic and primary care utilization, as well as county-level characteristics, including metropolitan status, mean household income, and primary care workforce capacity. Generalized estimating equations with a logit link were used to examine the characteristics associated with cancer screening. RESULTS: Compared with white enrollees, Black enrollees were more likely to receive screening for cervical cancer (AOR: 1.18; 95% CI: 1.15-1.22), breast cancer (AOR: 1.27; 95% CI: 1.19-1.36), and colorectal cancer (AOR: 1.07; 95% CI: 1.02-1.13), while similar rates were observed for prostate cancer screening (AOR: 1.06; 95% CI: 0.96-1.18). Primary care utilization and longer Medicaid enrollment were positively associated with cancer screening while co-occurring substance use disorder was negatively associated with cancer screening. CONCLUSION: Improving cancer screening rates among populations with SMI should focus on facilitating continuous insurance coverage and access to primary care.
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Detecção Precoce de Câncer , Transtornos Mentais , População Negra , Detecção Precoce de Câncer/estatística & dados numéricos , Feminino , Humanos , Masculino , Maryland/epidemiologia , Medicaid , Transtornos Mentais/complicações , Transtornos Mentais/diagnóstico , Transtornos Mentais/epidemiologia , Estados Unidos , População BrancaRESUMO
BACKGROUND: The American College of Obstetricians and Gynecologists recommends universal screening for tobacco, alcohol, and drug use as a part of routine prenatal care. However, little is known about the prevalence of prenatal substance use screening or factors that may contribute to differential rates of screening during prenatal care. OBJECTIVE: This study aimed to describe the prevalence of prenatal substance use screening by substance, year, state, and state-level prenatal substance use policies and to examine individual-level factors associated with receipt of screening. STUDY DESIGN: We analyzed 2016 to 2018 data from 103,608 women participating in the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. The Pregnancy Risk Assessment Monitoring System survey sampling weights were applied to all analyses. We described the percentage of individuals asked by a healthcare worker about substance use during a prenatal care appointment by substance, year, and state. Using chi-squared tests, we examined differences in the prevalence of screening by state-level prenatal substance use policies, including policies regarding classification of prenatal substance use as child abuse or neglect, mandatory testing or reporting of prenatal substance use, and targeted treatment funding and access for pregnant individuals with substance use disorders. Finally, we estimated the association between individual-level characteristics and receipt of prenatal substance use screening using logistic regression, controlling for year and state fixed effects and accounting for missingness using multiple imputation. RESULTS: In 2018, approximately 95% individuals reported being asked about cigarette or alcohol use during a prenatal care appointment, whereas only 80% reported being asked about drug use. The percentage of individuals who were asked about substance use during a prenatal care appointment increased overall between 2016 and 2018, with variability across states. For all substances, states with laws designating prenatal drug use as child abuse or neglect had lower prevalence of screening, whereas states with laws mandating providers to test for substance use in pregnancy had higher prevalence of screening. Several individual-level characteristics were associated with increased odds of reported prenatal substance use screening for one or more substances, including being younger, less educated, unmarried, Black (vs White), non-Hispanic, or publicly insured (vs privately insured), receiving adequate prenatal care, and having a history of prepregnancy cigarette use. CONCLUSION: Our study finds that despite recommendations for universal prenatal substance use screening, there are differences in who is actually asked about substance use during prenatal care appointments. This may be influenced by state-level prenatal substance use policies and selective screening approaches in which certain individuals are more likely to be asked about substance use during their prenatal care appointment. A better understanding of the repercussions of selective screening approaches on outcomes and the roles that policies, systems, and provider biases play in perpetuating these approaches is needed to advance guideline implementation efforts in prenatal care settings.
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Vigilância da População , Transtornos Relacionados ao Uso de Substâncias , Feminino , Humanos , Programas de Rastreamento , Gravidez , Cuidado Pré-Natal , Medição de Risco , Transtornos Relacionados ao Uso de Substâncias/diagnósticoRESUMO
OBJECTIVE: This study examined the association between enrollment in Maryland's behavioral health home (BHH) program and use of outpatient mental health services among people with serious mental illness. METHODS: The study sample, drawn from Maryland Medicaid administrative claims data from 2012 through 2017, included 12,232 individuals ages 21-64 with a serious mental illness who were enrolled in a BHH (N=3,319) or never enrolled (N=8,913). A marginal structural modeling approach with inverse probability of treatment weighting was used to examine the association between BHH enrollment and outpatient mental health utilization, measured as the number of visits per 3-month period. RESULTS: BHH enrollment was associated with 0.8 additional outpatient mental health visits per 3-month period, or approximately three additional visits annually. CONCLUSIONS: A specialty mental health system-based health home model with a primary goal of improving access to general medical care was associated with increased use of outpatient mental health services.
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Transtornos Mentais , Serviços de Saúde Mental , Psiquiatria , Adulto , Humanos , Maryland , Medicaid , Transtornos Mentais/terapia , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Persons with serious mental illness (SMI) die 10-20 years earlier than the general population; cancer is the second leading cause of death. Differences in cancer screening between SMI and the general population are not well understood. OBJECTIVES: To describe receipt of cancer screening among individuals with versus without SMI and to explore clinicians' perceptions around cancer screening for people with SMI. METHODS: Mixed-methods study using 2010-2017 MarketScan commercial insurance administrative claims data and semi-structured clinician interviews. In the quantitative analyses, we used multivariate logistic regression analyses to calculate the likelihood of receiving cervical, breast, colorectal, or prostate cancer screening among people with versus without SMI, defined as schizophrenia or bipolar disorder. We conducted semi-structured interviews with 17 primary care physicians and 15 psychiatrists. Interview transcripts were coded using a hybrid deductive/inductive approach. RESULTS: Relative to those without SMI, individuals with SMI were less likely to receive screening for cervical cancer [adjusted odds ratio (aOR): 0.80; 95% confidence interval (CI): 0.80-0.81], breast cancer (aOR: 0.79; 95% CI: 0.78-0.80), colorectal cancer (aOR: 0.90; 95% CI: 0.89-0.91), and prostate cancer (aOR: 0.85; 95% CI: 0.84-0.87). Clinicians identified 5 themes that may help explain the lower rates of cancer screening in persons with SMI: access to care, available support, prioritization of other issues, communication, and patient concerns. CONCLUSIONS: People with SMI were less likely to receive 4 common types of cancer screening. Improving cancer screening rates in the SMI population will likely require a multidisciplinary approach to overcome barriers to screening.
Assuntos
Detecção Precoce de Câncer/estatística & dados numéricos , Transtornos Mentais/epidemiologia , Neoplasias/diagnóstico , Neoplasias/epidemiologia , Adulto , Neoplasias da Mama/diagnóstico , Neoplasias Colorretais/diagnóstico , Comunicação , Comorbidade , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Revisão da Utilização de Seguros , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Neoplasias da Próstata/diagnóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores Socioeconômicos , Neoplasias do Colo do Útero/diagnóstico , Adulto JovemRESUMO
OBJECTIVE: To evaluate the impact of Maryland's behavioral health homes (BHHs) on receipt of follow-up care and readmissions following hospitalization among Medicaid enrollees with serious mental illness (SMI). DATA SOURCES: Maryland Medicaid administrative claims for 12 232 individuals. STUDY DESIGN: Weighted marginal structural models were estimated to account for time-varying exposure to BHH enrollment and time-varying confounders. These models compared changes over time in outcomes among BHH and comparison participants. Outcome measures included readmissions and follow-up care within 7 and 30 days following hospitalization. DATA COLLECTION/EXTRACTION METHODS: Eligibility criteria included continuous enrollment in Medicaid for the first two years of the study period; 21-64 years; and use of psychiatric rehabilitation services. PRINCIPAL FINDINGS: Over three years, BHH enrollment was associated with 3.8 percentage point (95% CI: 1.5, 6.1) increased probability of having a mental health follow-up service within 7 days of discharge from a mental illness-related hospitalization and 1.9 percentage point (95% CI: 0.0, 3.9) increased probability of having a general medical follow-up within 7 days of discharge from a somatic hospitalization. BHHs had no effect on probability of readmission. CONCLUSIONS: BHHs may improve follow-up care for Medicaid enrollees with SMI, but effects do not translate into reduced risk of readmission.