Community, Hospital, and Patient Factors Contributing to Ethnoracial Disparities in Follow-Up After Psychiatric Hospitalization.

OBJECTIVE: This study used an ecosocial perspective to examine ethnoracial disparities in timely outpatient follow-up care after psychiatric hospitalization in a cohort of Medicaid recipients. METHODS: This retrospective analysis used 2012-2013 New York State Medicaid claims data for 17,488 patients ages <65 years who were treated in hospital psychiatric units and discharged to the community. Claims data were linked to other administrative data sets capturing key social conditions and determinants of mental health for non-Latinx White (White hereafter), non-Latinx Black (Black), Latinx, non-Latinx Asian/Pacific Islander (Asian/Pacific Islander), non-Latinx American Indian or Native Alaskan (American Indian or Native Alaskan), and other ethnoracial groups. Regression models were used to estimate the variations in disparities in timely follow-up care that were attributable to community, organization (i.e., hospital), and individual patient characteristics. RESULTS: Overall, 60.1% of patients attended an outpatient mental health visit within 30 days of discharge. Compared with the rate for White patients, the attendance rates were 9.5 percentage points lower for Black patients and 7.8 percentage points higher for Asian/Pacific Islander patients. No significant difference in attendance rates was found between Latinx and White patients. Community factors, specifically urban versus rural classification and county poverty status, accounted for the greatest variation in timely follow-up care in all comparisons. CONCLUSIONS: Efforts to increase connection to outpatient mental health follow-up care after psychiatric hospitalization should incorporate cultural and structural competencies to address social conditions and determinants of mental health that underly ethnoracial disparities.

Racial-Ethnic Disparities in Outpatient Mental Health Care in the United States.

OBJECTIVE: The authors aimed to compare national rates and patterns of use of outpatient mental health care among Hispanic, non-Hispanic Black, and non-Hispanic White individuals. METHODS: Data from the 2018-2019 Medical Expenditure Panel Survey, a nationally representative survey of U.S. households, were analyzed, focusing on use of any outpatient mental health care service by non-Hispanic White (N=29,126), non-Hispanic Black (N=7,965), and Hispanic (N=12,640) individuals ages ≥4 years (N=49,731). Among individuals using any mental health care, analyses focused on those using psychotropic medications, psychotherapy, or both and on receipt of minimally adequate mental health care. RESULTS: The annual rate per 100 persons of any outpatient mental health service use was more than twice as high for White (25.3) individuals as for Black (12.2) or Hispanic (11.4) individuals. Among those receiving outpatient mental health care, Black (69.9%) and Hispanic (68.4%) patients were significantly less likely than White (83.4%) patients to receive psychotropic medications, but Black (47.7%) and Hispanic (42.6%) patients were significantly more likely than White (33.3%) patients to receive psychotherapy. Among those treated for depression, anxiety, attention-deficit hyperactivity disorder, or disruptive behavior disorders, no significant differences were found in the proportions of White, Black, or Hispanic patients who received minimally adequate treatment. CONCLUSIONS: Large racial-ethnic gaps in any mental health service use and smaller differences in patterns of treatment suggest that achieving racial-ethnic equity in outpatient mental health care delivery will require dedicated efforts to promote greater mental health service access for Black and Hispanic persons in need.

Measurement fidelity of clinical assessment methods in a global study on identifying reproducible brain signatures of obsessive-compulsive disorder.

OBJECTIVE: To describe the steps of ensuring measurement fidelity of core clinical measures in a five-country study on brain signatures of obsessive-compulsive disorder (OCD). METHOD: We collected data using standardized instruments, which included the Yale-Brown Obsessive-Compulsive Scale (YBOCS), the Dimensional YBOCS (DYBOCS), the Brown Assessment of Beliefs Scale (BABS), the 17-item Hamilton Depression Scale (HAM-D), the Hamilton Anxiety Scale (HAM-A), and the Structured Clinical Interview for DSM-5 (SCID). Steps to ensure measurement fidelity included translating instruments, developing a clinical decision manual, and continuing reliability training with 11-13 transcripts of each instrument by 13 independent evaluators across sites over 4 years. We use multigroup confirmatory factor analysis (MGCFA) to report interrater reliability (IRR) among the evaluators and factor structure for each scale in 206 participants with OCD. RESULTS: The overall IRR for most scales was high (ICC > 0.94) and remained good to excellent throughout the study. Consistent factor structures (configural invariance) were found for all instruments across the sites, while similarity in the factor loadings for the items (metric invariance) could be established only for the DYBOCS and the BABS. CONCLUSIONS: It is feasible to achieve measurement fidelity of clinical measures in multisite, multilinguistic global studies, despite the challenges inherent to such endeavors. Future studies should not only report IRR but also consider reporting methods of standardization of data collection and measurement invariance to identify factor structures of core clinical measures. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Medicaid Expansion and Racial-Ethnic Health Care Coverage Disparities Among Low-Income Adults With Substance Use Disorders.

OBJECTIVE: In light of historical racial-ethnic disparities in health care coverage, the authors assessed changes in coverage in nationally representative samples of Black, White, and Hispanic low-income adults with substance use disorders after the 2014 Affordable Care Act Medicaid expansion. METHODS: Data from 12 years of the annual National Survey on Drug Use and Health (2008-2019) identified low-income adults ages 18-64 years with alcohol, cannabis, cocaine, or heroin use disorder (N=749,033). Trends in coverage focused on non-Hispanic Black, non-Hispanic White, and Hispanic individuals. Age- and sex-adjusted difference-in-differences analysis assessed effects of expansion state residence on insurance coverage for the three groups. RESULTS: Before Medicaid expansion (2008-2013), 38.5% of Black, 37.6% of White, and 51.2% of Hispanic low-income adults with substance use disorders were uninsured. After expansion (2014-2019), these proportions significantly declined for Black (24.2%), White (22.0%), and Hispanic (34.5%) groups. Decreases in rates of individuals without insurance and increases in Medicaid coverage tended to be more pronounced for those in expansion states than for those in nonexpansion states. In nonexpansion states, the proportions of those without insurance significantly decreased among Black and White individuals but not among Hispanic individuals. Proportions receiving past-year substance use treatment did not significantly change and remained low postexpansion: Black, 10.7%; White, 14.6%; and Hispanic, 9.0%. CONCLUSIONS: After Medicaid expansion, coverage increased for low-income Black, White, and Hispanic adults with substance use disorders. For all three groups, Medicaid coverage disproportionately increased among those living in expansion states. However, coverage remained far from universal, especially for Hispanic adults with substance use disorders.

Implications of Telepsychiatry for Cost, Quality, and Equity of Mental Health Care.

This Viewpoint discusses overlapping challenges to multiple stakeholders as telepsychiatry continues to expand.

Wage theft and life expectancy inequities in the United States: A simulation study.

Wage theft - employers not paying workers their legally entitled wages and benefits - costs workers billions of dollars annually. We tested whether preventing wage theft could increase U.S. life expectancy and decrease inequities therein. We obtained nationally representative estimates of the 2001-2014 association between income and expected age at death for 40-year-olds (40 plus life expectancy at age 40) compiled from tax and Social Security Administration records, and estimates of the burden of wage theft from several sources, including estimates regarding minimum-wage violations (not paying workers the minimum wage) developed from Current Population Survey data. After modeling the relationship between income and expected age at death, we simulated the effects of scenarios preventing wage theft on mean expected age at death, assuming a causal effect of income on expected age at death. We simulated several scenarios, including one using data suggesting minimum-wage violations constituted 38% of all wage theft and caused 58% of affected workers' losses. Among women in the lowest income decile, mean expected age at death was 0.17 years longer in the counterfactual scenario than observed (95% confidence interval [CI]: 0.11-0.22), corresponding to 528,685 (95% CI: 346,018-711,353) years extended in the total 2001-2014 age-40 population. Among men in the lowest decile, the estimates were 0.12 (95% CI: 0.07-0.17) and 380,502 (95% CI: 229,630-531,374). Moreover, among women, mean expected age at death in the counterfactual scenario increased 0.16 (95% CI: 0.06-0.27) years more among the lowest decile than among the highest decile; among men, the estimate was 0.12 (95% CI: 0.03-0.21).

Healthcare coverage and service access for low-income adults with substance use disorders.

INTRODUCTION: Although health coverage facilitates service access to adults in the general population, uncertainty exists over the extent to which this relationship extends to low-income adults with substance use disorders. METHODS: The health status and service use patterns of low-income adults with substance use disorders who had continuous, discontinuous, and no past year health coverage were compared using data from the 2015-2019 National Survey on Drug Use and Health (NSDUH). The NSDUH is a nationally representative survey of the civilian non-institutionalized population. RESULTS: In the weighted sample (unweighted n = 9243), approximately 65.66% of low-income adults with substance use disorders had continuous coverage, 17.03% had discontinuous coverage, and 17.31% had no insurance coverage during the past year. Although few group differences were observed in self-reported health status, the uninsured group compared to the discontinously and continuously covered groups, respectively, was less likely to report a past year substance use treatment visit (11.03% vs. 14.83% vs. 15.61%), an outpatient care visit (53.39% vs. 71.27% vs. 79.04%), an emergency department visit (33.33% vs. 45.76% vs. 45.57%), or an inpatient admission (9.24% vs. 15.11% vs. 15.58%). CONCLUSIONS: Although the cross sectional design limits causal inferences, the correlations between lacking health insurance and low rates of substance use treatment and healthcare use raise the possibility that increasing healthcare coverage might increase access to substance use treatment and other needed healthcare services for low-income adults with substance use disorders.

Feasibility and Utility of Different Approaches to Violence Risk Assessment for Young Adults Receiving Treatment for Early Psychosis.

This pilot study examined violence risk assessment among a sample of young adults receiving treatment for early psychosis. In this study, thirty participants were assessed for violence risk at baseline. Participants completed follow-up assessments at 3, 6, 9 and 12 months to ascertain prevalence of violent behavior. Individuals were on average 24.1 years old (SD = 3.3 years) and predominantly male (n = 24, 80%). In this sample, six people (20%) reported engaging in violence during the study period. Individuals who engaged in violence had higher levels of negative urgency (t(28) = 2.21, p = 0.035) This study sought to establish the feasibility, acceptability, and clinical utility of violence risk assessment for clients in treatment for early psychosis. Overall, this study found that most individuals with early psychosis in this study (who are in treatment) were not at risk of violence. Findings suggest that violent behavior among young adults with early psychosis is associated with increased negative urgency.

Rates of Inpatient and Emergency Room Use Before and After Discharge Among Medicaid Enrollees in OnTrackNY.

OBJECTIVE: This study examined hospital and emergency room (ER) use among Medicaid enrollees before and after discharge from OnTrackNY, a coordinated specialty care program for recent-onset psychosis. METHODS: Medicaid claims data were linked to program data. Inpatient hospitalization, inpatient days, and ER visits were assessed in the 6 months prior to OnTrackNY enrollment and 6 months prior to and after discharge. The sample consisted of 138 participants with continuous Medicaid enrollment during the study. RESULTS: Inpatient visits significantly declined from the pre-OnTrackNY enrollment period to the predischarge period (ß=-1.23, standard error [SE]=0.22, p<0.001), did not significantly change in the first 6 months after discharge (ß=0.19, SE=0.26, p=0.48), and remained significantly lower than before OnTrackNY enrollment (ß=-1.05, SE=0.20, p<0.001). Similar patterns were observed for inpatient days and ER use. CONCLUSIONS: ER and hospital use declined during OnTrackNY participation and did not significantly change in the first 6 months after discharge.

Suicide Risk in Medicare Patients With Schizophrenia Across the Life Span.

Importance: Although adults with schizophrenia have an increased risk of suicide, sample size limitations of previous research have hindered characterizations of suicide risk across the life span. Objective: To describe suicide mortality rates and correlates among adults with schizophrenia across the life span and standardized mortality ratios (SMRs) for suicide compared with the general US population. Design, Setting, and Participants: Five national retrospective longitudinal cohorts of patients with schizophrenia in the Medicare program from January 1, 2007, to December 31, 2016, were identified by age: 18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years or older. Death record information was obtained from the National Death Index. The total cohort included 668 836 Medicare patients with schizophrenia, 2 997 308 years of follow-up, and 2218 suicide deaths. Data were analyzed from September 30, 2020, to March 10, 2021. Main Outcomes and Measures: For each age group, suicide mortality rates per 100 000 person-years and adjusted hazard ratios (aHRs) with 95% CIs of suicide were determined. Suicide SMRs were estimated for the total cohort and by sex and age cohorts standardized to the general US population by age, sex, and race/ethnicity. Results: The study population of adults 18 years and older included 668 836 Medicare recipients with schizophrenia (52.5% men, 47.5% women). The total suicide rate per 100 000 person-years was 74.00, which is 4.5 times higher than that for the general US population (SMR, 4.54; 95% CI, 4.35-4.73) and included a rate of 88.96 for men and 56.33 for women, which are 3.4 (SMR, 3.39; 95% CI, 3.22-3.57) and 8.2 (SMR, 8.16; 95% CI, 7.60-8.75) times higher, respectively, than the rates for the general US population. Suicide rates were significantly higher for men (aHR, 1.44; 95% CI, 1.29-1.61) and those with depressive (aHR, 1.32; 95% CI, 1.17-1.50), anxiety (aHR, 1.15; 95% CI, 1.02-1.30), drug use (aHR, 1.55; 95% CI, 1.36-1.76), and sleep disorders (aHR, 1.22; 95% CI, 1.07-1.39), suicidal ideation (aHR, 1.41; 95% CI, 1.22-1.63), and suicide attempts or self-injury (aHR, 2.48; 95% CI, 2.06-2.98). The adjusted hazards of suicide were lower for Hispanic patients (aHR, 0.66; 95% CI, 0.54-0.80) or Black patients (aHR, 0.29; 95% CI, 0.24-0.35) than White patients. The suicide rate declined with age, from 141.95 (SMR, 10.19; 95% CI, 9.29-11.18) for patients aged 18 to 34 years to 24.01 (SMR, 1.53; 95% CI, 1.32-1.77) for patients 65 years or older. The corresponding declines per 100 000 person-years were from 153.80 (18-34 years of age) to 34.17 (65 years or older) for men and from 115.70 (18-34 years of age) to 18.66 (65 years or older) for women. In the group aged 18 to 34 years, the adjusted hazards of suicide risk were significantly increased for patients with suicide attempt or self-injury (aHR, 2.57; 95% CI, 18.20-2.04) and with comorbid drug use disorders (aHR, 1.48; 95% CI, 1.17-1.88), but not with comorbid depressive disorders (aHR, 0.99; 95% CI, 0.38-1.26) during the year before the start of follow-up. Conclusions and Relevance: In this cohort study of adult Medicare patients with schizophrenia, suicide risk was elevated, with the highest absolute and relative risk among young adults. These patterns support suicide prevention efforts with a focus on young adults with schizophrenia, especially those with suicidal symptoms and substance use.

Effects of the ACA on Health Care Coverage for Adults With Substance Use Disorders.

OBJECTIVE: The authors assessed changes in health care coverage in nationally representative samples of low- and middle-income adults with and without substance use disorders following the 2014 Affordable Care Act marketplace launch and Medicaid expansion. METHODS: Data from the 2012-2018 (N=407,985) National Survey on Drug Use and Health identified low- and middle-income nonelderly adults with alcohol, marijuana, cocaine, or heroin use disorders. A sociodemographically adjusted difference-in-differences analysis assessed the trends in Medicaid and individually purchased private insurance between adults with and without substance use disorders. RESULTS: Between 2012-2013 and 2015-2016, the percentages without health insurance significantly declined for adults with substance use disorders (from 27.8% to 18.7%) and for those without these disorders (from 22.6% to 14.6%). These trends were related to gains in Medicaid and in individually purchased private insurance but not to gains in employer-based private insurance coverage. Between 2015-2016 and 2017-2018, however, the percentages without health insurance among adults with substance use disorders (18.7% to 18.4%) and without these disorders (14.7% to 14.7%) was little changed. CONCLUSIONS: With insurance gains having stalled and the downturn of the U.S. economy, there is renewed urgency to extend health care coverage to middle- and low-income adults with substance use disorders that meets their substance use and general health needs.

Age-Specific Prevalence and Incidence of Dementia Diagnoses Among Older US Adults With Schizophrenia.

Importance: People with schizophrenia are at high risk of receiving a diagnosis of dementia. Understanding the magnitude and timing of this increased risk has important implications for practice and policy. Objective: To estimate the age-specific incidence and prevalence of dementia diagnoses among older US adults with schizophrenia and in a comparison group without serious mental illness (SMI). Design, Setting, and Participants: This retrospective cohort study used a 50% random national sample of Medicare beneficiaries 66 years or older with fee-for-service plans and Part D prescription drug coverage from January 1, 2007, to December 31, 2017. The cohort with schizophrenia included adults with at least 12 months of continuous enrollment in fee-for-service Medicare and Part D and at least 2 outpatient claims or at least 1 inpatient claim for schizophrenia during the qualifying years. The comparison group included adults with at least 12 months of continuous enrollment in fee-for-service Medicare and Part D and without a diagnosis of schizophrenia, bipolar disorder, or recurrent major depressive disorder during the qualifying year. Data were analyzed from January 1 to July 31, 2020. Main Outcomes and Measures: Dementia was defined using the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse diagnosis codes for Alzheimer disease and related disorders or senile dementia. Incident diagnoses were defined by at least 12 consecutive eligible months without a qualifying code before meeting dementia criteria. Results: The study population of 8 011 773 adults 66 years or older (63.4% women; mean [SD] age, 74.0 [8.2] years) included 74 170 individuals with a diagnosis of schizophrenia (56.6% women) and 7 937 603 without an SMI diagnosis (63.5% women) who contributed 336 814 and 55 499 543 person-years of follow-up, respectively. At 66 years of age, the prevalence of diagnosed dementia was 27.9% (17 640 of 63 287) among individuals with schizophrenia compared with 1.3% (31 295 of 2 389 512) in the group without SMI. By 80 years of age, the prevalence of dementia diagnoses was 70.2% (2011 of 2866) in the group with schizophrenia and 11.3% (242 094 of 2 134 602) in the group without SMI. The annual incidence of dementia diagnoses per 1000 person-years at 66 years of age was 52.5 (95% CI, 50.1-54.9) among individuals with schizophrenia and 4.5 (95% CI, 4.4-4.6) among individuals without SMI and increased to 216.2 (95% CI, 179.9-252.6) and 32.3 (95% CI, 32.0-32.6), respectively, by 80 years of age. Conclusions and Relevance: In this cohort study, compared with older adults without SMI, those with schizophrenia had increased risk of receiving a diagnosis of dementia across a wide age range, possibly because of cognitive and functional deterioration related to schizophrenia or factors contributing to other types of dementia. High rates of dementia among adults with schizophrenia have implications for the course of illness, treatment, and service use.

Assessment of Prescription Opioid Medical Use and Misuse Among Parents and Their Adolescent Offspring in the US.

Importance: Limited information is available regarding the association between parental and adolescent medical prescription opioid use and misuse in the US. Objective: To examine the associations between parental and adolescent prescription opioid medical use and misuse. Design, Setting, and Participants: This cross-sectional, nationally representative study included 15 200 parent-adolescent dyads from the annual 2015-2017 National Survey on Drug Use and Health. Data were collected from January 6, 2015, to December 20, 2017, and analyzed from October 4, 2019, to October 15, 2020. Exposures: Parental past 12-month exclusive medical prescription opioid use and any misuse (ie, using without a prescription or in any way not directed by a physician). Main Outcomes and Measures: Adolescent past 12-month medical prescription opioid use or misuse. Multivariable regressions estimated associations between parental and offspring medical prescription opioid use or misuse, controlling for sociodemographic and psychosocial variables. Results: Respondents included 9400 mother-child and 5800 father-child dyads in the same household; children were aged 12 to 17 years (52.8% male; mean [SD] age, 14.5 [1.7] years). Controlling for other factors, parental medical prescription opioid use was associated with adolescent prescription opioid medical use (adjusted odds ratio [aOR], 1.28; 95% CI, 1.06-1.53) and misuse (aOR, 1.53; 95% CI, 1.07-2.25), whereas parental misuse was not. Parental medical prescription stimulant use was associated with adolescent medical prescription opioid use (aOR, 1.40; 95% CI, 1.02-1.91). Parental marijuana use (aOR, 1.84; 95% CI, 1.13-2.99), parent-adolescent conflict (aOR, 1.26; 95% CI, 1.05-1.52), and adolescent depression (aOR, 1.75; 95% CI, 1.26-2.44) were associated with adolescent prescription opioid misuse. Adolescent delinquency (aOR, 1.55; 95% CI, 1.38-1.74) and perceived schoolmates' drug use (aOR, 2.87; 95% CI, 1.95-4.23) were also associated with adolescent misuse and more weakly with medical use (aORs, 1.13 [95% CI, 1.05-1.22] and 1.61 [95% CI, 1.32-1.96], respectively). Conclusions and Relevance: Youth use of prescription opioids is in part a structural/environmental issue. The findings of this study suggest that parental medical prescription opioid use is associated with offspring prescription opioid use, whereas parental misuse is not. Restricting physicians' opioid prescribing to parents is a crucial public health goal. In addition, parents could be educated on the risks of their prescription opioid use for offspring and on practices to mitigate risk, including safe medication storage and disposal. Screening for parental prescription opioid use could be part of pediatric practice. Addressing adolescent mental health could also reduce adolescent prescription opioid misuse.

Private health insurance coverage of drug use disorder treatment: 2005-2018.

Many privately insured adults with drug use disorders in the United States do not have health care coverage for drug use treatment. The Affordable Care Act sought to redress this gap by including substance use treatments as essential health benefits under new plans offered. This study used data from 11,732 privately insured adult participants of the 2005-2018 National Survey on Drug Use and Health with drug use disorders to examine trends in drug use treatment coverage and the association of coverage with receiving treatment. 37.6% of the participants with drug use disorders did not know whether their plan covered drug use treatment, with little change over time. Among those who knew, coverage increased modestly between the 2005-2013 and 2014-2018 periods (73.5% vs. 77.5%, respectively, p = .015). Coverage was associated with receiving drug use treatment (adjusted odds ratio = 2.09, 95% confidence interval = 1.61-2.72, p < .001). However, even among participants with coverage, only 13.4% received treatment. Broader coverage of drug use treatment could potentially improve treatment rates.

Medical comorbid diagnoses among adult psychiatric inpatients.

OBJECTIVE: Shortened life expectancy of people with mental disorders has been attributed to medical comorbidities, yet these conditions remain under-recognized and under-treated. This study characterizes the medical demands placed on inpatient psychiatric units to help guide medical assessment and management practices in these settings. METHODS: Medicaid claims records and clinician data were linked with hospital and regional data for individuals with a principal diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. A modified Elixhauser Comorbidity Index (ECI) score was calculated for each unique individual (n = 14,458). Adjusted odds ratios (AORs) of having a medical comorbidity were calculated using logistic regression analyses. RESULTS: 74.9% of psychiatric inpatients had at least one medical comorbidity, including 57.5% of people ages 18-24. Higher rates of medical comorbidity were associated with older age, female gender, non-schizophrenia diagnoses, and engagement in care prior to hospitalization. Patients with medical comorbidities had lower odds (AOR 0.54; 99% CI 0.35-0.83) of being treated in hospitals with 100 or more total beds compared to smaller hospitals. CONCLUSIONS: A high prevalence of common medical diagnoses among psychiatric inpatients underscores the importance of adequate detection and medical treatment of medical comorbidities in psychiatric inpatient settings.

Developing a Scale to Measure Interprofessional Collaboration in HIV Prevention and Care: Implications for Research on Patient Access and Retention in the HIV Continuum of Care.

To adapt and validate a scale for measuring interprofessional collaboration in HIV prevention and care (IPC-HIV), primary survey data were collected (2012-2017) from 577 HIV service providers in 60 organizations in New York, New Jersey, and Michigan. Cross-sectional training data were used to develop the IPC-HIV scale. The model was validated by fitting the five-factor confirmatory factor-analysis model to a 30-item set. The scale measures five domains with reliable alpha coefficients: Interdependence, Professional Activities, Flexibility, Collective Ownership, and Reflection on Process. Correlations between subscales were significant (p < .05). The strongest correlation was between Reflection on Process and Collective Ownership subscale scores. Mean scores ranged lfrom 4.070 to 4.880, with the highest score for Flexibility across all locations. IPC-HIV is valid and reliable among HIV-prevention and care workers, and is recommended for examining the effect of IPC on patient access to HIV testing and primary care.

Exposure to Surgery and Anesthesia in Early Childhood and Subsequent Use of Attention Deficit Hyperactivity Disorder Medications.

BACKGROUND: Some recent clinical studies have found that early childhood exposure to anesthesia is associated with increased risks of behavioral deficits and clinical diagnoses of attention deficit hyperactivity disorder (ADHD). While diagnoses in claims data may be subject to inaccuracies, pharmacy claims are highly accurate in reflecting medication use. This study examines the association between exposure to surgery and anesthesia and subsequent ADHD medication use. METHODS: Longitudinal data for children enrolled in Texas and New York Medicaid from 1999 to 2010 were used. We assessed the association between a single exposure to anesthesia before age 5 years for 1 of 4 common pediatric surgical procedures (pyloromyotomy, inguinal hernia repair, circumcisions outside the perinatal period, and tonsillectomy and/or adenoidectomy) and persistent ADHD medication use (event defined as the initial ADHD medication prescription, and persistent use defined as filling 2 or more ≥30-day prescriptions between 6 months following surgery until censoring). Exposed children (n = 42,687) were matched on propensity score (ie, the probability of receiving surgery) estimated in logistic regression including sociodemographic and clinical covariates, to children without anesthesia exposure before age 5 years (n = 213,435). Cox proportional hazards models were used to evaluate the hazard ratio (HR) of ADHD medication use following exposure. Nonpsychotropic medications served as negative controls to determine if exposed children simply had higher overall medication use. RESULTS: Children with a single exposure to surgery and anesthesia were 37% more likely than unexposed children to persistently use ADHD medication (HR, 1.37; 95% confidence interval [CI], 1.30-1.44). The estimated HRs for common nonpsychotropic medication use following a single anesthetic exposure were 1.06 (95% CI, 1.04-1.07) for amoxicillin, 1.10 (95% CI, 1.08-1.12) for azithromycin, and 1.08 (95% CI, 1.05-1.11) for diphenhydramine. In comparison, the risk of using other psychotropic medication to treat conditions besides ADHD was also significantly higher, with HRs of 1.37 (95% CI, 1.24-1.51) for sedative/anxiolytics, 1.40 (95% CI, 1.25-1.58) for antidepressants, 1.31 (95% CI, 1.20-1.44) for antipsychotics, and 1.24 (95% CI, 1.10-1.40) for mood stabilizers. CONCLUSIONS: Medicaid-enrolled children receiving anesthesia for a single common pediatric surgical procedure under age 5 years were 37% more likely to require subsequent persistent use of ADHD medications than unexposed children. Because the increased use of ADHD medication is disproportionately higher than that of nonpsychotropic medications, unmeasured confounding may not account for all of the increase in ADHD medication use. By evaluating Medicaid data, this study assesses children who may be particularly vulnerable to neurotoxic exposures.

Relationship Between Continuity of Care and Discharge Planning After Hospital Psychiatric Admission.

OBJECTIVE: This study examined whether communication between inpatient and outpatient mental health providers during patients' inpatient stays was associated with whether patients attended postdischarge appointments. METHODS: Psychiatric inpatient medical records of 189 Medicaid recipients at two hospitals were reviewed to document whether inpatient staff had communicated with current or prior outpatient providers. Medicaid claims provided demographic, clinical, and outpatient attendance data. Associations between provider communications and follow-up care for patients who had or had not received outpatient mental health care within the 30 days prior to admission were evaluated. RESULTS: Inpatient staff communicated with outpatient providers for 118 (62%) patients. For patients who had not received outpatient care within 30 days of admission, compared with those who had, communication was associated with increased odds of attending timely outpatient appointments (odds ratio=2.73, 95% confidence interval=1.09-6.84). CONCLUSIONS: Communication with outpatient providers may be especially important for patients who were not engaged in outpatient care prior to admission.

Family Involvement in Psychiatric Hospitalizations: Associations With Discharge Planning and Prompt Follow-Up Care.

OBJECTIVE: Involving family in the care of inpatients with serious mental illness is known to be beneficial. This study examined frequencies of involvement by family in the care and discharge planning for 179 psychiatric inpatients. METHODS: Involvement by family in care and discharge planning was assessed from randomly selected medical records of inpatients with Medicaid and severe mental illness at two New York hospitals from 2012 to 2013. "Family" also included anyone close to the patient who provided support. Medicaid claims were reviewed for patient demographic and clinical characteristics and for postdischarge outpatient attendance data. Multiple regression models were used to test whether involvement by family was associated with comprehensive discharge planning (contacting outpatient providers, scheduling follow-up appointments, and forwarding a discharge summary to a provider) and initiation of outpatient treatment. RESULTS: Inpatient staff contacted a family member for 134 (75%) patients. Sixty-seven (37%) patients received comprehensive discharge planning, and 96 (53%) and 139 (78%) attended an outpatient appointment within 7 and 30 days of discharge, respectively. Inpatient staff contacting family, communicating about the patient's health and/or mental health, and communicating about the discharge plan were significantly associated with entry into follow-up care by 7 and 30 days postdischarge. Family phone calls and/or visits with patients, attendance at family therapy sessions, and communication with inpatient staff about services available to families were significantly associated with patients receiving comprehensive discharge planning. When analyses controlled for demographic and clinical factors, having any involvement between family members and inpatient staff was significantly associated with patients' attending an outpatient appointment by 7 days (odds ratio [OR]=2.79, 95% confidence interval [CI]=1.28-6.08) or 30 days (OR=3.07, 95% CI=1.29-7.32) after discharge. CONCLUSIONS: The association of family involvement with comprehensive discharge planning and prompt entry into outpatient care underscores the importance of family contact and communication with staff during inpatient hospitalizations.