ABSTRACT
BACKGROUND: It is unknown how much variation in adult mental health problems is associated with differences between societal/cultural groups, over and above differences between individuals. METHODS: To test these relative contributions, a consortium of indigenous researchers collected Adult Self-Report (ASR) ratings from 16 906 18- to 59-year-olds in 28 societies that represented seven culture clusters identified in the Global Leadership and Organizational Behavioral Effectiveness study (e.g. Confucian, Anglo). The ASR is scored on 17 problem scales, plus a personal strengths scale. Hierarchical linear modeling estimated variance accounted for by individual differences (including measurement error), society, and culture cluster. Multi-level analyses of covariance tested age and gender effects. RESULTS: Across the 17 problem scales, the variance accounted for by individual differences ranged from 80.3% for DSM-oriented anxiety problems to 95.2% for DSM-oriented avoidant personality (mean = 90.7%); by society: 3.2% for DSM-oriented somatic problems to 8.0% for DSM-oriented anxiety problems (mean = 6.3%); and by culture cluster: 0.0% for DSM-oriented avoidant personality to 11.6% for DSM-oriented anxiety problems (mean = 3.0%). For strengths, individual differences accounted for 80.8% of variance, societal differences 10.5%, and cultural differences 8.7%. Age and gender had very small effects. CONCLUSIONS: Overall, adults' self-ratings of mental health problems and strengths were associated much more with individual differences than societal/cultural differences, although this varied across scales. These findings support cross-cultural use of standardized measures to assess mental health problems, but urge caution in assessment of personal strengths.
Subject(s)
Mental Health , Personality Disorders , Adult , Humans , Personality Disorders/psychology , Anxiety , Anxiety Disorders , IndividualityABSTRACT
BACKGROUND: In response to the opioid epidemic, many states have enacted policies limiting opioid prescriptions. There is a paucity of evidence of the impact of opioid prescribing interventions in primary care populations, including whether unintended consequences arise from limiting the availability of prescribed opioids. OBJECTIVE: Our aim was to compare changes in opioid overdose and related adverse effects rate among primary care patients following the implementation of state-level prescribing policies. DESIGN: A cohort of primary care patients within an interrupted time series model. PARTICIPANTS: Electronic medical record data for 62,776 adult (18+ years) primary care patients from a major medical center in Vermont from January 1, 2016, to June 30, 2018. INTERVENTIONS: State-level opioid prescription policy changes limiting dose and duration. MAIN MEASURES: Changes in (1) opioid overdose rate and (2) opioid-related adverse effects rate per 100,000 person-months following the July 1, 2017, prescription policy change. KEY RESULTS: Among primary care patients, there was no change in opioid overdose rate following implementation of the prescribing policy (incidence rate ratio; IRR: 0.64, 95% confidence interval; CI: 0.22-1.88). There was a 78% decrease in the opioid-related adverse effects rate following the prescribing policy (IRR: 0.22, 95%CI: 0.09-0.51). This association was moderated by opioid prescription history, with decreases observed among opioid-naïve patients (IRR: 0.18, 95%CI: 0.06-0.59) and among patients receiving chronic opioid prescriptions (IRR: 0.17, 95%CI: 0.03-0.99), but not among those with intermittent opioid prescriptions (IRR: 0.51, 95%CI: 0.09-2.82). CONCLUSIONS: Limiting prescription opioids did not change the opioid overdose rate among primary care patients, but it reduced the rate of opioid-related adverse effects in the year following the state-level policy change, particularly among patients with chronic opioid prescription history and opioid-naïve patients. Limiting the quantity and duration of opioid prescriptions may have beneficial effects among primary care patients.
Subject(s)
Analgesics, Opioid , Practice Patterns, Physicians' , Adult , Analgesics, Opioid/adverse effects , Drug Prescriptions , Humans , Policy , Prescriptions , Primary Health Care , VermontABSTRACT
Despite the efficacy of medications for treating opioid use disorder (OUD), they are underutilized, especially in rural areas. Our objectives were to determine the association between primary care practitioners (PCPs) rurality and concerns for patient substance use, and to identify factors associated with PCP comfort treating OUD, focusing on barriers to treatment. We developed a web-based survey completed by 116 adult-serving PCPs located in Vermont's rural and non-rural counties between April-August 2020. The instrument included PCP-identified concerns for substance use among patients, barriers to treating patients with OUD, and current level of comfort treating patients with OUD. On a scale from 0 to 10, rural PCPs reported higher concern for heroin (mean difference; Mdiff = 1.38, 95% CI: 0.13 to 2.63), fentanyl (Mdiff = 1.52, 95% CI: 0.29 to 2.74), and methamphetamine (Mdiff = 1.61, 95% CI: 0.33 to 2.90) use among patients compared to non-rural PCPs, and practitioners in both settings expressed high concern regarding their patients' use of tobacco (7.6 out of 10) and alcohol (7.0 out of 10). There was no difference in reported comfort in treating patients with OUD among rural vs. non-rural PCPs (Mdiff = 0.65, 95%CI: 0.17 to 1.46; P = 0.119), controlling for higher comfort among male PCPs and those waivered to prescribe buprenorphine (Ps < 0.05). Lack of training/experience and medication diversion were PCP-identified barriers associated with less comfort treating OUD patients, while time constraints was associated with more comfort (Ps < 0.05). Taken together, these data highlight important areas for dissemination of evidence-based training, support, and resources to expand OUD treatment capacity in rural communities.
Subject(s)
Buprenorphine , Opioid-Related Disorders , Adult , Buprenorphine/therapeutic use , Humans , Male , Opiate Substitution Treatment , Opioid-Related Disorders/drug therapy , Primary Health Care , Rural PopulationABSTRACT
OBJECTIVE: Pediatric asthma is a common, relapsing-remitting, chronic inflammatory airway disease that when uncontrolled often leads to substantial patient and health care system burden. Improving management of asthma in primary care can help patients stay well controlled. METHODS: The Vermont Child Health Improvement Program (VCHIP) developed a quality improvement (QI) learning collaborative with a primary objective to improve clinical asthma management measures through improvement in primary care office systems to support asthma care. Seven months of medical record review data were evaluated for improvements on eight clinical asthma management measures. Pre and post office systems inventory (OSI) self-assessments detailing adherence to improvement strategies were analyzed for improvement. Logistic regressions were used to test for associations between OSI strategy post scores and the corresponding clinical asthma management measures by month seven. RESULTS: This study found significant improvement from baseline to month seven on seven of the eight clinical asthma management measures and between pre and post OSI for seven of the nine strategies assessed (N = 19 practices). Additionally, one point higher average OSI scores on the assessment and monitoring of asthma severity, asthma control, asthma action plans, and asthma education strategies were associated with significantly greater odds of improvement in their respective clinical asthma management measures. CONCLUSIONS: A QI learning collaborative approach in primary care can improve office systems and corresponding clinical management measures for pediatric patients with asthma. This suggests that linking specific office systems strategies to clinical measures may be a helpful tactic within the learning collaborative model.
Subject(s)
Asthma/therapy , Disease Management , Primary Health Care/organization & administration , Quality Improvement/organization & administration , Asthma/physiopathology , Cooperative Behavior , Humans , Inservice Training , Logistic Models , Practice Guidelines as Topic , Severity of Illness Index , VermontABSTRACT
PURPOSE: Evidence that fewer children are being seen at family physician (FP) practices has not been confirmed using population-level data. This study examines the proportion of children seen at FP and pediatrician practices over time and the influence of patient demographics and rurality on this trend. METHODS: We conducted a retrospective longitudinal analysis of Vermont all-payer claims (2009-2016) for children aged 0 to 21 years. The sample included 184,794 children with 2 or more claims over 8 years. Generalized estimating equations modeled the outcome of child attribution to a FP practice annually, with covariates for calendar year, child age, sex, insurance, and child Rural Urban Commuting Area (RUCA) category. RESULTS: Over time, controlling for other covariates, children were 5% less likely to be attributed to a FP practice (P <.001). Children had greater odds of attribution to a FP practice as they aged (odds ratio (OR) = 1.11, 95% CI, 1.10-1.11), if they were female (OR = 1.05, 95% CI, 1.03-1.07) or had Medicaid (OR = 1.09, 95% CI, 1.07-1.10). Compared with urban children, those from large rural cities (OR = 1.54, 95% CI, 1.51-1.57), small rural towns (OR = 1.45, 95% CI, 1.42-1.48), or isolated/small rural towns (OR = 1.96, 95% CI, 1.93-2.00) had greater odds of FP attribution. When stratified by RUCA, however, children had 3% lower odds of attending a FP practice in urban areas and 8% lower odds in isolated/small rural towns. CONCLUSIONS: The declining proportion of children attending FP practices, confirmed in this population-based analysis and more pronounced in rural areas, represents a continuing challenge.
Subject(s)
Family Practice/trends , Pediatrics/trends , Practice Patterns, Physicians'/trends , Primary Health Care/trends , Rural Health Services/trends , Adolescent , Child , Child, Preschool , Female , Humans , Infant , Infant, Newborn , Longitudinal Studies , Male , Retrospective Studies , Rural Population/statistics & numerical data , Vermont , Young AdultABSTRACT
OBJECTIVE: Intraosseous (IO) access is increasingly being used as an alternative to peripheral intravenous access, which is often difficult or impossible to establish in critically ill patients in the prehospital setting. Until recently, only Paramedics performed adult IO access. In 2014, Vermont Emergency Medical Services (EMS) expanded the Advanced Emergency Medical Technicians (AEMTs) scope of practice to include IO access in adult patients. This study compares successful IO access in adults performed by AEMTs compared to Paramedics in the prehospital setting. METHODS: All Vermont EMS patient encounters between January 1, 2013 and November 30, 2015 were examined, and 543 adult patients with a documented IO access insertion attempt were identified. The proportion of successful IO insertions was compared between AEMTs and Paramedics using a Chi-Squared statistic and a non-inferiority test. RESULTS: There was no significant difference in the percentage of successful IO access between AEMTs and Paramedics [95.2% and 95.6%, respectively; P = 0.84]. The confidence interval around this 0.4% difference (95% confidence interval = -4.2, 3.2) was within a pre-specified delta of ±10% indicating non-inferiority of AEMTs compared to Paramedics. CONCLUSIONS: This study's finding that successful IO access was not different among AEMTs and Paramedics lends evidence in support of expanding the scope of practice of AEMTs to include establishing IO access in adults.
Subject(s)
Emergency Medical Services/methods , Emergency Medical Technicians/education , Infusions, Intraosseous/methods , Adult , Female , Humans , Male , Retrospective StudiesABSTRACT
Students in Vermont with incomplete or undocumented immunization status are provisionally admitted to schools and historically had a calendar year to resolve their immunization status. The process of resolving these students' immunization status was challenging for school nurses. We conducted a school-based quality improvement effort to increase student compliance with Vermont immunization regulations using a collaborative learning approach with public health school liaisons and school nurses from public schools to reduce provisional admittance in 2011-2012. Strategies included using a tracking system, accessing the immunization registry, promoting immunization importance, tracking immunization plans, and working with medical homes to update records. Participating school nurses observed decreases in the number of provisionally admitted students, although this reduction was not significantly different than matched comparison schools. We also found the number of provisionally admitted students fluctuated throughout the year and resolving the immunization status of New Americans and exchange students required special attention. Our approach supports the coordinated school health model and demonstrates the critical role school nurses play in improving population health outcomes.
Subject(s)
Health Behavior , Immunization Programs/statistics & numerical data , Immunization/legislation & jurisprudence , Immunization/statistics & numerical data , School Health Services/statistics & numerical data , Adolescent , Child , Child, Preschool , Female , Humans , Immunization Programs/legislation & jurisprudence , Male , School Health Services/legislation & jurisprudence , School Nursing , VermontABSTRACT
INTRODUCTION: Obesity and smoking are independently associated with socioeconomic disadvantage and adverse health effects in women of reproductive age and their children, but little is known about co-occurring obesity and smoking. The purpose of this study was to investigate relationships between co-occurring obesity and smoking, socioeconomic status, and health biomarkers and outcomes in a nationally representative sample. METHODS: Data from non-pregnant women of reproductive age were obtained from the U.S. National Health and Nutrition Examination Surveys reported between 2007 and 2010. Linear and logistic regressions were used to examine associations between obesity and smoking alone and in combination with educational attainment and a range of health biomarkers and outcomes. RESULTS: Prevalence of co-occurring obesity and smoking was 8.1% (~4.1 million U.S. women of reproductive age) and increased as an inverse function of educational attainment, with the least educated women being 11.6 times more likely to be obese smokers than the most educated. Compared to women with neither condition, obese smokers had significantly poorer cardiovascular and glycemic biomarker profiles, and higher rates of menstrual irregularity, hysterectomy, oophorectomy, physical limitations, and depression. Obese smokers also had significantly worse high-density lipoprotein (HDL) cholesterol levels, physical mobility, and depression scores than those with obesity or smoking alone. CONCLUSIONS: Co-occurring obesity and smoking is highly associated with low educational attainment, a marker of socioeconomic disadvantage, and a broad range of adverse health biomarkers and outcomes. Interventions specifically targeting co-occurring obesity and smoking are likely necessary in efforts to reduce health disparities among disadvantaged women and their children.
Subject(s)
Biomarkers/blood , Educational Status , Obesity/epidemiology , Reproductive Health , Smoking/epidemiology , Adult , Comorbidity , Female , Humans , Logistic Models , Middle Aged , Nutrition Surveys , Prevalence , Risk Factors , United States/epidemiology , Young AdultABSTRACT
INTRODUCTION: Individuals dependent on alcohol or illicit drugs are vulnerable to cigarette smoking and related adverse health outcomes. Less research has been conducted regarding whether these same groups are vulnerable to smokeless tobacco (ST) use. The goal of this study is to examine vulnerability to ST use among individuals with other drug dependence. METHODS: Utilizing the most recent (2011) National Survey on Drug Use and Health (NDSUH), we determined odds ratios (ORs) for current cigarette smoking and ST use among those with current alcohol, cocaine, heroin, and marijuana dependence, adjusting for relevant sociodemographic characteristics. Vulnerability to cigarette smoking was assessed to confirm that alcohol and illicit drug dependence were associated with increased smoking in these data sets, as shown in prior studies. Identical analyses were completed in the 2009 and 2010 NSDUH to assess generality. RESULTS: Odds for current cigarette smoking were increased for each category of dependence (p < .0005): alcohol (OR with 99% CI = 3.30 [2.58, 4.21]), cocaine (OR = 4.50 [1.53, 13.20]), heroin (OR = 7.84 [1.92, 32.03]), and marijuana (OR = 3.55 [2.59, 4.88]). Odds for current ST use were also increased among those with alcohol dependence (OR = 1.56 [1.06, 2.30], p = .003) but not illicit drug dependence. Generality of the findings was confirmed in the 2009 and 2010 NSDUH. CONCLUSIONS: Consistent with earlier reports, alcohol and illicit drug dependence are associated with robust increases in risk for cigarette smoking. In the case of alcohol dependence, but not illicit drug dependence, this vulnerability also extends to ST use.
Subject(s)
Alcoholism/epidemiology , Illicit Drugs , Substance-Related Disorders/epidemiology , Tobacco Use Disorder/epidemiology , Tobacco, Smokeless/statistics & numerical data , Adolescent , Adult , Aged , Alcoholism/psychology , Comorbidity , Female , Health Surveys , Humans , Interviews as Topic , Logistic Models , Male , Middle Aged , Risk Factors , Socioeconomic Factors , Substance-Related Disorders/psychology , Tobacco Use Disorder/psychology , Tobacco, Smokeless/adverse effects , United States , Young AdultABSTRACT
AIMS: The goal of this study was to better understand the predictive relationship in both directions between negative (anger, sadness) and positive (happiness) moods and alcohol consumption using daily process data among heavy drinkers. METHODS: Longitudinal daily reports of moods, alcohol use and other covariates such as level of stress were assessed over 180 days using interactive voice response telephone technology. Participants were heavy drinkers (majority meeting criteria for alcohol dependence at baseline) recruited through their primary care provider. The sample included 246 (166 men, 80 women) mostly Caucasian adults. Longitudinal statistical models were used to explore the varying associations between number of alcoholic drinks and mood scores the next day and vice versa with gender as a moderator. RESULTS: Increased alcohol use significantly predicted decreased happiness the next day (P < 0.005), more strongly for females than males. Increased anger predicted higher average alcohol use the next day for males only (P < 0.005). CONCLUSION: This daily process study challenges the notion that alcohol use enhances positive mood for both males and females. Our findings also suggest a strong association between anger and alcohol use that is specific to males. Thus, discussions about the effects of drinking on one's feeling of happiness may be beneficial for males and females as well as anger interventions may be especially beneficial for heavy-drinking males.
Subject(s)
Affect/physiology , Alcohol Drinking/psychology , Alcohol Drinking/trends , Sex Characteristics , Telephone/trends , Adult , Aged , Aged, 80 and over , Emotions/physiology , Female , Humans , Longitudinal Studies , Male , Middle Aged , Speech Recognition Software/statistics & numerical data , Speech Recognition Software/trends , Telephone/statistics & numerical data , Time Factors , Young AdultABSTRACT
As the COVID-19 pandemic highlighted gaps in meeting adolescent behavioral health needs, primary care providers (PCPs) were a locus for interventions to address adolescent mental health and substance use concerns. Strength-based approaches may support PCP promotion of positive behavioral health in adolescents, but competing priorities or other factors may inhibit their use. We analyzed health record review data from 31 primary care practices to assess utilization of strength-based approaches during the health supervision visit (HSV) for adolescents with and without behavioral health concerns. We found that most had strengths identified (78%) or well-being topics addressed (83%). However, adolescents screening positive for depression were 40% less likely to have strengths identified, whereas those screening positive for anxiety or substance use were 89% and 163%, respectively, more likely to have well-being topics addressed. Primary care providers may need support for integrating strength-based approaches when managing adolescents screening positive for depression.
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PURPOSE: Few studies have addressed beliefs about treatment for opioid use disorder (OUD) among family members of people with OUD, particularly in rural communities. This study examined the beliefs of rural family members of people with OUD regarding treatment, including medication for OUD (MOUD), and recovery. METHODS: Semi-structured qualitative interviews were conducted with rural Vermont family members of people with OUD. Twenty family members completed interviews, and data were analyzed using thematic analysis. RESULTS: Four primary themes related to beliefs about OUD treatment emerged: (1) MOUD is another form of addiction or dependency and should be used short-term; (2) essential OUD treatment components include residential and mental health services and a strong support network involving family; (3) readiness as a precursor to OUD treatment initiation; and (4) stigma as an impediment to OUD treatment and other health care services. CONCLUSIONS: Rural family members valued mental health services and residential OUD treatment programs while raising concerns about MOUD and stigma in health care and the community. Several themes (e.g., MOUD as another form of addiction, residential treatment, and treatment readiness) were consistent with prior research. The belief that MOUD use should be short-term was inconsistent with the belief that OUD is a disease. Findings suggest a need for improved education on the effectiveness of MOUD for family members and on stigma for health care providers and community members.
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BACKGROUND: Craving is a central component to alcohol use disorders, although there are contradictory findings in the literature regarding the importance of craving in alcohol use. The study goal was to examine the bidirectional relationship between craving and alcohol consumption in heavy drinkers. METHODS: Participants received brief alcohol interventions from their primary care physicians and then were asked to make daily reports of craving and alcohol consumption to an interactive voice response (IVR) telephone system for 180 days. The study sample included 246 participants (166 men) with mean age of 46. Ninety-seven percent were Caucasian and 66% met criteria for alcohol dependence. Analysis used generalized estimating equations (GEE) to evaluate whether craving intensity predicted next day alcohol consumption and whether alcohol consumption predicted next day craving intensity. Significant interactions with gender led to stratified analyses. RESULTS: GEE analyses revealed a significant bidirectional relationship between craving and drinking, where craving intensity predicted next day total drinks consumed (p = 0.001), and total drinks predicted next day craving intensity (p = 0.02). Exploratory analysis found that gender significantly moderated the craving-drinking relationship (p = 0.002) with men increasing next day alcohol use more (b = 0.19) than women (b = 0.08). CONCLUSIONS: Findings suggest a bidirectional relationship between craving and drinking may contribute to the development or maintenance of heavy drinking, particularly for men. Based on our findings, we recommend that during brief interventions, physicians address both drinking and craving and provide advice for coping with craving.
Subject(s)
Alcohol Drinking/psychology , Alcoholism/psychology , Substance Withdrawal Syndrome/psychology , Telephone , Adult , Alcoholism/diagnosis , Female , Humans , Male , Middle Aged , Sex FactorsABSTRACT
BACKGROUND: Supplementation in the newborn nursery has been associated with shorter breastfeeding duration. However, supplementation may at times be necessary. RESEARCH AIM: To determine the association between type of supplementation in the newborn nursery (mother's own milk, formula, donor human milk) and breastfeeding outcomes at 2 and 6 months of age. METHODS: This was a prospective, longitudinal, observational multi-group cohort study. In total, 2,343 surveys were sent to parents who, prior to delivery, indicated intent to exclusively breastfeed. Participants were grouped by type of nursery supplementation. Surveys asked about breastfeeding outcomes when infants were 2 and 6 months old. Our final analytic sample included data from 1,111 healthy newborns ≥ 35 weeks. We used multiple logistic regression to compare future breastfeeding outcomes for infants who were exclusively directly breastfed or who received supplementation during their birth hospitalization. RESULTS: Both the donor human milk and formula groups had decreased breastfeeding at 2 and 6 months compared to the exclusively directly breastfed group. Notably, for infants who received formula compared to donor human milk, the odds of breastfeeding at 2 and 6 months were 74% and 58% lower, respectively (OR = 0.26, 95% CI [0.12, 0.56] at 2 months; OR = 0.42, 95% CI [0.19, 0.94] at 6 months). The donor human milk group had lower odds of breastfeeding at both follow up times compared to the mother's own milk group. CONCLUSION: Among those who intend to breastfeed, supplementation with donor human milk instead of formula in the newborn nursery may support longer breastfeeding.
Subject(s)
Breast Feeding , Infant Formula , Infant , Female , Infant, Newborn , Humans , Cohort Studies , Prospective Studies , Milk, Human , Dietary SupplementsABSTRACT
OBJECTIVE: To examine the association between supportive environments and adolescent suicidal behavior, especially among marginalized minority groups. METHODS: Participants included 12,196 middle and 16,981 high school students who completed the 2019 Vermont Youth Risk Behavior Survey. Multiple logistic regression models were used to assess the association between three protective factors that were part of a supportive environment (feeling like they matter to people in their community, usually eating dinner at home, having a trusted adult) and suicidality (plan or attempt), controlling for key demographics (sex, sexual orientation, gender identity, and race/ethnicity). Moderating effects of demographics were also explored. RESULTS: All supportive environment variables were protective of making a suicide plan and making a suicide attempt (ORs < 0.75, p-values < 0.005). Students of minority identities were significantly more likely to make a suicide plan (middle school ORs: 1.34-3.51, p-values < 0.0005; high school ORs: 1.19-3.38, p-values < 0.02) and attempt suicide (middle school ORs: 1.42-3.72, p-values < 0.006; high school ORs: 1.38-3.25, p-values < 0.0005) compared to students with majority demographic characteristics. Generally, the associations between having a supportive environment and suicidality did not vary within sexual orientation, gender identify, or race/ethnicity subgroups, suggesting that these supportive environment factors were more universally protective. However, a few associations were stronger among students in the majority demographic groups. CONCLUSIONS: These data suggest that having a supportive environment is protective of suicidality for adolescents from both majority and minority demographic groups.HIGHLIGHTSA supportive environment is protective of adolescent suicide plan and attempt.Minority sexual, gender, and racial identities are risk factors for suicidality.Minority and majority students are protected by supportive environments.
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OBJECTIVE: Characterize the prevalence of chronic physical illness types and mental illness and their comorbidity among adolescents and young adults (AYA) and assess the association of comorbidity on hospital utilization. METHODS: This study features a population-level sample of 61 339 insurance-eligible AYA with an analytic sample of 49 089 AYA (aged 12-21) in Vermont's 2018 all-payer database. We used multiple logistic regressions to examine the associations between physical illness types and comorbid mental illness and emergency department (ED) use and inpatient hospitalization. RESULTS: The analytic sample was 50% female, 63% Medicaid, and 43% had ≥1 chronic illness. Mental illness was common (31%) and highly comorbid with multiple physical illnesses. Among AYA with pulmonary illness, those with comorbid mental illness had 1.74-times greater odds (95% confidence interval [CI]: 1.49-2.05, P ≤.0005) of ED use and 2.9-times greater odds (95% CI: 2.05-4.00, P ≤.0005) of hospitalization than those without mental illness. Similarly, comorbid endocrine and mental illness had 1.84-times greater odds of ED use (95% CI: 1.39-2.44, P ≤.0005) and 2.1-times greater odds of hospitalization (95% CI: 1.28-3.46, P = .003), comorbid neurologic and mental illness had 1.36-times greater odds of ED use (95% CI: 1.18-1.56, P ≤.0005) and 2.4-times greater odds of hospitalization (95% CI: 1.73-3.29, P ≤.0005), and comorbid musculoskeletal and mental illness had 1.38-times greater odds of ED use (95% CI: 1.02-1.86, P = .04) and 2.1-times greater odds of hospitalization (95% CI: 1.20-3.52, P = .01). CONCLUSIONS: Comorbid physical and mental illness was common. Having a comorbid mental illness was associated with greater ED and inpatient hospital utilization across multiple physical illness types.
Subject(s)
Hospitalization , Mental Disorders , Young Adult , Adolescent , United States/epidemiology , Humans , Female , Male , Comorbidity , Mental Disorders/epidemiology , Medicaid , Emergency Service, Hospital , Chronic Disease , HospitalsABSTRACT
IMPORTANCE: Opioid-related mortality rates have risen dramatically over the past decade, and office-based opioid treatment using buprenorphine offers hope for combatting this trend. Vermont's policymakers, health care systems, and treatment providers have worked to expand access to treatment throughout the rural state. OBJECTIVE: The objective of the current study was to characterize the trends in the number of buprenorphine prescribers and the number of patients per prescriber in Vermont over the past decade (2010-2020). METHODS: We used Vermont's all-payer claims database to identify patients with buprenorphine claims between 2010 and 2020 and their prescribers. We conducted analyses of trends in the number of prescribers treating different numbers of patients, the number of patients treated by prescribers in those categories, and the number of rural (vs nonrural) patients filling buprenorphine prescriptions. We used Z tests to determine if there were statistical differences between trends. RESULTS: The number of buprenorphine prescribers treating 10+ patients grew more rapidly than other prescriber groups ( P < 0.001). Nearly half of Vermont patients in 2020 were treated by 33 high-volume prescribers who treated 100 or more patients with buprenorphine. The number of patients filling buprenorphine prescriptions in Vermont increased by 98% between 2010 and 2020, with greater increases seen among rural than nonrural residents (107% vs 72%; P = 0.008). CONCLUSIONS AND RELEVANCE: Since 2010, Vermont has increased utilization of its office-based opioid treatment capacity, particularly in rural counties.
Subject(s)
Buprenorphine , Pharmaceutical Services , Pharmacy , Humans , Analgesics, Opioid , VermontABSTRACT
Research on posttraumatic stress disorder (PTSD) among youth has focused on specific subgroups from developed countries. Most of the world's youth and war-like violence, however, is concentrated in developing countries, yet there is limited mental health data within affected countries. This study focused on a random community-based sample of 552 impoverished youth ages 6-18 within an informal settlement in Nairobi, Kenya, which experienced war-like violence for a month following the contested presidential election of 2007. Six months after the violence ended, 99 (18%) had PTSD according to the UCLA PTSD Reaction Index (Steinberg, Brymer, Decker, & Pynoos, 2004), and an additional 18 (3%) were found to have partial PTSD due to high overall scores. Kenyan psychologists conducted diagnostic interviews and found the positive predictive value of the assessment tool to be 72% in this sample; the confirmed prevalence was 12%. Similar to other studies worldwide, Criterion C (avoidance) was the limiting factor for diagnosing PTSD according to the DSM-IV-TR, and parent-child agreement was at best fair. The number of traumatic experiences was strongly associated with PTSD outcomes. Differences due to age or sex were not found. The findings indicate the need for universal mental health services for trauma-exposed youth and their families in the impoverished informal settlements of Nairobi, Kenya.
Subject(s)
Multiple Trauma/psychology , Poverty , Stress Disorders, Post-Traumatic/epidemiology , Violence/psychology , Adolescent , Child , Databases, Factual , Female , Humans , Interviews as Topic , Kenya/epidemiology , Male , WarfareABSTRACT
PURPOSE: To investigate the association between adolescent and young adult (AYA) well-care visits and emergency department (ED) utilization. METHODS: Vermont's all-payer claims data were used to evaluate visits for 49,089 AYAs (aged 12-21 years) with a health-care claim from January 1 through December 31, 2018. We performed multiple logistic regression analyses to determine the association between well-care visits and ED utilization, investigating potential moderating effects of age, insurance type, and medical complexity. RESULTS: Nearly half (49%) of AYAs who engaged with the health-care system did not attend a well-care visit in 2018. AYAs who did not attend a well-care visit had 24% greater odds (95% confidence interval [CI]: 1.19-1.30) of going to the ED at least once in 2018, controlling for age, sex, insurance type, and medical complexity. Older age, female sex, Medicaid insurance, and greater medical complexity independently predicted greater ED utilization in the adjusted model. In stratified analyses, late adolescents and young adults (aged 18-21 years) who did not attend a well-care visit had 47% greater odds (95% CI: 1.37 - 1.58) of ED visits, middle adolescents (aged 15-17 years) had 9% greater odds (95% CI: 1.01-1.18), and early adolescents (aged 12-14 years) had 16% greater odds (95% CI: 1.06 - 1.26). CONCLUSIONS: Not attending well-care visits is associated with greater ED utilization among AYAs engaged in health care. Focus on key quality performance metrics such as well-care visit attendance, especially for 18- to 21-year-olds during their transition to adult health care, may help reduce ED utilization.
Subject(s)
Emergency Service, Hospital , Medicaid , Adolescent , Adult , Child , Female , Health Facilities , Humans , United States , Young AdultABSTRACT
OBJECTIVE: To assess the association between follow-up after an asthma-related emergency department (ED) visit and the likelihood of subsequent asthma-related ED utilization. METHODS: Using data from California Medicaid (2014-2016), and Vermont (2014-2016) and Massachusetts (2013-2015) all-payer claims databases, we identified asthma-related ED visits for patients ages 3 to 21. Follow-up was defined as a visit within 14 days with a primary care provider or an asthma specialist. OUTCOME: asthma-related ED revisit after the initial ED visit. Models included logistic regression to assess the relationship between 14-day follow-up and the outcome at 60 and 365 days, and mixed-effects negative binomial regression to assess the relationship between 14-day follow-up and repeated outcome events (# ED revisits/100 child-years). All models accounted for zip-code level clustering. RESULTS: There were 90,267 ED visits, of which 22.6% had 14-day follow-up. Patients with follow-up were younger and more likely to have commercial insurance, complex chronic conditions, and evidence of prior asthma. 14-day follow-up was associated with decreased subsequent asthma-related ED revisits at 60 days (5.7% versus 6.4%, P < .001) and at 365 days (25.0% versus 28.3%, P < 0.001). Similarly, 14-day follow-up was associated with a decrease in the rate of repeated subsequent ED revisits (66.7 versus 77.3 revisits/100 child-years; P < 0.001). CONCLUSIONS: We found a protective association between outpatient 14-day follow-up and asthma-related ED revisits. This may reflect improved asthma control as providers follow the NHLBI guideline stepwise approach. Our findings highlight an opportunity for improvement, with only 22.6% of those with asthma-related ED visits having 14-day follow-up.