Building an Integrated Data Infrastructure to Examine the Spectrum of Suicide Risk Factors in Philadelphia Medicaid.

While there are many data-driven approaches to identifying individuals at risk of suicide, they tend to focus on clinical risk factors, such as previous psychiatric hospitalizations, and rarely include risk factors that occur in nonclinical settings, such as jails or emergency shelters. A better understanding of system-level encounters by individuals at risk of suicide could help inform suicide prevention efforts. In Philadelphia, we built a community-level data infrastructure that encompassed suicide death records, behavioral health claims, incarceration episodes, emergency housing episodes, and involuntary commitment petitions to examine a broader spectrum of suicide risk factors. Here, we describe the development of the data infrastructure, present key trends in suicide deaths in Philadelphia, and, for the Medicaid-eligible population, determine whether suicide decedents were more likely to interact with the behavioral health, carceral, and housing service systems compared to Medicaid-eligible Philadelphians who did not die by suicide. Between 2003 and 2018, there was an increase in the number of annual suicide deaths among Medicaid-eligible individuals, in part due to changes in Medicaid eligibility. There were disproportionately more suicide deaths among Black and Hispanic individuals who were Medicaid-eligible, who were younger on average, compared to suicide decedents who were never Medicaid-eligible. However, when we accounted for the racial and ethnic composition of the Medicaid population at large, we found that White individuals were four times as likely to die by suicide, while Asian, Black, Hispanic, and individuals of other races were less likely to die by suicide. Overall, 58% of individuals who were Medicaid-eligible and died by suicide had at least one Medicaid-funded behavioral health claim, 10% had at least one emergency housing episode, 25% had at least one incarceration episode, and 22% had at least one involuntary commitment. By developing a data infrastructure that can incorporate a broader spectrum of risk factors for suicide, we demonstrate how communities can harness administrative data to inform suicide prevention efforts. Our findings point to the need for suicide prevention in nonclinical settings such as jails and emergency shelters, and demonstrate important trends in suicide deaths in the Medicaid population.

Behavioral health service use post-jail release and reduced risk of return to jail.

This study examined whether behavioral health service use post-jail release was associated with reduced risk of jail reincarceration. The study sample included 20,615 individuals who had behavioral health diagnoses and were released from the Philadelphia County jail. Using administrative records of the county jail and state-, county-, and Medicaid-funded behavioral health service use from 2010 to 2018, we conducted Cox proportional hazard analyses to estimate the association between behavioral health service use post-jail release and the risk of return to jail within 3 years. Nearly 50% of the sample returned to jail within 3 years. Individuals who used behavioral health services were 26%-38% less likely to return to jail within 3 years than were individuals who did not. The study results suggest that connecting individuals with behavioral health services upon release from jail can reduce the risk of repeated jail incarceration.

The implementation of opioid prescribing report cards in Medicaid managed care: a community quality collaborative.

Philadelphia, Pennsylvania, is an urban epicenter of the opioid epidemic, and inappropriate opioid prescribing remains a top concern. To help address this issue, the Philadelphia Medicaid Opioid Prescribing Initiative, a type of community quality collaborative, mailed thousands of local Medicaid providers an individualized prescribing report card in 2017 and 2018. The report card featured details of providers' opioid prescribing, including peer comparison measures and inappropriate prescribing measures like concomitant opioid and benzodiazepine prescribing. This case study describes the unique process of developing and distributing the opioid prescribing report cards, with a particular focus on the role of Medicaid managed care organizations. Using Medicaid pharmacy claims, the extensive variation in prescribing measures within and across specialties is also illustrated. The report card's implementation points to the potential value of collaborations between public health departments and Medicaid managed care organizations and can provide insight for other locally grown policies.

Converting partial hospitals to community integrated recovery centers.

This paper describes the conversion of partial hospitals into recovery-oriented programs as part of system transformation. Steps included: participatory planning with stakeholders; strength based assessment of resources and needs; technical assistance; and changing funding strategies. Over a period of 8 years, use of partial hospitals decreased as persons with serious mental illnesses were transitioned to community integrated recovery centers. Preliminary outcomes suggest that these programs are more effective in engaging people in the community activities of their choice, confirming previous findings that showed that partial hospitals can be converted to recovery-oriented programs that focus more directly on promoting community inclusion.

Availability of lactation counseling services influences breastfeeding among infants admitted to to neonatal intensive care units.

PURPOSE: To assess the association between the presence of international board-certified lactation consultant (IBCLC) services at a delivery hospital and the breastfeeding practices of women whose infants required neonatal intensive care unit (NICU) admission. DESIGN: Cross-sectional study using population-level data. SETTING: Philadelphia, Pennsylvania. SUBJECTS: 2132 infants admitted to the NICU. MEASURES: Breastfeeding at hospital discharge was measured with the question, "Is the infant being breastfed?" Delivery hospitals were dichotomized as to the presence or absence of an IBCLC on staff ANALYSIS: Logistic regression was used to assess the relationship between breastfeeding at discharge and the presence of an IBCLC at the delivery facility while adjusting for maternal characteristics and birth outcomes. RESULTS: Among mothers of infants admitted to the NICU, breastfeeding rates among mothers who delivered at hospitals with an IBCLC were nearly 50% compared with 36.9% among mothers who delivered at hospitals without an IBCLC. The adjusted odds of breastfeeding initiation prior to hospital discharge were 1.34 (95% confidence interval = 1.03, 1.76) times higher for women who delivered at a facility with an IBCLC. CONCLUSIONS: To increase breastfeeding rates among the NICU population, these findings support the need for universal availability of IBCLCs at delivery facilities that have NICUs.

A comparison of breastfeeding rates in an urban birth cohort among women delivering infants at hospitals that employ and do not employ lactation consultants.

OBJECTIVE: To compare rates of breastfeeding at hospital discharge between facilities that employ and do not employ International Board Certified Lactation Consultants (IBCLCs). METHODS: This study used a cross-sectional design. Data from 11,525 birth certificates of Philadelphia residents who delivered in 2003 were used. Breastfeeding was assessed using a question included on the Pennsylvania birth record, "Is the infant being breastfed at discharge?" The Philadelphia Department of Public Health's lactation consultants collected information on number of hours worked annually by IBCLCs by facility. RESULTS: After adjusting for race/ethnicity, education, insurance status, age, marital status, route of delivery, birth weight, and gestational age, delivering in a hospital that employed an IBCLC was associated with a 2.28 (95% confidence interval [CI] =1.98,2.62) times increase in the odds of breastfeeding at hospital discharge. Among women receiving Medicaid, delivering at a hospital that employed IBCLCs was associated with a 4.13 (95% CI =3.22,4.80) times increase in the odds of breastfeeding at hospital discharge. CONCLUSIONS: The findings presented here identify an association between delivering at a facility that employs IBCLCs and breastfeeding at hospital discharge. As the strength of this association is not negligible, particularly for women on Medicaid, these findings may be used to encourage widespread use of IBCLCs.

It's not the heat, it's the humidity: wet weather increases legionellosis risk in the greater Philadelphia metropolitan area.

BACKGROUND: Legionella species are abundant in the environment and are increasingly recognized as a cause of severe pneumonia. Increases in cases of community-acquired legionellosis in the greater Philadelphia metropolitan area (GPMA) led to concern that changing environmental factors could influence occurrence of disease. METHODS: We evaluated the association between weather patterns and occurrence of legionellosis in the GPMA, using both traditional Poisson regression analysis and a case-crossover study approach. The latter approach controls for seasonal factors that could confound the relationship between weather and occurrence of disease and permits the identification of acute weather patterns associated with disease. RESULTS: A total of 240 cases of legionellosis were reported between 1995 and 2003. Cases occurred with striking summertime seasonality. Occurrence of cases was associated with monthly average temperature (incidence rate ratio [IRR] per degree Celsius, 1.07 [95% confidence interval [CI], 1.05-1.09]) and relative humidity (IRR per 1% increase in relative humidity, 1.09 [95% CI, 1.06-1.12]) by Poisson regression analysis. However, case-crossover analysis identified an acute association with precipitation (odds ratio [OR], 2.48 [95% CI, 1.30-3.12]) and increased humidity (OR per 1% increase in relative humidity, 1.08 [95% CI, 1.05-1.11]) 6-10 days before occurrence of cases. A significant dose-response relationship for occurrence of cases was seen with both precipitation and increased humidity. CONCLUSIONS: Although, in the GPMA, legionellosis occurred predominantly during summertime, the acute occurrence of disease is best predicted by wet, humid weather. This finding is consistent with the current understanding of the ecological profile of this pathogen and supports the contention that sporadic legionellosis occurs through contamination of water sources.

A metacarpophalangeal joint stabilization splint: the Galindo-Lim thumb metacarpophalangeal joint stabilization splint.

Creation of a splint should allow for maximal functional use of the hand as well as comfort. The design of the Galindo-Lim splint enhances functional use of the hand not only because it stabilizes the MCP joint but also because it does not cross the wrist crease, thus allowing full wrist motion. Independence in the performance of daily activities is easily achieved with the Galindo-Lim splint (Figure 5). The splint is appropriate for patients with a variety of diagnoses, including MCP joint volar plate injuries, collateral ligament injuries, joint hypermobility, and arthritic conditions.