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BACKGROUND: Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity. METHODS: We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes. DISCUSSION: Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).
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Doulas , Equidad en Salud , Medicaid , Humanos , Estados Unidos , Femenino , Embarazo , Racismo , Disparidades en Atención de Salud , Servicios de Salud Materna , Mortalidad Materna , Periodo Posparto , Adulto , Resultado del Embarazo , Proyectos de InvestigaciónRESUMEN
Importance: Insurance coverage affects health care access for many delivering women diagnosed with perinatal mood and anxiety disorders (PMADs). The Mental Health Parity and Addiction Equity Act (MHPAEA; passed in 2008) and the Patient Protection and Affordable Care Act (ACA; passed in 2010) aimed to improve health care access. Objective: To assess associations between MHPAEA and ACA implementation and psychotherapy use and costs among delivering women overall and with PMADs. Design, Setting, and Participants: This cross-sectional study conducted interrupted time series analyses of private insurance data from January 1, 2007, to December 31, 2019, for delivering women aged 15 to 44 years, including those with PMADs, to assess changes in psychotherapy visits in the year before and the year after delivery. It estimated changes in any psychotherapy use and per-visit out-of-pocket costs (OOPCs) for psychotherapy associated with MHPAEA (January 2010) and ACA (January 2014) implementation. Data analyses were performed from August 2022 to May 2023. Exposures: Implementation of the MHPAEA and ACA. Main Outcomes and Measures: Any psychotherapy use and per-visit OOPCs for psychotherapy standardized to 2019 dollars. Results: The study included 837â¯316 overall deliveries among 716â¯052 women (mean [SD] age, 31.2 [5.4] years; 7.6% Asian, 8.8% Black, 12.8% Hispanic, 64.1% White, and 6.7% unknown race and ethnicity). In the overall cohort, a nonsignificant step change was found in the delivering women who received psychotherapy after MHPAEA implementation of 0.09% (95% CI, -0.04% to 0.21%; P = .16) and a nonsignificant slope change of delivering women who received psychotherapy of 0.00% per month (95% CI, -0.02% to 0.01%; P = .69). A nonsignificant step change was found in delivering individuals who received psychotherapy after ACA implementation of 0.11% (95% CI, -0.01% to 0.22%; P = .07) and a significantly increased slope change of delivering individuals who received psychotherapy of 0.03% per month (95% CI, 0.00% to 0.05%; P = .02). Among those with PMADs, the MHPAEA was associated with an immediate increase (0.72%; 95% CI, 0.26% to 1.18%; P = .002) then sustained decrease (-0.05%; -0.09% to -0.02%; P = .001) in psychotherapy receipt; the ACA was associated with immediate (0.77%; 95% CI, 0.26% to 1.27%; P = .003) and sustained (0.07%; 95% CI, 0.02% to 0.12%; P = .005) monthly increases. In both populations, per-visit monthly psychotherapy OOPCs decreased (-$0.15; 95% CI, -$0.24 to -$0.07; P < .001 for overall and -$0.22; -$0.32 to -$0.12; P < .001 for the PMAD population) after MHPAEA passage with an immediate increase ($3.14 [95% CI, $1.56-$4.73]; P < .001 and $2.54 [95% CI, $0.54-$4.54]; P = .01) and steady monthly increase ($0.07 [95% CI, $0.02-$0.12]; P = .006 and $0.10 [95% CI, $0.03-$0.17]; P = .004) after ACA passage. Conclusions and Relevance: This study found complementary and complex associations between passage of the MHPAEA and ACA and access to psychotherapy among delivering individuals. These findings indicate the value of continuing efforts to improve access to mental health treatment for this population.
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Accesibilidad a los Servicios de Salud , Seguro de Salud , Atención Perinatal , Psicoterapia , Psicoterapia/economía , Psicoterapia/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Humanos , Femenino , Embarazo , Gastos en Salud/estadística & datos numéricos , AdultoRESUMEN
OBJECTIVES: Cognitive impairment and decreased executing functioning represent common symptoms of both ADHD and pregnancy. This study aimed to characterize temporal trends and racial/ethnic disparities in ADHD diagnosis during the perinatal period. METHODS: In this serial cross-sectional study, we used administrative claims to create a cohort of commercially insured women with a documented live birth between 2008 and 2020 and identified those with an ADHD diagnosis in the year before or after delivery. We applied logistic regression to assess the probability of ADHD diagnosis adjusting for race/ethnicity, age, and comorbid conditions. We used this model to calculate the predicted probability of ADHD diagnosis by racial/ethnic group for each year. RESULTS: We identified 736,325 deliveries from 2008 to 2020. Overall, 16,801 (2.28â¯%) of deliveries had an ADHD diagnosis in the year before or after delivery. ADHD rates increased 290â¯% from 101 (95%CI: 92-111) per 10,000 deliveries in 2008 to 394 (95%CI: 371-419) per 10,000 deliveries in 2020. White women experienced the highest rates followed by Black, Hispanic, and Asian, respectively. CONCLUSIONS: Increasing ADHD diagnosis rates during the perinatal period may reflect improved detection but racial disparities persist. Additional research is needed to develop equitable outreach strategies to better support women experiencing ADHD during the perinatal period.
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Importance: The US has the highest maternal mortality rate among developed countries. The Centers for Disease Control and Prevention deems nearly all of these deaths preventable, especially those attributable to mental health conditions. Coordination between US health care and social service systems could help further characterize circumstances and risks associated with perinatal suicide mortality. Objective: To examine contextual and individual precipitating circumstances and risks associated with perinatal suicide. Design, Setting, and Participants: This cross-sectional observational study used a convergent mixed methods design to explore factors contributing to maternal suicides and deaths of undetermined intent (hereinafter, undetermined deaths) identified in National Violent Death Reporting System (NVDRS) data for January 1, 2003, to December 31, 2021. Analyses included decedents who were aged 10 to 50 years and pregnant or post partum at death (collectively, the perinatal group) and demographically matched female decedents who were not pregnant or recently pregnant (nonperinatal group) at death. Analyses were performed between December 2022 and December 2023. Exposures: Pregnancy status at death (perinatal or nonperinatal). Main Outcomes and Measures: The main outcomes included contributing circumstances associated with suicides and undetermined deaths cited in coroner, medical examiner, or law enforcement case narratives. The study examined quantitative differences between groups using a matched analysis and characterized key themes of salient suicide circumstances using qualitative content analysis. Results: This study included 1150 perinatal decedents identified in the NVDRS: 456 (39.6%) were pregnant at death, 203 (17.7%) were pregnant within 42 days of death, and 491 (42.7%) were pregnant within 43 to 365 days before death, yielding 694 postpartum decedents. The nonperinatal comparison group included 17â¯655 female decedents aged 10 to 50 years. The mean (SD) age was 29.1 (7.4) years for perinatal decedents and 35.8 (10.8) years for nonperinatal decedents. Compared with matched nonperinatal decedents, perinatal decedents had higher odds of the following identified contributing circumstances: intimate partner problems (IPPs) (odds ratio [OR], 1.45 [95% CI, 1.23-1.72]), recent argument (OR, 1.33 [95% CI, 1.09-1.61]), depressed mood (OR, 1.39 [95% CI, 1.19-1.63]), substance abuse or other abuse (OR, 1.21 [95% CI, 1.03-1.42]), physical health problems (OR, 1.37 [95% CI, 1.09-1.72]), and death of a family member or friend (OR, 1.47 [95% CI, 1.06-2.02]). The findings of the qualitative analysis emphasized the importance of mental health and identified 128 decedents (12.4%) with postpartum depression. Conclusions and Relevance: This study provides insights into complex factors surrounding maternal suicide, and it highlights opportunities for further research to understand long-term consequences of perinatal mental health. These findings also underscore the need for targeted evidence-based interventions and effective policies targeting mental health, substance use, and IPPs to prevent maternal suicide and enhance maternal health outcomes.
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Suicidio , Humanos , Femenino , Embarazo , Estudios Transversales , Adulto , Suicidio/estadística & datos numéricos , Suicidio/psicología , Estados Unidos/epidemiología , Adolescente , Persona de Mediana Edad , Adulto Joven , Niño , Factores de Riesgo , Mortalidad Materna , Mortalidad Perinatal/tendenciasRESUMEN
BACKGROUND: The economic cost of perinatal mood and anxiety disorders (PMADs) is high and includes the cost of reduced maternal economic productivity, more preterm births, and increases in other maternal mental health expenditures. PMADs also substantially contribute the cost of maternal morbidity. This paper offers a discussion of the quality-of-care cascade model of PMADs, which outlines care pathways that people typically face as well as gaps and unmet needs that frequently happen along the way. The model uses the US health system as an example. A discussion of international implications follows. DISCUSSION: The quality-of-care cascade model outlines downward dips in quality of care along the perinatal mental health treatment continuum, including access (many Americans do not have access to affordable health insurance), enrollment (even when individuals are offered health insurance, some do not enroll), coverage (even if individuals have health insurance, some needed services or providers may not be covered), choice (even if services and providers are covered, patients may not be able to choose among plans, institutions, or clinicians), consistency (even if patients have a choice of plan or provider, a consistent source of care may not be accessible), referral (even if care is available and accessible, referral services may not be), quality (even if patients have access to both care and referral services, there may be gaps in the quality of care provided), adherence (even if patients receive high-quality care, they may not be adherent to treatment), barriers (societal forces that may influence people's choices and behaviors), and shocks (unanticipated events that could disrupt care pathways). In describing the quality-of-care cascade model, this paper uses the US healthcare system as the primary example. However, the model can extend to examine quality-of-care dips along the perinatal mental health treatment continuum within the international context. Although the US healthcare system may differ from other healthcare systems in many respects, shared commonalities lead to quality-of-care dips in countries with healthcare systems structured differently than in the US. IMPLICATIONS FOR HEALTH POLICIES: The global cost of PMADs remains substantial, and addressing the costs of these conditions could have a significant impact on overall cost and quality of care internationally. The quality-of-care cascade model presented in this paper could help identify, understand, and address the complex contributing factors that lead to dips in quality-of-care for perinatal mental health conditions across the world.
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Política de Salud , Servicios de Salud Mental , Calidad de la Atención de Salud , Humanos , Femenino , Servicios de Salud Mental/economía , Estados Unidos , Accesibilidad a los Servicios de Salud , Embarazo , Salud Mental , Trastornos de Ansiedad/terapia , Salud ReproductivaRESUMEN
OBJECTIVE: The authors evaluated associations between employment at discharge from Veterans Health Administration Vocational Rehabilitation Service (VR) programs and suicide and other causes of death. METHODS: For veterans receiving VR between October 1, 2005, and September 30, 2014 (N=78,293), proportional hazards analyses were used to test associations of employment with suicide, drug overdose, and external and natural cause mortality rates over 1 and 5 years postdischarge and through December 31, 2019. The analyses were adjusted for clinical and sociodemographic characteristics and propensity for employment. RESULTS: Of the veterans, 94.1% had a psychiatric diagnosis, and 35.5% were employed at VR discharge. In proportional hazards analyses, employment was associated with lower mortality rates through 1 year (suicide, hazard ratio [HR]=0.54; overdose, HR=0.70; external causes, HR=0.62; and natural causes, HR=0.51) and 5 years postdischarge (overdose, HR=0.72; external causes, HR=0.81; and natural causes, HR=0.72). Through December 31, 2019, employment was associated with lower risks for overdose (HR=0.80) and death by external (HR=0.81) and natural (HR=0.80) causes. CONCLUSIONS: Employment at VR discharge was associated with lower mortality risk among veterans with psychiatric diagnoses.
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Perinatal mood and anxiety disorders (PMAD), which include depression and/or anxiety in the year before and/or after delivery, are common complications of pregnancy, affecting up to one in four perinatal individuals, with costs of over $15 billion per year in the US. In this paper, we provide an overview of the disparities in utilization and delivery outcomes for individuals with perinatal mood and anxiety disorders in the US. In addition, we discuss the current US screening and treatment guidelines as well as the high societal costs of illness of PMAD for both perinatal individuals and children. Finally, we outline opportunities for quality improvement of PMAD care in the US, including leveraging increased engagement with healthcare system during prenatal care, working toward a more cohesive national strategy to address PMAD, leaning into evidence-based policymaking through collaboration with a panel of experts, and generating state-level profiles focused on PMAD.
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Posttraumatic stress disorder (PTSD) is a burdensome disorder, affecting 3-4 percent of delivering people in the US, with higher rates seen among Black and Hispanic people. The extent of clinical diagnosis remains unknown. We describe the temporal and racial and ethnic trends in perinatal PTSD diagnoses among commercially insured people with live-birth deliveries during the period 2008-20, using administrative claims from Optum's Clinformatics Data Mart Database. Predicted probabilities from our logistic regression analysis showed a 394 percent increase in perinatal PTSD diagnoses, from 37.7 per 10,000 deliveries in 2008 to 186.3 per 10,000 deliveries in 2020. White people had the highest diagnosis rate at all time points (208.0 per 10,000 deliveries in 2020), followed by Black people, people with unknown race, Hispanic people, and Asian people (188.7, 171.9, 146.9, and 79.8 per 10,000 deliveries in 2020, respectively). The significant growth in perinatal PTSD diagnosis rates may reflect increased awareness, diagnosis, or prevalence of the disorder. However, these rates fall well below the estimated prevalence of PTSD in the perinatal population.
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Trastornos por Estrés Postraumático , Femenino , Humanos , Embarazo , Asiático , Hispánicos o Latinos , Parto , Trastornos por Estrés Postraumático/diagnóstico , Trastornos por Estrés Postraumático/epidemiología , Estados Unidos/epidemiología , Blanco , Negro o Afroamericano , Grupos RacialesRESUMEN
We aimed to determine whether antidepressant prescriptions for perinatal mood and anxiety disorder (PMAD) increased after several professional organizations issued clinical recommendations in 2015 and 2016. This serial, cross-sectional, logistic regression analysis evaluated changes in antenatal and postpartum antidepressant prescriptions among commercially insured people who had a live-birth delivery as well as a PMAD diagnosis during the period 2008-20. For people with antenatal PMAD, the odds of an antenatal antidepressant prescription decreased 3 percent annually from 2008 to 2016 and increased by 32 percent in 2017, and the annual rate of change increased 5 percent for 2017-20 compared with 2008-16. For people with postpartum PMAD, the odds of a postpartum antidepressant prescription decreased 2 percent annually from 2008 to 2016 and experienced no significant change in 2017, but the annual rate of change increased 3 percent for 2017-20 compared with 2008-16. The clinical recommendations issued in 2015 and 2016 were associated with increased antidepressant prescriptions for PMAD, particularly for antenatal PMAD. These findings indicate that clinical recommendations represent an effective tool for changing prescribing patterns.
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Antidepresivos , Trastornos de Ansiedad , Humanos , Femenino , Embarazo , Estudios Transversales , Antidepresivos/uso terapéutico , Trastornos de Ansiedad/tratamiento farmacológico , Prescripciones de Medicamentos , Seguro de SaludRESUMEN
OBJECTIVE: The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration. METHODS: The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models. RESULTS: In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload. CONCLUSIONS: Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.
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Personal de Salud , Servicios de Salud Mental , United States Department of Veterans Affairs , Carga de Trabajo , Humanos , Estados Unidos , Servicios de Salud Mental/estadística & datos numéricos , Personal de Salud/estadística & datos numéricos , Personal de Salud/psicología , Masculino , Femenino , Adulto , Persona de Mediana Edad , Autonomía Profesional , Encuestas y Cuestionarios , ObjetivosRESUMEN
Nationwide, perinatal mood and anxiety disorder (PMAD) diagnoses among privately insured people increased by 93.3 percent from 2008 to 2020, growing faster in 2015-20 than in 2008-14. Most states and demographic subgroups experienced increases, suggesting worsening morbidity in maternal mental health nationwide. PMAD-associated suicidality and psychotherapy rates also increased nationwide from 2008 to 2020. Relative to 2008-14, psychotherapy rates continued to rise in 2015-20, whereas suicidality rates declined.
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Trastornos de Ansiedad , Rosa , Femenino , Embarazo , Humanos , Trastornos de Ansiedad/epidemiología , Ansiedad , Seguro de SaludRESUMEN
Objective: We sought to examine trends in diagnosed behavioral health (BH) conditions [mental health (MH) disorders or substance use disorders (SUD)] among pregnant and postpartum individuals between 2008-2020. We then explored the relationship between BH conditions and race/ethnicity, acknowledging race/ethnicity as a social construct that influences health disparities. Methods: This study included delivering individuals, aged 15-44 years, and continuously enrolled in a single commercial health insurance plan for 1 year before and 1 year following delivery between 2008-2020. We used BH conditions as our outcome based on relevant ICD 9/10 codes documented during pregnancy or the postpartum year. Results: In adjusted analyses, white individuals experienced the highest rates of BH conditions, followed by Black, Hispanic, and Asian individuals, respectively. Asian individuals had the largest increase in BH rates, increasing 292%. White individuals had the smallest increase of 192%. The trend remained unchanged even after adjusting for age and Bateman comorbidity score, the trend remained unchanged. Conclusions: The prevalence of diagnosed BH conditions among individuals in the perinatal and postpartum periods increased over time. As national efforts continue to work toward improving perinatal BH, solutions must incorporate the needs of diverse populations to avert preventable morbidity and mortality.
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Etnicidad , Hispánicos o Latinos , Adolescente , Adulto , Femenino , Humanos , Embarazo , Adulto Joven , Asiático , Negro o Afroamericano , Morbilidad , Blanco , Estados UnidosRESUMEN
PURPOSE: To estimate the societal costs of untreated perinatal mood and anxiety disorders (PMADs) in Vermont for the 2018-2020 average annual birth cohort from conception through five years postpartum. METHODS: We developed a cost analysis model to calculate the excess cases of outcomes attributed to PMADs in the state of Vermont. Then, we modeled the associated costs of each outcome incurred by birthing parents and their children, projected five years for birthing parents who do not achieve remission by the end of the first year postpartum. RESULTS: We estimated that the total societal cost of untreated PMADs in Vermont could reach $48 million for an annual birth cohort from conception to five years postpartum, amounting to $35,910 in excess societal costs per birthing parent with an untreated PMAD and their child. CONCLUSION: Our model provides evidence of the high costs of untreated PMADs for birthing parents and their children in Vermont. Our estimates for Vermont are slightly higher but comparable to national estimates, which are $35,500 per birthing parent-child pair, adjusted to 2021 US dollars. Investing in perinatal mental health prevention and treatment could improve health outcomes and reduce economic burden of PMADs on individuals, families, employers, and the state.
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Trastornos de Ansiedad , Costo de Enfermedad , Humanos , Vermont , Femenino , Embarazo , Trastornos de Ansiedad/economía , Adulto , Costos de la Atención en Salud/estadística & datos numéricos , Trastornos del Humor/economía , Complicaciones del Embarazo/economía , Complicaciones del Embarazo/psicología , Atención Perinatal/economíaRESUMEN
BACKGROUND: Simultaneous urine testing for albumin (UAlb) and serum creatinine (SCr), that is, 'dual testing,' is an accepted quality measure in the management of diabetes. As chronic kidney disease (CKD) is defined by both UAlb and SCr testing, this approach could be more widely adopted in kidney care. OBJECTIVE: We assessed time trends and facility-level variation in the performance of outpatient dual testing in the integrated Veterans Health Administration (VHA) system. DESIGN, SUBJECTS AND MAIN MEASURES: This retrospective cohort study included patients with any inpatient or outpatient visit to the VHA system during the period 2009-2018. Dual testing was defined as UAlb and SCr testing in the outpatient setting within a calendar year. We assessed time trends in dual testing by demographics, comorbidities, high-risk (eg, diabetes) specialty care and facilities. A generalised linear mixed-effects model was applied to explore individual and facility-level predictors of receiving dual testing. KEY RESULTS: We analysed data from approximately 6.9 million veterans per year. Dual testing increased, on average, from 17.4% to 21.2%, but varied substantially among VHA centres (0.3%-43.7% in 2018). Dual testing was strongly associated with diabetes (OR 10.4, 95% CI 10.3 to 10.5, p<0.0001) and not associated with VHA centre complexity level. However, among patients with high-risk conditions including diabetes, <50% received dual testing in any given year. As compared with white veterans, black veterans were less likely to be tested after adjusting for other individual and facility characteristics (OR 0.93, 95% CI 0.92 to 0.93, p<0.0001). CONCLUSIONS: Dual testing for CKD in high-risk specialties is increasing but remains low. This appears primarily due to low rates of testing for albuminuria. Promoting dual testing in high-risk patients will help to improve disease management and patient outcomes.
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Diabetes Mellitus , Insuficiencia Renal Crónica , Veteranos , Humanos , Estados Unidos/epidemiología , Creatinina , Salud de los Veteranos , Estudios Retrospectivos , Pacientes Ambulatorios , Diabetes Mellitus/epidemiología , Diabetes Mellitus/terapia , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/epidemiología , Insuficiencia Renal Crónica/terapia , United States Department of Veterans AffairsRESUMEN
BACKGROUND: Promoting appropriate pharmacotherapy requires understanding the factors that influence how clinicians prescribe medications. While prior work has focused on patient and clinician factors, features of the organizational setting have received less attention, though identifying sources of variation in prescribing may help identify opportunities to improve patient safety and outcomes. OBJECTIVE: To evaluate the relationship between the number of clinicians who prescribe medications in a facility and facility prescribing intensity of six individual medication classes by clinician specialty: benzodiazepines, antipsychotics, antiepileptics, and antidepressants by psychiatrists and antibiotics, opioids, antiepileptics, and antidepressants by primary care clinicians (PCPs). DESIGN: We used 2017 Veterans Health Administration (VHA) administrative data. SUBJECTS: We included patient-clinician dyads of older patients (> 55 years) with an outpatient encounter with a clinician in 2017. Patient-clinician data from 140 VHA facilities were included (n = 13,347,658). Analysis was repeated for years 2014 to 2016. MAIN MEASURES: For each medication, facility prescribing intensity measures were calculated as clinician prescribing intensity averaged over all clinicians at each facility. Clinician prescribing intensity measures included percentage of each clinician's patients prescribed the medication and mean number of days supply per patient among all patients of each clinician. KEY RESULTS: As the number of prescribing clinicians in a facility increased, the intensity of prescribing decreased. Every increase of 10 facility clinicians was associated with a significant decline in prescribing intensity for both specialties for different medication classes: for psychiatrists, declines ranged from 6 to 11%, and for PCPs, from 2 to 3%. The pattern of more clinicians less prescribing was significant across all years. CONCLUSION: Future work should explore the mechanisms that link the number of facility clinicians with prescribing intensity for benzodiazepines, antipsychotics, antiepileptics, antidepressants, antibiotics, and opioids. Facilities with fewer clinicians may need additional resources to avoid unwanted prescribing of potentially harmful or unnecessary medications.
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Analgésicos Opioides , Anticonvulsivantes , Humanos , Analgésicos Opioides/uso terapéutico , Anticonvulsivantes/uso terapéutico , Antibacterianos/uso terapéutico , Psicotrópicos/uso terapéutico , Benzodiazepinas/uso terapéutico , Antidepresivos , Pautas de la Práctica en MedicinaRESUMEN
PURPOSE: To assess the relationship between behavioral health provider (BHP) perceptions of support during COVID-19 and burnout and self-reported workload. DESIGN: We conducted a cross-sectional analysis of provider-level data collected from the 2020 and 2021 All Employee Survey (AES). SETTING: The Veterans Health Administration. SUBJECTS: 36,541 (10,332 [28.28%] with missing data) respondents in 2020 and 2021 combined. MEASURES: Main outcomes were self-reported burnout and self-reported workload. Main predictors were 6 COVID-19-related provider-perceived support domains. Covariates were 11 AES demographic predictors. ANALYSIS: We conducted mixed-effects logistic regression modeling for each domain and outcome pairing. We summarized our results using average marginal effects (AMEs) and odds ratios (ORs). RESULTS: All 6 domains of feeling prepared, heard, protected, cared for, honored, and having flexible policies were significantly negatively associated with burnout (AMEs -.20 to -.10, ORs .38-.63, P < .001) and positively associated with reasonable workload (AMEs .11-.20, ORs 1.63-2.59, P < .001). Feeling prepared had the largest associations with burnout (OR .38) and reasonable workload (OR 2.59). CONCLUSION: Creating a work environment with flexible policies and where staff feel prepared, heard, protected, cared for, and honored could support BHPs in feeling less burned out and that their workload is reasonable.
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Agotamiento Profesional , COVID-19 , Liderazgo , Carga de Trabajo , Humanos , COVID-19/psicología , COVID-19/epidemiología , Agotamiento Profesional/psicología , Agotamiento Profesional/epidemiología , Estudios Transversales , Carga de Trabajo/psicología , Masculino , Femenino , Estados Unidos , Adulto , Persona de Mediana Edad , United States Department of Veterans Affairs , SARS-CoV-2 , Personal de Salud/psicología , Pandemias , Cultura Organizacional , Encuestas y CuestionariosRESUMEN
BACKGROUND: Perinatal Mood and Anxiety Disorders (PMADs) affect one in five birthing individuals and represent a leading cause of maternal mortality. While these disorders are associated with a variety of poor outcomes and generate significant societal burden, underdiagnosis and undertreatment remain significant barriers to improved outcomes. We aimed to quantify whether the Patient Protection Affordable Care Act (ACA) improved PMAD diagnosis and treatment rates among Michigan Medicaid enrollees. METHODS: We applied an interrupted time series framework to administrative Michigan Medicaid claims data to determine if PMAD monthly diagnosis or treatment rates changed after ACA implementation for births 2012 through 2018. We evaluated three treatment types, including psychotherapy, prescription medication, and either psychotherapy or prescription medication. Participants included the 170,690 Medicaid enrollees who had at least one live birth between 2012 and 2018, with continuous enrollment from 9 months before birth through 3 months postpartum. RESULTS: ACA implementation was associated with a statistically significant 0.76% point increase in PMAD diagnosis rates (95% CI: 0.01 to 1.52). However, there were no statistically significant changes in treatment rates among enrollees with a PMAD diagnosis. CONCLUSION: The ACA may have improved PMAD detection and documentation in clinical settings. While a higher rate of PMAD cases were identified after ACA Implementation, Post-ACA cases were treated at similar rates as Pre-ACA cases.
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Medicaid , Patient Protection and Affordable Care Act , Embarazo , Femenino , Estados Unidos/epidemiología , Humanos , Michigan/epidemiología , Análisis de Series de Tiempo Interrumpido , Trastornos de Ansiedad/diagnóstico , Trastornos de Ansiedad/epidemiología , Trastornos de Ansiedad/terapia , Cobertura del SeguroRESUMEN
OBJECTIVE: This study quantified the prevalence of postpartum mood and anxiety disorder (PMAD) diagnoses among symptomatic Michigan Medicaid enrollees and explored factors associated with receiving a diagnosis. METHODS: Data sources comprised Michigan Medicaid administrative claims and Phase 7 Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS) survey responses, linked at the individual level. Participants were continuously enrolled in Michigan Medicaid, delivered a live birth (2012-2015), responded to the survey, and screened positive for PMAD symptoms on the adapted two-item Patient Health Questionnaire. Unadjusted and adjusted weighted logistic regression analyses were used to predict the likelihood of having a PMAD diagnosis (for the overall sample and stratified by race). RESULTS: The weighted analytic cohort represented 24,353 deliveries across the 4-year study. Only 19.8% of respondents with symptoms of PMAD had a PMAD diagnosis between delivery and 3 months afterward. Black respondents were less likely to have PMAD diagnoses (adjusted odds ratio [AOR]=0.23, 95% CI=0.11-0.49) compared with White respondents. Among White respondents, no covariates were significantly associated with having a diagnosis. However, among Black respondents, more comorbid conditions and more life stressors were statistically significantly associated with having a diagnosis (AOR=3.18, 95% CI=1.27-7.96 and AOR=3.12, 95% CI=1.10-8.88, respectively). CONCLUSIONS: Rate of PMAD diagnosis receipt differed by race and was low overall. Black respondents were less likely than White respondents to receive a diagnosis. Patient characteristics influencing diagnosis receipt also differed by race, indicating that strategies to improve detection of these disorders require a tailored approach.
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Trastornos de Ansiedad , Medicaid , Embarazo , Femenino , Estados Unidos/epidemiología , Humanos , Trastornos de Ansiedad/diagnóstico , Trastornos de Ansiedad/epidemiología , Michigan/epidemiología , Ansiedad , Periodo PospartoRESUMEN
OBJECTIVE: Burnout is widespread among psychotherapists and leads to negative mental and other health outcomes, absenteeism, and turnover. Job resources, including institutional support for evidence-based practices, can buffer against burnout and may improve satisfaction among therapists. The Veterans Health Administration (VHA) is the nation's largest integrated health system and employs 23,000 therapists, including psychologists, social workers, and counselors. The authors assessed associations between perceived institutional support for evidence-based treatment and satisfaction and burnout among VHA therapists. METHODS: This analysis used data from the VHA's national 2018 Mental Health Provider Survey. Responding therapists (N=5,341) answered questions about the quality of mental health care and job satisfaction. Multilevel logistic regression models were used to predict burnout and satisfaction. The authors tested availability of evidence-based treatment and measurement-based care (MBC) as predictors; analyses were adjusted for therapist workload, demographic characteristics, and potential clustering by facility. RESULTS: VHA therapists had less burnout and more job satisfaction when they perceived receiving institutional support for evidence-based psychotherapy (EBP) and MBC, irrespective of whether the analyses were adjusted for workload. Less difficulty in scheduling EBP was significantly associated with decreased likelihood of burnout (OR=0.83, p<0.001) and increased satisfaction (OR=1.09, p=0.008). Less difficulty ending psychotherapy was significantly associated with decreased likelihood of burnout (OR=0.89, p=0.002) and increased satisfaction (OR=1.12, p=0.004). CONCLUSIONS: Support for evidence-based practices, including EBP and MBC, was closely linked to VHA therapists' satisfaction and burnout. Expanding support for therapists to provide evidence-based treatment may benefit therapists, patients, and the health care system.