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1.
JAMA Netw Open ; 7(10): e2436906, 2024 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-39352699

RESUMEN

Importance: Data from surveys show increased mental health disorders in youths. However, little is known about clinical diagnosis over time. Objective: To assess the incidence, prevalence, and changes from 2017 to 2021 for depression and anxiety diagnosed clinically among children, adolescents, and young adults and to identify potential disparities. Design, Setting, and Participants: This cohort study included approximately 1.7 million individuals aged 5 to 22 years in Southern California. Data were extracted from electronic medical records; International Statistical Classification of Diseases, Tenth Revision (ICD-10), codes were used to identify depression and/or anxiety diagnosis for each study year from January 1, 2017, to December 31, 2021. Rates were stratified by age, gender, race and ethnicity, estimated household income, weight status, and comorbidity history. Changes over time and association with these variables were assessed using Poisson regression. Data were analyzed between June 1, 2022, and November 29, 2023. Main Outcomes and Measures: Clinical diagnosis of (1) depression and (2) anxiety without a depression diagnosis using ICD-10 codes. Results: Among the 1.7 million participants, mean (SD) age was approximately 14 (5) years, and 51% were male. In terms of race and ethnicity for each study year, approximately 50% of participants were Hispanic; 8%, non-Hispanic Asian; 8%, non-Hispanic Black; and 23%, non-Hispanic White. From 2017 to 2021, depression diagnosis increased by 55.6% (from 1.35% to 2.10%) for incidence and 60.0% (from 2.55% to 4.08%) for prevalence; anxiety without depression diagnosis increased by 31.1% (from 1.77% to 2.32%) for incidence and 35.2% (from 3.13% to 4.22%) for prevalence (P < .001 for trend). The increases in rates were higher during the COVID-19 pandemic (2020-2021) than before the pandemic (2017-2019), except for depression incidence. Rates increased across all subgroups. Rates were highest for subgroups aged 14 to 17 and 18 to 22 years; female participants; those of non-Hispanic American Indian or Alaska Native, non-Hispanic White, or multiple races or ethnicities; and subgroups with higher household income, obesity (and underweight for anxiety without depression), or comorbidities. Among these factors, age was the most important factor for depression diagnosis, whereas weight status was the most important factor for anxiety without depression diagnosis. Conclusions and Relevance: This cohort study, using electronic medical record data from a large integrated health care system, found an increase in clinically diagnosed depression from 2017 to 2021, with a higher increase during the COVID-19 pandemic and higher rates in some subgroups. Equally important, this study identified high rates and an increase in clinical diagnosis of anxiety without a depression diagnosis. These results support the increased need in public health and health care effort to combat the mental health crisis in youths.


Asunto(s)
Ansiedad , COVID-19 , Depresión , Humanos , Adolescente , Femenino , Masculino , Adulto Joven , Niño , Depresión/epidemiología , Ansiedad/epidemiología , Prevalencia , COVID-19/epidemiología , COVID-19/psicología , Incidencia , California/epidemiología , Preescolar , Estudios de Cohortes , Estados Unidos/epidemiología , SARS-CoV-2
2.
J Child Adolesc Trauma ; 17(3): 877-886, 2024 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-39309345

RESUMEN

Despite well-documented associations between adverse childhood experiences (ACEs) and lifelong impairments in health and well-being, few studies have examined how to facilitate implementation of ACEs screening and referral programs in pediatric settings. We sought to identify facilitators and barriers related to screening for and addressing ACEs in a large integrated healthcare delivery system in Southern California. Using a developmental evaluation approach, we conducted twenty semi-structured interviews with pediatricians, nurses, social workers, and community referral organization staff. Interviews took place across six pediatric clinic pilot sites in Kaiser Permanente Southern California, where more than 7,000 pediatric patients were screened for ACEs between July 2018 and December 2019. Thematic analysis was conducted to identify themes. Key facilitators for screening and referrals for pediatric ACEs screening included providing clinician education to normalize conversations about ACEs, using screening data to provide more holistic and compassionate care, and collaborating across different types of clinicians. Key barriers included screening tool challenges related to patient confusion and cultural differences, capacity limitations, training issues, and care team silos. When used in the context of a trauma- and resilience-informed workforce, ACEs screening may be a powerful tool to support more collaborative and impactful care decisions that move away from symptom management to address root causes and promote prevention.

3.
J Am Med Inform Assoc ; 31(10): 2173-2180, 2024 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-39231045

RESUMEN

IMPORTANCE: Firearm injuries constitute a public health crisis. At the healthcare encounter level, they are, however, rare events. OBJECTIVE: To develop a predictive model to identify healthcare encounters of adult patients at increased risk of firearm injury to target screening and prevention efforts. MATERIALS AND METHODS: Electronic health records data from Kaiser Permanente Southern California (KPSC) were used to identify healthcare encounters of patients with fatal and non-fatal firearm injuries, as well as healthcare visits of a sample of matched controls during 2010-2018. More than 170 predictors, including diagnoses, healthcare utilization, and neighborhood characteristics were identified. Extreme gradient boosting (XGBoost) and a split sample design were used to train and test a model that predicted risk of firearm injury within the next 3 years at the encounter level. RESULTS: A total of 3879 firearm injuries were identified among 5 288 529 KPSC adult members. Prevalence at the healthcare encounter level was 0.01%. The 15 most important predictors included demographics, healthcare utilization, and neighborhood-level socio-economic factors. The sensitivity and specificity of the final model were 0.83 and 0.56, respectively. A very high-risk group (top 1% of predicted risk) yielded a positive predictive value of 0.14% and sensitivity of 13%. This high-risk group potentially reduces screening burden by a factor of 11.7, compared to universal screening. Results for alternative probability cutoffs are presented. DISCUSSION: Our model can support more targeted screening in healthcare settings, resulting in improved efficiency of firearm injury risk assessment and prevention efforts.


Asunto(s)
Registros Electrónicos de Salud , Aprendizaje Automático , Heridas por Arma de Fuego , Humanos , Adulto , Masculino , Femenino , Heridas por Arma de Fuego/epidemiología , Persona de Mediana Edad , California/epidemiología , Medición de Riesgo/métodos , Armas de Fuego , Anciano , Adulto Joven , Adolescente
4.
Psychiatr Serv ; : appips20240148, 2024 Sep 23.
Artículo en Inglés | MEDLINE | ID: mdl-39308169

RESUMEN

OBJECTIVE: This study investigated ICD-10-CM codes for adverse social determinants of health (SDoH) across 12 U.S. health systems by using data from multiple health care encounter types for diverse patients covered by multiple payers. METHODS: The authors described documentation of 11 SDoH ICD-10-CM code categories (e.g., educational problems or social environmental problems) between 2016 and 2021; assessed changes over time by using chi-square tests for trend in proportions; compared documentation in 2021 by gender, age, race-ethnicity, and site with chi-square tests; and compared all patients' mental health outcomes in 2021 with those of patients with documented SDoH ICD-10-CM codes by using exact binomial tests and one-proportion z tests. RESULTS: Documentation of any SDoH ICD-10-CM code significantly increased, from 1.7% of patients in 2016 to 2.7% in 2021, as did that for all SDoH categories except educational problems. Documentation was often more prevalent among female patients and those of other or unknown gender than among male patients and among American Indian or Alaska Native, Black or African American, and Hispanic individuals than among those belonging to other race-ethnicity categories. More educational problems were documented for younger patients, and more social environmental problems were documented for older patients. Psychiatric diagnoses and emergency department visits and hospitalizations related to mental health were more common among patients with documented SDoH codes. CONCLUSIONS: SDoH ICD-10-CM code documentation was infrequent and differed by population subgroup. Differences may reflect documentation practices or true SDoH prevalence variation. Standardized SDoH documentation methods are needed in health care settings.

5.
Inj Prev ; 2024 Jun 21.
Artículo en Inglés | MEDLINE | ID: mdl-38906684

RESUMEN

INTRODUCTION: Information about causes of injury is key for injury prevention efforts. Historically, cause-of-injury coding in clinical practice has been incomplete due to the need for extra diagnosis codes in the International Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9-CM) coding. The transition to ICD-10-CM and increased use of clinical support software for diagnosis coding is expected to improve completeness of cause-of-injury coding. This paper assesses the recording of external cause-of-injury codes specifically for those diagnoses where an additional code is still required. METHODS: We used electronic health record and claims data from 10 health systems from October 2015 to December 2021 to identify all inpatient and emergency encounters with a primary diagnosis of injury. The proportion of encounters that also included a valid external cause-of-injury code is presented. RESULTS: Most health systems had high rates of cause-of-injury coding: over 85% in emergency departments and over 75% in inpatient encounters with primary injury diagnoses. However, several sites had lower rates in both settings. State mandates were associated with consistently high external cause recording. CONCLUSIONS: Completeness of cause-of-injury coding improved since the adoption of ICD-10-CM coding and increased slightly over the study period at most sites. However, significant variation remained, and completeness of cause-of-injury coding in any diagnosis data used for injury prevention planning should be empirically determined.

6.
Surg Obes Relat Dis ; 20(7): 621-633, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-38443200

RESUMEN

BACKGROUND: Analyzing trajectories of weight loss may address how particular groups of patients respond to metabolic and bariatric surgery. OBJECTIVES: The Bariatric Experience Long Term (BELONG) study was designed to use a theoretical model to examine determinants of weight loss and recurrence. SETTING: Large integrated health system in Southern California with 11 surgical practices and 23 surgeons. METHODS: A total of n = 1338 patients who had metabolic and bariatric surgery were surveyed before surgery to measure factors related to median percent total weight loss (%TWL) over 5 years. Longitudinal weight data were available for n = 1024 (76.5% of the sample). Data were analyzed using latent growth mixture models (GMM) to estimate trajectories of weight change separately for gastric sleeve and bypass operations. These trajectories were then described using relevant variables from the baseline survey. RESULTS: For both gastric sleeve (n = 733) and bypass (n = 291) operations, 3 latent trajectories of median %TWL were found corresponding to most, moderate, and least %TWL. Sleeve trajectories were distinguished by body mass index at surgery and geocoded environmental factors. Bypass trajectories varied by self-reported and geocoded environmental factors, comorbidity burden, race, experiential avoidance, and weight control strategies. CONCLUSIONS: Future research should examine the role of the built and perceived environment in surgical weight loss. Bariatric practices should focus less on the presurgical period for predictors of long-term weight loss and begin efforts to monitor real-time patient-reported outcomes to help tailor intervention strategies for patients who either do not lose an expected amount of weight or who begin to experience weight recurrence.


Asunto(s)
Cirugía Bariátrica , Obesidad Mórbida , Pérdida de Peso , Humanos , Pérdida de Peso/fisiología , Femenino , Masculino , Persona de Mediana Edad , Cirugía Bariátrica/estadística & datos numéricos , Adulto , Obesidad Mórbida/cirugía , Índice de Masa Corporal , Trayectoria del Peso Corporal , California/epidemiología
7.
J Pain ; 25(7): 104485, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-38311195

RESUMEN

Prescription opioid tapering has increased significantly over the last decade. Evidence suggests that tapering too quickly or without appropriate support may unintentionally harm patients. The aim of this analysis was to understand patients' experiences with opioid tapering, including support received or not received for pain control or mental health. Patients with evidence of opioid tapering from 6 health care systems participated in semi-structured, in-depth interviews; family members of suicide decedents with evidence of opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. Participants included 176 patients and 16 family members. Results showed that 24% of the participants felt their clinicians checked in with them about their taper experiences while 41% reported their clinicians did not. A majority (68%) of individuals who experienced suicide behavior during tapering reported that clinicians did check in about mood and mental health changes specifically; however, 27% of that group reported no such check-in. More individuals reported negative experiences (than positive) with pain management clinics-where patients are often referred for tapering and pain management support. Patients reporting successful tapering experiences named shared decision-making and ability to adjust taper speed or pause tapering as helpful components of care. Fifty-six percent of patients reported needing more support during tapering, including more empathy and compassion (48%) and an individualized approach to tapering (41%). Patient-centered approaches to tapering include reaching out to monitor how patients are doing, involving patients in decision-making, supporting mental health changes, and allowing for flexibility in the tapering pace. PERSPECTIVE: Patients tapering prescription opioids desire more provider-initiated communication including checking in about pain, setting expectations for withdrawal and mental health-related changes, and providing support for mental health. Patients preferred opportunities to share decisions about taper speed and to have flexibility with pausing the taper as needed.


Asunto(s)
Analgésicos Opioides , Deprescripciones , Manejo del Dolor , Humanos , Masculino , Femenino , Analgésicos Opioides/administración & dosificación , Persona de Mediana Edad , Adulto , Manejo del Dolor/métodos , Anciano , Salud Mental , Reducción Gradual de Medicamentos , Investigación Cualitativa
8.
Child Abuse Negl ; : 106709, 2024 Feb 27.
Artículo en Inglés | MEDLINE | ID: mdl-38418328

RESUMEN

BACKGROUND: Adverse Childhood Experiences (ACEs) screening in healthcare settings is emerging as one of the tangible responses to address the consistent evidence linking ACEs with health. Kaiser Permanente Southern California (KPSC) began ACEs screening in pediatric primary care in 2018 and has developed screening and referral processes based on continued feedback from stakeholders as well as data driven assessment. OBJECTIVE: We give an overview of the state of ACEs screening in pediatric healthcare settings, challenges facing pediatric providers, and suggestions to address them. We then describe the development of our ACEs screening and referral process within KPSC as an example of how a large healthcare system has implemented and adapted ACEs screening from pilot testing, to phased expansion, to complete implementation. PARTICIPANTS AND SETTING: Children aged 2-18 years old who were members of KPSC 2018-2023. RESULTS: We present data on the tailored screening and referral workflows we have developed, rates of positive screens and referrals, and how the initiation of ACEs screening may affect the rates of visit to behavioral health as a treatment option. We also integrate qualitative data to demonstrate the perspective of parents, with the goal of understanding what might help or hinder receipt of behavioral health treatment after ACEs screening. CONCLUSIONS: We close with future directions for ACEs screening in healthcare settings and considerations for pediatric healthcare providers who may want to begin ACEs screening or adapt their screening and referral processes.

9.
Perm J ; 28(1): 180-187, 2024 03 15.
Artículo en Inglés | MEDLINE | ID: mdl-38282469

RESUMEN

BACKGROUND: Screening for adverse childhood experiences (ACEs) in prenatal and pediatric populations is recommended by the California ACEs Aware initiative and is a promising practice to interrupt ACEs in children and mitigate ACEs-related health complications in children and families. Yet, integrating ACEs screening into clinical practice poses several challenges. OBJECTIVE: The objective of this report was to evaluate the Kaiser Permanente Northern California and Kaiser Permanente Southern California pilots and implementation of ACEs screening into routine prenatal (Kaiser Permanente Northern California) and pediatric (Kaiser Permanente Southern California) care. MATERIALS AND METHODS: These pilots were evaluated and compared to identify common challenges to implementation and offer promising practices for negotiating these challenges. Evaluation methods included feedback from staff, clinicians, and patients, as well as comparisons of methods to overcome various barriers to screening implementation. RESULTS: Implementing ACEs screening, like implementation of any new component of clinical care, takes careful planning, education, creation of content and workflows, and continuous integration of feedback from both patients and staff. CONCLUSION: This evaluation can serve as support for care teams who are considering implementing ACEs screening or who are already screening for ACEs. More research is needed regarding the relationship between ACEs and preventable and treatable health outcomes to improve health for patients and their families.


Asunto(s)
Experiencias Adversas de la Infancia , Embarazo , Femenino , Niño , Humanos
10.
J Pain ; 25(4): 1094-1105, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37952862

RESUMEN

Mental health and suicide-related harms resulting from prescription opioid tapering are poorly documented and understood. Six health systems contributed opioid prescribing data from January 2016 to April 2020. Patients 18 to 70 years old with evidence of opioid tapering participated in semi-structured interviews. Individuals who experienced suicide attempts were oversampled. Family members of suicide decedents who had experienced opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. The study participants included 176 patients and 16 family members. Patients were 68% female, 80% White, and 15% Hispanic, mean age 58. All family members were female spouses of White, non-Hispanic male decedents. Among the subgroup (n = 60) who experienced a documented suicide attempt, reported experiencing suicidal ideation during tapering, or were family members of suicide decedents, 40% reported that opioid tapering exacerbated previously recognized mental health issues, and 25% reported that tapering triggered new-onset mental health concerns. Among participants with suicide behavior, 47% directly attributed it to opioid tapering. Common precipitants included increased pain, reduced life engagement, sleep problems, withdrawal, relationship dissolution, and negative consequences of opioid substitution with other substances for pain relief. Most respondents reporting suicide behavior felt that the decision to taper was made by the health care system or a clinician (67%) whereas patients not reporting suicide behavior were more likely to report it was their own decision (42%). This study describes patient-reported mental health deterioration or suicide behavior while tapering prescription opioids. Clinicians should screen for, monitor, and treat suicide behavior while assisting patients in tapering opioids. PERSPECTIVE: This work describes changes in patient-reported mental health and suicide behavior while tapering prescription opioids. Recommendations for improving care include mental health and suicide risk screening during and following opioid tapering.


Asunto(s)
Analgésicos Opioides , Trastornos Relacionados con Opioides , Humanos , Masculino , Femenino , Persona de Mediana Edad , Adolescente , Adulto Joven , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Ideación Suicida , Prioridad del Paciente , Reducción Gradual de Medicamentos , Salud Mental , Trastornos Relacionados con Opioides/psicología , Pautas de la Práctica en Medicina , Dolor/tratamiento farmacológico , Medición de Resultados Informados por el Paciente
11.
Child Dev ; 95(4): 1092-1108, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38115174

RESUMEN

This study examined cortisol stress response trajectories across adolescence in 454 maltreated and comparison youth recruited from Los Angeles County between 2002 and 2005 (66.7% maltreated; 46.7% girls; 39.0% Latino; 37.7% Black; 12.3% Mixed or Biracial; 11.0% White; Mage = 10.9 years, SD = 1.2). Adolescents' peak activation and cortisol reactivity and recovery slopes following the Trier Social Stress Test for Children were calculated at four waves, then used to model peak activation and cortisol reactivity and recovery trajectories arrayed by age. Maltreated youth had blunted cortisol reactivity at age 9 relative to comparison youth (b = -.19, p = .02). Sexually and physically abused youth showed blunted cortisol reactivity and recovery trajectories relative to emotionally abused and neglected youth.


Asunto(s)
Maltrato a los Niños , Hidrocortisona , Estrés Psicológico , Humanos , Femenino , Hidrocortisona/metabolismo , Masculino , Adolescente , Niño , Estrés Psicológico/metabolismo , Estrés Psicológico/fisiopatología , Maltrato a los Niños/psicología , Los Angeles , Estudios Longitudinales
12.
Diabetes Obes Metab ; 26(1): 224-232, 2024 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-37823225

RESUMEN

AIMS: To assess maternal pre-existing type 1 diabetes (T1D), type 2 diabetes (T2D), gestational diabetes mellitus (GDM) during pregnancy and risk of depression and anxiety from childhood to young adulthood in offspring. MATERIALS AND METHODS: This birth cohort included singletons born during 1995-2015, followed using electronic medical records through 2020. Cox regression was used to estimate hazard ratio (HR) of depression or anxiety diagnosis during follow-up associated with in-utero exposure to maternal diabetes. RESULTS: Among 439 590 offspring, 29 891 (6.8%) had depression and 51 918 (11.8%) had anxiety. T1D, followed by T2D and GDM requiring antidiabetes medication were associated with risk of depression and anxiety in offspring. Compared with no diabetes during pregnancy, the adjusted HRs (95% confidence interval) of depression in offspring associated with T1D, T2D or GDM requiring medications were 1.44 (1.09-1.91), 1.30 (1.15-1.47) and 1.18 (1.11-1.26) respectively; conversely, HRs were 0.97 (0.82-1.15) for T2D and 0.99 (0.94-1.04) for GDM without medications. The associations with anxiety followed similar patterns. The significant associations were observed for offspring ages 5-12 and >12-18 years and attenuated for 18-25 years. CONCLUSION: These data suggest that the severity of diabetes (T1D vs. T2D requiring medications vs. GDM requiring medications) during pregnancy may increase the vulnerability of offspring for depression or anxiety.


Asunto(s)
Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Diabetes Gestacional , Embarazo , Femenino , Niño , Humanos , Adulto Joven , Adulto , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/epidemiología , Depresión/complicaciones , Depresión/epidemiología , Diabetes Gestacional/epidemiología , Diabetes Gestacional/tratamiento farmacológico , Ansiedad/complicaciones , Ansiedad/epidemiología
13.
BMC Public Health ; 23(1): 2220, 2023 11 10.
Artículo en Inglés | MEDLINE | ID: mdl-37950238

RESUMEN

BACKGROUND: Firearm injury is a significant public health concern in the United States. METHODS: Data on fatal and nonfatal firearm injuries were obtained from a cohort of N = 7,473,650 members of Kaiser Permanente Southern California, a large integrated healthcare system between 2010 and 2020. Age-adjusted rates of combined fatal and nonfatal firearm injury per 100,000 members were calculated by year, with the 2010 US census as the reference population. Trends were evaluated using Poisson or negative binomial regression. RESULTS: There was an increasing trend in overall firearm injuries between 2010 and 2020 among adults in this large integrated healthcare system (p < .0001), primarily driven by non-self-inflicted firearm injuries (p < .0001). Self-inflicted injuries decreased during this time (p = .01). Injuries among youth showed no significant change. CONCLUSION: There was an increasing trend in firearm injuries between 2010 and 2020 among adults in this large integrated healthcare system, primarily driven by non-self-inflicted firearm injuries; however, self-inflicted injuries decreased during this time. Injuries among youth showed no significant change.


Asunto(s)
Armas de Fuego , Heridas por Arma de Fuego , Adulto , Adolescente , Humanos , Estados Unidos , Heridas por Arma de Fuego/epidemiología , California/epidemiología , Distribución por Edad , Atención a la Salud
14.
Res Sq ; 2023 Aug 29.
Artículo en Inglés | MEDLINE | ID: mdl-37693617

RESUMEN

Background: Studies suggest a link between prenatal gestational diabetes mellitus (GDM) exposure and poor mental health outcomes. We examined associations between prenatal GDM exposure and depressive and anxiety symptoms in children and assessed physical activity as a potential modifier of these associations. Method: Seventy children (AgeM(SD): 12(2.0), 56% GDM, 59% female) and their parents completed surveys: Center for Epidemiological Studies Depression Scale for Children (CES-DC), State-Trait Anxiety Inventory for Children (STAIC), Child Behavior Checklist (CBCL), and 3-day physical activity recall (3DPAR). Associations between mental health measures with GDM exposure and interactions between GDM exposure and child moderate-to-vigorous physical activity (MVPA) were assessed using regression. Results: GDM-exposed children had higher anxiety (p = 0.03) and internalizing symptoms (CBCL) (p = 0.04) than unexposed children. There was an interaction between GDM exposure and child MVPA on anxiety (p = 0.02), internalizing (p = 0.04) and externalizing symptoms (p = 0.004). In the low MVPA group, GDM exposed children had more depressive (p = 0.03), anxiety (p = 0.003), and internalizing symptoms (p = 0.03) than unexposed children. In the high MVPA group, there were no group differences except with externalizing symptoms (p = 0.04). Conclusion: Prenatal GDM is associated with higher anxiety and internalizing symptoms in children. Child MVPA modified the relationship between GDM exposure and mental health outcomes suggesting that physical activity during childhood could mitigate the negative mental health outcomes associated with prenatal GDM exposure.

15.
Obes Surg ; 33(10): 3198-3205, 2023 10.
Artículo en Inglés | MEDLINE | ID: mdl-37612577

RESUMEN

PURPOSE: Weight loss surgery is an effective, long-term treatment for severe obesity but individual response to surgery varies widely. The purpose of this study was to test a comprehensive theoretical model of factors that may be correlated with the greatest surgical weight loss at 1-3 years following surgery. Such a model would help determine what predictive factors to measure when patients are preparing for surgery that may ensure the best weight outcomes. MATERIALS AND METHODS: The Bariatric Experience Long Term (BELONG) study collected self-reported and medical record-based baseline information as correlates of 1- and 3-year % total weight loss (TWL) in n = 1341 patients. Multiple linear regression was used to determine the associations between 120 baseline variables and %TWL. RESULTS: Participants were 43.4 ± 11.3 years old, Hispanic or Black (52%; n = 699), women (86%; n = 1149), and partnered (72%; n = 965) and had annual incomes of ≥ $51,000 (60%; n = 803). A total of 1006 (75%) had 3-year follow-up weight. Regression models accounted for 10.1% of the variance in %TWL at 1-year and 13.6% at 3 years. Only bariatric operation accounted for a clinically meaningful difference (~ 5%) in %TWL at 1-year. At 3 years after surgery, only bariatric operation, Black race, and BMI ≥ 50 kg/m2 were associated with clinically meaningful differences in %TWL. CONCLUSIONS: Our findings combined with many others support a move away from extensive screening and selection of patients at the time of surgery to a focus on improving access to this treatment.


Asunto(s)
Cirugía Bariátrica , Bariatria , Obesidad Mórbida , Adulto , Femenino , Humanos , Persona de Mediana Edad , Hispánicos o Latinos , Obesidad Mórbida/cirugía , Pérdida de Peso , Negro o Afroamericano , Masculino
16.
Child Abuse Negl ; 138: 106090, 2023 04.
Artículo en Inglés | MEDLINE | ID: mdl-36758373

RESUMEN

BACKGROUND: Rates of child maltreatment (CM) obtained from electronic health records are much lower than national child welfare prevalence rates indicate. There is a need to understand how CM is documented to improve reporting and surveillance. OBJECTIVES: To examine whether using natural language processing (NLP) in outpatient chart notes can identify cases of CM not documented by ICD diagnosis code, the overlap between the coding of child maltreatment by ICD and NLP, and any differences by age, gender, or race/ethnicity. METHODS: Outpatient chart notes of children age 0-18 years old within Kaiser Permanente Washington (KPWA) 2018-2020 were used to examine a selected set of maltreatment-related terms categorized into concept unique identifiers (CUI). Manual review of text snippets for each CUI was completed to flag for validated cases and retrain the NLP algorithm. RESULTS: The NLP results indicated a crude rate of 1.55 % to 2.36 % (2018-2020) of notes with reference to CM. The rate of CM identified by ICD code was 3.32 per 1000 children, whereas the rate identified by NLP was 37.38 per 1000 children. The groups that increased the most in identification of maltreatment from ICD to NLP were adolescents (13-18 yrs. old), females, Native American children, and those on Medicaid. Of note, all subgroups had substantially higher rates of maltreatment when using NLP. CONCLUSIONS: Use of NLP substantially increased the estimated number of children who have been impacted by CM. Accurately capturing this population will improve identification of vulnerable youth at high risk for mental health symptoms.


Asunto(s)
Maltrato a los Niños , Procesamiento de Lenguaje Natural , Femenino , Adolescente , Niño , Humanos , Recién Nacido , Lactante , Preescolar , Clasificación Internacional de Enfermedades , Washingtón/epidemiología , Registros Electrónicos de Salud
17.
Dev Psychopathol ; 35(1): 130-141, 2023 02.
Artículo en Inglés | MEDLINE | ID: mdl-34092276

RESUMEN

The functioning of the hypothalamic-pituitary-adrenal (HPA) axis is implicated in the etiology and maintenance of depressive and posttraumatic stress disorder (PTSD) symptoms. However, different maltreatment experiences as well as the increased sensitivity of the HPA axis during puberty may alter associations between the HPA axis and mental health. To address these gaps, the current study examined the potential bidirectional associations between cortisol reactivity to a stressor, PTSD symptoms, and depressive symptoms among early adolescents across two time points, 1 year apart (n = 454; Mage = 10.98 at Time 1 and Mage = 12.11 at Time 2). Multiple-group path models tested the pathways between cortiol reactivity and mental health prior to and during puberty, for different types of maltreatment . Overall, the results showed that associations between cortisol output and symptoms of PTSD and depression were driven by those in the midst of puberty. Specifically, higher cortisol output at Time 1 was linked with higher levels of subsequent PTSD and depressive symptoms for neglected youth who had reached puberty. However, depressive symptoms predicted subsequent lower cortisol output for the physical abuse and emotional abuse groups. These findings demonstrate longitudinal links between cortisol, depressive symptoms, and PTSD symptoms among youth with different types of maltreatment histories and highlight the need to consider the reorganization of the stress system during puberty in order to advance our understanding of the HPA axis and mental health.


Asunto(s)
Trastornos por Estrés Postraumático , Adolescente , Humanos , Depresión/psicología , Hidrocortisona/metabolismo , Sistema Hipotálamo-Hipofisario/metabolismo , Sistema Hipófiso-Suprarrenal/metabolismo , Pubertad , Estrés Psicológico/psicología
18.
Acad Pediatr ; 23(3): 604-609, 2023 04.
Artículo en Inglés | MEDLINE | ID: mdl-36122825

RESUMEN

BACKGROUND AND OBJECTIVES: Few studies have tested multiple socio-ecological risk factors assocated with firearm injury among pediatric populations and distinguished self-inflicted from non-self-inflicted injury. To address this gap, the current study examined demographic, individual psychosocial, and neighborhood variables as risk factors for firearm injury among a large cohort of children and adolescents. METHODS: Retrospective cohort study. Data were obtained from the electronic health records of a large integrated healthcare system. The cohort included children <18 years with at least one clinical encounter between January 1, 2010 and December 31, 2018. Poisson regression was used to examine demographic (age, gender, race and ethnicity, Medicaid status), psychosocial (depression, substance use disorder, medical comorbidities), and neighborhood education variables as potential risk factors for non-self-inflicted and self-inflicted firearm injuries. RESULTS: For non-self-inflicted injury, the highest relative risk was found for children age 12-17 years old compared to 0-5 year olds (RR = 37.57); other risk factors included male gender, Black and Hispanic race and ethnicity (compared to White race), being a Medicaid recipient, lower neighborhood education, and substance use disorder diagnosis. For self-inflicted injury, only age 12-17 years old and male gender were associated with increased risk. CONCLUSIONS: These results reinforce the established higher risk for firearm injury among adolescent males, highlight differences between self-inflicted and non-self-inflicted injuries, and the need to consider demographic, psychosocial, and neighborhood variables as risk factors to inform interventions aimed to reduce firearm injuries among children and adolescents.


Asunto(s)
Armas de Fuego , Trastornos Relacionados con Sustancias , Heridas por Arma de Fuego , Adolescente , Estados Unidos/epidemiología , Niño , Humanos , Masculino , Preescolar , Estudios Retrospectivos , Heridas por Arma de Fuego/epidemiología , Trastornos Relacionados con Sustancias/epidemiología , Características de la Residencia
19.
JAMA Netw Open ; 5(12): e2247421, 2022 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-36534401

RESUMEN

Importance: Screening for adverse childhood experiences (ACEs) in primary care settings has been increasing as a response to the overwhelming and consistent evidence of the deleterious associations between ACEs and later physical and mental health. However, there is little empirical guidance on the appropriate implementation of ACEs screening in pediatric primary care. Objective: To test the use of a pilot intervention for ACEs screening and referral on the receipt of behavioral health care for children and adolescents within a large integrated health care delivery system. Design, Setting, and Participants: A retrospective cohort study was conducted in a large integrated health care system serving Southern California. Child and adolescent members of the target health care system younger than 18 years between July 1, 2018, and November 30, 2021, who received a positive screening for ACEs at the pilot clinic were included. This pilot clinic implemented an intervention that included additional screening questions and incorporated social workers into the process of evaluation and referral for behavioral health needs following ACEs screening. Exposures: ACEs screening. Main Outcomes and Measures: Visit to a behavioral health care service within 90 days of a positive ACEs screen determined as a score of 1 or higher and behavioral symptoms. Results: The cohort consisted of 4030 children (mean [SD] age, 9.94 [4.55] years) with positive ACEs screening, 48% adolescents (11-17.99 years), approximately equal gender (51% females), 73% Hispanic, and 33% with Medicaid insurance. After the intervention, children were more likely to have a behavioral health services visit within 90 days of the screening than before the intervention (from 4.33% to 32.48%; incidence rate ratio, 7.50; 95% CI, 1.55-36.2). Conclusions and Relevance: In this cohort study, the implementation of a new ACEs screening and referral process was associated with increased receipt of behavioral health services among children with a positive ACEs screening. This could be useful strategy for other health care systems responding to state and local mandates to screen and provide care for children with ACEs.


Asunto(s)
Experiencias Adversas de la Infancia , Femenino , Estados Unidos , Humanos , Niño , Adolescente , Masculino , Estudios Retrospectivos , Estudios de Cohortes , Salud Mental , Tamizaje Masivo
20.
Artículo en Inglés | MEDLINE | ID: mdl-36276588

RESUMEN

Background: Suicide risk prediction models derived from machine learning of electronic health records and insurance claims are an innovation in suicide prevention. Some models do not include opioid-related variables despite the relationship between opioids and suicide. This study evaluated whether inclusion of opioid-related variables improved suicide risk prediction models developed by the Mental Health Research Network. Methods: Approximately 630 opioid-related variables and interactions terms were introduced into existing suicide prediction models run in datasets of patient visits in mental health care (n = 27,755,401 visits) or primary care when a mental health diagnosis was given (n = 19,340,461 visits). Training and validation datasets were created. LASSO regression with 10-fold validation identified variables to be added to the models. Results: The new models predicting suicide attempts and suicide deaths in the mental health specialty visit sample performed as well as the existing models (new C-statistic for attempts model = 0.855, CI: 0.853-0.857 versus original C-statistic = 0.851, CI 0.848-0.853; death model = 0.868, CI: 0.856-0.879 versus 0.861, CI 0.848-0.875). The new model for suicide death in the primary care sample improved (0.855, CI: 0.837-0.874 versus 0.833, CI 0.813-0.853) while performance of the new model for suicide attempt in that sample degraded (0.843, CI: 0.839-0.847 versus 0.853, CI 0.849-0.857). Limitations: Analyses did not include patients without recent care, data did not include illicit opioid use or unrecognized opioid use disorder. Conclusions: Among patients with mental health diagnoses, inclusion of opioid-related variables did not improve prediction of suicide risk beyond mental health predictors.

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