Trends in Neonatal Opioid Withdrawal Syndrome and Opioid Exposure Diagnoses Among Infants With Private Health Insurance, 2016-2021: Introduction of the P04.14 ICD-10-CM Code.

OBJECTIVE: The opioid epidemic has led to a surge in diagnoses of neonatal opioid withdrawal syndrome (NOWS). Many states track the incidence of NOWS by using the P96.1 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code for "neonatal withdrawal symptoms from maternal use of drugs of addiction." In October 2018, an ICD-10-CM code for neonatal opioid exposure (P04.14) was introduced. This code can be used when an infant is exposed to opioids in utero but does not have clinically significant withdrawal symptoms. We analyzed the effect of the P04.14 code on the incidence rate of NOWS (P96.1) and "other" neonatal drug exposure diagnoses (P04.49). METHODS: We used private health insurance data collected for infants in the United States from the first quarter of 2016 through the third quarter of 2021 to describe incidence rates for each code over time and examine absolute and percentage changes before and after the introduction of code P04.14. RESULTS: The exclusive use of code P96.1 declined from an incidence rate per 1000 births of 1.08 in 2016-2018 to 0.70 in 2019-2021, a -35.7% (95% CI, -47.6% to -23.8%) reduction. Use of code P04.49 only declined from an incidence rate of 2.34 in 2016-2018 to 1.64 in 2019-2021, a -30.0% (95% CI, -36.4% to -23.7%) reduction. Use of multiple codes during the course of treatment increased from an average incidence per 1000 births of 0.56 in 2016-2018 to 0.79 in 2019-2021, a 45.5% (95% CI, 24.8%-66.1%) increase. CONCLUSION: The introduction of ICD-10-CM code P04.14 altered the use of other neonatal opioid exposure codes. The use of multiple codes increased, indicating that some ambiguity may exist about which ICD-10-CM code is most appropriate for a given set of symptoms.

Associations between outpatient treatment and the use of intensive psychiatric healthcare services.

The current manuscript examines concurrent and longitudinal associations between the utilization of outpatient and intensive psychiatric services among Medicaid-enrolled youth. Using an administrative dataset of Medicaid claims from 2007 to 2017, youth were included if they were between the ages of 10-18 (M = 13.4, SD = 2.6) and had a psychiatric Medicaid claim (N = 33,590). Psychiatric services were coded as outpatient, emergency department (ED), inpatient, or residential based on Medicaid codes. Logistic regression analyses indicated that the receipt of even one outpatient visit significantly reduced the odds of having an ED, inpatient, and residential visit within 60-, 90-, and 120-day windows. Survival analyses indicated most youth did not have any ED, inpatient, or residential visit following their first outpatient visit. For remaining youth, having an outpatient visit significantly increased the risk of having an ED, inpatient, and residential visit following their initial appointment, which may suggest these youth are being triaged to a more appropriate level of care. Classification accuracy analyses indicated a cutoff of 2 outpatient visits yielded maximum accuracy in determining youth with ED, inpatient, and residential visits. Findings highlight use of outpatient-level services in reducing risk of more intensive service utilization.

Examining Patterns of Psychotherapy Service Utilization Among Medicaid-Enrolled Adolescents.

OBJECTIVE: Adolescents with behavioral health disorders (i.e., mental health disorders and substance use) often experience frequent recurrence of symptoms, suggesting a need for an ongoing behavioral health intervention, rather than a single course of treatment. However, little is known about mental health care service use among adolescents over longer periods. The authors examined longitudinal patterns of outpatient behavioral health service utilization in a large sample of adolescents. METHODS: Medicaid claims for 8,197 adolescents (ages 10.0-13.9 years, mean±SD=11.5±1.2; 61% male) from one Indiana county between 2006 and 2017 were examined, with a focus on outpatient psychotherapy visits. Latent class analysis (LCA) was used to detect clusters of longitudinal patterns of outpatient psychotherapy visits across 5 years, beginning with an adolescent's first behavioral health visit. RESULTS: A five-class LCA model emerged with unique classes of service use based on duration and level of engagement (frequency) of monthly outpatient psychotherapy visits. Most adolescents fell in the nonuse class (38.7% of the sample). Additional classes were defined as late-onset low engagement (17.1%), early-onset high engagement (15.5%), early-onset moderate engagement (16.7%), and continuously high engagement (11.9%). Statistically significant differences were found across the classes in average duration and frequency of involvement (p<0.001), as well as in demographic characteristics (race, age, gender, and ethnicity) and behavioral health diagnoses (p<0.001). CONCLUSIONS: These findings confirm that adolescents with behavioral health diagnoses do not follow a uniform pattern of psychotherapy utilization. The distinct patterns of service use point toward the need to identify appropriate long-term service recommendations for adolescents.

Reciprocal innovation: A new approach to equitable and mutually beneficial global health partnerships.

Global health researchers often discount mutual learning and benefit to address shared health challenges across high and low- and middle-income settings. Drawing from a 30-year partnership called AMPATH that started between Indiana University in the US and Moi University in Kenya, we describe an innovative approach and program for mutual learning and benefit coined 'reciprocal innovation.' Reciprocal innovation harnesses a bidirectional, co-constituted, and iterative exchange of ideas, resources, and innovations to address shared health challenges across diverse global settings. The success of AMPATH in Kenya, particularly in HIV/AIDS and community health, resulted in several innovations being 'brought back' to the US. To promote the bidirectional flow of learning and innovations, the Indiana CTSI reciprocal innovation program hosts annual meetings of multinational researchers and practitioners to identify shared health challenges, supports pilot grants for projects with reciprocal exchange and benefit, and produces educational and training materials for investigators. The transformative power of global health to address systemic health inequities embraces equitable and reciprocal partnerships with mutual benefit across countries and communities of academics, practitioners, and policymakers. Leveraging a long-standing partnership, the Indiana CTSI has built a reciprocal innovation program with promise to redefine global health for shared wellbeing at a global scale.

Evaluation of a Program to Reduce Infant Mortality Risk Factors in Central Indiana.

The purpose of the program WeCare was to provide a personalized approach to addressing the wide array of psycho-social-cultural-fiscal needs to reduce risk factors for infant mortality (IM) by supporting maternal and infant health through health coaching by community health workers (CHWs). A prospective cohort study of 1,513 women from highest risk ZIP codes for IM in central Indiana were followed over three years. The WeCare program focused on training and deploying CHWs to provide evidence-based, patient-centered social care and support to pregnant and postpartum women and tracked outcomes in health risk categories (mental health, nutrition, safe sleep, breastfeeding) targeted for behavioral change. The low birth weight rate among program participants was lower (8.9%) than Marion County's rate (10%) (p=0.23) with statistically significant improvement in many risk behaviors. Despite limitations, the personalized coaching provided by the CHWs provided an effective, practical approach to maternal and child health disparities.

Exposure to alcohol outlets, alcohol access, and alcohol consumption among adolescents.

BACKGROUND: Adolescents who live near more alcohol outlets tend to consume more alcohol, despite laws prohibiting alcohol purchases for people aged <21 years. We examined relationships between adolescents' exposure to alcohol outlets, the sources through which they access alcohol, and their alcohol consumption. METHODS: Participants for this longitudinal study (n = 168) were aged 15-18 years and were from 10 cities in the San Francisco Bay Area. We collected survey data to measure participant characteristics, followed by 1 month of GPS tracking to measure exposure to alcohol outlets (separated into exposures near home and away from home for bars, restaurants, and off-premise outlets). A follow-up survey approximately 1 year later measured alcohol access (through outlets, family members, peers aged <21 years, peers aged ≥21 years) and alcohol consumption (e.g. count of drinking days in last 30). Generalized structural equation models related exposure to alcohol outlets, alcohol access, and alcohol consumption. RESULTS: Exposure to bars and off-premise outlets near home was positively associated with accessing alcohol from peers aged <21, and in turn, accessing alcohol from peers aged <21 was positively associated with alcohol consumption. There was no direct association between exposure to alcohol outlets near home or away from home and alcohol consumption. CONCLUSIONS: Interventions that reduce adolescents' access through peers aged <21 may reduce adolescents' alcohol consumption.

Assessment of the Effects of Pediatric Attention Deficit Hyperactivity Disorder on Family Stress and Well-Being: Development of the IMPACT 1.0 Scale.

Medications may lessen core symptoms of attention deficit hyperactivity disorder (ADHD), yet families continue to report stress and have a low quality of life. Primary care providers manage almost half of all children with ADHD but do not have a brief measure to assess ADHD impacts on family in the context of everyday family life. The IMPACT (Impact Measure of Parenting-Related ADHD Challenges and Treatment) 1.0 Scale was codeveloped with input from parent advisors and administered to 79 parents of children with ADHD. Exploratory factor analysis, correlations with validated instruments, and test-retest reliability were examined. Exploratory factor analysis resulted in 4 subscales (Misbehavior, Siblings, Time, School), which demonstrated moderate to high test-retest reliability. Scale domains were related to severity and change in ADHD symptoms. Significant correlations were found between IMPACT scores, adaptive functioning in the home, and ADHD-related quality of life. The IMPACT 1.0 Scale provides a novel, reliable, and valid method to assess family impact of ADHD.

Impact of socioeconomic markers on parents' retention of pediatric oncology home care education: A pilot study.

Little is known about the extent to which parents retain the education on how to manage home medical emergencies. We sought to describe retention of pediatric oncology home care education (POHCE) in a cohort of 24 parents of newly diagnosed children with cancer and investigate sociodemographic disparities in this retention. We measured retention using a vignette-based survey instrument. The mean score was 4 (range 0-6, SD = 1.6) and parents with high school only education and those with limited cancer health literacy scored lowest (2.5 and 2.8, respectively). Future POHCE interventions can focus on parents' literacy and education levels as predictors to tailor alternative education strategies.

Medicaid Coverage and Continuity for Juvenile Justice-Involved Youth.

This study examined Medicaid coverage and continuity for youth with varying levels of justice system involvement and the impact of a policy change allowing Medicaid suspension, rather than termination. Data for this study were collected using a retrospective cohort design using arrest records and Medicaid enrollment tables for 20,688 youth. Age, gender, race/ethnicity, and deepest level of justice system involvement all were associated with time to de-enrollment from Medicaid. Suspension was associated with a small improvement in Medicaid continuity for justice-involved youth. In addition, youth with deeper levels of justice system involvement had faster time to de-enrollment. This study highlights the importance of maximizing opportunities to keep youth enrolled, as gaps in coverage will likely affect juveniles' access to physical, mental, and behavioral health care.

Adolescent Burmese Refugees Perspectives on Determinants of Health.

Over 70,000 Burmese refugees have resettled in the United States in the past decade. While Burmese adolescents quickly acculturate into American society, their perspectives on health are not well-known. The purpose of this study was to identify adolescent Burmese refugee perspectives on determinants of health and health-related experiences after resettlement. In this qualitative study, Burmese adolescents took photographs depicting health-related experiences that were used as elicitation tools during focus groups. These discussions were recorded, transcribed, and analyzed for themes. Participants described positive determinants of health, including family and church. Rampant tobacco use was identified by the participants as a determinant of poor health within the Burmese community. Notably, the participants were proud to serve as liaisons within their community, despite the stressful nature of this role. Our results highlight the need to screen this population for anxiety, secondary to serving as a liaison for their community, as well as tobacco use.

Preventive Care Use Among Justice-Involved and Non-Justice-Involved Youth.

BACKGROUND AND OBJECTIVES: Youth involved in the juvenile justice system (ie, arrested youth) are at risk for health problems. Although increasing preventive care use by justice-involved youth (JIY) is 1 approach to improving their well-being, little is known about their access to and use of care. The objective of this study was to determine how rates of well-child (WC) and emergency department visits, as well as public insurance enrollment continuity, differed between youth involved in the justice system and youth who have never been in the system. We hypothesized that JIY would exhibit less frequent WC and more frequent emergency service use than non-justice-involved youth (NJIY). METHODS: This was a retrospective cohort study of administrative medical and criminal records of all youth (ages 12-18) enrolled in Medicaid in Marion County, Indiana, between January 1, 2004, and December 31, 2011. RESULTS: The sample included 88 647 youth; 20 668 (23%) were involved in the justice system. JIY had lower use rates of WC visits and higher use rates of emergency services in comparison with NJIY. JIY had more and longer gaps in Medicaid coverage compared with NJIY. For all youth sampled, both preventive and emergency services use varied significantly by Medicaid enrollment continuity. CONCLUSIONS: JIY experience more and longer gaps in Medicaid coverage, and rely more on emergency services than NJIY. Medicaid enrollment continuity was associated with differences in WC and emergency service use among JIY, with policy implications for improving preventive care for these vulnerable youth.

Mortality of Youth Offenders Along a Continuum of Justice System Involvement.

INTRODUCTION: Black male youth are at high risk of homicide and criminal justice involvement. This study aimed to determine how early mortality among youth offenders varies based on race; gender; and the continuum of justice system involvement: arrest, detention, incarceration, and transfer to adult courts. METHODS: Criminal and death records of 49,479 youth offenders (ages 10-18 years at first arrest) in Marion County, Indiana, from January 1, 1999, to December 31, 2011, were examined. Statistical analyses were completed in November 2014. RESULTS: From 1999 to 2011 (aggregate exposure, 386,709 person-years), 518 youth offender deaths occurred. The most common cause of death was homicide (48.2%). The mortality rate of youth offenders was nearly 1.5 times greater than that among community youth (standardized mortality ratio, 1.48). The youth offender mortality rate varied depending on the severity of justice system involvement. Arrested youth had the lowest rate of mortality (90/100,000), followed by detained youth (165/100,000); incarcerated youth (216/100,000); and youth transferred to adult court (313/100,000). A proportional hazards model demonstrated that older age, male gender, and more severe justice system involvement 5 years post-arrest predicted shorter time to mortality. CONCLUSIONS: Youth offenders face greater risk for early death than community youth. Among these, black male youth face higher risk of early mortality than their white male counterparts. However, regardless of race/ethnicity, mortality rates for youth offenders increase as youth involvement in the justice system becomes more protracted and severe. Thus, justice system involvement is a significant factor to target for intervention.

Psychiatric medication refill practices of juvenile detainees.

To examine the psychiatric medication fill rates of adolescents after release from juvenile detention. The team reviewed 177 charts. A fill was defined as a psychiatric medication charge to Medicaid 30- or 90-days after release. Differences in demographic characteristics were compared among individuals with fills at 30- or 90-days and those with no medication fills. Forty-five percent of patients were on at least one psychiatric medication. Among detainees on a psychiatric medication, 62 % had a fill by 30 days after release, and 78 % by 90 days. At least 50 % of the adolescents on a psychiatric medication were on an atypical antipsychotic. There was no significant relationship between medication fill and race, age, or sex. Despite the known associations between mental health diagnosis and treatment-seeking with age, sex, and race, it appears that psychiatric medication fill patterns after release from detention are not associated with these factors.

Incorporating geospatial capacity within clinical data systems to address social determinants of health.

Linking electronic health record (EHR) systems with community information systems (CIS) holds great promise for addressing inequities in social determinants of health (SDH). While EHRs are rich in location-specific data that allow us to uncover geographic inequities in health outcomes, CIS are rich in data that allow us to describe community-level characteristics relating to health. When meaningfully integrated, these data systems enable clinicians, researchers, and public health professionals to actively address the social etiologies of health disparities.This article describes a process for exploring SDH by geocoding and integrating EHR data with a comprehensive CIS covering a large metropolitan area. Because the systems were initially designed for different purposes and had different teams of experts involved in their development, integrating them presents challenges that require multidisciplinary expertise in informatics, geography, public health, and medicine. We identify these challenges and the means of addressing them and discuss the significance of the project as a model for similar projects.

Chlamydia screening among young women: individual- and provider-level differences in testing.

OBJECTIVE: We assessed differences in chlamydia screening rates according to race/ethnicity, insurance status, age, and previous sexually transmitted infection (STI) or pregnancy. METHODS: A retrospective cohort study was performed using electronic medical record and billing data for women 14 to 25 years of age in 2002-2007, assessing differences in the odds of a chlamydia test being performed at that visit. RESULTS: Adjusted odds of a chlamydia test being performed were lower among women 14 to 15 years of age (odds ratio: 0.83 [95% confidence interval: 0.70-1.00]) and 20 to 25 years of age (20-21 years, odds ratio: 0.78 [95% confidence interval: 0.70-0.89]; 22-23 years, odds ratio: 0.76 [95% confidence interval: 0.67-0.87]; 24-25 years, odds ratio: 0.64 [95% confidence interval: 0.57-0.73]), compared with women 18 to 19 years of age. Black women had 3 times increased odds (odds ratio: 2.96 [95% confidence interval: 2.66-3.28]) and Hispanic women nearly 13 times increased odds (odds ratio: 12.89 [95% confidence interval: 10.85-15.30]) of testing, compared with white women. Women with public (odds ratio: 1.74 [95% confidence interval: 1.58-1.91]) and public pending (odds ratio: 6.85 [95% confidence interval: 5.13-9.15]) insurance had increased odds of testing, compared with women with private insurance. After first STI diagnosis, differences according to race/ethnicity persisted but were smaller; after first pregnancy, differences persisted. CONCLUSIONS: Despite recommendations to screen all sexually active young women for chlamydia, providers screened women differently according to age, race/ethnicity, and insurance status, although differences were reduced after first STI or pregnancy.

Mental health screening and STI among detained youth.

Our objective was to understand the relationship between mental health screening results, health disparity, and STI risk among detained adolescents. In this 24-month cross-sectional study of 1,181 detainees (age 13-18 years), we examined associations between race, gender, mental health screening results (as measured by the Massachusetts Youth Screening Instrument-2nd Edition) and sexually transmitted infection rates (STI; chlamydia, gonorrhea, and trichomonas). Consistent with previous research, females and black youth were disproportionately affected by STI. Race and gender differences were also noted in mental health screening. The odds of having an STI increased by 23% (OR = 1.23, 95% CI = 1.06, 1.37) with each one-unit increase in the alcohol/drug subscale score for females. Gender-specific STI interventions for detained youth are warranted. For young women with substance abuse, specific interventions are necessary and may help reduce health disparity in this vulnerable population.

Cigarette tax increase and media campaign cost of reducing smoking-related deaths.

BACKGROUND: Tobacco use results in 500,000 premature deaths annually. Most smokers begin using tobacco before age 21, so the greatest impact on preventing smoking-related mortality is likely to come from campaigns targeting youths. This study estimates the cost-effectiveness of an anti-smoking media campaign and dollar 1 per pack increase in cigarette taxes on the lifetime decrease in smoking-attributable mortality among the cohort of all 18-year-olds in the United States during the year 2000. METHODS: Cost-effectiveness analysis conducted from a societal perspective. RESULTS: The combined effects of a media campaign and dollar 1 per pack tax increase will result in a societal savings of between dollar 590,000 per life-year saved, at a 3% discount rate and dollar 1.4 million per life year saved, at a 7% discount rate. CONCLUSIONS: A media campaign and $1 per pack cigarette tax increase will reduce overall smoking prevalence, significantly decrease smoking-attributable mortality, and decrease net societal costs.