Racial and Ethnic Disparities in Kidney Replacement Therapies Among Adults With Kidney Failure: An Observational Study of Variation by Patient Age.

RATIONALE & OBJECTIVE: Non-Hispanic Black and Hispanic patients present with kidney failure at younger ages than White patients. Younger patients are also more likely to receive transplants and home dialysis than in-center hemodialysis (ICHD), but it is unknown whether racial and ethnic disparities in treatment differ by age. We compared use of kidney replacement therapies between racial and ethnic groups among patients with incident kidney failure overall and by age. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 830,402 US adult (age >21 years) patients initiating kidney failure treatment during the period of 2011-2018. EXPOSURES: Patient race and ethnicity (non-Hispanic Black, non-Hispanic White, Hispanic, or other) and age group (22-44, 45-64, 65-74, or 75-99 years). OUTCOME: Treatment modality (transplant, peritoneal dialysis [PD], home hemodialysis [HHD], or ICHD) as of day 90 of treatment. ANALYTICAL APPROACH: Differences in treatment modalities were quantified for patient subgroups defined by race and ethnicity and by age. Log-binomial regression models were fit to estimate adjusted risk ratios. RESULTS: 81% of patients were treated with ICHD, 3.0% underwent transplants (85% preemptive, 57% living-donor), 10.5% were treated with PD, and 0.7% were treated with HHD. Absolute disparities in treatment were most pronounced among patients aged 22-44 years. Compared with non-Hispanic White patients, whose percentages of treatment with transplant, PD, and HHD were 10.9%, 19.0%, and 1.2%, respectively, non-Hispanic Black patients were less commonly treated with each modality (unadjusted percentages, 1.8%, 13.8%, and 0.6%, respectively), as were Hispanic patients (4.4%, 16.9%, and 0.5%, respectively; all differences P < 0.001). After adjustment, the largest relative disparities were observed for transplant among the 22-44-year age group; compared with non-Hispanic White patients, the adjusted risk ratios for non-Hispanic Black and Hispanic patients were 0.21 (95% CI, 0.19-0.23) and 0.47 (95% CI, 0.43, 0.51), respectively. LIMITATIONS: Race and ethnicity data not self-reported. CONCLUSIONS: Among adults with incident kidney failure, racial and ethnic disparities in transplant and home dialysis use are most pronounced among the youngest adult patient age group.

Substance use, substance use disorders, and treatment in adolescent and young adult cancer survivors-Results from a national survey.

BACKGROUND: Substance use can exacerbate cancer-related morbidity and mortality in adolescent/young adult (AYA) cancer survivors and place them at increased risk for adverse health outcomes. The objective of this study was to assess substance use, misuse, and substance use disorders [SUDs], as well as receipt of treatment for SUDs, among AYA cancer survivors. METHODS: The authors used data from the National Survey of Drug Use and Health (2015-2018) to identify a nationally representative sample of AYAs aged 12 to 34 years. Outcomes assessed past-year tobacco, alcohol, marijuana, and illicit drug use; misuse of prescription opioids; SUDs; and SUD treatment. Multiple logistic regression was estimated to compare outcomes between 832 AYAs who reported a cancer history (survivors) and 140,826 AYAs who did not, adjusting sequentially for sociodemographic characteristics and health status. RESULTS: In regressions adjusting for sociodemographic characteristics, survivors were more likely than a noncancer comparison group of peers to use alcohol (6% relative increase; P = .048) and illicit drugs (34% relative increase; P = .012), to misuse prescription opioids (59% relative increase; P < .001), and to have a marijuana (67% relative increase; P = .011), illicit drug (77% relative increase; P < .001), or prescription opioid (67% relative increase; P = .048) SUD. When further adjusting for health status, survivors were still 41% more likely (P < .001) to misuse prescription opioids than noncancer peers. Among those with SUDs, survivors were more likely than peers to receive treatment (unadjusted, 21.5% vs 8.0%; adjusted, P < .05). CONCLUSIONS: AYA survivors were as likely as or more likely than noncancer peers to report substance use problems. These findings underscore the importance of interventions to reduce substance use and improve SUD treatment among AYA cancer survivors. LAY SUMMARY: The authors assessed substance use, misuse, and substance use disorders, as well as the receipt of treatment for substance use disorders, among adolescent and young adult (AYA) cancer survivors. In a nationally representative AYA sample, cancer survivors, despite their increased risk for morbidity and early mortality, were as likely as or more likely than peers without cancer to experience substance use problems. In particular, survivors had a significantly higher rate of prescription opioid misuse than peers. However, only 1 in 5 AYA survivors who experienced substance use disorders received treatment. These findings underscore the importance of interventions toward reducing substance use and improving access to treatment among AYA survivors.

National estimates of mental health service use and unmet needs among adult cancer survivors.

BACKGROUND: Cancer survivors are at elevated risk for developing mental health (MH) disorders. This study assessed MH service use and unmet service needs among a nationally representative sample of cancer survivors. METHODS: Respondents aged 18 to 64 years were identified from the 2015-2018 National Survey of Drug Use and Health data. Outcomes assessed past-year MH service use and self-reported unmet MH needs. Outcomes were compared between respondents who reported a cancer history (survivors) and those who did not (controls), descriptively and in adjusted analyses controlling for sociodemographic factors and health status. Analyses were stratified by age groups (18-34, 35-49, and 50-64 years). RESULTS: Comparing 3540 survivors with 149,843 controls, within each age group, a higher proportion of survivors than controls received any MH service (P values < .05); this difference persisted among those aged 35 to 49 years (P = .004) in fully adjusted models. Moreover, a higher proportion of survivors than controls reported an unmet need for MH care; this difference was larger among young adults aged 18 to 34 years (20.8% vs 9.0%; P < .001) than those aged 35 to 49 years (9.4% vs 5.3%; P < .001) and 50 to 64 years (4.8% vs 3.4%; P = .029). In fully adjusted models, the survivor-control difference in self-reported unmet MH needs persisted among young adults (24% relative increase; P = .023). Among cancer survivors, young adult survivors had the highest likelihood of reporting unmet MH needs. CONCLUSIONS: This nationally representative study found an increased perception of unmet needs for MH care among cancer survivors, particularly among young adult survivors, compared with the general population without cancer.

Mental health among nonelderly adult cancer survivors: A national estimate.

BACKGROUND: This study assessed mental health (MH) outcomes across age groups in a nationally representative US sample of adult cancer survivors. METHODS: The 2015 to 2017 National Survey on Drug Use and Health was used to identify respondents aged 18 to 64 years. The authors compared MH outcomes between respondents with a cancer history and respondents without a cancer history in adjusted analyses controlling for demographics and socioeconomic status. Outcomes included past-year major depressive episodes, serious psychological distress, suicidal thoughts, suicidal plans, suicidal attempts, any mental illness, and serious mental illness. All analyses were stratified by age group (18-34, 35-49, or 50-64 years). RESULTS: In a comparison of 2656 survivors and 112,952 individuals without cancer, within each age group, survivors had an elevated prevalence of MH problems in 5 of the 7 outcome measures. Among young adults (aged 18-34 years), survivors were more likely than noncancer counterparts to experience major depressive episodes (18.1% vs 9.6%), serious psychological distress (34.2% vs 17.9%), suicidal thoughts (10.5% vs 7.0%), any mental illness (41.1% vs 23.3%), and serious mental illness (13.2% vs 5.9%) in the past year (P values <.05). These differences persisted in adjusted analyses (P values <.01). Similar survivor-comparison differences were observed among older groups but with a smaller magnitude. Among survivors, young adult survivors had the highest likelihood of experiencing MH problems across all outcomes (P values <.05). CONCLUSIONS: This population-based study shows an elevated prevalence of MH problems among adult cancer survivors in comparison with the general population. This finding highlights the importance of developing strategies to ensure the early detection of mental illness and to improve access to MH treatment for cancer survivors.

Effect of Medicaid Disenrollment on Health Care Utilization Among Adults With Mental Health Disorders.

BACKGROUND: Medicaid is an important source of insurance coverage for those with mental health (MH) disorders in the United States. Although disruptions in Medicaid coverage are common, little is known about the dynamic relationship between Medicaid disenrollment and MH care utilization. OBJECTIVE: We estimated changes in all-cause and MH-related health care use post Medicaid disenrollment among a nationwide cohort of adults with MH disorders. SUBJECTS: We identified 8841 persons (197,630 person-months) ages 18-64 with MH disorders and Medicaid coverage from Panels 4 to 19 Medical Expenditure Panel Survey. METHODS: Using a quasi-experimental design and propensity weighting, we estimated logit models examining changes in service utilization per-person-per-month. We used a "post" indicator to estimate average differences in service use postdisenrollment (vs. those with continuous Medicaid coverage) and a count variable measuring total months since coverage loss to estimate changes over time. OUTCOME MEASURES: All-cause outpatient visits, MH-related outpatient visits, and acute care visits. RESULTS: Becoming uninsured after Medicaid disenrollment was associated with average reductions of 52% [-14.75 percentage-points, 95% confidence interval (CI): -17.59, -11.91] in the likelihood of receiving any outpatient service, 35% (-2.23 percentage-points, 95% CI: -3.71, -0.75) in the likelihood of receiving any MH-related outpatient service, and 52% (-2.44 percentage-points; 95% CI: -3.35, -1.52) in the likelihood of receiving any acute service in a month. Health care use declined the most in the month immediately postdisenrollment, and declines continued over the next half-year (while uninsured). CONCLUSIONS: Insurance loss after disenrollment from Medicaid led to a persistent disruption in the receipt of health care services for beneficiaries with MH disorders.

Prior Authorization Policies and Preferred Drug Lists in Medicaid Plans: Stakeholder Perspectives on the Implications for Youth with ADHD.

This qualitative study describes how Medicaid policies create challenges for the delivery and receipt of mental health treatment for low-income youth in Georgia. We conducted focus groups with caregivers of Medicaid-enrolled children with ADHD and semi-structured interviews with providers and administrators at four safety net clinics that provided mental health care to these youth. Stakeholders reported that prior authorization policies for psychosocial services, restrictiveness of preferred drug lists, and changes in preferred drug lists in Medicaid plans created barriers to treatment continuity and quality for youth with ADHD and led to more administrative burden for safety-net clinics serving these youth.

Discontinuity of Medicaid Coverage: Impact on Cost and Utilization Among Adult Medicaid Beneficiaries With Major Depression.

BACKGROUND: Gaps in Medicaid coverage may disrupt access to and continuity of care. This can be detrimental for beneficiaries with chronic conditions, such as major depression, for whom disruptions in access to outpatient care may lead to increased use of acute care. However, little is known about how Medicaid coverage discontinuities impact acute care utilization among adults with depression. OBJECTIVE: Examine the relationship between Medicaid discontinuities and service utilization among adults with major depression. SUBJECTS: A total of 139,164 adults (18-64) with major depression was identified using the 2003-2004 Medicaid Analytic eXtract Files. METHODS: We used generalized linear and two-part models to examine the effect of Medicaid discontinuity on service utilization. To establish causality in this relationship, we used instrumental variables analysis, relying on exogenous variation in a state-level policy for identification. OUTCOME MEASURES: Emergency department (ED) visits, inpatient episodes, inpatient days, and Medicaid-reimbursed costs. RESULTS: Approximately 29.4% of beneficiaries experienced coverage disruptions. In instrumental variables models, those with coverage disruptions incurred an increase of $650 in acute care costs per-person per Medicaid-covered month compared with those with continuous coverage, evidenced by an increase in ED use (0.1 more ED visits per-person-month) and inpatient days (0.6 more days per-person-month). The increase in acute costs contributed to an overall increase in all-cause costs by $310 per-person-month (all P-values<0.001). CONCLUSIONS: Among depressed adults, those experiencing coverage disruptions have, on average, significantly greater use of costly ED/inpatient services than those with continuous coverage. Maintenance of continuous Medicaid coverage may help prevent acute episodes requiring high-cost interventions.

Emergency Department Use Among Hispanic Adults: The Role of Acculturation.

OBJECTIVES: We provide the first known examination of differences in nonurgent and urgent emergency department (ED) usage between Hispanic and non-Hispanic white individuals, with varying levels of acculturation. MATERIALS AND METHODS: We pooled cross-sectional data for Hispanic and non-Hispanic white adults (ages 18-64) from the 2011 to 2013 National Health Interview Surveys. Using logistic regression models, we examined differences in past-year ED use, urgent ED use, and nonurgent ED use by acculturation level, which we measure by combining information on respondents' citizenship status, birthplace, and length of stay (immigrants <5, 5-10, >10 y in the United States; naturalized citizens; US born). RESULTS: Overall, 17.8% of Hispanic individuals and 18.5% of non-Hispanic white individuals use the ED annually. Compared with US-born non-Hispanic white individuals, the least acculturated Hispanic individuals are 14.4% points (P<0.001) less likely to use the ED for any reason, 9.8% points (P<0.001) less likely to use it for a nonurgent reason, and 5.3% points (P<0.01) less likely to use it for an urgent reason. CONCLUSIONS: Contrary to popular perception, the least acculturated Hispanic individuals are the least likely to use the ED. As acculturation level rises, so does one's likelihood of using the ED, particularly for nonurgent visits.

Availability of Youth Services in U.S. Mental Health Treatment Facilities.

Despite concern about access to mental health (MH) services for youth, little is known about the specialty treatment infrastructure serving this population. We used national data to examine which types of MH treatment facilities (hospital- and community-based) were most likely to offer youth services and which types of communities were most likely to have this infrastructure. Larger (p < 0.001) and privately owned (p < 0.001) facilities were more likely to offer youth services. Rural counties, counties in which a majority of residents were nonwhite, and/or counties with a higher percentage of uninsured residents were less likely to have a community-based MH treatment facility that served youth (p < 0.001).

Contextual socioeconomic status and mental health counseling use among US adolescents with depression.

Most adolescents with depressive disorders do not receive any mental health services, even though effective treatments exist. Although research has examined numerous individual-level factors associated with mental health service use among depressed adolescents, less is known about the role of contextual factors. This study examines the relationship between contextual-level socioeconomic status (SES) and clinic-based mental health counseling use among US adolescents with high depressive symptoms in urban and suburban areas. Data from the first two waves of the National Longitudinal Study of Adolescent Health (N = 1,133; 59 % female) were analyzed using multilevel logistic models in which adolescents were nested within counties. After controlling for individual-level predisposing, enabling, and need characteristics, as well as county racial/ethnic composition, county SES was positively associated with clinic-based counseling use among depressed youth. A one standard deviation increase in the county affluence index was associated with 43 % greater odds of receiving any clinical counseling services. Furthermore, the positive relationship between county affluence and clinical counseling use was no longer significant after controlling for the county supply of mental health specialist physicians. The results indicate that county residential context is a key correlate of mental health service use among depressed adolescents, such that those who live in lower SES counties with fewer mental health specialists are less likely to receive treatment.

Correlates of mental health service use and type among Asian Americans.

This study uses data from the National Latino and Asian American Study to investigate correlates of mental health service use among Asian Americans with mental health needs. Our study contributes to the extant literature by: (1) differentiating between mental health service use types; and (2) examining a broader swatch of Asian Americans with mental health needs, ranging from mild to severe cases. Multinomial logistic regression analyses revealed heterogeneity in service use patterns by ethnicity, age, marital status, English proficiency, and generation status. Unmet mental health needs continue to be a problem despite treatments that could improve the quality of life of Asian Americans. Our study provides a more nuanced understanding of mental health service utilization patterns in this understudied population.

Association of Medicaid expansion with health insurance, unmet need for medical care and substance use disorder treatment among people who inject drugs in 13 US states.

BACKGROUND AND AIMS: Impoverished people who inject drugs (PWID) are at the epicenter of US drug-related epidemics. Medicaid expansion is designed to reduce cost-related barriers to care by expanding Medicaid coverage to all US adults living at or below 138% of the federal poverty line. This study aimed to measure whether Medicaid expansion is (1) positively associated with the probability that participants are currently insured; (2) inversely related to the probability of reporting unmet need for medical care due to cost in the past year; and (3) positively associated with the probability that they report receiving substance use disorder (SUD) treatment in the past year, among PWID subsisting at ≤ 138% of the federal poverty line. DESIGN: A two-way fixed-effects model was used to analyze serial cross-sectional observational data. SETTING: Seventeen metro areas in 13 US states took part in the study. PARTICIPANTS: Participants were PWID who took part in any of the three waves (2012, 2015, 2018) of data gathered in the Center for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS), were aged ≤ 64 years and had incomes ≤ 138% of the federal poverty line. For SUD treatment analyses, the sample was further limited to PWID who used drugs daily, a proxy for SUD. MEASUREMENTS: State-level Medicaid expansion was measured using Kaiser Family Foundation data. Individual-level self-report measures were drawn from the NHBS surveys (e.g. health insurance coverage, unmet need for medical care because of its cost, SUD treatment program participation). FINDINGS: The sample for the insurance and unmet need analyses consisted of 19 946 impoverished PWID across 13 US states and 3 years. Approximately two-thirds were unhoused in the past year; 41.6% reported annual household incomes < $5000. In multivariable models, expansion was associated with a 19.0 [95% confidence interval (CI) = 9.0, 30.0] percentage-point increase in the probability of insurance coverage, and a 9.0 (95% CI = -15.0, -0.2) percentage-point reduction in the probability of unmet need. Expansion was unrelated to SUD treatment among PWID who used daily (n = 17 584). CONCLUSIONS: US Medicaid expansion may curb drug-related epidemics among impoverished people who inject drugs by increasing health insurance coverage and reducing unmet need for care. Persisting non-financial barriers may undermine expansion's impact upon substance use disorder treatment in this sample.

Addressing public stigma and disparities among persons with mental illness: the role of federal policy.

Stigma against mental illness is a complex construct with affective, cognitive, and behavioral components. Beyond its symbolic value, federal law can only directly address one component of stigma: discrimination. This article reviews three landmark antidiscrimination laws that expanded protections over time for individuals with mental illness. Despite these legislative advances, protections are still not uniform for all subpopulations with mental illness. Furthermore, multiple components of stigma (e.g., prejudice) are beyond the reach of legislation, as demonstrated by the phenomenon of label avoidance; individuals may not seek protection from discrimination because of fear of the stigma that may ensue after disclosing their mental illness. To yield the greatest improvements, antidiscrimination laws must be coupled with antistigma programs that directly address other components of stigma.

Use of antipsychotic medications in pediatric populations: what do the data say?

Recent reports of antipsychotic medication use in pediatric populations describe large increases in rates of use. Much interest in the increasing use has focused on potentially inappropriate prescribing for non-Food and Drug Administration-approved uses and use amongst youth with no mental health diagnosis. Different studies of antipsychotic use have used different time periods, geographic and insurance populations of youth, and aggregations of diagnoses. We review recent estimates of use and comment on the similarities and dissimilarities in rates of use. We also report new data obtained on 11 health maintenance organizations that are members of the Mental Health Research Network in order to update and extend the knowledge base on use by diagnostic indication. Results indicate that most use in pediatric populations is for disruptive behaviors and not psychotic disorders. Differences in estimates are likely a function of differences in methodology; however, there is remarkable consistency in estimates of use by diagnosis.

Depression and substance abuse and dependency in relation to current smoking status and frequency of smoking among nondaily and daily smokers.

BACKGROUND AND OBJECTIVES: Daily smoking rates are decreasing while intermittent or nondaily smoking rates are increasing. Little is known about the association of depression, alcohol abuse and dependence, and illicit drug abuse and dependence with different patterns of smoking, particularly nondaily smoking. Thus, we examined these relationships among current smokers versus nonsmokers and among those who smoke daily versus less frequently. METHODS: We conducted a secondary analysis of 37,897 adults who participated in the 2008 National Survey on Drug Use and Health. We developed logistic regression models examining predictors of (i) current smoking and (ii) number of days smoking per month (1-10 days, 11-29 days, and ≥30 days) among current smokers, focusing on past-year major depression, alcohol abuse and dependence, and illicit drug abuse and dependence. RESULTS: Compared to nonsmokers, current smokers more frequently reported a major depressive episode (p < .001), alcohol dependence (p < .001) and abuse (p < .001), and illicit drug dependence (p < .001) and abuse (p < .001), controlling for sociodemographics. Among current smokers, greater smoking frequency was associated with illicit drug dependence (p = .004), but lower likelihood of alcohol dependence (p = .01), alcohol abuse (p = .01), and illicit drug abuse (p = .01). CONCLUSIONS: Although depression and substance use were associated with greater likelihood of smoking, most measures were inversely associated with frequency of smoking. Thus, it is important to examine underlying mechanisms contributing to these counterintuitive findings in order to inform intervention approaches. SCIENTIFIC SIGNIFICANCE: With increased rates of nondaily smoking, developing a greater understanding about the mental health correlates related to this pattern of smoking is critical.

Employee Engagement in Quality Improvement and Patient Sociodemographic Characteristics in Federally Qualified Health Centers.

Quality improvement (QI) work is critical, particularly in federally qualified health centers (FQHCs) that treat underserved populations. In a national sample of 45 FQHCs, we examined how patients' sociodemographic characteristics were associated with employee engagement in QI, via innovation contests that solicited ideas for improving care and offered opportunities to vote on ideas. We posited that patients' sociodemographic characteristics influence the complexity and intensity of clinical work and thus employees' capacity to engage in QI. Regression results indicated that the percentage of patients living in poverty was negatively associated with employee participation in idea submission and voting. Moreover, the percentage of Hispanic patients was negatively associated with participation in voting. The percentage of Black patients, however, was not associated with either outcome. FQHCs that serve a higher share of low income and/or Hispanic patients may face resource and personnel constraints that reduce employees' capacity to contribute to QI efforts.

Stakeholder perspectives on the advantages and challenges of expanded school mental health services for publically-insured youth.

Although partnerships between community-based mental health (MH) organizations and school systems to deliver MH services on school grounds (i.e., expanded school mental health, ESMH services) are growing, qualitative research is needed about stakeholders' perspectives on ESMH services. This study collected qualitative data from caregivers, MH providers, and MH administrators recruited from three MH organizations to understand their perspectives regarding potential advantages and challenges associated with ESMH services. The three MH organizations were located in three regions of Georgia and the majority of youth served by the organizations were enrolled in Medicaid. We conducted four focus groups with 33 caregivers and 13 semistructured interviews with MH administrators and providers, and we implemented a thematic content analysis. Caregivers, providers, and MH administrators described how ESMH services could improve MH services by (a) facilitating appointment attendance through the reduction of logistical barriers to care (including geographic barriers, missed class time, and missed work time) and (b) enhancing communication between providers and teachers. However, some participants also described logistical issues with ESMH services including school space constraints and challenges scheduling appointments. In addition, some caregivers expressed concerns about peer stigma if MH services are delivered at school (vs. the clinic). Providers and MH administrators discussed problems with low caregiver engagement and challenges collaborating with school personnel that stem from lack of understanding of MH problems and treatment. Although ESMH services can improve MH treatment among low-income youth, MH providers and MH administrators may consider collaborating with school personnel to proactively develop strategies to address challenges to its success. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Evaluating Medicaid Managed Care Network Adequacy Standards And Associations With Specialty Care Access For Children.

Medicaid managed care plans cover more than 80 percent of Medicaid-enrolled children, including many children with special health care needs (CSHCN). Federal rules require states to set network adequacy standards to improve specialty care access for Medicaid managed care enrollees. Using a quasi-experimental design and 2016-19 National Survey of Children's Health data, we examined the association between quantitative network adequacy standards and access to specialty care among 8,614 Medicaid-enrolled children, including 3,157 with special health care needs, in eighteen states. Outcomes included whether the child had any visit to non-mental health specialists, any visit to mental health professionals, or any unmet health care needs and whether the caregiver ever felt frustrated in getting services for the child in the past year. We observed no association between the adoption of any quantitative network adequacy standard and the above outcomes among Medicaid-enrolled children. Among CSHCN, however, adopting any quantitative standard was positively associated with caregivers feeling frustrated in getting services for the child, especially among CSHCN who visited non-mental health specialists. Without additional interventions, adopting new network adequacy standards may have unintended consequences for CSHCN.