Rural Perspectives on Health Services for Transgender and Gender Diverse Youth.

As the world grows more diverse, physicians and public health practitioners must become adept at providing care to everyone, including people who identify as transgender or gender diverse (TGD). Although this population is growing in all age demographics, there is a large increase in young TGD individuals who require pediatric health care providers to improve their practices. While a few comprehensive care clinics have been established to serve the TGD community, they are mostly located in urban areas. In addition to the unique barriers faced by rural TGD youth, providers must care for their patients with limited resources. In this commentary, we offer a set of recommendations to improve provider education, build connections between the health system and community, address the fragmentation of health services in rural areas and improve the transition from pediatric to adult health care.

Association between asthma and influenza vaccine uptake among US adolescents: a retrospective survey study.

OBJECTIVE: Despite longstanding recommendations for children with asthma to receive the influenza vaccine, vaccine uptake in this population remains low. We used the nationally representative National Immunization Survey-Teen to analyze the impact of asthma on adolescent influenza vaccination rates. METHODS: Adolescents ages 13-17 years with provider-reported data on vaccine coverage were included in the analysis. The primary outcome was being up-to-date on influenza vaccination, defined as receiving the seasonal influenza vaccine in at least one of the past 3 years, and was analyzed using logistic regression. Asthma was defined by parent report of whether the adolescent has ever been told by a health professional that he or she has asthma. Data were collected in 2016-2017 and analyzed in 2020. RESULTS: Of 36,655 adolescents in the analytic sample (mean age 15 years, 49% female), 55% were up-to-date on influenza vaccination, and 21% had been diagnosed with asthma. On bivariate analysis, vaccination was more common among adolescents who had been diagnosed with asthma compared to those who were not (60% vs. 53%, P < 0.001). On multivariable analysis, asthma diagnosis was associated with greater likelihood of being up-to-date on seasonal influenza vaccination (adjusted odds ratio: 1.29; 95% confidence interval: 1.22, 1.36; P < 0.001). CONCLUSIONS: Seasonal influenza vaccination rates remain low among adolescents. Despite concerns about vaccine effectiveness in children with asthma, this diagnosis was associated with increased likelihood of influenza vaccination, possibly in relation to increased health care use (and exposure to vaccine encouragement) among adolescents with asthma.

Concordance of Data on Children's Unmet Health Care Needs Between 2 National Surveys.

OBJECTIVE: We used public data from 2 national surveys to determine how survey mode and questionnaire wording potentially impact estimated prevalence and predictors of children's unmet health care needs. METHODS: Data from 2016-2017 were obtained for the National Health Interview Survey (NHIS), where interviewers ask caregivers about each type of unmet health care need in person, and the National Survey of Children's Health (NSCH), a self-administered questionnaire asking a general question about any unmet health care needs, with subparts about specific types of unmet needs. Weighted proportions and multivariable logistic regression were used to analyze each data set. RESULTS: The weighted proportion of any unmet health care needs was significantly higher in the NHIS (7.5%; 95% confidence interval [CI], 7.0-8.1; N = 17 723) than in the NSCH (3.3%; 95% CI, 2.9-3.7; N = 65 766). When analyzing specific unmet needs, unmet need for dental care was significantly higher according to the NHIS (4.2% vs 1.9% in the NSCH), as was unmet need for vision care (1.7% vs 0.8%). Conversely, estimates of unmet need for medical care were comparable between the surveys (1.4% and 1.0%). On multivariable analysis, predictors of unmet health care needs, such as being uninsured, had effect sizes of similar magnitude in both surveys. CONCLUSION: The NHIS design, asking about each type of unmet need in person, may have been more conducive to identifying the full range of unmet health care needs among children. However, our results did not indicate that this was a source of bias in multivariable regression analysis.

Insurance coverage and health care use among children with diabetes.

BACKGROUND: Health insurance coverage may be associated with pediatric diabetes mellitus (DM) management. However, it is unknown how continuity of insurance coverage is associated with health care use outcomes in pediatric DM. METHODS: We used the nationally representative 2016-2019 National Survey of Children's Health to examine how interruption of health insurance coverage may affect health care use among children with DM. Children ages 0-17 years with DM were included in the analysis. Outcomes included emergency department visits, specialist visits, and unmet health care needs in the last 12 months. Insurance coverage was classified as continuous private, continuous public, or discontinuous (including gaps in coverage and year-round lack of coverage). RESULTS: Based on a sample of 548 children, 56% percent had continuous private insurance coverage, as compared to 32% with continuous public insurance, and 12% with discontinuous coverage. Thirty-five percent of children had visited the ED in the past 12 months, and only 47% had visited any specialist in the past 12 months, including but not limited to a pediatric endocrinologist. An estimated 19% of children had unmet health care needs over the past 12 months. On multivariable analysis, children with coverage gaps were significantly less likely than children with continuous private coverage to have a visited a specialist in the past 12 months (adjusted odds ratio: 0.27; 95% CI: 0.08, 0.88; p = 0.030). CONCLUSIONS: This study points to a need to establish and maintain specialist follow-up for children with DM, especially those from socioeconomically disadvantaged backgrounds.

Change of address as a measure of housing insecurity predicting rural emergency department revisits after asthma exacerbation.

OBJECTIVE: Housing insecurity is an important socioeconomic factor that may impact emergency department (ED) use for children with asthma, but housing insecurity screening has primarily relied on patient surveys or linkage to external data sources. Using patient addresses recorded in the electronic medical record (EMR), we sought to correlate recent changes in address (as a proxy for housing insecurity) with ED revisit risk. METHODS: We retrospectively identified patients age 2-17 years seen in our rural ED for asthma exacerbation during 2016-2018. We used EMR data from the 12 months before the earliest ED visit to compare patients with and without a recent change of address (over previous 12 months) on 30- and 90-day all-cause and asthma-specific ED revisits. RESULTS: The study included 632 children, of whom 85 (13%) had a recent address change before the index ED visit. Moving was not associated with asthma-specific 30-day or 90-day revisits. Ninety-day all-cause revisits were more common among patients who had recently moved (36% vs. 25%; p = 0.019), although this difference was not statistically significant after multivariable adjustment for Medicaid insurance coverage and number of recent health system encounters (odds ratio: 1.49; 95% confidence interval: 0.91, 2.46; p = 0.114). CONCLUSIONS: A history of recent address change in the EMR was not independently associated with repeat ED visits for asthma exacerbation. Many children presenting to the ED did not have recent encounters with our health system where address could be ascertained. This EMR-based proxy for housing insecurity may be more applicable to patients under continuous follow-up.

Social Determinants of Health and Emergency Department Use Among Children With Sickle Cell Disease.

Sickle cell disease (SCD) is associated with disproportionate emergency department (ED) use. This study described the social determinants of health associated with ED visits and hospital admission from the ED among children with SCD using a nationally representative dataset. We analyzed data from 126 children 0 to 17 years of age with SCD included in the 2011 to 2017 rounds of the National Health Interview Survey (mean age, 8 y; 50% female individuals; 74% African American). Study variables were summarized using weighted means and proportions and compared according to ED use and admission by Wald tests. Fifty-two identified children had visited the ED within the last 12 months and 21 were admitted to the hospital after their most recent ED visit. Children living in a single-mother household were more likely to visit the ED (P=0.040), as were younger children (mean age, 6 vs. 9 y; P=0.034), with no evaluated social determinants of health significantly impacting hospital admission from the ED. The lack of association between ED use and either poverty or insurance type may be related to the overall high level of social disadvantage among children with SCD. Our findings demonstrate the need to better characterize specific social factors impacting acute care use among children with SCD.

Prematurity and breastfeeding initiation: A sibling analysis.

AIM: Studies suggest breastfeeding initiation is less common for premature infants. This association may be confounded by socio-economic characteristics that correlate with the risk of premature birth. We compared premature and term-born children to determine whether prematurity independently predicted likelihood of breastfeeding continuation and duration. METHODS: Data were obtained from women ages 15-44 years reporting at least two live pregnancies on the 2011-2017 National Survey of Family Growth. Participants completed a pregnancy and breastfeeding history. Breastfeeding initiation was defined as breastfeeding for at least 1 week, and duration of exclusive breastfeeding was recorded in months. Sibling fixed effects regression models were used to evaluate the impact of prematurity. RESULTS: Among families with some children who were breastfed and others who were not (n = 2848 children), preterm birth was not associated with breastfeeding initiation (odds ratio = 1.11; P = .468). Among children who were ever breastfed, exclusive breastfeeding lasted 5% fewer months among children born preterm, compared with term-born siblings (incidence rate ratio = 0.95; P = .060). CONCLUSION: Using sibling-group analysis to control for confounding, we found no independent association between prematurity and likelihood of breastfeeding initiation. This suggests interventions supporting breastfeeding for premature infants may need to address external barriers to breastfeeding not specifically preterm birth.

Gender Differences in Research Productivity of Academic Physicians Before and During the COVID-19 Pandemic.

Objective: The gendered impact of the COVID-19 on scientific productivity has been primarily studied in nonclinical academic fields. We investigated the gendered effect of the pandemic on diverse measures of research participation among physician faculty, who experienced an increase in clinical duties concomitant with pandemic-era challenges to research. Materials and Methods: Physician faculty employed in both 2019 (prepandemic) and 2021 (pandemic era) were identified at one U.S. medical school. Annual outcomes included scientific publications, Institutional Review Board (IRB)-approved protocols, and extramural funding submissions (funding data were unavailable for 2019). Mixed-effects Poisson regression models compared the pandemic impact by gender. Results: The study included 105 women and 116 men, contributing to 122 publications, 214 IRB protocols, and 99 extramural funding applications. Controlling for potential confounders such as faculty rank and track (tenure vs. nontenure), women's publication count increased by 140% during the pandemic (95% confidence interval [CI]: +40% to +310%, p = 0.001) but was unchanged among men (95% CI: -30% to +50%; p > 0.999). The number of IRB protocols decreased from 2019 to 2021, but to a greater extent among men than women. In 2021, there was no gender difference in the number of extramural funding submissions. Conclusions: Among physician faculty at our medical school, women achieved parity with men on multiple measures of scholarly activity, and women's research productivity outpaced that of men in the same faculty track and rank. Targeted initiatives to support research among women faculty, junior investigators, and clinical investigators may have helped avert exacerbation of prepandemic gender disparities in research participation.

Well-child visit attendance of children who have experienced a parental COVID-19 diagnosis.

BACKGROUND: Due to the COVID-19 pandemic, rates of well-child visit (WCV) attendance have significantly decreased. We wanted to see how a parent's positive diagnosis for COVID-19 affected a child's WCV attendance along with other factors. Therefore, we hypothesized that in families with at least 1 positive COVID-19 diagnosis, the rates of WCV attendance would be lower than in families that have not experienced COVID-19. METHODS: Using National Health Interview Survey (NHIS) data from 2020, we analyzed sample adult responses for the sample child to questions about last WCV attendance. We included children whose parents completed the survey during quarters 3 and 4 of 2020. The outcome of this study was WCV attendance in the past 12 months with the exposure of interest being parental diagnosis of COVID-19. RESULTS: In our sample (N=1,413), 91% of children attended a WCV in the past 12 months, and 5% had a parent with a positive COVID-19 diagnosis. On adjusted analysis, there was a negative but not statistically significant association between a parent with a positive COVID-19 diagnosis and WCV attendance (OR=0.32; 95% CI: 0.09, 1.20; p=0.092). CONCLUSIONS: Nationwide, there has been a significant decrease in children attending recommended WCVs since the start of the pandemic. Having a parent test positive for COVID-19 may contribute to decreases in WCV attendance in traditional medical office settings. Alternative options exist that may improve WCV attendance; these include telemedicine or virtual visits, as well as visits completed in non-traditional settings such as mobile health clinics and school-based clinics. Further expansion of these options for WCVs must still take into account health disparities that exist among marginalized communities.

Factors Influencing US Hospital and Medical School Participation in Pediatric COVID-19 Research.

BACKGROUND AND OBJECTIVES: Literature suggests that funding for pediatric clinical trials is inequitably awarded. Furthermore, although coronavirus disease 2019 (COVID-19) affected all hospitals, institutions with already limited resources were more severely impacted. We hypothesized that there would be difference in schools and hospitals that were able to participate in the initial round of pediatric COVID-19 clinical research. METHODS: We searched online databases for preregistered studies using the keywords "COVID-19," "COVID," "SARS-CoV-2," "2019-nCov," "2019 novel coronavirus," and "severe acute respiratory syndrome coronavirus 2." Search results were limited to studies enrolling participants from birth to 17 years, studies started in 2020, and studies originating in the United states. We calculated the proportion of institutions with active COVID-19 pediatric clinical studies in 2020 and compared institutional characteristics between institutions with and without at least one qualifying COVID-19 study, using rank-sum tests, χ2 tests, or Fisher's exact tests, as appropriate. RESULTS: We identified 150 allopathic medical schools, 34 osteopathic medical schools, and 178 children's hospitals meeting inclusion criteria. Among included institutions, 25% of medical schools and 20% children's hospitals participated in 1 of the registered pediatric COVID-19 studies the year before the study period. Institutions that participated in pediatric COVID-19 studies had more publications, more National Institutes of Health funding, and more studies registered on Clinicaltrials.gov in 2019. CONCLUSIONS: Despite the pandemic affecting everyone, participation in early clinical research on the impact of COVID-19 in pediatric populations was concentrated in a few well-resourced institutions that were highly experienced in research.

Increasing Pediatricians' Scholarly Productivity on and off the Tenure Track.

INTRODUCTION: Physician faculty have increasingly been appointed to nontenure track positions, which provide limited support for scholarly activity. We evaluated how a centralized departmental research group affected the scholarly productivity of faculty on and off the tenure track. METHODS: A research team providing both mentorship and logistical study support was implemented in 2018. We identified a pre-intervention cohort of physician faculty employed in July 2016, and a postintervention cohort, employed in July 2018. A publication search was conducted for these cohorts in the period 2017 to 2018 and 2019 to 2020, respectively. RESULTS: Seventy-five faculty were included in the analysis, with approximately two-thirds appointed on the clinical (nontenure) track. In the pre-intervention cohort (n = 59), 15 faculty (25%) had at least one publication in the period 2017 to 2018. In the postintervention cohort (n = 59), 33 faculty (56%) published at least one article in the period 2019 to 2020 (P = .001). Multivariable random-effects regression analysis confirmed that postintervention, odds of publishing in a given year increased for both clinical-track and tenure-track faculty. CONCLUSION: Both clinical and tenure-track faculty contribute to the academic mission at medical schools, yet scholarly activity is supported and rewarded for tenure-track faculty more often than for clinical-track faculty. Our centralized research team successfully fostered scholarly activity among both clinical-track and tenure-track faculty.

Prior health care utilization among adolescents treated for a suicide attempt at a rural ED.

PURPOSE: To characterize prior contact with a rural academic health system among young people treated for a suicide attempt in the system's emergency departments (EDs). METHODS: We retrospectively examined electronic medical records from a health system serving 29 medically underserved rural counties in the Southeastern United States. Patients ages 10-25 years were included in the study if they were admitted to the ED for a suicide attempt in 2015-2018. Patients were stratified according to whether they had any encounter in the same health system in the 12 months prior to the attempt. FINDINGS: Of 236 patients meeting inclusion criteria, only 10% had contact with the health system in the 12 months prior to ED treatment for a suicide attempt. Patients who lived farther than 25 km from the flagship hospital were less likely to have had prior contact (odds ratio [OR]: 0.10, 95% confidence interval [CI]: 0.02-0.34). Young adults ages 19-25 years were also less likely to have prior contact than adolescents (OR: 0.27, 95% CI: 0.08-0.76). CONCLUSIONS: Few adolescents and young adults in this rural region received prior health care from the same health system where they were treated for a suicide attempt. Hospitals operating in rural areas need to partner with community health care providers to ensure adequate reach of screening and treatment programs to prevent youth suicide and reduce care fragmentation.

Influence of measles-mumps-rubella vaccine series initiation and completion on influenza vaccination among adolescents.

Background: Influenza vaccine participation in adolescents is low. Barriers to the influenza vaccine may be shared with the measles-mumps-rubella (MMR) vaccine. Methods: We studied adolescents aged 13-17 years who participated in the National Immunization Survey-Teen between 2011 and 2017 (N = 129,200). Data were analyzed to determine whether MMR vaccination status was associated with being up-to-date on the influenza vaccination. Results: A total of 49% adolescents received at least one dose of the influenza vaccine within the past 3 years, and 92% completed the MMR series. In multivariable analysis, not initiating or not completing the MMR series was associated with lower odds of being up-to-date on influenza vaccination. Conclusions: Adolescents who do not initiate or complete the MMR vaccine series have lower odds of being up-to-date on their influenza vaccination. Lower influenzavaccine participation is associated with lower socioeconomic status, lack of insurance, increased time since last child visit, and higher maternal education.

Human papillomavirus vaccine series follow-through: comparison of four clinics in an academic medical center.

OBJECTIVE: The Centers for Disease Control & Prevention (CDC) recommends that the human papillomavirus (HPV) vaccine series be initiated at ages 11-12 years, but many children never follow-through with the series. By examining differences in clinic-specific vaccine series follow-through rates across four clinics, we aimed to identify best practices related to communication around the vaccine and pathways to follow-through. METHODS: We used the electronic medical record (EMR) to retrospectively analyze HPV vaccine follow-through at four clinic settings. We limited the sample to children ages 11-17 who received a dose of the vaccine series at any of the clinics between January 2015 and June 2018. The primary outcome was follow-through of the HPV vaccine series within 18 months of initiation. RESULTS: A total of 3,813 patients were included in this study, 29% of which followed through with the HPV vaccine series. There was significant variability of vaccine follow-through among the clinics (p<0.001), with the Med/Peds clinic having the highest rate of follow-through (32%). After adjusting for confounding variables, multivariable analysis found that Med/Peds and Family Medicine had higher odds of HPV vaccine series follow-through than the Pediatrics clinic. CONCLUSIONS: We found that the likelihood of vaccine series follow-through was highest when the series was started in the Med/Peds and Family Medicine clinics, compared to Pediatrics and Adolescent Medicine. These results suggest that further qualitative research is needed to understand what communication strategies are most effective at facilitating HPV vaccine uptake among adolescents, and how the most effective strategies can be shared among clinics.

The Influence of a Sister's Breastfeeding Experience on a Mother's Breastfeeding Behavior: Is There an Intragenerational Effect?

Objective: Intergenerational transmission of breastfeeding attitudes and behaviors from mother to daughter are well known, but there is limited research on intragenerational transmission of breastfeeding attitudes or behaviors within families. This study aimed to understand how initiation and duration of breastfeeding are influenced by past breastfeeding experiences of sisters among women in a longitudinal population-based cohort. Methods: Data were obtained on women enrolled in the 1979 National Longitudinal Survey of Youth (NLSY) who had at least one child enrolled in a substudy of cohort members' children. For each mother in the study, we determined whether any of her sisters also enrolled in the main NLSY study had previously breastfed one of their children. Results: Mothers whose sister(s) had prior breastfeeding experience were more likely to breastfeed their first-born child on unadjusted analysis (70% versus 45%, chi-square p < 0.001) and had a longer median of breastfeeding duration (median 14.5 versus 12 weeks, rank-sum p = 0.039). However, on a multivariable analysis accounting for potential confounding by maternal characteristics, infant characteristics, and differences among households, sisters' breastfeeding experience was no longer independently associated with the likelihood of breastfeeding initiation (odds ratio: 1.16; confidence interval [95% CI]: 0.73-1.85; p = 0.520) or the hazard of breastfeeding discontinuation (hazard ratio: 0.96; 95% CI: 0.82-1.12; p = 0.598). Conclusion: After adjusting for socioeconomic characteristics, intragenerational transmission of breastfeeding behavior was negligible among mothers raised in the same household. Other forms of intragenerational transmission (e.g., influence of extended family members) may be more salient influences on women's decision to breastfeed.

The Impact of Medical Financial Hardship on Children's Health.

Objective. To determine whether living in a family with medical financial hardship decreases children's access to health care. Methods. We identified children aged 4 to 17 years from the 2013 to 2018 National Health Interview Surveys. Medical financial hardship was defined as living in a family where one or more family members had problems paying medical bills in the past 12 months. Results. Of 53 483 children in the analysis, 19% were exposed to medical financial hardship. This was adversely associated with children's health status and health care use, especially greater odds of delaying care (odds ratio [OR] = 5.28; 95% confidence interval [CI] = 4.51-6.19) and having unmet health care needs (OR = 4.43; 95% CI = 4.00-4.91). Conclusions. One fifth of children live in families experiencing medical financial hardship, and this exposure is adversely correlated with child health outcomes even controlling for established measures of socioeconomic status, such as family income, health insurance coverage, and need-based program participation.

Primary Care Use and Assessment of Adolescents' Sexual Health During Hospitalization.

OBJECTIVES: Hospitalization provides an opportunity to address sexual health needs of adolescents who may not otherwise receive regular medical care. We investigated documentation of a sexual health discussion with adolescents hospitalized at our medical center to determine if previous primary care physician (PCP) visits in the same health system were associated with sexual health documentation during the hospital admission. METHODS: We retrospectively identified adolescents aged 13 to 17 years discharged from the pediatric general ward. Documented discussion of sexual health was reviewed in the electronic medical record. Previous PCP visits were identified from the affiliated primary care clinics within 12 months before hospitalization. We also queried follow-up PCP visits within 90 days of discharge to determine if a sexual health discussion during hospitalization was followed-up in the outpatient setting. RESULTS: We analyzed 394 patients (49% girls; median age 15 years), of whom 122 (31%) had documentation of a sexual health discussion while hospitalized and 75 (19%) had previous PCP visits in our health system. On multivariable analysis, older age (P < .001), female sex (P = .016), admission from the emergency department (P < .001), and a genitourinary primary problem at admission (P = .007), but not previous PCP visits, were associated with increased likelihood of sexual health documentation. CONCLUSIONS: Although discussion of sexual health was uncommon overall for hospitalized adolescents, we noted that nearly 4 in 5 adolescents for whom this was documented had not recently visited a PCP in our health system. These findings highlight hospitalization as a unique opportunity for sexual health intervention among adolescents who may not regularly see a PCP.

Parity and the Association Between Maternal Sociodemographic Characteristics and Breastfeeding.

Objective: Although clinicians recognize the importance of breastfeeding for child health, breastfeeding initiation can be limited by maternal characteristics such as race/ethnicity, age at first birth, and educational attainment. We hypothesized that the strong influence of prior infant feeding experiences on multiparous women's decision to initiate and continue breastfeeding may mean that these maternal characteristics influence breastfeeding more strongly for primiparas than multiparas. Materials and Methods: Using Pregnancy Risk Assessment and Monitoring System (PRAMS) (Phase 8) survey data from 2016 to 2017, we analyzed mothers' responses to the supplemental question about parity, "Before you got pregnant with your new baby, did you ever have any other babies who were born alive?" Study variables were summarized by using weighted means and proportions and compared according to parity by using Wald tests. In the overall cohort, we evaluated the interaction between parity and each covariate by using logistic regression. Results: In our sample (N = 20,694), 40% of respondents were first-time mothers, and 88% had initiated breastfeeding. Primiparas were more likely to breastfeed than multiparas (92% versus 86%; p < 0.001), but they had shorter mean breastfeeding duration. On unadjusted analysis, four covariates were more strongly associated with breastfeeding initiation among primiparas than multiparas (maternal age, educational attainment, receiving breastfeeding information from a nurse or other medical professional, and receiving breastfeeding information from family or friends). Conclusions: Breastfeeding initiation is impacted more strongly by maternal characteristics for primiparas than multiparas.

Documentation of drug abuse in the family or household of children admitted to the hospital for non-accidental trauma.

BACKGROUND: Drug abuse in the family is known to increase the risk of child abuse, but its impact on outcomes of hospitalizations for non-accidental trauma (NAT) has not been characterized. OBJECTIVE: We aimed to identify how frequently drug abuse in the household was documented among children with known or suspected NAT, and to correlate drug abuse in the family with hospitalization outcomes. PARTICIPANTS AND SETTING: At our tertiary care hospital, we retrospectively queried hospital admissions of children ages 0-17 who had a Child Abuse and Neglect consultation ordered during an inpatient stay. METHODS: Case manager documentation and consult notes from the inpatient response team were used to determine suspected or confirmed presence of household substance abuse. RESULTS: We identified 185 children meeting inclusion criteria (59 % <1 year; 34 % 1-5 years; 7% 6-14 years of age). Drug abuse in the family was documented in 44 cases (24 %). Among 178 children surviving to discharge, drug abuse was associated with lower likelihood of discharge home (50 % vs. 70 % among children with no documented drug abuse, p = 0.018). After discharge, we found no statistically significant differences in rehospitalizations or emergency department visits according to documentation of drug abuse in the family. CONCLUSION: Our study addresses the role of family drug abuse in outcomes of hospitalizations for NAT. Significantly, half of cases with suspected or known drug abuse had no prior CPS involvement, and drug abuse was associated with discharge outcomes after controlling for prior CPS involvement.