Whole-cell Rieske non-heme iron biocatalysts.

Rieske non-heme iron oxygenases (ROs) possess the ability to catalyze a wide range of reactions. Their ability to degrade aromatic compounds is a unique characteristic and makes ROs interesting for a variety of potential applications. However, purified ROs can be challenging to work with due to low stability and long, complex electron transport chains. Whole cell biocatalysis represents a quick and reliable method for characterizing the activity of ROs and harnessing their metabolic potential. In this protocol, we outline a step-by-step protocol for the overexpression of ROs for whole cell biocatalysis and characterization. We have utilized a caffeine-degrading, N-demethylation system, expressing the RO genes ndmA and ndmD, as an example of this method.

Evaluation of the Tuberculosis Infection Care Cascade Among Pregnant Individuals in a Low-Tuberculosis-Burden Setting.

In the United States, tuberculosis (TB) screening is recommended for pregnant individuals with TB risk factors. We conducted a retrospective study of perinatal TB infection testing and treatment in a tertiary health system. Of 165 pregnant individuals with positive TB infection tests, only 9% completed treatment within 4.6 years of follow-up.

Quality-of-Care Outcomes in Vertical Relationships Between Physicians and Health Systems.

Importance: Vertical relationships (ownership, affiliations, joint contracting) between physicians and health systems are increasing in the US. Many proponents of vertical relationships argue that increased spending associated with consolidation is accompanied by improvements in quality of care. Objective: To assess the association of vertical relationships between primary care physicians (PCPs) and large health systems and quality of care. Design, Setting, and Participants: This stacked difference-in-differences study compared outcomes for patients whose attributed PCP entered a vertical relationship with a large system in 2015 or 2017 to patients whose PCP was either never or always in a vertical relationship with a large system from 2013 to 2017. Models account for differences between PCPs, patient characteristics, market concentration, and secular trends. Data were derived from the 2013 to 2017 Massachusetts All-Payer Claims Database. The study population included commercially insured individuals attributed to a PCP in the Massachusetts Health Quality Partners' Massachusetts Provider Database in 2013, 2015, or 2017. Analyses were conducted between January 2021 and January 2024. Exposure: PCPs attributed to patients in the study entering a vertical relationship with a large health system in 2015 or 2017. Main Outcomes and Measures: Low-value care utilization, posthospitalization follow-up, utilization among patients with ambulatory care-sensitive conditions, practice site visit fragmentation, and timeliness of specialty care. Results: The study population included 4 603 172 patient-year observations from 2013 to 2017. Among all patients in the study, 53.5% were female, 35.3% had any chronic condition, and the mean (SD) age was 38.9 (20.3) years. There was no association between vertical relationships and low-value care or ambulatory care-sensitive conditions utilization. A patient's PCP entering a vertical relationship had no association with the probability of follow-up within 90 days of cancer diagnosis with any oncologist but was associated with a 7.34-percentage point (pp) (95% CI, 2.28-12.40; P = .01) increase in the probability of follow-up with an oncologist in the health system. Vertical relationships were associated with increased posthospitalization follow-up with a physician in the health system by 7.51 pp (95% CI, 2.96-12.06: P = .001) in the 2015 subgroup. PCP-health system vertical relationships were associated with a significant decrease in fragmentation of practice site visits of -1.05 pp (95% CI, -2.05 to 0.05; P = .04). Conclusions and Relevance: In this study, vertical relationships between PCPs and large health systems were associated with patient steering and changes in care delivery processes, but not necessarily improvements in patient outcomes.

Access to Care and Outcomes With the Affordable Care Act for Persons With Criminal Legal Involvement: A Scoping Review.

Importance: By expanding health insurance to millions of people in the US, the Patient Protection and Affordable Care Act (ACA) may have important health, economic, and social welfare implications for people with criminal legal involvement-a population with disproportionately high morbidity and mortality rates. Objective: To scope the literature for studies assessing the association of any provision of the ACA with 5 types of outcomes, including insurance coverage rates, access to care, health outcomes, costs of care, and social welfare outcomes among people with criminal legal involvement. Evidence Review: The literature search included results from PubMed, CINAHL Complete, APA Psycinfo, Embase, Social Science Database, and Web of Science and was conducted to include articles from January 1, 2014, through December 31, 2023. Only original empirical studies were included, but there were no restrictions on study design. Findings: Of the 3538 studies initially identified for potential inclusion, the final sample included 19 studies. These 19 studies differed substantially in their definition of criminal legal involvement and units of analysis. The studies also varied with respect to study design, but difference-in-differences methods were used in 10 of the included studies. With respect to outcomes, 100 unique outcomes were identified across the 19 studies, with at least 1 in all 5 outcome categories determined prior to the literature search. Health insurance coverage and access to care were the most frequently studied outcomes. Results for the other 3 outcome categories were mixed, potentially due to heterogeneous definitions of populations, interventions, and outcomes and to limitations in the availability of individual-level datasets that link incarceration data with health-related data. Conclusions and Relevance: In this scoping review, the ACA was associated with an increase in insurance coverage and a decrease in recidivism rates among people with criminal legal involvement. Future research and data collection are needed to understand more fully health and nonhealth outcomes among people with criminal legal involvement related to the ACA and other health insurance policies-as well as the mechanisms underlying these relationships.

Tuberculosis treatment loss to follow-up in children exposed at home: A prospective cohort study.

Background: Loss to follow-up (LTFU) from tuberculosis (TB) treatment and care is a significant public health problem. It is important to understand what drives LTFU in children - a population whose treatment and management depend on an adult caregiver - to better provide support services to families affected by TB. Methods: We conducted a prospective cohort study of household contacts in Lima, Peru (2009-12). Using multilevel logistic regression analysis, we explored individual-level characteristics of children and their adult household members with TB disease to identify risk factors for LTFU among children initiated on treatment for TB. Results: A total of 154 child (0-14 years) household contacts were diagnosed with TB and initiated on treatment. While most (n = 133, 86.4%) had a successful outcome, 20 (13.0%) children were LTFU. Six (30.0%) children were LTFU within three months, nine (45.0%) between five to seven months, and three (15.0%) after seven months of treatment being initiated. In univariable analysis, children with index patients above 25 years of age had decreased odds of being LTFU (odds ratio = 0.26; 95% confidence interval = 0.08-0.84) compared to children with index patients 25 years or younger. Conclusions: In this cohort, more than 10% of children sick with TB who were exposed to the disease at home were LTFU. An integrated, family-centred TB prevention and management approach may reduce barriers to a child completing their course of TB treatment.

Task-sharing spinal anaesthesia care in three rural Indian hospitals: a non-inferiority randomised controlled clinical trial.

BACKGROUND: Task-sharing of spinal anaesthesia care by non-specialist graduate physicians, termed medical officers (MOs), is commonly practised in rural Indian healthcare facilities to mitigate workforce constraints. We sought to assess whether spinal anaesthesia failure rates of MOs were non-inferior to those of consultant anaesthesiologists (CA) following a standardised educational curriculum. METHODS: We performed a randomised, non-inferiority trial in three rural hospitals in Tamil Nadu and Chhattisgarh, India. Patients aged over 18 years with low perioperative risk (ASA I & II) were randomised to receive MO or CA care. Prior to the trial, MOs underwent task-based anaesthesia training, inclusive of remotely accessed lectures, simulation-based training and directly observed anaesthetic procedures and intraoperative care. The primary outcome measure was spinal anaesthesia failure with a non-inferiority margin of 5%. Secondary outcome measures consisted of incidence of perioperative and postoperative complications. FINDINGS: Between 12 July 2019 and 8 June 2020, a total of 422 patients undergoing surgical procedures amenable to spinal anaesthesia care were randomised to receive either MO (231, 54.7%) or CA care (191, 45.2%). Spinal anaesthesia failure rate for MOs (7, 3.0%) was non-inferior to those of CA (5, 2.6%); difference in success rate of 0.4% (95% CI=0.36-0.43%; p=0.80). Additionally, there were no statistically significant differences observed between the two groups for intraoperative or postoperative complications, or patients' experience of pain during the procedure. INTERPRETATION: This study demonstrates that failure rates of spinal anaesthesia care provided by trained MOs are non-inferior to care provided by CAs in low-risk surgical patients. This may support policy measures that use task-sharing as a means of expanding anaesthesia care capacity in rural Indian hospitals. TRIAL REGISTRATION NUMBER: NCT04438811.

Immunogenicity of a 30-valent M protein mRNA group A Streptococcus vaccine.

BACKGROUND: Group A Streptococcus (Strep A) causes both uncomplicated and severe invasive infections, as well as the post-infection complications acute rheumatic fever and rheumatic heart disease. Despite the high global burden of disease resulting from Strep A infections, there is not a licensed vaccine. A 30-valent M protein-based vaccine has previously been shown to be immunogenic in animal models and in a Phase I clinical trial (NCT02564237). Here, we assessed the immunogenicity of a 30-valent messenger (m)RNA vaccine designed to express the same M peptide targets as the 30-valent protein vaccine and compared it with the protein vaccine. METHODS: Female New Zealand white rabbits were immunized with one of four vaccine formulations (3 doses of each formulation at days 1, 28, and 56): soluble mRNA (100 µg/animal), C-terminal transmembrane mRNA (100 µg/animal), protein vaccine (400 µg/animal), or a non-translatable RNA control (100 µg/animal). Serum was collected one day prior to the first dose and on days 42 and 70. Rabbit serum samples were assayed for antibody levels against synthetic M peptides by ELISA. HL-60 opsonophagocytic killing (OPK) assays were performed to assess functional antibody levels. RESULTS: Serum IgG levels were similar for the mRNA and protein vaccines. The CtTM version of the mRNA vaccine elicited slightly higher antibody levels than the mRNA designed to express soluble proteins. OPK activity was similar for the mRNA and protein vaccines, regardless of M type. CONCLUSIONS: The total antibody responses and functional antibody levels elicited by the 30-valent mRNA Strep A vaccines were similar to those observed following immunization with the analogous protein vaccine. The mRNA vaccine platform provides potential advantages to protein-based vaccines including inherent adjuvant activity, increased production efficiency, lower cost, and the potential to rapidly change epitopes/peptides, all of which are important considerations related to multivalent Strep A vaccine development.

Disparities in Psychiatric Emergency Department Boarding of Children and Adolescents.

Importance: Since the COVID-19 pandemic, emergency department boarding of youth with mental health concerns has increased. Objective: To summarize characteristics (including gender, age, race, ethnicity, insurance, diagnosis, and barriers to placement) of youth who boarded in emergency departments while awaiting inpatient psychiatric care and to test for racial, ethnic, and gender disparities in boarding lengths and inpatient admission rates after boarding. Secondarily, to assess whether statewide demand for inpatient psychiatric care correlated with individual outcomes. Design, Setting, and Participants: This cross-sectional analysis included administrative data collected from May 2020 to June 2022 and represented a statewide study of Massachusetts. All youth aged 5 to 17 years who boarded in Massachusetts emergency departments for 3 or more midnights while awaiting inpatient psychiatric care were included. Exposure: Boarding for 3 or more midnights while awaiting inpatient psychiatric care. Main Outcomes and Measures: Emergency department boarding length (number of midnights) and whether inpatient care was received after boarding. Statistical analyses performed included logistic and gamma regressions; assessed gender, racial, and ethnic disparities; and correlations between statewide demand for psychiatric care and boarding outcomes. Results: A total of 4942 boarding episodes were identified: 2648 (54%) for cisgender females, 1958 (40%) for cisgender males, and 336 (7%) for transgender or nonbinary youth. A total of 1337 youth (27%) were younger than 13 years. Depression was the most common diagnosis (2138 [43%]). A total of 2748 episodes (56%) resulted in inpatient admission, and 171 transgender and nonbinary youth (51%) received inpatient care compared with 1558 cisgender females (59%; adjusted difference: -9.1 percentage points; 95% CI, -14.7 to -3.6 percentage points). Transgender or nonbinary youth boarded for a mean (SD) of 10.4 (8.3) midnights compared with 8.6 (6.9) midnights for cisgender females (adjusted difference: 2.2 midnights; 95% CI, 1.2-3.2 midnights). Fewer Black youth were admitted than White youth (382 [51%] and 1231 [56%], respectively; adjusted difference: -4.3 percentage points; 95% CI, -8.4 to -0.2 percentage points). For every additional 100 youth boarding statewide on the day of assessment, the percentage of youth admitted was 19.4 percentage points lower (95% CI, -23.6% to -15.2%) and boarding times were 3.0 midnights longer (95% CI, 2.4-3.7 midnights). Conclusions and Relevance: In this cross-sectional study, almost one-half of 3 or more midnight boarding episodes did not result in admission, highlighting a need to understand the effects of boarding without admission. Gender and racial disparities were identified, suggesting the need for targeted resources to reduce boarding and promote equitable access to care.

Emotional Invalidation and Relationship Quality: A Mediational Model Through a Social Learning Lens.

While we know childhood experiences are influential on a child's later socioemotional awareness and behavior, we are still searching for specific mechanisms that influence the transferability of childhood experiences and adult relationship functioning. In this study, we seek to further this area of investigation by examining the interpretation of ambiguous social interactions and perceptions of emotional invalidation as potential mediators of the relationship between perceptions of childhood emotional invalidation and current relationship quality. Participants completed online measures of hostile intent attributions, perceptions of childhood emotional invalidation, and current relationship quality with a significant other. They read emotionally provocative interpersonal scenarios and then reported likely emotionally invalidating reactions from their significant other to measure current perceptions of emotional invalidation. Results supported our hypotheses that perceptions of current emotional invalidation in a close, personal relationship would mediate the relationship between perceptions of childhood maternal emotional invalidation and both current relationship support and relationship conflict. Furthermore, the strength of this mediational pathway outweighed the influence of a more general hostile attribution bias. These findings have implications for prevention and intervention strategies designed to enhance interpersonal functioning.

Systems analysis and improvement approach to optimize tuberculosis (SAIA-TB) screening, treatment, and prevention in South Africa: a stepped-wedge cluster randomized trial.

BACKGROUND: The use of systems engineering tools, including the development and use of care cascades using routinely collected data, process mapping, and continuous quality improvement, is used for frontline healthcare workers to devise systems level change. South Africa experiences high rates of tuberculosis (TB) infection and disease as well as HIV co-infection. The Department of Health has made significant gains in HIV services over the last two decades, reaching their set "90-90-90" targets for HIV. However, TB services, although robust, have lagged in comparison for both disease and infection. The Systems Analysis and Improvement Approach (SAIA) is a five-step implementation science method, drawn from systems engineering, to identify, define, and implement workflow modifications using cascade analysis, process mapping, and repeated quality improvement cycles within healthcare facilities. METHODS: This stepped-wedge cluster randomized trial will evaluate the effectiveness of SAIA on TB (SAIA-TB) cascade optimization for patients with TB and high-risk contacts across 16 clinics in four local municipalities in the Sarah Baartman district, Eastern Cape, South Africa. We hypothesize that SAIA-TB implementation will lead to a 20% increase in each of: TB screening, TB preventive treatment initiation, and TB disease treatment initiation during the 18-month intervention period. Focus group discussions and key informant interviews with clinic staff will also be conducted to determine drivers of implementation variability across clinics. DISCUSSION: This study has the potential to improve TB screening, treatment initiation, and completion for both active disease and preventive measures among individuals with and without HIV in a high burden setting. SAIA-TB provides frontline health care workers with a systems-level view of their care delivery system with the aim of sustainable systems-level improvements. TRIAL REGISTRATION: Clinicaltrials.gov, NCT06314386. Registered 18 March 2024, https://clinicaltrials.gov/study/NCT06314386 . NCT06314386.

Preferences for Postacute Care at Home vs Facilities.

Importance: Two in 5 US hospital stays result in rehabilitative postacute care, typically through skilled nursing facilities (SNFs) or home health agencies (HHAs). However, a lack of clear guidelines and understanding of patient and caregiver preferences make it challenging to promote high-value patient-centered care. Objective: To assess preferences and willingness to pay for facility-based vs home-based postacute care among patients and caregivers, considering demographic variations. Design, Setting, and Participants: In September 2022, a nationally representative survey was conducted with participants 45 years or older. Using a discrete choice experiment, participants acting as patients or caregivers chose between facility-based and home-based postacute care that best met their preferences, needs, and family conditions. Survey weights were applied to generate nationally representative estimates. Main Outcomes and Measures: Preferences and willingness to pay for various attributes of postacute care settings were assessed, examining variation based on demographic factors, socioeconomic status, job security, and previous care experiences. Results: A total of 2077 adults were invited to participate in the survey; 1555 (74.9%) completed the survey. In the weighted sample, 52.9% of participants were women, 6.5% were Asian or Pacific Islander, 1.7% were American Indian or Alaska Native, 11.2% were Black or African American, 78.4% were White; the mean (SD) age was 62.6 (9.6) years; and there was a survey completion rate of 74.9%. Patients and caregivers showed a substantial willingness to pay for home-based and high-quality care. Patients and caregivers were willing to pay an additional $58.08 per day (95% CI, 45.32-70.83) and $45.54 per day (95% CI, 31.09-59.99) for HHA care compared with a shared SNF room, respectively. However, increased demands on caregiver time within an HHA scenario and socioeconomic challenges, such as insecure employment, shifted caregivers' preferences toward facility-based care. There was a strong aversion to below average quality. To avoid below average SNF care, patients and caregivers were willing to pay $75.21 per day (95% CI, 61.68-88.75) and $79.10 per day (95% CI, 63.29-94.91) compared with average-quality care, respectively. Additionally, prior awareness and experience with postacute care was associated with willingness to pay for home-based care. No differences in preferences among patients and caregivers based on race, educational background, urban or rural residence, general health status, or housing type were observed. Conclusions and Relevance: The findings of this survey study underscore a prevailing preference for home-based postacute care, aligning with current policy trends. However, attention is warranted for disadvantaged groups who are potentially overlooked during the shift toward home-based care, particularly those facing caregiver constraints and socioeconomic hardships. Ensuring equitable support and improved quality measure tools are crucial for promoting patient-centric postacute care, with emphasis on addressing the needs of marginalized groups.

Microbial metabolism of caffeine and potential applications in bioremediation.

With increasing global consumption of caffeine-rich products, such as coffee, tea, and energy drinks, there is also an increase in urban and processing waste full of residual caffeine with limited disposal options. This waste caffeine has been found to leach into the surrounding environment where it poses a threat to microorganisms, insects, small animals, and entire ecosystems. Growing interest in harnessing this environmental contaminant has led to the discovery of 79 bacterial strains, eight yeast strains, and 32 fungal strains capable of metabolizing caffeine by N-demethylation and/or C-8 oxidation. Recently observed promiscuity of caffeine-degrading enzymes in vivo has opened up the possibility of engineering bacterial strains capable of producing a wide variety of caffeine derivatives from a renewable resource. These engineered strains can be used to reduce the negative environmental impact of leached caffeine-rich waste through bioremediation efforts supplemented by our increasing understanding of new techniques such as cell immobilization. Here, we compile all of the known caffeine-degrading microbial strains, discuss their metabolism and related enzymology, and investigate their potential application in bioremediation.

Trends in Integration Between Physician Organizations and Pharmacies for Self-Administered Drugs.

Importance: Increasing integration across medical services may have important implications for health care quality and spending. One major but poorly understood dimension of integration is between physician organizations and pharmacies for self-administered drugs or in-house pharmacies. Objective: To describe trends in the use of in-house pharmacies, associated physician organization characteristics, and associated drug prices. Design, Setting, and Participants: A cross-sectional study was conducted from calendar years 2011 to 2019. Participants included 20% of beneficiaries enrolled in fee-for-service Medicare Parts A, B, and D. Data analysis was performed from September 15, 2020, to December 20, 2023. Exposures: Prescriptions filled by in-house pharmacies. Main Outcomes and Measures: The share of Medicare Part D spending filled by in-house pharmacies by drug class, costliness, and specialty was evaluated. Growth in the number of physician organizations and physicians in organizations with in-house pharmacies was measured in 5 specialties: medical oncology, urology, infectious disease, gastroenterology, and rheumatology. Characteristics of physician organizations with in-house pharmacies and drug prices at in-house vs other pharmacies are described. Results: Among 8 020 652 patients (median age, 72 [IQR, 66-81] years; 4 570 114 [57.0%] women), there was substantial growth in the share of Medicare Part D spending on high-cost drugs filled at in-house pharmacies from 2011 to 2019, including oral anticancer treatments (from 10% to 34%), antivirals (from 12% to 20%), and immunosuppressants (from 2% to 9%). By 2019, 63% of medical oncologists, 20% of urologists, 29% of infectious disease specialists, 21% of gastroenterologists, and 22% of rheumatologists were in organizations with specialty-relevant in-house pharmacies. Larger organizations had a greater likelihood of having an in-house pharmacy (0.75 percentage point increase [95% CI, 0.56-0.94] per each additional physician), as did organizations owning hospitals enrolled in the 340B Drug Discount Program (10.91 percentage point increased likelihood [95% CI, 6.33-15.48]). Point-of-sale prices for high-cost drugs were 1.76% [95% CI, 1.66%-1.87%] lower at in-house vs other pharmacies. Conclusions and Relevance: In this cross-sectional study of physician organization-operated pharmacies, in-house pharmacies were increasingly used from 2011 to 2019, especially for high-cost drugs, potentially associated with organizations' financial incentives. In-house pharmacies offered high-cost drugs at lower prices, in contrast to findings of integration in other contexts, but their growth highlights a need to understand implications for patient care.

Who Transmits Tuberculosis to Whom: A Cross-Sectional Analysis of a Cohort Study in Lima, Peru.

Rationale: The persistent burden of tuberculosis (TB) disease emphasizes the need to identify individuals with TB for treatment and those at a high risk of incident TB for prevention. Targeting interventions toward those at high risk of developing and transmitting TB is a public health priority. Objectives: We aimed to identify characteristics of individuals involved in TB transmission in a community setting, which may guide the prioritization of targeted interventions. Methods: We collected clinical and sociodemographic data from a cohort of patients with TB in Lima, Peru. We used whole-genome sequencing data to assess the genetic distance between all possible pairs of patients; we considered pairs to be the result of a direct transmission event if they differed by three or fewer SNPs, and we assumed that the first diagnosed patient in a pair was the transmitter and the second was the recipient. We used logistic regression to examine the association between host factors and the likelihood of direct TB transmission. Measurements and Main Results: Analyzing data from 2,518 index patients with TB, we identified 1,447 direct transmission pairs. Regardless of recipient attributes, individuals less than 34 years old, males, and those with a history of incarceration had a higher likelihood of being transmitters in direct transmission pairs. Direct transmission was more likely when both patients were drinkers or smokers. Conclusions: This study identifies men, young adults, former prisoners, alcohol consumers, and smokers as priority groups for targeted interventions. Innovative strategies are needed to extend TB screening to social groups such as young adults and prisoners with limited access to routine preventive care.

I spy: Factors influencing the observation of oxytetracycline in calcified structures of fishes viewed using standard light and fluorescence microscopy.

The antibiotic oxytetracycline (OTC) is a fluorochrome marker, and fluorescence microscopy is used to view OTC marks in fishes' calcified structures. However, OTC marks have been observed in calcified structures using standard light microscopy for multiple species. Therefore, we conducted an experiment to investigate potential factors (i.e., season, total length of fish, growth rate, and sex) influencing the observation of OTC in calcified structures (otoliths and fin rays or spines) from channel catfish Ictalurus punctatus, gray redhorse Moxostoma congestum, Guadalupe bass Mircopterus treculii, and redbreast sunfish Lepomis auritus viewed using standard light and fluorescence microscopy. OTC stains were not observed in any otoliths under standard light; however, OTC marks were commonly observed in I. punctatus spines using standard light microscopy (56.2%). Ninety-nine percent of otoliths and 88.9% of spines and fin rays had a visible fluorescent OTC mark when viewed using fluorescence microscopy. There was a negative relationship between the observed OTC mark and total length of fish for each season, but fish injected in the summer had the most structures with an observed OTC mark under either light condition. Understanding how OTC marking is affected by biological processes and environmental conditions will assist in future studies that rely on chemical marking of calcified structures by increasing efficacy of OTC marking and interpretation of marks.

Association of race and ethnicity with opioid prescribing for Medicare beneficiaries following total joint replacements.

BACKGROUND: Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries. METHODS: We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering. RESULTS: Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002). CONCLUSIONS: Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.