Disparities in opioid use disorder-related hospital use among postpartum Virginia Medicaid members.

INTRODUCTION: The overdose crisis is increasingly revealing disparities in opioid use disorder (OUD) outcomes by race and ethnicity. Virginia, like other states, has witnessed drastic increases in overdose deaths. However, research has not described how the overdose crisis has impacted pregnant and postpartum Virginians. We report the prevalence of OUD-related hospital use during the first year postpartum among Virginia Medicaid members in the years preceding the COVID-19 pandemic. We secondarily assess how prenatal OUD treatment is associated with postpartum OUD-related hospital use. METHODS: This population-level retrospective cohort study used Virginia Medicaid claims data for live infant deliveries between July 2016 and June 2019. The primary outcome of OUD-related hospital use included overdose events, emergency department visits, and acute inpatient stays. Independent variables of interest were prenatal receipt of medication for OUD (MOUD) and receipt of non-MOUD treatment components in line with a comprehensive care approach (e.g., case management, behavioral health). Both descriptive and multivariate analyses were performed for all deliveries and stratified by White and Black non-Hispanic individuals to bring attention to the devastating impacts of the overdose crisis within communities of color. RESULTS: The study sample included 96,649 deliveries. Over a third were by Black birthing individuals (n = 34,283). Prenatally, 2.5 % had evidence of OUD, which occurred more often among White (4 %) than Black (0.8 %) non-Hispanic birthing individuals. Postpartum OUD-related hospital use occurred in 10.7 % of deliveries with OUD, more commonly after deliveries by Black, non-Hispanic birthing individuals with OUD (16.5 %) than their White, non-Hispanic counterparts (9.7 %), and this disparity persisted in the multivariable analysis (Black AOR 1.64, 95 % CI 1.14-2.36). Postpartum OUD-related hospital events were less frequent for individuals receiving versus not receiving postpartum MOUD within 30 days prior to the event. Prenatal OUD treatment, including MOUD, was not associated with decreased odds of postpartum OUD-related hospital use in the race-stratified models. CONCLUSION: Postpartum individuals with OUD are at high risk for mortality and morbidity, especially Black individuals not receiving MOUD after delivery. An urgent need remains to effectively address the systemic and structural drivers of racial disparities in transitions of OUD care through the one-year postpartum period.

Effect of Goal-Setting Approaches Within a Gamification Intervention to Increase Physical Activity Among Economically Disadvantaged Adults at Elevated Risk for Major Adverse Cardiovascular Events: The ENGAGE Randomized Clinical Trial.

Importance: Health promotion efforts commonly communicate goals for healthy behavior, but the best way to design goal setting among high-risk patients has not been well examined. Objective: To test the effectiveness of different ways to set and implement goals within a behaviorally designed gamification intervention to increase physical activity. Design, Setting, and Participants: Evaluation of the Novel Use of Gamification With Alternative Goal-setting Experiences was conducted from January 15, 2019, to June 1, 2020. The 24-week randomized clinical trial included a remotely monitored 8-week introductory intervention period, 8-week maintenance intervention period, and 8-week follow-up period. A total of 500 adults from lower-income neighborhoods in and around Philadelphia, Pennsylvania, who had either an atherosclerotic cardiovascular disease (ASCVD) condition or a 10-year ASCVD risk score greater than or equal to 7.5% were enrolled. Participants were paid for enrolling in and completing the trial. Interventions: All participants used a wearable device to track daily steps, established a baseline level, and were then randomly assigned to an attention control or 1 of 4 gamification interventions that varied only on how daily step goals were set (self-chosen or assigned) and implemented (immediately or gradually). Main Outcome Measures: The primary outcome was change in mean daily steps from baseline to the 8-week maintenance intervention period. Other outcomes included changes in minutes of moderate to vigorous physical activity. All randomly assigned participants were included in the intention-to-treat analysis. Results: Of the 500 participants, 331 individuals (66.2%) were Black, 114 were White (22.8%), and 348 were women (69.6%). Mean (SD) age was 58.5 (10.8) years and body mass index was 33.2 (7.8). A total of 215 participants (43.0%) had an ASCVD condition. Compared with the control arm, participants with self-chosen and immediate goals had significant increases in the number of daily steps during the maintenance intervention period (1384; 95% CI, 805-1963; P < .001) that were sustained during the 8-week follow-up (1391; 95% CI, 785-1998; P < .001). This group also had significant increases in daily minutes of moderate to vigorous physical activity during the maintenance intervention (4.1; 95% CI, 1.8-6.4; P < .001) that were sustained during follow-up (3.5; 95% CI, 1.1-5.8; P = .004). No other gamification arms had consistent increases in physical activity compared with the control arm. No major adverse events were reported. Conclusions and Relevance: In this trial among economically disadvantaged adults at elevated risk for major adverse cardiovascular events, a gamification intervention led to increases in physical activity that were sustained during 8 weeks of follow-up when goals were self-chosen and implemented immediately. Trial Registration: ClinicalTrials.gov Identifier: NCT03749473.

Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine.

BACKGROUND: People who inject drugs (PWID) experience poor outcomes and fuel HIV epidemics in middle-income countries in Eastern Europe and Central Asia. We assess integrated/co-located (ICL) healthcare for HIV-infected PWID, which despite international recommendations, is neither widely available nor empirically examined. METHODS: A 2010 cross-sectional study randomly sampled 296 HIV-infected opioid-dependent PWID from two representative HIV-endemic regions in Ukraine where ICL, non-co-located (NCL) and harm reduction/outreach (HRO) settings are available. ICL settings provide onsite HIV, addiction, and tuberculosis services, NCLs only treat addiction, and HROs provide counseling, needles/syringes, and referrals, but no opioid substitution therapy (OST). The primary outcome was receipt of quality healthcare, measured using a quality healthcare indicator (QHI) composite score representing percentage of eight guidelines-based recommended indicators met for HIV, addiction and tuberculosis treatment. The secondary outcomes were individual QHIs and health-related quality-of-life (HRQoL). RESULTS: On average, ICL-participants had significantly higher QHI composite scores compared to NCL- and HRO-participants (71.9% versus 54.8% versus 37.0%, p<0.001) even after controlling for potential confounders. Compared to NCL-participants, ICL-participants were significantly more likely to receive antiretroviral therapy (49.5% versus 19.2%, p<0.001), especially if CD4 ≤ 200 (93.8% versus 62.5% p<0.05); guideline-recommended OST dosage (57.3% versus 41.4%, p<0.05); and isoniazid preventive therapy (42.3% versus 11.2%, p<0.001). Subjects receiving OST had significantly higher HRQoL than those not receiving it (p<0.001); however, HRQoL did not differ significantly between ICL- and NCL-participants. CONCLUSIONS: These findings suggest that OST alone improves quality-of-life, while receiving care in integrated settings collectively and individually improves healthcare quality indicators for PWID.