Breastfeeding patterns and effects of minimal supplementation on breastfeeding exclusivity and duration in term infants: A prospective sub-study of a randomised controlled trial.

AIM: Despite international recommendations, less than one-third of Australian women exclusively breastfeed for 6 months. The aims of this study were to prospectively determine rates and factors associated with the type and duration of breastfeeding in the first year and examine the effect of minimal supplementation. METHODS: We conducted a sub-study of a randomised controlled trial in Sydney, Australia, which included 635 women with uncomplicated term births who intended to breastfeed. Data were collected daily for 56 days, and then at 2, 6 and 12 months post-partum. RESULTS: Breastfeeding outcomes were evaluated for 553 (87%), 480 (76%) and 392 (62%) women at 2, 6 and 12 months. Exclusive breastfeeding was 81% at 2 months and 8% at 6 months. Partial breastfeeding was 75% at 6 months and 54% at 12 months. Factors associated with breastfeeding cessation included caesarean birth, low milk supply, problems latching, increased time to breastfeed, use of formula >7 days in the first 2 months, return to work and early introduction of solids. Breast pain in the first week was associated with a 10% decrease in exclusive breastfeeding. Cracked nipples and no previous breastfeeding experience were associated with supplementation of ≤7 days but had no effect on long-term breastfeeding duration. CONCLUSIONS: Exclusive breastfeeding declined significantly between 2 and 6 months post-partum. Early intervention and education to prolong breastfeeding duration should include strategies to manage breast pain and nipple damage to minimise prolonged supplementation. Consistent guidelines about introduction of complementary foods, improved maternity leave and workplace incentives could be effective in prolonging breastfeeding.

Patterns of Opioid and Benzodiazepine Use in Opioid-Naïve Patients with Newly Diagnosed Low Back and Lower Extremity Pain.

BACKGROUND: The morbidity and mortality associated with opioid and benzodiazepine co-prescription is a pressing national concern. Little is known about patterns of opioid and benzodiazepine use in patients with acute low back pain or lower extremity pain. OBJECTIVE: To characterize patterns of opioid and benzodiazepine prescribing among opioid-naïve, newly diagnosed low back pain (LBP) or lower extremity pain (LEP) patients and to investigate the relationship between benzodiazepine prescribing and long-term opioid use. DESIGN/SETTING: We performed a retrospective analysis of a commercial database containing claims for more than 75 million enrollees in the USA. PARTICIPANTS: Participants were adult patients newly diagnosed with LBP or LEP between 2008 and 2015 who did not have a red flag diagnosis, had not received an opioid prescription in the 6 months prior to diagnosis, and had 12 months of continuous enrollment after diagnosis. MAIN OUTCOMES AND MEASURES: Among patients receiving at least one opioid prescription within 12 months of diagnosis, we defined discrete patterns of benzodiazepine prescribing-continued use, new use, stopped use, and never use. We tested the association of these prescription patterns with long-term opioid use, defined as six or more fills within 12 months. RESULTS: We identified 2,497,653 opioid-naïve patients with newly diagnosed LBP or LEP. Between 2008 and 2015, 31.9% and 11.5% of these patients received opioid and benzodiazepine prescriptions, respectively, within 12 months of diagnosis. Rates of opioid prescription decreased from 34.8% in 2008 to 27.0% in 2015 (P < 0.001); however, prescribing of benzodiazepines only decreased from 11.6% in 2008 to 10.8% in 2015. Patients with continued or new benzodiazepine use consistently used more opioids than patients who never used or stopped using benzodiazepines during the study period (one-way ANOVA, P < 0.001). For patients with continued and new benzodiazepine use, the odds ratio of long-term opioid use compared with those never prescribed a benzodiazepine was 2.99 (95% CI, 2.89-3.08) and 2.68 (95% CI, 2.62-2.75), respectively. LIMITATIONS: This study used administrative claims analyses, which rely on accuracy and completeness of diagnostic, procedural, and prescription codes. CONCLUSION: Overall opioid prescribing for low back pain or lower extremity pain decreased substantially during the study period, indicating a shift in management within the medical community. Rates of benzodiazepine prescribing, however, remained at approximately 11%. Concurrent prescriptions of benzodiazepines and opioids after LBP or LEP diagnosis were associated with increased risk of long-term opioid use.

A randomized, placebo-controlled crossover trial of phentermine-topiramate ER in patients with binge-eating disorder and bulimia nervosa.

OBJECTIVE: Open trials suggest phentermine/topiramate ER (PHEN/TPM-ER), food and drug administration (FDA) approved for obesity, has utility for binge eating. With no randomized controlled trials (RCTs) yet performed, this trial aimed to evaluate PHEN/TPM-ERs efficacy and safety in a crossover RCT for patients with binge-eating disorder (BED) or bulimia nervosa (BN). METHOD: Participants were randomized to 12-weeks PHEN/TPM-ER (3.75 mg/23 mg-15 mg/92 mg) or placebo followed by 2-weeks drug washout, then 12-week crossover. Demographics, vitals, eating disorder behaviors, mood, and side effects were measured. Primary outcome was objective binge-eating (OBE) days/4-weeks; secondary outcomes included binge abstinence. Mixed-effect models estimated treatment effects, with fixed effects adjusting for treatment, study period, and diagnosis. RESULTS: The 22 adults (BED = 18, BN = 4) were female (96%), Caucasian (55%), aged 42.9 (SD = 10.1) years with body mass index = 31.1 (SD = 6.2) kg/m2 . Baseline OBE days/4-weeks decreased from 16.2 (SD = 7.8) to 4.2 (SD = 8.4) after PHEN/TPM-ER versus 13.2 (SD = 9.1) after placebo (p < .0001), with abstinence rates = 63.6% on PHEN/TPM-ER versus 9.1% on placebo (p < .0001). Weight changes = -5.8 kg on PHEN/ TPM-ER versus +0.4 kg on placebo. Drop-out = 2 (9%) on PHEN/TPM-ER and 2 (9%) on placebo, with few side effects. Vital sign changes with PHEN/TPM-ER were minimal and similar to placebo. Responses were not significantly different for BED versus BN. DISCUSSION: This first RCT to evaluate the efficacy and safety of PHEN/TPM-ER for BED/BN found this drug combination significantly more effective at reducing binge eating than placebo and well tolerated. However, with only four participants with BN, findings regarding the safety of PHEN/TPM-ER in patients with BN must be taken with caution. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT02553824 registered on 9/17/2015. https://clinicaltrials.gov/ct2/show/NCT02553824.

The impact of state parity laws on copayments for and adherence to oral endocrine therapy for breast cancer.

BACKGROUND: Adherence to endocrine therapy for breast cancer is often inadequate, in part because of out-of-pocket costs for medication. Numerous states have enacted parity laws to limit patient cost-sharing for oral anticancer drugs. The objective of this study was to estimate the impact of these laws on patient copayments for and adherence to oral endocrine therapy for breast cancer. METHODS: Administrative health insurance claims data from 2007 to 2014 derived from a US health care database were used to identify female patients aged 18 to 64 years with invasive cancer or ductal carcinoma in situ of the breast who initiated endocrine therapy and were enrolled in fully insured health plans in states that either enacted parity legislation between 2008 and 2013 or had not yet enacted such legislation by 2015. Differences-in-differences analysis was used to compare copayments for and adherence to endocrine therapy during the 1-year period before and after each year of legislation enactment. RESULTS: In total, 6900 individuals who received 7778 unique drug therapy courses were identified. Parity legislation was associated with significant decreases in the 25th percentile of copayments for anastrozole of $4.39 (95% confidence interval [CI], -$4.52 to -$4.26; P < .001) and for exemestane of $3.08 (95% CI, -$4.80 to -$1.35; P < .001). The median copayment for exemestane decreased by $10.25 (95% CI, -$12.61 to -$7.89; P < .001). A higher median monthly copayment was significantly associated with a greater risk of medication nonadherence (adjusted risk ratio, 1.006 per dollar increase; P < .001). CONCLUSIONS: Parity laws had a modest effect on lowering the cost of anastrozole and exemestane, but more focused efforts to limit out-of-pocket costs for endocrine therapy may have a greater impact on medication adherence.

A population-based comparison of the post-operative outcomes of open and laparoscopic appendicectomy in children.

OBJECTIVE: To assess and compare the post-operative outcomes of open and laparoscopic appendicectomy in children. DESIGN: Record linkage analysis of administrative hospital (Admitted Patient Data Collection) and emergency department (Emergency Department Data Collection) data.Participants, setting: Children under 16 years of age who underwent an appendicectomy in a public or private hospital in New South Wales between January 2002 and December 2013. MAIN OUTCOME MEASURES: Association between type of appendicectomy and post-operative complications within 28 days of discharge, adjusted for patient characteristics and type of hospital. RESULTS: Of 23 961 children who underwent appendicectomy, 19 336 (81%) had uncomplicated appendicitis and 4625 (19%) had appendicitis complicated by abscess, perforation, or peritonitis. The proportion of laparoscopic appendicectomies increased from 11.8% in 2002 to 85.8% in 2013. In cases of uncomplicated appendicitis, laparoscopic appendicectomy was associated with more post-operative complications (mostly symptomatic re-admissions or emergency department presentations) than open appendicectomy (7.4% v 5.8%), but with a reduced risk of post-operative intestinal obstruction (adjusted odds ratio [aOR], 0.59; 95% CI, 0.36-0.97). For cases of complicated appendicitis, the risk of wound infections was lower for laparoscopic appendicectomy (aOR, 0.67; 95% CI, 0.50-0.90), but not the risks of intestinal obstruction (aOR, 0.97; 95% CI, 0.62-1.52) or intra-abdominal abscess (aOR, 1.06; 95% CI, 0.72-1.55). CONCLUSION: Post-appendicectomy outcomes were similar for most age groups and hospital types. Children with uncomplicated appendicitis have lower risk of post-operative bowel obstruction after laparoscopic appendicectomy than after open appendicectomy, but may be discharged before their post-operative symptoms have adequately resolved.

Gestation at birth, mode of birth, infant feeding and childhood hospitalization with infection.

INTRODUCTION: Infections are a leading cause of mortality and morbidity in preschool children. We aimed to assess the impact of the co-occurrence of cesarean section, early birth and formula feeding on hospitalization with infection in early childhood. MATERIAL AND METHODS: Population-based retrospective record-linkage cohort study of 488 603 singleton livebirths ≥32 weeks' gestational age in New South Wales, Australia, 2007-2012. Multivariable Cox-regression was used to estimate independent and combined adjusted associations of gestational age, mode of birth (vaginal or cesarean section by labor onset) and formula feeding with time to first and repeat hospitalization with infection for children less than five years of age. RESULTS: In all, 95 346 (19.5%) children were hospitalized with infection, and of these 24.8% (23 615) more than once. Median age at first and repeat hospitalization was 1.1 and 1.7 years, respectively. Earlier gestation, modes of birth other than spontaneous vaginal, and formula feeding were independently associated with an increased risk of first and repeat hospitalization with infection. At 32-36 weeks' gestation, co-occurrence of perinatal factors (cf. spontaneous vaginal birth at 39+ weeks without formula feeding) was associated with a 2-fold and 1.5-fold increased risk of first and repeat hospitalization, respectively. For births at 37-38 weeks, the increased risk was 1.5-fold and 1.25-fold for first and repeat hospitalization, respectively. CONCLUSIONS: Cesarean section, labor induction, birth at <39 weeks and formula feeding increase the risk of infection-related hospitalization in childhood, which increases further when these factors co-occur. Reducing early planned birth and supporting breastfeeding are potentially cost-effective approaches to reducing the risk of hospitalization.

The impact of general anesthesia on child development and school performance: a population-based study.

BACKGROUND: There has been considerable interest in the possible adverse neurocognitive effects of exposure to general anesthesia and surgery in early childhood. AIMS: The aim of this data linkage study was to investigate developmental and school performance outcomes of children undergoing procedures requiring general anesthesia in early childhood. METHODS: We included children born in New South Wales, Australia of 37+ weeks' gestation without major congenital anomalies or neurodevelopmental disability with either a school entry developmental assessment in 2009, 2012, or Grade-3 school test results in 2008-2014. We compared children exposed to general anesthesia aged <48 months to those without any hospitalization. Children with only 1 hospitalization with general anesthesia and no other hospitalization were assessed separately. Outcomes included being classified developmentally high risk at school entry and scoring below national minimum standard in school numeracy and reading tests. RESULTS: Of 211 978 children included, 82 156 had developmental assessment and 153 025 had school test results, with 12 848 (15.7%) and 25 032 (16.4%) exposed to general anesthesia, respectively. Children exposed to general anesthesia had 17%, 34%, and 23% increased odds of being developmentally high risk (adjusted odds ratio [aOR]: 1.17; 95% CI: 1.07-1.29); or scoring below the national minimum standard in numeracy (aOR: 1.34; 95% CI: 1.21-1.48) and reading (aOR: 1.23; 95% CI: 1.12-1.36), respectively. Although the risk for being developmentally high risk and poor reading attenuated for children with only 1 hospitalization and exposure to general anesthesia, the association with poor numeracy results remained. CONCLUSION: Children exposed to general anesthesia before 4 years have poorer development at school entry and school performance. While the association among children with 1 hospitalization with 1 general anesthesia and no other hospitalization was attenuated, poor numeracy outcome remained. Further investigation of the specific effects of general anesthesia and the impact of the underlying health conditions that prompt the need for surgery or diagnostic procedures is required, particularly among children exposed to long duration of general anesthesia or with repeated hospitalizations.

Formula supplementation in hospital and subsequent feeding at discharge among women who intended to exclusively breastfeed: An administrative data retrospective cohort study.

BACKGROUND: Among women who intend to exclusively breastfeed, it is important to identify mothers and their infants who have a greater risk of formula supplementation in hospital, and are unlikely to recover exclusive breastfeeding at discharge. We investigated factors associated with in-hospital formula feeding among healthy term infants born to women who intended to exclusively breastfeed, and among this group, predictors of infant feeding at discharge. METHODS: Retrospective cohort study utilizing routinely collected clinical data for women who intended to exclusively breastfeed and gave birth to healthy term infants in five hospitals in New South Wales, Australia, 2010-2013. Robust Poisson regression was used to obtain adjusted relative risks (aRR) for the associations between formula feeding in hospital, feeding at discharge, and associated factors. RESULTS: Of 24 713 mother-infant dyads in the study population, 16.5% received formula in hospital. After adjustment, the strongest predictors of formula supplementation were breastfeeding difficulties (aRR 2.90 [95% confidence interval {CI} 2.74-3.07]), Asian born mother (aRR 2.07 [95% CI 1.92-2.23]), and neonatal conditions (aRR 2.00 [95% CI 1.89-2.13]). Among infants who received formula (n=3998), 49.3% were fully breastfeeding at discharge, 33.1% partially breastfeeding, and 17.5% formula-only feeding. Compared with formula-only feeding, special care nursery admission (aRR 1.23 [95% CI 1.17-1.30]) and ≥1 neonatal conditions (compared with none) were most strongly associated with fully breastfeeding at discharge (aRR 1.21 [95% CI 1.16-2.16]). CONCLUSION: Women and their infants who receive formula in hospital need additional support to attain exclusive breastfeeding by hospital discharge. Such support is especially needed for younger women, smokers, and women with breastfeeding difficulties.

Gestational age, mode of birth and breastmilk feeding all influence acute early childhood gastroenteritis: a record-linkage cohort study.

BACKGROUND: Acute gastroenteritis (AGE) is a leading cause of infectious morbidity in childhood. Clinical studies have implicated caesarean section, early birth and formula feeding in modifying normal gut microbiota development and immune system homeostasis in early life. Rates of early birth and cesarean delivery are also increasing worldwide. This study aimed to investigate the independent and combined associations of the mode and timing of birth and breastmilk feeding with AGE hospitalisations in early childhood. METHODS: Population-based record-linkage study of 893,360 singleton livebirths of at least 33 weeks gestation without major congenital conditions born in hospital, New South Wales, Australia, 2001-2011. Using age at first AGE hospital admission, Cox-regression was used to estimate the associations for gestational age, vaginal birth or caesarean delivery by labour onset and formula-only feeding while adjusting for confounders. RESULTS: There were 41,274 (4.6 %) children admitted to hospital at least once for AGE and the median age at first admission was 1.4 years. Risk of AGE admission increased with decreasing gestational age (37-38 weeks: 15 % increased risk, 33-36 weeks: 25 %), caesarean section (20 %), planned birth (17 %) and formula-only feeding (18 %). The rate of AGE admission was highest for children who were born preterm by modes of birth other than vaginal birth following the spontaneous onset of labour and who received formula-only at discharge from birth care (62-78 %). CONCLUSIONS: Vaginal birth following spontaneous onset of labour at 39+ weeks gestation with any breastfeeding minimised the risk of gastroenteritis hospitalisation in early childhood. Given increasing trends in early planned birth and caesarean section worldwide, these results provide important information about the impact obstetric interventions may have on the development of the infant gut microbiota and immunity.

Factors associated with changes into public or private maternity care for a second pregnancy.

OBJECTIVE: The aim of this study was to determine whether outcomes in a first pregnancy were associated with changes into and out of public maternity care. METHODS: The study population included 155492 women with first and second sequential singleton births, 2000-09 in New South Wales. Analyses were stratified by whether obstetric care for the first birth involved private or public maternity care. Interventions, infant and maternal outcomes were assessed as predictors of a change in care. Adjusted odds ratios for changing care were obtained from logistic regression using backwards elimination. RESULTS: Similar proportions of women changed from private to public care between first and second births (9.6% compared with 9.4% public to private, P-value=0.10). Although interventions (operative delivery, epidural) and outcomes (low Apgar, preterm birth, perinatal death, postpartum haemorrhage, perineal tear and severe maternal morbidity) were all associated with changes from public to private care, only poor infant condition (adjusted odds ratio 1.39, 95% confidence interval 1.15-1.68) was associated with a change from private to public care. CONCLUSIONS: The majority of women had consistent care type for both births. This may indicate that women are generally satisfied with care, they rationalise that their first birth care was optimal or they value continuity of carer across pregnancies.

Investigating linkage rates among probabilistically linked birth and hospitalization records.

BACKGROUND: With the increasing use of probabilistically linked administrative data in health research, it is important to understand whether systematic differences occur between the populations with linked and unlinked records. While probabilistic linkage involves combining records for individuals, population perinatal health research requires a combination of information from both the mother and her infant(s). The aims of this study were to (i) describe probabilistic linkage for perinatal records in New South Wales (NSW) Australia, (ii) determine linkage proportions for these perinatal records, and (iii) assess records with linked mother and infant hospital-birth record, and unlinked records for systematic differences. METHODS: This is a population-based study of probabilistically linked statutory birth and hospital records from New South Wales, Australia, 2001-2008. Linkage groups were created where the birth record had complete linkage with hospital admission records for both the mother and infant(s), partial linkage (the mother only or the infant(s) only) or neither. Unlinked hospital records for mothers and infants were also examined. Rates of linkage as a percentage of birth records and descriptive statistics for maternal and infant characteristics by linkage groups were determined. RESULTS: Complete linkage (mother hospital record - birth record - infant hospital record) was available for 95.9% of birth records, partial linkage for 3.6%, and 0.5% with no linked hospital records (unlinked). Among live born singletons (complete linkage = 96.5%) the mothers without linked infant records (1.6%) had slightly higher proportions of young, non-Australian born, socially disadvantaged women with adverse pregnancy outcomes. The unlinked birth records (0.4%) had slightly higher proportions of nulliparous, older, Australian born women giving birth in private hospitals by caesarean section. Stillbirths had the highest rate of unlinked records (3-4%). CONCLUSIONS: This study shows that probabilistic linkage of perinatal records can achieve high, representative levels of complete linkage. Records for mother's that did not link to infant records and unlinked records had slightly different characteristics to fully linked records. However, these groups were small and unlikely to bias results and conclusions in a substantive way. Stillbirths present additional challenges to the linkage process due to lower rates of linkage for lower gestational ages, where most stillbirths occur.

Alternatives to low birthweight as a population-level indicator of infant and child health.

BACKGROUND: Low birthweight (<2500 g) is often used as a population-level indicator of maternal-child health, as it is easy to measure and correlates with poorer infant health outcomes. However, it conflates preterm birth and intrauterine growth restriction, which have different causal pathways and require different approaches to prevention. Small for gestational age (SGA) (a proxy for growth restriction) and preterm birth may be more informative measures. We evaluated low birthweight as a population-level indicator. METHODS: We conducted a population-based cohort study of singleton live births in New South Wales (NSW), Australia, using linked data from 1994-2006 birth, hospital, death and educational records, with follow-up until 2014. Outcomes of babies born of low birthweight, preterm and SGA were compared with well-grown term infants (i.e. not low birthweight or SGA). Overlap between groups and temporal trends were also examined. RESULTS: Of 1 093 765 singleton live births, 47 946 (4.4%) infants were low birthweight and had poorer outcomes than well-grown term infants (2.7% vs. 0.1% infant mortality; 13% vs. 6% below national minimum numeracy standard). SGA and preterm infants also had poorer outcomes (0.5%, 2.3% infant mortality respectively; 10%, 11% below numeracy standard) but 80% of SGA and 47% of preterm infants were not low birthweight. For all outcomes, low birthweight identified a smaller proportion of infants with poor outcomes than preterm birth and than either SGA or low birthweight at term. The proportion of low-birthweight births remained constant over time, while the proportion of births that were preterm increased and proportion of SGA decreased. CONCLUSIONS: Low birthweight, SGA and preterm infants are all at higher risk of poorer outcomes but low birthweight inadequately captures, and masks trends in, both preterm births and births that are SGA. Reporting preterm births and an indicator of growth restriction at term will identify vulnerable groups better than using the measure of low birthweight.

Defining and describing treatment heterogeneity in new-onset idiopathic lower back and extremity pain through reconstruction of longitudinal care sequences.

BACKGROUND CONTEXT: Despite established guidelines, long-term management of surgically-treated low back pain (LBP) and lower extremity pain (LEP) remains heterogeneous. Understanding care heterogeneity could inform future approaches for standardization of practices. PURPOSE: To describe treatment heterogeneity in surgically-managed LBP and LEP. STUDY DESIGN/SETTING: Retrospective study of a nationwide commercial database spanning inpatient and outpatient encounters for enrollees of eligible employer-supplied healthcare plans (2007-2016). PATIENT SAMPLE: A population-based sample of opioid-naïve adult patients with newly-diagnosed LBP or LEP were identified. Inclusion required at least 12-months of pre-diagnosis and post-diagnosis continuous follow-up. EXPOSURE: Included treatments/evaluations include conservative management (chiropractic manipulative therapy, physical therapy, epidural steroid injections), imaging (x-ray, MRI, CT), pharmaceuticals (opioids, benzodiazepines), and spine surgery (decompression, fusion). OUTCOME MEASURES: Primary outcomes-of-interest were 12-month net healthcare expenditures (inpatient and outpatient) and 12-month opioid usage. METHODS: Analyses include interrogation of care sequence heterogeneity and temporal trends in sequence-initiating services. Comparisons were conducted in the framework of sequence-specific treatment sequences, which reflect the personalized order of healthcare services pursued by each patient. Outlier sequences characterized by high opioid use and costs were identified from frequently observed surgical treatment sequences using Mahalanobis distance. RESULTS: A total of 2,496,908 opioid-naïve adult patients with newly-diagnosed LBP or LEP were included (29,519 surgical). In the matched setting, increased care sequence heterogeneity was observed in surgical patients (0.51 vs. 0.12 previously-unused interventions/studies pursued per month). Early opioid and MRI use has decreased between 2008 and 2015 but is matched by increases in early benzodiazepine and x-ray use. Outlier sequences, characterized by increased opioid use and costs, were found in 5.8% of surgical patients. Use of imaging prior to conservative management was common in patients pursuing outlier sequences compared to non-outlier sequences (96.5% vs. 63.8%, p<.001). Non-outlier sequences were more frequently characterized by early conservative interventions (31.9% vs. 7.4%, p<.001). CONCLUSIONS: Surgically-managed LBP and LEP care sequences demonstrate high heterogeneity despite established practice guidelines. Outlier sequences associated with high opioid usage and costs can be identified and are characterized by increased early imaging and decreased early conservative management. Elements that may portend suboptimal longitudinal management could provide opportunities for standardization of patient care.

Variation in Rate of Attention-Deficit/Hyperactivity Disorder Management by Primary Care Providers.

OBJECTIVE: To describe variation in rates of attention-deficit/hyperactivity disorder (ADHD) management by pediatrics primary care providers (PCPs) and to assess influence of clinician characteristics on variation. METHODS: Retrospective cohort study of electronic health records from all office visits of patients aged 4 to 17 years seen at least twice between 2015 and 2017 by 73 clinicians in 9 pediatrics practices of a community-based primary health care network in California. Outcomes per clinician: 1) percent patients seen for ADHD management; (2) percent ADHD patients with diagnosed comorbid conditions. Logistic random-effects regression models examined practice- and clinician-level variation. RESULTS: Of 40,323 patients in the cohort, 2039 (5.1%) carried an ADHD diagnosis, of which 1142 (56%) received ADHD medication. Percent of patients seen for ADHD management varied by clinician from 0.0% to 8.3% (median 3.0%). After accounting for practice-level variation and patient characteristics (ie, sex, age, insurance), clinician characteristics explained 28% of clinician variation in ADHD management. ADHD management rate was associated with high-percent full-time equivalent (odds ratio 1.17; 95% confidence interval 1.07-1.27). Percent of ADHD patients with diagnoses of comorbidities varied by clinician from 0.0% to 100% (median 35%). Association between ADHD management rate and comorbidity diagnosis was minimal (R = 0.10). CONCLUSIONS: Objective electronic health records measures showed that PCPs in this network varied widely in their involvement in ADHD management. For most PCPs, percent of patients with ADHD and diagnosis of comorbidities was lower than estimated prevalence rates. Exploration of modifiable factors associated with PCP variation is needed to inform strategies for implementation of evidence-based practices.

Inpatient Observation After Transition From Intravenous to Oral Antibiotics.

OBJECTIVES: Children hospitalized with infections are commonly transitioned from intravenous (IV) to enteral (per os [PO]) antibiotics before discharge, after which they may be observed in the hospital to ensure tolerance of PO therapy and continued clinical improvement. We sought to describe the frequency and predictors of in-hospital observation after transition from IV to PO antibiotics in children admitted for skin and soft tissue infections (SSTIs). METHODS: We conducted a retrospective cohort study of children with SSTIs discharged between January 1, 2016, and June 30, 2018, using the Pediatric Health Information System database. Children were classified as observed if hospitalized ≥1 day after transitioning from IV to PO antibiotics. We calculated the proportion of observed patients and used logistic regression with random intercepts to identify predictors of in-hospital observation. RESULTS: Overall, 15% (558 of 3704) of hospitalizations for SSTIs included observation for ≥1 hospital day after the transition from IV to PO antibiotics. The proportion of children observed differed significantly between hospitals (range of 4%-27%; P < .001). Observation after transition to PO antibiotics was less common in older children (adjusted odds ratio [aOR] = 0.69; 95% confidence interval [CI] 0.52-0.90; P = .045). Children initially prescribed vancomycin (aOR = 1.36; 95% CI 1.03-1.79; P = .032) or with infections located on the neck (aOR = 1.72; 95% CI 1.32-2.24; P < .001) were more likely to be observed. CONCLUSIONS: Children hospitalized for SSTIs are frequently observed after transitioning from IV to PO antibiotics, and there is substantial variability in the observation rate between hospitals. Specific factors predict in-hospital observation and should be investigated as part of future studies aimed at improving the care of children hospitalized with SSTIs.

Timing and Predictors of Subspecialty Career Choice Among Internal Medicine Residents: A Retrospective Cohort Study.

BACKGROUND: Internal medicine residents face numerous career options after residency training. Little is known about when residents make their final career choice. OBJECTIVE: We assessed the timing and predictive factors of final career choices among internal medicine residents at graduation, including demographics, pre-residency career preferences, and rotation scheduling. METHODS: We conducted a retrospective study of graduates of an academic internal medicine residency program from 2014 to 2017. Main measures included demographics, rotation schedules, and self-reported career choices for residents at 5 time points: recruitment day, immediately after Match Day, end of postgraduate year 1 (PGY-1), end of PGY-2, and at graduation. RESULTS: Of the 138 residents eligible for the study, 5 were excluded based on participation in a fast-track program for an Accreditation Council for Graduate Medical Education subspecialty fellowship. Among the remaining 133 residents, 48 (36%) pursued general internal medicine fields and 78 (59%) pursued fellowship training. Career choices from recruitment day, Match Day, and PGY-1 were only weakly predictive of the career choice. Many choices demonstrated low concordance throughout training, and general medicine fields (primary care, hospital medicine) were frequently not decided until after PGY-2. Early clinical exposure to subspecialty rotations did not predict final career choice. CONCLUSIONS: Early career choices before and during residency training may have low predictability toward final career choices upon graduation in internal medicine. These choices may continue to have low predictability beyond PGY-2 for many specialties. Early clinical exposure may not predict final career choice for subspecialties.

Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse.

Importance: Through prescription writing, dental clinicians are a potential source of initial opioid exposure and subsequent abuse for adolescents and young adults. Objective: To examine the association between index dental opioid prescriptions from dental clinicians for opioid-naive adolescents and young adults in 2015 and new persistent use and subsequent diagnoses of abuse in this population. Design, Setting, and Participants: This retrospective cohort study examined outpatient opioid prescriptions for patients aged 16 to 25 years in the Optum Research Database in 2015. Prescriptions were linked by National Provider Identifier number to a clinician category. Exposures: Individuals were included in the index dental opioid (opioid-exposed) cohort if they filled an opioid prescription from a dental clinician in 2015, had continuous health plan coverage and no record of opioid prescriptions for 12 months before receiving the prescription, and had 12 months of health plan coverage after receiving the prescription. Two age- and sex-matched opioid-nonexposed control individuals were selected for each opioid-exposed individual and were assigned a corresponding phantom prescription date. Main Outcomes and Measures: Receipt of an opioid prescription within 90 to 365 days, a health care encounter diagnosis associated with opioid abuse within 365 days, and all-cause mortality within 365 days of the index opioid or phantom prescription date. Results: Among 754 002 individuals with continuous enrollment in 2015, 97 462 patients (12.9%) received 1 or more opioid prescriptions, of whom 29 791 (30.6%) received prescriptions supplied by a dental clinician. The opioid-exposed cohort included 14 888 participants (7882 women [52.9%], 11 273 white [75.7%], with mean [SD] age, 21.8 [2.4] years), and the randomly selected opioid-nonexposed cohort included 29 776 participants (15 764 women [52.9%], 20 078 [67.4%] white, with mean [SD] age, 21.8 [2.4] years). Among the 14 888 individuals in the index dental opioid cohort, 1021 (6.9%) received another opioid prescription 90 to 365 days later compared with 30 of 29 776 (0.1%) opioid-nonexposed controls (adjusted absolute risk difference, 6.8%; 95% CI, 6.3%-7.2%), and 866 opioid-exposed individuals (5.8%) experienced 1 or more subsequent health care encounters with an opioid abuse-related diagnosis compared with 115 opioid-nonexposed controls (0.4%) (adjusted absolute risk difference, 5.3%; 95% CI, 5.0%-5.7%). There was only 1 death in each cohort. Conclusions and Relevance: The findings suggest that a substantial proportion of adolescents and young adults are exposed to opioids through dental clinicians. Use of these prescriptions may be associated with an increased risk of subsequent opioid use and abuse.

Expenditures and Health Care Utilization Among Adults With Newly Diagnosed Low Back and Lower Extremity Pain.

Importance: Low back pain (LBP) with or without lower extremity pain (LEP) is one of the most common reasons for seeking medical care. Previous studies investigating costs in this population targeted patients receiving surgery. Little is known about health care utilization among patients who do not undergo surgery. Objectives: To assess use of health care resources for LBP and LEP management and analyze associated costs. Design, Setting, and Participants: This cohort study used a retrospective analysis of a commercial database containing inpatient and outpatient data for more than 75 million individuals. Participants were US adults who were newly diagnosed with LBP or LEP between 2008 and 2015, did not have a red-flag diagnosis, and were opiate naive prior to diagnosis. Dates of analysis were October 6, 2018, to March 7, 2019. Exposures: Newly diagnosed LBP or LEP. Main Outcomes and Measures: The primary outcome was total cost of care within the first 6 and 12 months following diagnosis, stratified by whether patients received spinal surgery. An assessment was performed to determine whether patients who did not undergo surgery received care in accordance with proposed guidelines for conservative LBP and LEP management. Costs resulting from use of different health care services were estimated. Results: A total of 2 498 013 adult patients with a new LBP or LEP diagnosis (median [interquartile range] age, 47 [36-58] years; 1 373 076 [55.0%] female) were identified. More than half (55.7%) received no intervention. Only 1.2% of patients received surgery, but they accounted for 29.3% of total 12-month costs ($784 million). Total costs of care among the 98.8% of patients who did not receive surgery were $1.8 billion. Patients who did not undergo surgery frequently received care that was inconsistent with clinical guidelines for LBP and LEP: 32.3% of these patients received imaging within 30 days of diagnosis and 35.3% received imaging without a trial of physical therapy. Conclusions and Relevance: The findings suggest that surgery is rare among patients with newly diagnosed LBP and LEP but remains a significant driver of spending. Early imaging in patients who do not undergo surgery was also a major driver of increased health care expenditures. Avoidable costs among patients with typically self-limited conditions result in considerable economic burden to the US health care system.

Atrial Fibrillation Burden Signature and Near-Term Prediction of Stroke: A Machine Learning Analysis.

BACKGROUND: Atrial fibrillation (AF) increases the risk of stroke 5-fold and there is rising interest to determine if AF severity or burden can further risk stratify these patients, particularly for near-term events. Using continuous remote monitoring data from cardiac implantable electronic devices, we sought to evaluate if machine learned signatures of AF burden could provide prognostic information on near-term risk of stroke when compared to conventional risk scores. METHODS AND RESULTS: We retrospectively identified Veterans Health Administration serviced patients with cardiac implantable electronic device remote monitoring data and at least one day of device-registered AF. The first 30 days of remote monitoring in nonstroke controls were compared against the past 30 days of remote monitoring before stroke in cases. We trained 3 types of models on our data: (1) convolutional neural networks, (2) random forest, and (3) L1 regularized logistic regression (LASSO). We calculated the CHA2DS2-VASc score for each patient and compared its performance against machine learned indices based on AF burden in separate test cohorts. Finally, we investigated the effect of combining our AF burden models with CHA2DS2-VASc. We identified 3114 nonstroke controls and 71 stroke cases, with no significant differences in baseline characteristics. Random forest performed the best in the test data set (area under the curve [AUC]=0.662) and convolutional neural network in the validation dataset (AUC=0.702), whereas CHA2DS2-VASc had an AUC of 0.5 or less in both data sets. Combining CHA2DS2-VASc with random forest and convolutional neural network yielded a validation AUC of 0.696 and test AUC of 0.634, yielding the highest average AUC on nontraining data. CONCLUSIONS: This proof-of-concept study found that machine learning and ensemble methods that incorporate daily AF burden signature provided incremental prognostic value for risk stratification beyond CHA2DS2-VASc for near-term risk of stroke.