A novel use of HIV surveillance and court data to understand and improve care among a population of people with HIV experiencing criminal charges in North Carolina 2017-2020.

Objectives Objectives: To enumerate the population of people with HIV (PWH) with criminal charges and to estimate associations between charges and HIV outcomes. Methods: We linked statewide North Carolina criminal court records to confidential HIV records (both 2017-2020) to identify a population of defendants with diagnosed HIV. We used generalized estimating equations to examine changes in viral suppression (outcome) pre-post criminal charges (exposure), adjusting for other demographic and legal system factors. Results: 9,534 PWH experienced criminal charges. Compared to others with charges, PWH were more likely to be male and report Black race. The median duration of unresolved charges was longer for PWH. When adjusting for demographic factors, the period following resolution of charges was modestly associated with an increased risk of viral suppression (aRR 1.03 (95% confidence interval 1.02-1.04) compared to the pre-charge period. Conclusions: A significant portion of PWH in NC had criminal charges during a three-year period, and these charges went unresolved for a longer time than those without HIV. These preliminary findings raise questions regarding whether PWH have appropriate access to legal services.

Suicide Mortality Among Formerly Incarcerated People Compared With the General Population in North Carolina, 2000-2020.

We aimed to compare rates and characteristics of suicide mortality in formerly incarcerated people with those of the general population in North Carolina. We conducted a retrospective cohort study of 266,400 people released from North Carolina state prisons between January 1, 2000, and March 1, 2020. Using direct and indirect standardization by age, sex, and calendar year, we calculated standardized suicide mortality rates and standardized mortality ratios comparing formerly incarcerated people with the North Carolina general population. We evaluated effect modification by race/ethnicity, sex, age, and firearm involvement. Formerly incarcerated people had approximately twice the overall suicide mortality of the general population for 3 years after release, with the highest rate of suicide mortality being observed in the 2-week period after release. In contrast to patterns in the general population, formerly incarcerated people had higher rates of non-firearm-involved suicide mortality than firearm-involved suicide mortality. Formerly incarcerated female, White and Hispanic/Latino, and emerging adult people had a greater elevation of suicide mortality than their general-population peers compared with other groups. These findings suggest a need for long-term support for formerly incarcerated people as they return to community living and a need to identify opportunities for interventions that reduce the harms of incarceration for especially vulnerable groups. This article is part of a Special Collection on Mental Health.

Hurricane Florence and suicide mortality in North Carolina: a controlled interrupted time-series analysis.

BACKGROUND: Natural disasters are associated with increased mental health disorders and suicidal ideation; however, associations with suicide deaths are not well understood. We explored how Hurricane Florence, which made landfall in September 2018, may have impacted suicide deaths in North Carolina (NC). METHODS: We used publicly available NC death records data to estimate associations between Hurricane Florence and monthly suicide death rates using a controlled, interrupted time series analysis. Hurricane exposure was determined by using county-level support designations from the Federal Emergency Management Agency. We examined effect modification by sex, age group, and race/ethnicity. RESULTS: 8363 suicide deaths occurred between January 2014 and December 2019. The overall suicide death rate in NC between 2014 and 2019 was 15.53 per 100 000 person-years (95% CI 15.20 to 15.87). Post-Hurricane, there was a small, immediate increase in the suicide death rate among exposed counties (0.89/100 000 PY; 95% CI -2.69 to 4.48). Comparing exposed and unexposed counties, there was no sustained post-Hurricane Florence change in suicide death rate trends (0.02/100 000 PY per month; 95% CI -0.33 to 0.38). Relative to 2018, NC experienced a statewide decline in suicides in 2019. An immediate increase in suicide deaths in Hurricane-affected counties versus Hurricane-unaffected counties was observed among women, people under age 65 and non-Hispanic black individuals, but there was no sustained change in the months after Hurricane Florence. CONCLUSIONS: Although results did not indicate a strong post-Hurricane Florence impact on suicide rates, subgroup analysis suggests differential impacts of Hurricane Florence on several groups, warranting future follow-up.

Innovations in suicide prevention research (INSPIRE): a protocol for a population-based case-control study.

BACKGROUND: Suicide deaths have been increasing for the past 20 years in the USA resulting in 45 979 deaths in 2020, a 29% increase since 1999. Lack of data linkage between entities with potential to implement large suicide prevention initiatives (health insurers, health institutions and corrections) is a barrier to developing an integrated framework for suicide prevention. OBJECTIVES: Data linkage between death records and several large administrative datasets to (1) estimate associations between risk factors and suicide outcomes, (2) develop predictive algorithms and (3) establish long-term data linkage workflow to ensure ongoing suicide surveillance. METHODS: We will combine six data sources from North Carolina, the 10th most populous state in the USA, from 2006 onward, including death certificate records, violent deaths reporting system, large private health insurance claims data, Medicaid claims data, University of North Carolina electronic health records and data on justice involved individuals released from incarceration. We will determine the incidence of death from suicide, suicide attempts and ideation in the four subpopulations to establish benchmarks. We will use a nested case-control design with incidence density-matched population-based controls to (1) identify short-term and long-term risk factors associated with suicide attempts and mortality and (2) develop machine learning-based predictive algorithms to identify individuals at risk of suicide deaths. DISCUSSION: We will address gaps from prior studies by establishing an in-depth linked suicide surveillance system integrating multiple large, comprehensive databases that permit establishment of benchmarks, identification of predictors, evaluation of prevention efforts and establishment of long-term surveillance workflow protocols.

Estimating the Number of Persons with HIV in Jails via Web Scraping and Record Linkage.

This paper presents methods to estimate the number of persons with HIV in North Carolina jails by applying finite population inferential approaches to data collected using web scraping and record linkage techniques. Administrative data are linked with web-scraped rosters of incarcerated persons in a nonrandom subset of counties. Outcome regression and calibration weighting are adapted for state-level estimation. Methods are compared in simulations and are applied to data from the US state of North Carolina. Outcome regression yielded more precise inference and allowed for county-level estimates, an important study objective, while calibration weighting exhibited double robustness under misspecification of the outcome or weight model.

Postrelease mortality among persons hospitalized during their incarceration.

PURPOSE: Health and mortality of people released from incarceration have received increased attention, and yet little is known about the postrelease experiences of those hospitalized during incarceration. METHODS: For persons incarcerated and released from the North Carolina (NC) state prison system between January 1, 2008, and June 30, 2015, we examined postrelease mortality from 2008 to 2016 by history of prison hospitalization. RESULTS: Among 111,479 released persons, 0.9% (n = 1010) were hospitalized during their incarceration, and of those, 10.5% (n = 106) died during follow-up compared with 3.2% (3511/110,469) of other released persons. Those hospitalized in prison had a higher postrelease death rate (adjusted hazard ratio: 2.44), a lower 8-year conditional probability of survival (0.80 vs. 0.94), and were more likely to die from chronic causes (79.2% vs. 51.0%) than other released persons. The postrelease standardized mortality rate among men hospitalized in prison was 3.1 times higher than that of those not hospitalized and 7.1 times the rate of all NC men. CONCLUSIONS: People hospitalized during incarceration constitute a particularly vulnerable, yet relatively easily identifiable priority population to focus health interventions supporting continuity of care after prison release. Yet such efforts may be particularly challenging in NC and other Medicaid non-expansion states.

Prevalence of Chronic Health Conditions Among Adults Released From the North Carolina Prison System, 2015-2016.

BACKGROUND In the United States each year nearly 570,000 people return from state prisons to the community. Prevalence data of chronic health problems for this population are lacking, impeding planning of health care programs to serve people with chronic conditions who are re-entering the community.METHOD We used medication dispensing records as a proxy for diagnoses in assessing the prevalence of 10 major and 20 substituent health conditions among incarcerated people released from the North Carolina state prison system from July 2015 through June 2016.RESULTS Among 20,585 released people, 13% were female; 50% were black; 43% were white; and 4% were aged 55 years or older. Thirty-three percent had ≥ 1 condition and 13% had two or more. The prevalence of chronic health conditions was the following: psychiatric, 15%; cardiovascular, 15%; neurologic, 7%; pulmonary, 6%; diabetes mellitus, 3%; and infectious, 3%. Seventy-one percent of those aged 55 years or older had a chronic medical condition. Among those with a psychiatric condition, 56% had another chronic illness.LIMITATIONS We could not identify unmedicated health conditions; medications prescribed across multiple disease categories were excluded from our analysis.CONCLUSION In North Carolina, at least one in three people released from the state prison system had a chronic health condition, and among those with psychiatric conditions, most had comorbid medical disease. Coordination of health care after release from incarceration is essential to avoid preventable complications and unnecessary utilization of acute care services. Greater eligibility for Medicaid is needed to scale up transition programs for this population.

Predictors of initial weight loss after gastric bypass surgery in twelve Veterans Affairs Medical Centers.

The objective of this study was to identify determinants of significant weight loss one year after gastric bypass surgery among United States veterans. Using data from the Veterans Affairs (VA) Surgical Quality Improvement Program, we identified 516 veterans who had gastric bypass surgery (24% laparoscopic) in one of twelve VA bariatric centers in 2000-2006 and one or more postoperative weight measures. The probability of losing 30% or more of baseline weight at one year was estimated via logistic regression, examining the following potential predictor variables: age, gender, race, marital status, body mass index (BMI), American Society of Anesthesiologists class, comorbidity burden, smoking status, diabetes medications taken and surgical procedure (open or laparoscopic). The 516 cases had a mean BMI of 49 kg/m(2), mean age of 51.5 years, 74% were male, 77% were Caucasian, and 55% were married. The predicted mean weight loss was 76 (95% CI: 73-79) pounds (22%) at six months and 109 (95% CI: 104-114) pounds (32%) at one-year. Based upon estimated individual trajectories of 370 patients with adequate follow-up data, 58% of the sample lost 30% or more of their baseline weight at one year; and <1% lost <10% of their baseline weight at 1 year. In the logistic regression, patients were more likely to lose 30% or more of their baseline weight if they were female (odds ratio (OR) = 2.5, p < 0.01) or Caucasian (OR = 2.3, p < 0.01). We conclude that gastric bypass surgery yields significant weight loss for most patients in Veterans Affairs Medical Centers, but is particularly effective for female and Caucasian patients.

How price responsive is the demand for specialty care?

OBJECTIVES: Outpatient visit co-payments have increased in recent years. We estimate the patient response to a price change for specialty care, based on a co-payment increase from $15 to $50 per visit for veterans with hypertension. DESIGN, SETTING, AND PATIENTS: A retrospective cohort of veterans required to pay co-payments was compared with veterans exempt from co-payments whose nonequivalence was reduced via propensity score matching. Specialty care expenditures in 2000-2003 were estimated via a two-part mixed model to account for the correlation of the use and level outcomes over time, and results from this correlated two-part model were compared with an uncorrelated two-part model and a correlated random intercept two-part mixed model. RESULTS: A $35 specialty visit co-payment increase had no impact on the likelihood of seeking specialty care but induced lower specialty expenditures over time among users who were required to pay co-payments. The log ratio of price responsiveness (semi-elasticity) for specialty care increased from -0.25 to -0.31 after the co-payment increase. Estimates were similar across the three models. CONCLUSION: A significant increase in specialty visit co-payments reduced specialty expenditures among patients obtaining medications at the Veterans Affairs medical centers. Longitudinal expenditure analysis may be improved using recent advances in two-part model methods.

Survival among high-risk patients after bariatric surgery.

CONTEXT: Existing evidence of the survival associated with bariatric surgery is based on cohort studies of predominantly younger women with a low inherent obesity-related mortality risk. The association of survival and bariatric surgery for older men is less clear. OBJECTIVE: To determine whether bariatric surgery is associated with reduced mortality in a multisite cohort of predominantly older male patients who have a high baseline mortality rate. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of bariatric surgery programs in Veterans Affairs medical centers. Mortality was examined for 850 veterans who had bariatric surgery in January 2000 to December 2006 (mean age 49.5 years; SD 8.3; mean body mass index [BMI] 47.4; SD 7.8) and 41,244 nonsurgical controls (mean age 54.7 years, SD 10.2; mean BMI 42.0, SD 5.0) from the same 12 Veteran Integrated Service Networks; the mean follow-up was 6.7 years. Four Cox proportional hazards models were assessed: unadjusted and controlled for baseline covariates on unmatched and propensity-matched cohorts. MAIN OUTCOME MEASURE: All-cause mortality through December 2008. RESULTS: Among patients who had bariatric surgery, the 1-, 2-, and 6-year crude mortality rates were, respectively, 1.5%, 2.2%, and 6.8% compared with 2.2%, 4.6%, and 15.2% for nonsurgical controls. In unadjusted Cox regression, bariatric surgery was associated with reduced mortality (hazard ratio [HR], 0.64; 95% confidence interval [CI], 0.51-0.80). After covariate adjustment, bariatric surgery remained associated with reduced mortality (HR, 0.80; 95% CI, 0.63-0.995). In analysis of 1694 propensity-matched patients, bariatric surgery was no longer significantly associated with reduced mortality in unadjusted (HR, 0.83; 95% CI, 0.61-1.14) and time-adjusted (HR, 0.94; 95% CI, 0.64-1.39) Cox regressions. CONCLUSION: In propensity score-adjusted analyses of older severely obese patients with high baseline mortality in Veterans Affairs medical centers, the use of bariatric surgery compared with usual care was not associated with decreased mortality during a mean 6.7 years of follow-up.

Discontinuation of diabetes and lipid-lowering medications after bariatric surgery at Veterans Affairs medical centers.

BACKGROUND: Bariatric surgery has largely been performed on middle-age female populations and been associated with significant medication discontinuation; however, it is unknown whether similar medication discontinuation rates could be achieved in men. The purpose of the present analysis was to examine the discontinuation rate of diabetes or lipid-lowering medications and the patient factors associated with medication discontinuation among veterans undergoing bariatric surgery. METHODS: We identified the demographic and health status information for 284 veterans with diabetes and 298 veterans with hyperlipidemia who had undergone bariatric surgery at 1 of 12 Veterans Affairs bariatric centers in 2000 to 2006 from the Veterans Affairs National Surgical Quality Improvement Program data. We also identified the medications that had been prescribed and discontinued using the Veterans Affairs administrative data. Medication discontinuation was estimated using a logistic regression model. RESULTS: Of the 284 veterans with diabetes and 298 with hyperlipidemia, 52% and 40% had discontinued their medications at 1 year, respectively. The veterans with diabetes were more likely to discontinue medication if they had been taking oral hypoglycemic agents alone (odds ratio 2.77, P <.001) than were those taking insulin or oral hypoglycemic agents and insulin. The veterans with hyperlipidemia were more likely to discontinue medication if they had only been taking fibrates (odds ratio 6.15, P <.01) than were those veterans taking statins and fibrates. CONCLUSION: Bariatric surgery led to significant medication discontinuation within 1 year for high-risk veterans with diabetes or hyperlipidemia.

Health care utilization and expenditure changes associated with bariatric surgery.

CONTEXT: Bariatric surgery provides significant reductions in weight and comorbidity, and has the potential to reduce health care utilization. It is unknown whether health care utilization and expenditures are reduced for veterans after bariatric surgery. OBJECTIVES: To examine health care utilization and expenditures of severely obese individuals before and after bariatric surgery within the Veterans Health Administration. DESIGN, SETTING, AND PATIENTS: We conducted a retrospective, longitudinal cohort study of health care use and expenditures among all veterans who underwent bariatric surgery in 1 of 12 approved Department of Veterans Affairs bariatric centers from 2000 to 2006. Bariatric patients were identified via Current Procedural Terminology-4 codes from a database of major surgical procedures maintained by the National Surgical Quality Improvement Program. MAIN OUTCOME MEASURE: The main outcomes of interest for our analysis were multivariable adjusted inpatient and outpatient health care utilization and expenditures in the 3 years prior to surgery and in the 3 years after surgery. RESULTS: Between 2000 and 2006, 846 veterans had bariatric surgery, 25% of whom underwent a laparoscopic procedure. The mean initial body mass index was 48.5, the mean age was 51; and 73% were male. In multivariable models including all years of data, outpatient, inpatient, and overall expenditures significantly decreased in the years after surgery because of higher clinical resources required in the months before and during surgery. When excluding the 6 months leading up to surgery and the 6 months just after surgery, outpatient expenditures remained lower in the postsurgical period, but inpatient and overall expenditures were significantly higher. CONCLUSION: Our analyses indicate that this cohort of older, male bariatric surgery patients does not achieve a reduction in health care expenditures 3 years after their procedure. These results are at variance from other, similar published studies and may reflect differences in study populations or systems of care.