Does Universal Coverage Mitigate Racial Disparities in Potentially Avoidable Maternal Complications?

OBJECTIVE: Potentially avoidable maternity complications (PAMCs) have been validated as an indicator of access to quality prenatal care. African-American mothers have exhibited a higher incidence of PAMCs, which has been attributed to unequal health coverage. The objective of this study was to assess if racial disparities in the incidence of PAMCs exist in a universally insured population. STUDY DESIGN: PAMCs in each racial group were compared relative to White mothers using multivariate logistic regression. Stratified subanalyses assessed for adjusted differences in the odds of PAMCs for each racial group within direct versus purchased care. RESULTS: A total of 675,553 deliveries were included. Among them, 428,320 (63%) mothers were White, 112,170 (17%) African-American, 37,151 (6%) Asian/Pacific Islanders, and 97,912 (15%) others. African-American women (adjusted odds ratio [aOR]: 1.05, 95% CI: 1.02-1.08) were more likely to have PAMCs compared with White women, and Asian women (aOR: 0.92, 95% CI: 0.89-0.95) were significantly less likely to have PAMCs compared with White women. On stratified analysis according to the system of care, equal odds of PAMCs among African-American women compared with White women were realized within direct care (aOR: 1.03, 95% CI: 1.00-1.07), whereas slightly higher odds among African-American persisted in purchased (aOR: 1.05, 95% CI: 1.01-1.10). CONCLUSION: Higher occurrence of PAMCs among minority women sponsored by a universal health coverage was mitigated compared with White women. Protocol-based care as in the direct care system may help overcome health disparities.

Prenatal use of medications for gastroesophageal reflux disease and early childhood fracture risk.

BACKGROUND: Gastroesophageal reflux disease is a common condition in pregnancy and is often managed with medications. Specific medications have been linked to osteoporosis and fragility fracture in older adults. This study assessed whether maternal use of antireflux medications is associated with early childhood fracture. METHODS: TRICARE beneficiaries during pregnancy were retrospectively identified using the Military Health System Data Repository and pharmacy data. Mother and infant data were linked; children with continuous enrollment for the first 5 years of life were included. Differences in the children's fracture risk were analyzed through multivariate analysis, adjusting for region, rank, and military branch of service. RESULTS: A total of 378 150 patients comprised the final cohort with 3.3% (n = 12 479) prescribed antireflux medications during pregnancy. A significant decrease in fracture rate was found among children of women who were prescribed antireflux medications during pregnancy compared with those who were not (0.8% vs 1.2%, RR = 0.70, 95% CI 0.58-0.85). There was no difference in fracture risk between histamine type 2 receptor antagonists and proton pump inhibitors. A significantly increased fracture incidence was seen in pregnancies with multiple gestations (RR = 1.38, 95% CI 1.04-1.85). There was no identified difference in fracture risk for women with gestational diabetes, preeclampsia, preterm or low birthweight, chronic hypertension, induction, or breech presentation when compared to women without these conditions. CONCLUSIONS: We found no increase in early childhood fracture risk with maternal antireflux medication use. This suggests that prenatal exposure to antireflux medications does not affect fetal bones to a clinically significant extent.

Collecting sexual orientation and gender identity information in the emergency department : the divide between patient and provider perspectives.

BACKGROUND: In the USA, The Joint Commission and Institute of Medicine have called for collection of patient sexual orientation (SO) and gender identity (GI) information in healthcare. In a recent study, we reported that ED clinicians believe patients will refuse to provide this information; however, very few patients say they would refuse to provide SO/GI. As part of this study, we interviewed patients and providers regarding the importance of collecting this information. While these interviews were briefly summarised in our prior report, the qualitative data warranted a more thorough analysis and exposition to explore provider and patient views as well as risks and benefits of collecting SO/GI. METHODS: A purposive sample of 79 participants was recruited for semi-structured interviews between August 2014 and January 2015. Participants included community members who had a previous ED encounter and ED providers from 3 community and 2 academic centres in a major US metropolitan area. Interviews were conducted one-on-one in person, audio-recorded and transcribed verbatim. Data were analysed using the constant comparative method. RESULTS: Fifty-three patients and 26 ED providers participated. Patients perceived collection of SO/GI to be important in most clinical circumstances because SO/GI is relevant to their identity and allows providers to treat the whole person. However, many providers felt SO/GI was not relevant in most clinical circumstances because similar care is provided to all patients regardless of SO/GI. Patients and providers agreed there are risks associated with collecting SO/GI in the ED. CONCLUSIONS: ED clinicians do not perceive routine collection of SO/GI to be medically relevant in most circumstances. However, patients feel routine SO/GI collection allows for recognition of individual identity and improved therapeutic relationships in the ED. These discordant perspectives may be hindering patient-centred care, especially for sexual and gender minority patients.

Comparison of Epidemiology of the Injuries and Outcomes in Two First-Level Trauma Centers in Colombia Using the Pan-American Trauma Registry System.

INTRODUCTION: The aim of this study was to compare the epidemiology of traumatic injuries and mortality outcomes between two tertiary-care trauma centers in Colombia using data from Pan-American Trauma Registry (PATR). METHODS: January 1-December 31, 2012, data from the Hospital Universitario del Valle (HUV, public) and Fundacion Valle del Lili (FVL, private) in Cali, Colombia, were considered. Differences in demographic and clinical information were compared using descriptive statistics. Propensity score matching was used to match patients on age, gender, and ISS. Within matched cohorts, multivariable logistic regression models were used to assess for differences in in-hospital mortality, further adjusting for insurance type, employment, heart rate, presence of hypotension (SBP < 90), and GCS score. RESULTS: HUV (8539; 78% male) and FVL (10,456; 60% male) had a combined total of 18,995 trauma cases in 2012 with comparable mean ages of 29.7 years. There were significant differences in insurance status, injury severity, and mechanism of injury between patients at HUV and FLV. On risk-adjusted logistic regression analyses with propensity score matched cohorts, the odds of death in HUV was higher compared to patients presenting at FVL hospital (OR [95% CI]:4.93 [3.37-7.21], p < 0.001). CONCLUSION: The study established the utility of the PATR and revealed important trends in patient demographics, injury epidemiology, and mortality outcomes, which can be used to target trauma initiatives throughout the region. It underscores the profound importance that differences in case mix play in the risk of trauma-related mortality, further emphasizing the need to monitor and evaluate unique aspects of trauma in LMIC. LEVEL OF EVIDENCE: III.

Intrapartum obstetric care in the United States military: Comparison of military and civilian care systems within TRICARE.

BACKGROUND: Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE. METHODS: TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care. RESULTS: A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds (aOR 1.37 [CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery (aOR[CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery (aOR 1.31 [CI 1.19-1.44]) compared with direct care. CONCLUSION: Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States.

Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy?

STUDY OBJECTIVE: To determine if racial differences exist in receipt of minimally invasive hysterectomy (defined as total vaginal hysterectomy [TVH] and total laparoscopic hysterectomy [TLH]) compared with an open approach (total abdominal hysterectomy [TAH]) within a universally insured patient population. DESIGN: Retrospective data analysis (Canadian Task Force classification II-2). SETTING: The 2006-2010 national TRICARE (universal insurance coverage to US Armed Services members and their dependents) longitudinal claims data. PATIENTS: Women aged 18 years and above who underwent hysterectomy stratified into 4 racial groups: white, African American, Asian, and "other." INTERVENTION: Receipt of hysterectomy (TAH, TVH, or TLH). MEASUREMENTS AND MAIN RESULTS: We used risk-adjusted multinomial logistic regression models to determine the relative risk ratios of receipt of TVH and TLH compared with TAH in each racial group compared with referent category of white patients for benign conditions. Among 33 015 patients identified, 60.82% (n = 20 079) were white, 26.11% (n = 8621) African American, 4.63% (n = 1529) Asian, and 8.44% (n = 2786) other. Most hysterectomies (83.9%) were for benign indications. Nearly 42% of hysterectomies (n = 13 917) were TAH, 27% (n = 8937) were TVH, and 30% (n = 10 161) were TLH. Overall, 36.37% of white patients received TAH compared with 53.40% of African American patients and 51.01% of Asian patients (p < .001). On multinomial logistic regression analyses, African American patients were significantly less likely than white patients to receive TVH (relative risk ratio [RRR], .63; 95% confidence interval [CI], .58-.69) or TLH (RRR, .65; 95% CI, .60-.71) compared with TAH. Similarly, Asian patients were less likely than white patients to receive TVH (RRR, .71; 95% CI, .60-.84) or TLH (RRR, .69; 95% CI, .58-.83) compared with TAH. Analyses by benign indications for surgery showed similar trends. CONCLUSION: We demonstrate that racial minority patients are less likely to receive a minimally invasive surgical approach compared with an open abdominal approach despite universal insurance coverage. Further work is warranted to better understand factors other than insurance access that may contribute to racial differences in surgical approach to hysterectomies.

Unmet surgical needs in children: a household survey in Nepal.

PURPOSE: While an estimated two billion people lack access to surgical care, little data are available on surgical conditions for pediatric populations in low- and middle-income countries. Our study aims to assess pediatric surgical needs in Nepal. METHODS: A countrywide cross-sectional study was performed in 15 randomly chosen districts; 3 clusters (2 rural; 1 urban) per district were selected. The prevalence of surgical conditions, unmet surgical needs, and barriers to care were analyzed among children (0-18 years of age). RESULTS: Overall, 1,350 households and 2,695 individuals were surveyed (response rate: 97 %); 800 respondents (29.7 %, 95 % CI 27.9-31.4 %) were pediatric; 59.8 % (95 % CI 56.3-63.2 %) were male; median age was 10 years (IQR 5-15). Of them, 84 (10.5 %, 95 % CI 8.5-12.8 %) had a surgical condition; 48 (6.0 %, 95 % CI 4.5-7.9 %) reported an unmet need for surgical care. Based on this, we estimate that 706,076 (95 % CI 529,557-929,666) children live with untreated surgical conditions. Barriers to care included limited availability of services (31.3 %), funds (22.9 %), time (4.2 %), and fear/mistrust of medical services (16.7 %). CONCLUSION: Close to 700,000 children in Nepal are estimated to need surgical consultation. Programs to address this should be developed alongside efforts by policy makers and donors to rectify the lack of care, bolster limited funds, and strengthen healthcare systems.

Surgical needs of Nepal: pilot study of population based survey in Pokhara, Nepal.

BACKGROUND: The Surgeons OverSeas assessment of surgical need (SOSAS) tool, a population-based survey on surgical conditions in low- and middle-income countries (LMICs), was performed in Sierra Leone and Rwanda. This pilot study in Nepal is the initial implementation of the SOSAS survey in South Asia. METHODS: A pilot study of SOSAS, modified for Nepal's needs and reprogrammed using mobile data collection software, was undertaken in Pokhara in January 2014. Cluster randomized sampling was utilized to interview 100 individuals in 50 households within two wards of Pokhara, one rural and one urban. The first portion of the survey retrieved demographic data, including household members and time to nearest health facilities. The second portion interviewed two randomly selected individuals from each household, inquiring about surgical conditions covering six anatomical regions. RESULTS: The pilot SOSAS in Nepal was easily completed over 3 days, including training of 18 Nepali interns over 2 days. The response rate was 100 %. A total of 13 respondents had a current surgical need (face 4, chest 1, back 1, abdomen 1, groin 3, extremity 3), although eight reported there was no need for surgical care. Five respondents (5 %) had a current unmet surgical need. CONCLUSION: The SOSAS pilot study in Nepal was successfully conducted, demonstrating the feasibility of performing SOSAS in South Asia. The estimated 5 % current unmet surgical need will be used for sample size calculation for the full country survey. Utilizing and improving on the SOSAS tool to measure the prevalence of surgical conditions in Nepal will help enumerate the global surgical burden of disease.

Monthly Sulfadoxine-Pyrimethamine During Pregnancy Prevents Febrile Respiratory Illnesses: A Secondary Analysis of a Malaria Chemoprevention Trial in Uganda.

Background: Trials evaluating antimalarials for intermittent preventive treatment in pregnancy (IPTp) have shown that dihydroartemisinin-piperaquine (DP) is a more efficacious antimalarial than sulfadoxine-pyrimethamine (SP); however, SP is associated with higher birthweight, suggesting that SP demonstrates "nonmalarial" effects. Chemoprevention of nonmalarial febrile illnesses (NMFIs) was explored as a possible mechanism. Methods: In this secondary analysis, we leveraged data from 654 pregnant Ugandan women without HIV infection who participated in a randomized controlled trial comparing monthly IPTp-SP with IPTp-DP. Women were enrolled between 12 and 20 gestational weeks and followed through delivery. NMFIs were measured by active and passive surveillance and defined by the absence of malaria parasitemia. We quantified associations among IPTp regimens, incident NMFIs, antibiotic prescriptions, and birthweight. Results: Mean "birthweight for gestational age" Z scores were 0.189 points (95% CI, .045-.333) higher in women randomized to IPTp-SP vs IPTp-DP. Women randomized to IPTp-SP had fewer incident NMFIs (incidence rate ratio, 0.74; 95% CI, .58-.95), mainly respiratory NMFIs (incidence rate ratio, 0.69; 95% CI, .48-1.00), vs IPTp-DP. Counterintuitively, respiratory NMFI incidence was positively correlated with birthweight in multigravidae. In total 75% of respiratory NMFIs were treated with antibiotics. Although overall antibiotic prescriptions were similar between arms, for each antibiotic prescribed, "birthweight for gestational age" Z scores increased by 0.038 points (95% CI, .001-.074). Conclusions: Monthly IPTp-SP was associated with reduced respiratory NMFI incidence, revealing a potential nonmalarial mechanism of SP and supporting current World Health Organization recommendations for IPTp-SP, even in areas with high-grade SP resistance. While maternal respiratory NMFIs are known risk factors of lower birthweight, most women in our study were presumptively treated with antibiotics, masking the potential benefit of SP on birthweight mediated through preventing respiratory NMFIs.

Psychiatric Conditions During Pregnancy and Postpartum in a Universally Insured American Population.

BACKGROUND: Mental health conditions are common and can have significant effects during the perinatal period. Our objective was to determine the incidences and predictors of psychiatric conditions during pregnancy and postpartum among universally insured American women. MATERIAL AND METHODS: This was an Institutional Review Board (IRB)-approved protocol using a retrospective cohort of 104,866 deliveries covered by TRICARE from 2005 to 2014. We used TRICARE claims data to identify pregnant women without current psychiatric conditions who developed new psychiatric condition(s) during pregnancy or postpartum compared with those who did not, as identified by International Classification of Diseases (ICD)-9 CM codes. Predictors of psychiatric conditions during pregnancy or postpartum were determined using stepwise logistic regression models. RESULTS: A total of 104,866 women met the inclusion criteria; of these, 35% (n = 36,192) were diagnosed with a new psychiatric condition during pregnancy or within 1 year of delivery, 15% (n = 15,636) with a psychiatric condition during pregnancy, and 20% (n = 20,556) with a psychiatric condition within 1 year of delivery. We demonstrated that the African-American race (odds ratio [OR] 1.16, 95% CI 1.10-1.22), active duty status (OR 1.20, 95% CI 1.14-1.25), and severe maternal morbidity during delivery (OR 1.18, 95% CI 1.02-1.35) were significantly associated with the occurrence of a psychiatric condition within 1 year of delivery. For Asian women, there was a 28% higher odds of developing a psychiatric disorder during pregnancy (adjusted OR 1.28, 95% CI 1.17-1.40) compared with White women. Active duty women were twice as likely to be diagnosed with post-traumatic stress disorder (adjusted OR 2.31, 95% CI 1.83-2.90). CONCLUSION: In a universally insured population, the incidences of psychiatric conditions in pregnancy and within a year of delivery were similar to the American population. Additionally, the development of psychiatric conditions in pregnancy and within a year of delivery may be associated with race, active duty status, and complicated births.

Early Childhood Outcomes Among Infants Born by Vaginal Birth After Cesarean and Repeat Cesarean Delivery in the Military Health System.

OBJECTIVE: This study examines whether children delivered by repeat cesarean section experience higher incidences of otitis media, respiratory infections, and allergic diseases than children delivered by vaginal birth after cesarean section (VBAC) in the Military Health System. STUDY DESIGN: This is a retrospective cohort study from the Military Health System Data Repository of women who underwent repeat cesarean section or VBAC between 2006 and 2012 and their offspring through 2014. RESULTS: About 11,659 infants with 2 years of follow-up were identified. Infants delivered by VBAC had lower odds of developing respiratory illness (P < .000), otitis media (P < .001), and allergies (P = .022) compared with infants born by repeat cesarean section. There were no differences in the development of food allergies. CONCLUSION: Emerging data regarding early childhood health are additional factors that can influence the mother's decision on mode of birth after a primary cesarean section.

Sex differences in long-term outcomes after traumatic injury: A mediation analysis.

BACKGROUND: We sought to examine the association and potential mediators between sex and long-term trauma outcomes. METHODS: Moderately-to-severely injured patients admitted to 3 level-1 trauma centers were contacted between 6 and 12-months post-injury to assess for functional limitations, use of pain medications, and posttraumatic stress disorder (PTSD). Multivariable adjusted regression analyses were used to compare long-term outcomes by sex. Potential mediators of the relationship between sex and outcomes was explored using mediation analysis. RESULTS: 2607 patients were followed, of which 45% were female. Compared to male, female patients were more likely to have functional limitations (OR: 1.45; 95% CI: 1.31-1.60), take pain medications (OR: 1.17; 95% CI: 1.02-1.38), and screen positive for PTSD (OR: 1.60; 95% CI: 1.46-1.76) post-injury. Age, extremity injury, previous psychiatric illness, and pre-injury unemployment, partially mediated the effect of female sex on long-term outcomes. CONCLUSIONS: There are significant sex differences in long-term trauma outcomes, which are partially driven by patient and injury-related factors.

Towards diaspora-driven research capacity strengthening in low- and middle-income countries: results from India and Nepal.

BACKGROUND: Biomedical research from high-income countries often informs practice and policy in low- and middle-income countries (LMICs) with vastly different socioeconomic and health systems. Engagement of LMIC-based researchers is integral to setting research priorities in the local context. METHODS: A program, comprising a research seminar and workshop, and utilizing diaspora health professionals to understand research needs and build research capacity in LMICs, was created and pilot-tested at two institutions in India (65 participants) and Nepal (30 participants). Pre- and post-program surveys were instituted to assess participants' attitudes towards research. RESULTS: In the pre-program survey, most participants (India: 76%, Nepal: 100%) perceived research as 'very/extremely important' in their careers. However, a majority felt that finding time (India: 75%, Nepal: 81%) and funding (India: 82%, Nepal: 100%) for research was 'difficult/very difficult'. After the program, 86-91% and 86-100% of participants from India and Nepal, respectively, felt that the various courses were very useful/useful for their research careers. CONCLUSIONS: Research is seen as an integral part of educational training and career advancement in LMICs. However, inadequate training, funding and mentorship remain a challenge. Engagement of diaspora health workers may serve as an important avenue for collaborative biomedical research capacity strengthening in LMICs.

Universal Health Insurance and its association with long term outcomes in Pediatric Trauma Patients.

BACKGROUND: Racial disparities in mortality exist among pediatric trauma patients; however, little is known about disparities in outcomes following discharge. METHODS: We conducted a longitudinal cohort study of children admitted for moderate to severe trauma, covered by TRICARE from 2006 to 2014. Patients were followed up to 90days after discharge. All children <18 years with a primary trauma diagnosis, an Injury Severity Score >9 and 90days of follow-up after discharge were included. Complications, readmissions and utilization of healthcare services up to 90days after discharge were compared between Black and White patients. RESULTS: Of the 5192 children included, majority were White (74.6%, n=3871), with 15.4% Black (n=800) and 10.0% Other (n=521). Most common injuries involved the extremities or the pelvic girdle followed by the head or neck. Complication and readmission rates were 3.6% and 8.9% within 30days of discharge respectively and 4.4% and 9.3% within 90days of discharge. 99.0% of children had at least one outpatient visit by 90days. After adjusting for patient and injury characteristics no significant differences were detected between Black and White children in outcomes after discharge. CONCLUSIONS: Universal insurance may help mitigate disparities in post discharge care in pediatric trauma populations by increasing access to outpatient services overall and within each racial group. Further studies are required to determine the appropriate timing and frequency of follow up care in order to achieve maximum reduction in use of acute care services after discharge.

Assessment of Patient-Centered Approaches to Collect Sexual Orientation and Gender Identity Information in the Emergency Department: The EQUALITY Study.

Importance: Health care and government organizations call for routine collection of sexual orientation and gender identity (SOGI) information in the clinical setting, yet patient preferences for collection methods remain unknown. Objective: To assess of the optimal patient-centered approach for SOGI collection in the emergency department (ED) setting. Design, Setting, and Participants: This matched cohort study (Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity [EQUALITY] Study) of 4 EDs on the east coast of the United States sequentially tested 2 different SOGI collection approaches between February 2016 and March 2017. Multivariable ordered logistic regression was used to assess whether either SOGI collection method was associated with higher patient satisfaction with their ED experience. Eligible adults older than 18 years who identified as a sexual or gender minority (SGM) were enrolled and then matched 1 to 1 by age (aged ≥5 years) and illness severity (Emergency Severity Index score ±1) to patients who identified as heterosexual and cisgender (non-SGM), and to patients whose SOGI information was missing (blank field). Patients who identified as SGM, non-SGM, or had a blank field were invited to complete surveys about their ED visit. Data analysis was conducted from April 2017 to November 2017. Interventions: Two SOGI collection approaches were tested: nurse verbal collection during the clinical encounter vs nonverbal collection during patient registration. The ED physicians, physician assistants, nurses, and registrars received education and training on sexual or gender minority health disparities and terminology prior to and throughout the intervention period. Main Outcomes and Measures: A detailed survey, developed with input of a stakeholder advisory board, which included a modified Communication Climate Assessment Toolkit score and additional patient satisfaction measures. Results: A total of 540 enrolled patients were analyzed; the mean age was 36.4 years and 66.5% of those who identified their gender were female. Sexual or gender minority patients had significantly better Communication Climate Assessment Toolkit scores with nonverbal registrar form collection compared with nurse verbal collection (mean [SD], 95.6 [11.9] vs 89.5 [20.5]; P = .03). No significant differences between the 2 approaches were found among non-SGM patients (mean [SD], 91.8 [18.9] vs 93.2 [13.6]; P = .59) or those with a blank field (92.7 [15.9] vs 93.6 [14.7]; P = .70). After adjusting for age, race, illness severity, and site, SGM patients had 2.57 (95% CI, 1.13-5.82) increased odds of a better Communication Climate Assessment Toolkit score category during form collection compared with verbal collection. Conclusions and Relevance: Sexual or gender minority patients reported greater comfort and improved communication when SOGI was collected via nonverbal self-report. Registrar form collection was the optimal patient-centered method for collecting SOGI information in the ED.

Patterns of use and factors associated with early discontinuation of opioids following major trauma.

BACKGROUND: Inappropriate use of prescription opioids is a growing public-health issue. We sought to estimate the proportion of traumatic injury patients using legal prescription opioids up to 1-year after hospitalization. METHODS: We used 2006-2014 claims data from TRICARE insurance to identify adults hospitalized secondary to trauma between 2007 and 2013. Prescription opioid use was evaluated for one-year post-discharge. Risk-adjusted Cox Proportional-hazards models were used to evaluate predictors of opioid discontinuation. RESULTS: Only 1% of patients sustained legal prescription opioid use at 1-year following trauma. Lower socioeconomic status (HR 0.92, 95% CI 0.87-0.98) and higher injury severity (HR 0.88, 95% CI 0.84-0.91) were associated with sustained use. Younger patients (HR 1.12, 95% CI 1.04-1.21) and Black patients (HR 1.09, 95% CI 1.04-1.15) were found to have a higher likelihood of opioid discontinuation. CONCLUSIONS: In this population, adult patients who sustained trauma were not at high risk of sustained legal prescription opioid use.

Incidence and Predictors of Opioid Prescription at Discharge After Traumatic Injury.

IMPORTANCE: In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored. OBJECTIVE: To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort. DESIGN, SETTING, AND PARTICIPANTS: Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration's list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016. EXPOSURES: Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors. MAIN OUTCOMES AND MEASURES: Prescription of opioid analgesics at discharge. RESULTS: Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge. CONCLUSIONS AND RELEVANCE: The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioids.

Disparities in receipt of a laparoscopic operation for ectopic pregnancy among TRICARE beneficiaries.

BACKGROUND: Racial disparities in receipt of a laparoscopic operation for ectopic pregnancy are attributed to inequalities in access to care. This study sought to determine if racial disparities in laparoscopic operation for ectopic pregnancy exist among a universally insured population. METHODS: Using 2006-2010 TRICARE (insurance for members of the United States Armed Services and their dependents) data, patients who received a laparoscopic operation or laparotomy for ectopic pregnancy were stratified into direct/military or purchased/civilian system of care. Odds of receipt of a laparoscopic operation in each racial group were compared adjusting for patient demographics, system of care, and severity of ectopic pregnancy. RESULTS: Among 3,041 patients in the study sample, 1,878 (61.7%) received laparotomy and 1,163 (38.2%) received a laparoscopic operation within 30 days of diagnosis. Overall, 42.4% of white women received a laparoscopic operation compared with 33.1% of Asian women and 34.9% of black women (P < .001). On multivariable analysis, black women had a 33% lesser odds of receiving a laparoscopic operation (odds ratio: 0.67; confidence interval: 0.55-0.83) compared with white women. These disparities were absent within direct care (odds ratio: 0.93; confidence interval: 0.71-1.21) but were present within purchased care (odds ratio: 0.54; confidence interval: 0.40-0.73). CONCLUSION: Racial minority patients are less likely to receive a laparoscopic operation for ectopic pregnancy despite universal insurance coverage within civilian/purchased care. Further work is warranted to better understand the factors other than insurance access that may contribute to racial disparities in selection of operative approach.