RESUMO
Importance: Mortality rates in US youth have increased in recent years. An understanding of the role of racial and ethnic disparities in these increases is lacking. Objective: To compare all-cause and cause-specific mortality trends and rates among youth with Hispanic ethnicity and non-Hispanic American Indian or Alaska Native, Asian or Pacific Islander, Black, and White race. Design, Setting, and Participants: This cross-sectional study conducted temporal analysis (1999-2020) and comparison of aggregate mortality rates (2016-2020) for youth aged 1 to 19 years using US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Data were analyzed from June 30, 2023, to January 17, 2024. Main Outcomes and Measures: Pooled, all-cause, and cause-specific mortality rates per 100â¯000 youth (hereinafter, per 100â¯000) for leading underlying causes of death were compared. Injuries were classified by mechanism and intent. Results: Between 1999 and 2020, there were 491â¯680 deaths among US youth, including 8894 (1.8%) American Indian or Alaska Native, 14â¯507 (3.0%) Asian or Pacific Islander, 110â¯154 (22.4%) Black, 89â¯251 (18.2%) Hispanic, and 267â¯452 (54.4%) White youth. Between 2016 and 2020, pooled all-cause mortality rates were 48.79 per 100â¯000 (95% CI, 46.58-51.00) in American Indian or Alaska Native youth, 15.25 per 100â¯000 (95% CI, 14.75-15.76) in Asian or Pacific Islander youth, 42.33 per 100â¯000 (95% CI, 41.81-42.86) in Black youth, 21.48 per 100â¯000 (95% CI, 21.19-21.77) in Hispanic youth, and 24.07 per 100â¯000 (95% CI, 23.86-24.28) in White youth. All-cause mortality ratios compared with White youth were 2.03 (95% CI, 1.93-2.12) among American Indian or Alaska Native youth, 0.63 (95% CI, 0.61-0.66) among Asian or Pacific Islander youth, 1.76 (95% CI, 1.73-1.79) among Black youth, and 0.89 (95% CI, 0.88-0.91) among Hispanic youth. From 2016 to 2020, the homicide rate in Black youth was 12.81 (95% CI, 12.52-13.10) per 100â¯000, which was 10.20 (95% CI, 9.75-10.66) times that of White youth. The suicide rate for American Indian or Alaska Native youth was 11.37 (95% CI, 10.30-12.43) per 100â¯000, which was 2.60 (95% CI, 2.35-2.86) times that of White youth. The firearm mortality rate for Black youth was 12.88 (95% CI, 12.59-13.17) per 100â¯000, which was 4.14 (95% CI, 4.00-4.28) times that of White youth. American Indian or Alaska Native youth had a firearm mortality rate of 6.67 (95% CI, 5.85-7.49) per 100â¯000, which was 2.14 (95% CI, 1.88- 2.43) times that of White youth. Black youth had an asthma mortality rate of 1.10 (95% CI, 1.01-1.18) per 100â¯000, which was 7.80 (95% CI, 6.78-8.99) times that of White youth. Conclusions and Relevance: In this study, racial and ethnic disparities were observed for almost all leading causes of injury and disease that were associated with recent increases in youth mortality rates. Addressing the increasing disparities affecting American Indian or Alaska Native and Black youth will require efforts to prevent homicide and suicide, especially those events involving firearms.
Assuntos
Asma , Disparidades nos Níveis de Saúde , Mortalidade , Transtornos Relacionados ao Uso de Substâncias , Suicídio , Ferimentos e Lesões , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Adulto Jovem , Causas de Morte/tendências , Estudos Transversais , Etnicidade/estatística & dados numéricos , Mortalidade/etnologia , Mortalidade/tendências , Suicídio/etnologia , Suicídio/estatística & dados numéricos , Estados Unidos/epidemiologia , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/etnologia , Ferimentos e Lesões/mortalidade , Grupos Raciais/etnologia , Grupos Raciais/estatística & dados numéricos , Indígena Americano ou Nativo do Alasca/estatística & dados numéricos , Brancos/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricos , Nativo Asiático-Americano do Havaí e das Ilhas do Pacífico/estatística & dados numéricos , Asma/epidemiologia , Asma/etnologia , Asma/mortalidade , Homicídio/etnologia , Homicídio/estatística & dados numéricos , Armas de Fogo/estatística & dados numéricos , Ferimentos por Arma de Fogo/epidemiologia , Ferimentos por Arma de Fogo/etnologia , Ferimentos por Arma de Fogo/mortalidade , Acidentes de Trânsito/mortalidade , Acidentes de Trânsito/estatística & dados numéricos , Acidentes de Trânsito/tendências , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/etnologia , Transtornos Relacionados ao Uso de Substâncias/mortalidadeRESUMO
PURPOSE: Women and children continue to miss preventive visits. Which neighborhood factors predict inadequate prenatal care (PNC) and well-child visit (WCV) attendance remain unclear. DESCRIPTION: In a retrospective case-control study at Virginia Commonwealth University Health System, mothers with less than 50% adherence or initiation after 5 months gestation were eligible as cases and those with ≥ 80% adherence and initiation before 5 months were eligible as controls. Children in the lowest quintile of adherence were eligible as cases and those with ≥ 80% of adherence were eligible as controls. Cases and controls were randomly selected at a 1:2 ratio and matched on birth month. Covariates were derived from the 2018 American Community Survey. A hotspot was defined as a zip code tabulation area (ZCTA) with a proportion of controls less than 0.66. ZCTAs with fewer than 5 individuals were excluded. Weighted quantile regression was used to determine which covariates were most associated with inadequate attendance. ASSESSMENT: We identified 38 and 35 ZCTAs for the PNC and WCV analyses, respectively. Five of 11 hotspots for WCV were also hotspots for PNC. Education and income predicted 51% and 34% of the variation in missed PNCs, respectively; language, education and transportation difficulties explained 33%, 29%, and 17% of the variation in missed WCVs, respectively. Higher proportions of Black residents lived in hotspots of inadequate PCV and WCV attendance. CONCLUSION: Neighborhood-level factors performed well in predicting inadequate PCV and WCV attendance. The disproportionate impact impact of inadequate PCV and WCV in neighborhoods where higher proportions of Black people lived highlights the potential influence of systemic racism and segregation on healthcare utilization.
Assuntos
Cuidado Pré-Natal , Características de Residência , Humanos , Gravidez , Feminino , Estudos Retrospectivos , Estudos de Casos e Controles , RendaRESUMO
BACKGROUND: Developmental disabilities (DD) affect over 10% of children 0 to 5 years of age, and early interventions are known to improve outcomes, yet barriers remain in connecting children to these services. OBJECTIVE: To identify gaps in services for young children with DD and established risk conditions in Virginia. METHODS: Data from the 2018 Virginia All Payers Claim Database and the American Community Survey were used to estimate the proportion of children with DD, and among those children, the proportion that received at least one intervention service. Logistic and binomial regression models were used to examine the socio-demographic associations with having developmental needs met, at the individual and zip code tabulation (ZCTA) level. RESULTS: Approximately 12% of children 0 to 5 years were found to have DD or established risk condition diagnosis, and only 54% of these received intervention services during that year. Individual-level analyses suggest that odds of having developmental needs met are higher among older children, boys, and children with public insurance. ZCTA-level analyses suggested higher odds of developmental needs being met in areas with higher levels of unemployment, while areas with high proportions of people with limited English proficiency and a high school education or less had lower odds of having needs met. CONCLUSIONS: Receiving early childhood developmental services in Virginia is associated with having public insurance and living in an area with higher levels of unemployment, higher education, and English-proficiency. Efforts are needed to improve delivery of services overall, specifically targeted to those areas with high levels of unmet need.
Assuntos
Deficiências do Desenvolvimento , Intervenção Educacional Precoce , Criança , Masculino , Humanos , Pré-Escolar , Adolescente , Virginia , Necessidades e Demandas de Serviços de SaúdeRESUMO
PURPOSE: Primary care is the foundation of the health care workforce and the only part that extends life and improves health equity. Previous research on the geographic and specialty distribution of physicians has relied on the American Medical Association's Masterfile, but these data have limitations that overestimate the workforce. METHODS: We present a pragmatic, systematic, and more accurate method for identifying primary care physicians using the National Plan and Provider Enumeration System (NPPES) and the Virginia All-Payer Claims Database (VA-APCD). Between 2015 and 2019, we identified all Virginia physicians and their specialty through the NPPES. Active physicians were defined by at least 1 claim in the VA-APCD. Specialty was determined hierarchically by the NPPES. Wellness visits were used to identify non-family medicine physicians who were providing primary care. RESULTS: In 2019, there were 20,976 active physicians in Virginia, of whom 5,899 (28.1%) were classified as providing primary care. Of this primary care physician workforce, 52.4% were family medicine physicians; the remaining were internal medicine physicians (18.5%), pediatricians (16.8%), obstetricians and gynecologists (11.8%), and other specialists (0.5%). Over 5 years, the counts and relative percentages of the workforce made up by primary care physicians remained relatively stable. CONCLUSIONS: Our novel method of identifying active physicians with a primary care scope provides a realistic size of the primary care workforce in Virginia, smaller than some previous estimates. Although the method should be expanded to include advanced practice clinicians and to further delineate the scope of practice, this simple approach can be used by policy makers, payers, and planners to ensure adequate primary care capacity.
Assuntos
Medicina , Especialização , Humanos , Atenção Primária à Saúde , Estados Unidos , Virginia , Recursos HumanosRESUMO
BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends against the routine use of ß-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services. METHODS: Using the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse. RESULTS: Fifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% ß-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15-1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15-1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11-1.29; P < .0001). CONCLUSIONS: Overuse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.
Assuntos
Bronquiolite/tratamento farmacológico , Uso Excessivo dos Serviços de Saúde/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Uso Excessivo de Medicamentos Prescritos/estatística & dados numéricos , Radiografia Torácica/estatística & dados numéricos , Corticosteroides/uso terapêutico , Agonistas Adrenérgicos beta/uso terapêutico , Antibacterianos/uso terapêutico , Bronquiolite/diagnóstico por imagem , Estudos Transversais , Serviços Médicos de Emergência , Feminino , Fidelidade a Diretrizes , Humanos , Lactente , Recém-Nascido , Seguro Saúde , Masculino , Distribuição de Poisson , Estudos Retrospectivos , VirginiaRESUMO
PURPOSE: Despite the benefits of well-child care visits, up to one-half of these visits are missed. Little is known about why children miss them, so we undertook a qualitative study to elucidate these factors. METHODS: We interviewed 17 caregivers whose children had missed well-child visits and 6 clinicians, focusing on 3 areas: the value of well-child visits, barriers to attendance, and facilitators of attendance. Transcripts were analyzed with a grounded theory approach and thematic analysis. RESULTS: Caregivers and clinicians identified similar important aspects of well-child visits: immunizations, detection of disease, and monitoring of growth and development. Both groups identified similar barriers to attendance: transportation, difficulty taking time off from work, child care, and other social stressors. CONCLUSIONS: Further work to explore how addressing social determinants of health might improve attendance of well-child visits is needed.
Assuntos
Atitude do Pessoal de Saúde , Cuidadores/psicologia , Saúde da Criança , Visita a Consultório Médico , Criança , Feminino , Humanos , Masculino , Exame Físico , Serviços Preventivos de Saúde , Relações Profissional-Família , Pesquisa Qualitativa , Determinantes Sociais da SaúdeRESUMO
BACKGROUND: Adult opioid use and neonatal abstinence syndrome (NAS) are growing public health problems in the United States (U.S.). Our objective was to determine how opioid use disorder treatment access impacts the relationship between adult opioid use and NAS. METHODS: We conducted a cross-sectional state-level ecologic study using 36 states with available Healthcare Cost and Utilization Project State Inpatient Databases in 2014. Opioid use disorder treatment access was determined by the: 1) proportion of people needing but not receiving substance use treatment, 2) density of buprenorphine-waivered physicians, and 3) proportion of individuals in outpatient treatment programs (OTPs). The incidence of NAS was defined as ICD-9 code 779.5 (drug withdrawal syndrome in newborn) from any discharge diagnosis field per 1000 live births in that state. RESULTS: Unmet need for substance use disorder treatment correlated with NAS (r = 0.54, 95% CI: 0.26-0.73). The correlation between adult illicit drug use/dependence and NAS was higher in states with a lower density of buprenorphine-waivered physicians and individuals in OTPs. CONCLUSIONS: Measures of opioid use disorder treatment access dampened the correlation between illicit drug use/dependence and NAS. Future studies using community- or individual-level data may be better poised to answer the question of whether or not opioid use disorder treatment access improves NAS relative to adult opioid use.
Assuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Síndrome de Abstinência Neonatal/epidemiologia , Transtornos Relacionados ao Uso de Opioides/terapia , Complicações na Gravidez/terapia , Buprenorfina/uso terapêutico , Correlação de Dados , Estudos Transversais , Feminino , Humanos , Recém-Nascido , Síndrome de Abstinência Neonatal/prevenção & controle , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Gravidez , Complicações na Gravidez/tratamento farmacológico , Estados Unidos/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVES: It is unclear which specific well-child visits (WCVs) are most frequently missed and whether age-specific patterns of attendance differ by race or insurance type. METHODS: We conducted a retrospective cohort study of children 0 to 6 years old between 2011 and 2016 within 2 health networks spanning 20 states. WCVs were identified by using International Classification of Diseases, Ninth and 10th Revisions and Current Procedural Terminology codes. We calculated adherence to the 13 American Academy of Pediatrics-recommended WCVs from birth to age 6 years. To address data completeness, we made 2 adherence calculations after a child's last recorded WCV: 1 in which we assumed all subsequent WCVs were attended outside the network and 1 in which we assumed none were. RESULTS: We included 152 418 children in our analysis. Most children were either publicly insured (77%) or uninsured (14%). The 2-, 4-, and 6-month visits were the most frequently attended (63% [assuming no outside care after the last recorded WCV] to 90% [assuming outside care]), whereas the 15- and 18-months visits (41%-75%) and 4-year visit (19%-49%) were the least frequently attended. Patients who were publicly insured and uninsured (versus privately insured) had higher odds of missing WCVs. Hispanic and Asian American (versus non-Hispanic white) patients had higher odds of attending WCVs. DISCUSSION: The 15- and 18-month WCVs as well as the 4-year WCV are the least frequently attended WCVs. The former represent opportunities to identify developmental delays, and the latter represents an opportunity to assess school readiness.