Hospital Quality Indicators for Opioid-Exposed Infants: Results From an Expert Consensus Panel.

OBJECTIVE: To elicit expert consensus on quality indicators for the hospital-based care of opioid-exposed infants. METHODS: We used the ExpertLens online platform to conduct a 3-round modified Delphi panel. Expert panelists included health care providers, parents in recovery, quality experts, and public health experts. We identified 49 candidate quality indicators from a literature review and environmental scan. A total of 32 experts rated the importance and feasibility of the indicators using a 9-point Likert scale (Round 1), reviewed and discussed the initial ratings (round 2), and revised their original ratings (Round 3). Numeric scores corresponded with descriptive ratings of "low" (1-3), "uncertain" (4-6), or "high" (7-9). We measured consensus using the RAND/UCLA Appropriateness Method. RESULTS: Candidate quality indicators assessed structures, processes, and outcomes in multiple domains of clinical care. After the final round, 36 indicators were rated "high" on importance and feasibility. Experts had strong consensus on the importance of quality indicators to assess universal screening of pregnant people for substance use disorder, hospital staff training, standardized assessment for neonatal opioid withdrawal syndrome, nonpharmacologic interventions, and transitions of care. For indicators focused on processes and outcomes, experts saw feasibility as dependent on the information routinely documented in electronic medical records or billing records. To present a more complete picture of hospital quality, experts suggested development of composite measures that summarize quality across multiple indicators. CONCLUSIONS: A panel of experts reached consensus on a range of quality indicators for hospital-based care of opioid-exposed infants, with potential for use in national benchmarking, intervention studies, or hospital performance measurement.

County-Level Atrazine Use and Gastroschisis.

Importance: The incidence of gastroschisis, a birth defect involving the herniation of the small bowel through the abdominal wall, has increased in the US since the 1960s. The pesticide atrazine is a hypothesized cause of gastroschisis; however, examination of the association between atrazine and gastroschisis has been limited. Objective: To evaluate national trends in gastroschisis incidence, maternal and infant characteristics associated with gastroschisis, and whether county-level atrazine use is associated with gastroschisis. Design, Setting, and Participants: This retrospective, repeated cross-sectional study examined birth certificate data of all live births in the US and data on atrazine use from the US Geological Survey from January 1, 2009, through December 31, 2019. The data analysis was performed between August 5, 2021, and May 26, 2023. Exposures: County-level atrazine use. Main Outcomes and Measures: The primary outcome was gastroschisis incidence. Covariates included maternal age, race and ethnicity, body mass index (measured by weight in kilograms divided by height in meters squared), parity, insurance type, Chlamydia infection during pregnancy, smoking, and rurality. Mixed-effects logistic regression models (year fixed effects and county random effects) were constructed using different county-level atrazine exposure variables (1-, 5-, and 10-year means). Results: Between 2009 and 2019, 39 282 566 live births were identified, with 10 527 infant diagnoses of gastroschisis. Infants with gastroschisis were more likely to have mothers who identified as non-Hispanic White (61% vs 54%; P < .001), had a lower body mass index (median [IQR], 23.4 [20.8-27.2] vs 25.4 [22.0-30.8]; P < .001), were more likely to be nulliparous (median [IQR], 0 [0-1] vs 1 [0-2]; P < .001), and were more commonly covered by Medicaid (63% vs 43%; P < .001). During the study period, the rate (per 1000 live births) of gastroschisis decreased from 0.31 (95% CI, 0.29-0.33) to 0.22 (95% CI, 0.21-0.24). The median (IQR) county-level atrazine use estimates were higher among infants with gastroschisis (1 year, 1389 [IQR, 198-10 162] vs 1023 [IQR, 167-6960] kg; 5 years, 1425 [IQR, 273-9895] vs 1057 [IQR, 199-6926] kg; 10 years, 1508 [IQR, 286-10 271] vs 1113 [IQR, 200-6650] kg; P < .001). In adjusted models, higher county levels of atrazine (each 100 000-kg increase) were associated with a higher incidence of gastroschisis (1 year: adjusted odds ratio [AOR], 1.12 [95% CI, 1.01-1.24]; 5 years: AOR, 1.15 [95% CI, 1.02-1.30]; 10 years: AOR, 1.21 [95% CI, 1.07-1.38]). Conclusions and Relevance: In this cross-sectional study, higher county levels of atrazine were associated with infant diagnoses of gastroschisis. While atrazine is the second-most used herbicide in the US, numerous countries around the world have banned it out of concern for adverse effects on human health. These findings suggest that exploring alternatives to atrazine in the US may be warranted.

Performance of Phenotype Algorithms for the Identification of Opioid-Exposed Infants.

OBJECTIVE: Observational studies examining outcomes among opioid-exposed infants are limited by phenotype algorithms that may under identify opioid-exposed infants without neonatal opioid withdrawal syndrome (NOWS). We developed and validated the performance of different phenotype algorithms to identify opioid-exposed infants using electronic health record data. METHODS: We developed phenotype algorithms for the identification of opioid-exposed infants among a population of birthing person-infant dyads from an academic health care system (2010-2022). We derived phenotype algorithms from combinations of 6 unique indicators of in utero opioid exposure, including those from the infant record (NOWS or opioid-exposure diagnosis, positive toxicology) and birthing person record (opioid use disorder diagnosis, opioid drug exposure record, opioid listed on medication reconciliation, positive toxicology). We determined the positive predictive value (PPV) and 95% confidence interval for each phenotype algorithm using medical record review as the gold standard. RESULTS: Among 41 047 dyads meeting exclusion criteria, we identified 1558 infants (3.80%) with evidence of at least 1 indicator for opioid exposure and 32 (0.08%) meeting all 6 indicators of the phenotype algorithm. Among the sample of dyads randomly selected for review (n = 600), the PPV for the phenotype requiring only a single indicator was 95.4% (confidence interval: 93.3-96.8) with varying PPVs for the other phenotype algorithms derived from a combination of infant and birthing person indicators (PPV range: 95.4-100.0). CONCLUSIONS: Opioid-exposed infants can be accurately identified using electronic health record data. Our publicly available phenotype algorithms can be used to conduct research examining outcomes among opioid-exposed infants with and without NOWS.

Participants' perspectives of "NeuroSask: Active and Connect"-a virtual chronic disease management program for individuals with a neurological condition.

Introduction: Neurological conditions account from more than half of Canadians requiring chronic care. Both physical activity and the development of a self-management skillset are critical components supporting individuals with chronic health conditions. "NeuroSask: Active and Connected" is a virtual chronic disease management program offering twice weekly neuro-physiotherapist directed "active" exercise sessions, followed by weekly knowledge-exchange "connect" sessions with invited guest experts. NeuroSask was launched April 2020 in response to the restricted services and supports for people with neurological conditions. The program aimed to provide seated physical activity, social interaction, and access to expertise in neurological conditions and neurorehabilitation. A program evaluation of NeuroSask was conducted to gain participants' perspectives. Methods: All participants registered for the NeuroSask program were invited to complete optional online surveys (SurveyMonkey) circulated by email at 3 occasions post-program launch: 10 weeks, 1 year, and 2 years. Participants could complete any one or all of the surveys, at their discretion. The number of potential respondents changed dependent on the total number of participants registered for NeuroSask at the time the survey was circulated. Questions were co-designed by multi-stakeholder team members. Descriptive statistics were used for closed-ended questions and a reflexive thematic analysis was completed with coding conducted in NVivo 12 Plus for open-ended text. Results: Response rates (participants/registrants) were as follows: 10-week survey 260/793, one year survey 326/1224, and 2-year survey 434/1989. 90% of participants reported being in either the age categories of 40-59 years or above 60 years. 75% of both survey respondents and program registrants were female. 70% of both survey respondents and program registrants reported a diagnosis of multiple sclerosis and 30% reported other neurological conditions. Survey respondents were from all ten Canadian provinces, with 45% reporting living outside of large cities. Respondents reported preferring online vs. in person format for this type of programming. Three main themes, and eight corresponding subthemes were identified highlighting the perceived impact and key components of the NeuroSask program: Theme 1 "together in a positive and encouraging environment" (subthemes 1a: connection, 1b: empowerment); Theme 2 "access to enthusiastic qualified leaders from home" (subthemes 2a: leader characteristics, 2b: accessibility, 2c: program logistics); Theme 3 "being able to enjoy everyday life" (subthemes 3a: symptom benefits and beyond, 3b: carry-over, 3c: keep going, please do not cancel). Conclusion: NeuroSask is an example of an accessible and meaningful virtual approach to providing ongoing support for some individuals with neurological conditions. It was perceived as beneficial for fostering community and connection in a positive environment with perceived benefits extending beyond symptom management to participant reported improvements in function, daily life, and disease experience.

Antipsychotic Medications and Mortality in Children and Young Adults.

Importance: Dose-related effects of antipsychotic medications may increase mortality in children and young adults. Objective: To compare mortality for patients aged 5 to 24 years beginning treatment with antipsychotic vs control psychiatric medications. Design, Setting, and Participants: This was a US national retrospective cohort study of Medicaid patients with no severe somatic illness or schizophrenia or related psychoses who initiated study medication treatment. Study data were analyzed from November 2022 to September 2023. Exposures: Current use of second-generation antipsychotic agents in daily doses of less than or equal to 100-mg chlorpromazine equivalents or greater than 100-mg chlorpromazine equivalents vs that for control medications (α agonists, atomoxetine, antidepressants, and mood stabilizers). Main Outcome and Measures: Total mortality, classified by underlying cause of death. Rate differences (RDs) and hazard ratios (HRs) adjusted for potential confounders with propensity score-based overlap weights. Results: The 2 067 507 patients (mean [SD] age, 13.1 [5.3] years; 1 060 194 male [51.3%]) beginning study medication treatment filled 21 749 825 prescriptions during follow-up with 5 415 054 for antipsychotic doses of 100 mg or less, 2 813 796 for doses greater than 100 mg, and 13 520 975 for control medications. Mortality was not associated with antipsychotic doses of 100 mg or less (RD, 3.3; 95% CI, -5.1 to 11.7 per 100 000 person-years; HR, 1.08; 95% CI, 0.89-1.32) but was associated with doses greater than 100 mg (RD, 22.4; 95% CI, 6.6-38.2; HR, 1.37; 95% CI, 1.11-1.70). For higher doses, antipsychotic treatment was significantly associated with overdose deaths (RD, 8.3; 95% CI, 0-16.6; HR, 1.57; 95% CI, 1.02-2.42) and other unintentional injury deaths (RD, 12.3; 95% CI, 2.4-22.2; HR, 1.57; 95% CI, 1.12-2.22) but was not associated with nonoverdose suicide deaths or cardiovascular/metabolic deaths. Mortality for children aged 5 to 17 years was not significantly associated with either antipsychotic dose, whereas young adults aged 18 to 24 years had increased risk for doses greater than 100 mg (RD, 127.5; 95% CI, 44.8-210.2; HR, 1.68; 95% CI, 1.23-2.29). Conclusions and Relevance: In this cohort study of more than 2 million children and young adults without severe somatic disease or diagnosed psychosis, antipsychotic treatment in doses of 100 mg or less of chlorpromazine equivalents or in children aged 5 to 17 years was not associated with increased risk of death. For doses greater than 100 mg, young adults aged 18 to 24 years had significantly increased risk of death, with 127.5 additional deaths per 100 000 person-years.

Consistency and Adequacy of Public and Commercial Health Insurance for US Children, 2016 to 2021.

Importance: Before and during the COVID-19 public health emergency (PHE), commercially and publicly insured children may have faced different challenges in obtaining consistent and adequate health insurance. Objective: To compare overall rates, COVID-19 PHE-related changes, and child and family characteristics associated with inconsistent and inadequate coverage for publicly and commercially insured children. Design, Settings, and Participants: This was a cross-sectional study using nationally representative data from the 2016 to 2021 National Survey of Children's Health of children from age 0 to 17 years living in noninstitutional settings. Exposure: Parent- or caregiver-reported current child health insurance type defined as public or commercial. Main Outcomes and Measures: Inconsistent insurance, defined as having an insurance gap in the past year; and inadequate insurance, defined by failure to meet 3 criteria: (1) benefits usually/always sufficient to meet child's needs; (2) coverage usually/always allows child to access needed health care practitioners; and (3) no or usually/always reasonable annual out-of-pocket payments for child's health care. Survey-weighted logistic regression was used to compare outcomes by insurance type, by year (2020-2021 vs 2016-2019), and by child characteristics within insurance type. Results: Of this nationally representative sample of 203 691 insured children, 34.5% were publicly insured (mean [SD] age, 8.4 [4.1] years; 47.4% female) and 65.5% were commercially insured (mean [SD] age, 8.7 [5.6]; 49.1% female). Most publicly insured children were either non-Hispanic Black (20.9%) or Hispanic (36.4%); living with 2 married parents (38.4%) or a single parent (33.1%); and had a household income less than 200% of the federal poverty level (79%). Most commercially insured children were non-Hispanic White (62.8%), living with 2 married parents (79.0%); and had a household income of 400% of the federal poverty level or higher (49.1%). Compared with commercially insured children, publicly insured children had higher rates of inconsistent coverage (4.2% vs 1.4%; difference, 2.7 percentage points [pp]; 95% CI, 2.3 to 3.2) and lower rates of inadequate coverage (12.2% vs 33.0%; difference, -20.8 pp; 95% CI, -21.6 to -20.0). Compared with the period from 2016 to 2019, inconsistent insurance decreased by 42% for publicly insured children and inadequate insurance decreased by 6% for commercially insured children during the COVID-19 PHE (2020-2021). The child and family characteristics associated with inadequate and inconsistent insurance varied by insurance type. Conclusions and Relevance: The findings of this cross-sectional study indicate that insurance gaps are a particular problem for publicly insured children, whereas insurance inadequacy and particularly, out-of-pocket costs are a challenge for commercially insured children. Both challenges improved during the COVID-19 PHE. Improving children's health coverage after the PHE will require policy solutions that target the unique needs of commercially and publicly insured children.

Identifying Optimal Methods for Addressing Confounding Bias When Estimating the Effects of State-level Policies.

BACKGROUND: Policy evaluation studies that assess how state-level policies affect health-related outcomes are foundational to health and social policy research. The relative ability of newer analytic methods to address confounding, a key source of bias in observational studies, has not been closely examined. METHODS: We conducted a simulation study to examine how differing magnitudes of confounding affected the performance of 4 methods used for policy evaluations: (1) the two-way fixed effects difference-in-differences model; (2) a 1-period lagged autoregressive model; (3) augmented synthetic control method; and (4) the doubly robust difference-in-differences approach with multiple time periods from Callaway-Sant'Anna. We simulated our data to have staggered policy adoption and multiple confounding scenarios (i.e., varying the magnitude and nature of confounding relationships). RESULTS: Bias increased for each method: (1) as confounding magnitude increases; (2) when confounding is generated with respect to prior outcome trends (rather than levels), and (3) when confounding associations are nonlinear (rather than linear). The autoregressive model and augmented synthetic control method had notably lower root mean squared error than the two-way fixed effects and Callaway-Sant'Anna approaches for all scenarios; the exception is nonlinear confounding by prior trends, where Callaway-Sant'Anna excels. Coverage rates were unreasonably high for the augmented synthetic control method (e.g., 100%), reflecting large model-based standard errors and wide confidence intervals in practice. CONCLUSIONS: In our simulation study, no single method consistently outperformed the others, but a researcher's toolkit should include all methodologic options. Our simulations and associated R package can help researchers choose the most appropriate approach for their data.

Medications for Opioid Use Disorder During the Prenatal Period and Infant Outcomes.

This cross-sectional study explores the association between mothers' receipt of opioid use disorder treatment during pregnancy and their infants' health services use in the first year of life.

Buprenorphine Out-of-Pocket Costs and Discontinuation in Privately Insured Adults With Opioid Use Disorder.

This cohort study examined the association between out-of-pocket costs for an initial buprenorphine prescription and its discontinuation among commercially insured US adults with opioid use disorder.

Patient and Community Factors Affecting Treatment Access for Opioid Use Disorder.

OBJECTIVE: To examine whether access to treatment for women with opioid use disorder (OUD) varied by race and ethnicity, community characteristics, and pregnancy status. METHODS: We conducted a secondary data analysis of a simulated patient caller study of buprenorphine-waivered prescribers and opioid-treatment programs in 10 U.S. states. We conducted multivariable analyses, accounting for potential confounders, to evaluate factors associated with likelihood of successfully securing an appointment. Descriptive statistics and significance testing examined 1) caller characteristics and call outcome by assigned race and ethnicity and clinic type (combined, opioid-treatment programs, and buprenorphine-waivered prescribers) and 2) clinic and community characteristics and call outcome by community race and ethnicity distribution (majority White vs majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander) and clinic type. A multiple logistic regression model was fitted to assess the likelihood of obtaining an appointment by callers' race and ethnicity and pregnancy status with the exposure of interest being majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander community distribution. RESULTS: In total, 3,547 calls reached clinics to schedule appointments. Buprenorphine-waivered prescribers were more likely to be in communities that were more than 50% White (88.9% vs 77.3%, P<.001), and opioid-treatment programs were more likely to be in communities that were less than 50% White (11.1% vs 22.7%, P<.001). Callers were more likely to be granted appointments in majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander communities (adjusted odds ratio [aOR] 1.06, 95% CI 1.02-1.10 per 10% Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander community population) and at opioid-treatment programs (aOR 4.94, 95% CI 3.52-6.92) and if they were not pregnant (aOR 1.79, 95% CI 1.53-2.09). CONCLUSION: Clinic distribution and likelihood of acceptance for treatment varied by community race and ethnicity distribution. Access to treatment for OUD remains challenging for pregnant people and in many historically marginalized U.S. communities.

Methodological considerations for estimating policy effects in the context of co-occurring policies.

Understanding how best to estimate state-level policy effects is important, and several unanswered questions remain, particularly about the ability of statistical models to disentangle the effects of concurrently enacted policies. In practice, many policy evaluation studies do not attempt to control for effects of co-occurring policies, and this issue has not received extensive attention in the methodological literature to date. In this study, we utilized Monte Carlo simulations to assess the impact of co-occurring policies on the performance of commonly-used statistical models in state policy evaluations. Simulation conditions varied effect sizes of the co-occurring policies and length of time between policy enactment dates, among other factors. Outcome data (annual state-specific opioid mortality rate per 100,000) were obtained from 1999 to 2016 National Vital Statistics System (NVSS) Multiple Cause of Death mortality files, thus yielding longitudinal annual state-level data over 18 years from 50 states. When co-occurring policies are ignored (i.e., omitted from the analytic model), our results demonstrated that high relative bias (> 82%) arises, particularly when policies are enacted in rapid succession. Moreover, as expected, controlling for all co-occurring policies will effectively mitigate the threat of confounding bias; however, effect estimates may be relatively imprecise (i.e., larger variance) when policies are enacted in near succession. Our findings highlight several key methodological issues regarding co-occurring policies in the context of opioid-policy research yet also generalize more broadly to evaluation of other state-level policies, such as policies related to firearms or COVID-19, showcasing the need to think critically about co-occurring policies that are likely to influence the outcome when specifying analytic models.

County-level Factors and Treatment Access Among Insured Women With Opioid Use Disorder.

BACKGROUND: An over 40% increase in overdose deaths within the past 2 years and low levels of engagement in treatment call for a better understanding of factors that influence access to medication for opioid use disorder (OUD). OBJECTIVE: To examine whether county-level characteristics influence a caller's ability to secure an appointment with an OUD treatment practitioner, either a buprenorphine-waivered prescriber or an opioid treatment program (OTP). RESEARCH DESIGN AND SUBJECTS: We leveraged data from a randomized field experiment comprised of simulated pregnant and nonpregnant women of reproductive age seeking treatment for OUD among 10 states in the US. We employed a mixed-effects logistic regression model with random intercepts for counties to examine the relationship between appointments received and salient county-level factors related to OUD. MEASURES: Our primary outcome was the caller's ability to secure an appointment with an OUD treatment practitioner. County-level predictor variables included socioeconomic disadvantage rankings, rurality, and OUD treatment/practitioner density. RESULTS: Our sample comprised 3956 reproductive-aged callers; 86% reached a buprenorphine-waivered prescriber and 14% an OTP. We found that 1 additional OTP per 100,000 population was associated with an increase (OR=1.36, 95% CI: 1.08 to 1.71) in the likelihood that a nonpregnant caller receives an OUD treatment appointment from any practitioner. CONCLUSIONS: When OTPs are highly concentrated within a county, women of reproductive age with OUD have an easier time securing an appointment with any practitioner. This finding may suggest greater practitioners' comfort in prescribing when there are robust OUD specialty safety nets in the county.

Maternal Opioid Use Disorder and the Risk of Postneonatal Infant Mortality.

Importance: The risk of serious long-term outcomes for infants born to individuals with opioid use disorder (OUD) is not fully characterized, nor is it well understood whether risks are modified by infant diagnosis of neonatal opioid withdrawal syndrome (NOWS). Objective: To characterize the risk of postneonatal infant mortality among infants with a NOWS diagnosis or born to individuals with OUD. Design, Setting, and Participants: The study team conducted a retrospective cohort study of 390 075 infants born from 2007 through 2018 to mothers who were enrolled in Tennessee Medicaid from 183 days prior to delivery through 28 days post partum (baseline). Maternal and infant baseline characteristics were measured using administrative claims and birth certificates, and infants were followed up from day 29 post partum through day 365 or death. Deaths were identified using linked death certificates through 2019. These data were analyzed from February 10, 2022, through March 3, 2023. Exposure: Infant exposures included birth to an individual with OUD or postnatal diagnosis of NOWS. The study team defined a pregnant individual's OUD status (maternal OUD) as having OUD diagnosis or a maintenance medication prescription fill during baseline; this study defined NOWS as having NOWS diagnosis up to day 28. Groups were categorized by exposures as maternal OUD with NOWS (OUD positive/NOWS positive), maternal OUD without NOWS (OUD positive/NOWS negative), no documented maternal OUD with NOWS (OUD negative/NOWS positive), and no documented maternal OUD or NOWS (OUD negative/NOWS negative, unexposed). Main Outcome and Measures: The outcome was postneonatal infant death, confirmed by death certificates. Cox proportional hazards models were used, adjusting for baseline maternal and infant characteristics, to estimate adjusted hazard ratios (aHRs) and 95% CIs for the association between maternal OUD or NOWS diagnosis with postneonatal death. Results: Pregnant individuals in the cohort had a mean (SD) age of 24.5 (5.2) years; 51% of infants were male. The study team observed 1317 postneonatal infant deaths and incidence rates of 3.47 (OUD negative/NOWS negative, 375 718), 8.41 (OUD positive/NOWS positive, 4922); 8.95 (OUD positive/NOWS negative, 7196), and 9.25 (OUD negative/NOWS positive, 2239) per 1000 person-years. After adjustment, the risk of postneonatal death was elevated for all groups, relative to the unexposed: OUD positive/NOWS positive (aHR, 1.54; 95% CI, 1.07-2.21), OUD positive/NOWS negative (aHR, 1.62; 95% CI, 1.21-2.17), and OUD negative/NOWS positive (aHR, 1.64; 95% CI, 1.02-2.65). Conclusions and Relevance: Infants born to individuals with OUD or with a NOWS diagnosis had an increased risk of postneonatal infant mortality. Future work is necessary to create and evaluate supportive interventions for individuals with OUD during and after pregnancy to reduce adverse outcomes.

Prevalence of Buprenorphine Providers Requiring Cash Payment From Insured Women Seeking Opioid Use Disorder Treatment.

CONTEXT: Medications for opioid use disorder (OUD) are known to be effective, especially in reducing the risk of overdose death. Yet, many individuals suffering from OUD are not receiving treatment. One potential barrier can be the patient's ability to access providers through their insurance plans. DATA AND METHODS: We used an audit (simulated patient) study methodology to examine appointment-granting behavior by buprenorphine prescribers in 10 different US states. Trained callers posed as women with OUD and were randomly assigned Medicaid or private insurance status. Callers request an OUD treatment appointment and then asked whether they would be able to use their insurance to cover the cost of care, or alternatively, whether they would be required to pay fully out-of-pocket. FINDINGS: We found that Medicaid and privately insured women were often asked to pay cash for OUD treatment--40% of the time over the full study sample. Such buprenorphine provider requests happened more than 60% of the time in some states. Areas with more providers or with more generous provider payments were not obviously more willing to accept the patient's insurance benefits for OUD treatment. Rural providers were less likely to require payment in cash in order for the woman to receive care. CONCLUSIONS: State-to-state variation was the most striking pattern in our field experiment data. The wide variation suggests that women of reproductive age with OUD in certain states face even greater challenges to treatment access than perhaps previously thought; however, it also reveals that some states have found ways to curtail this problem. Our findings encourage greater attention to this public health challenge and possibly opportunities for shared learning across states.

Treatment access for opioid use disorder among women with medicaid in Florida.

INTRODUCTION: Opioid use disorder (OUD) remains prevalent. Medications for OUD (MOUD) are standard care for pregnant and non-pregnant women. Previous research has identified barriers to MOUD for women with Medicaid but did not account for the type of MOUD (methadone vs. buprenorphine) or pregnancy status. We examined access to MOUD by treatment type for pregnant and non-pregnant women with Medicaid in Florida. METHODS: A secondary analysis of Florida "secret-shopper" data was conducted. Calls were made to clinicians from the 2018 Substance Abuse and Mental Health Services Administration provider list by women posing as either a pregnant or non-pregnant woman with OUD and Medicaid. We examined 546 calls to buprenorphine-waivered providers (BWP) and 139 to opioid treatment programs (OTP). Counts and percentages were used to describe caller success by type of treatment and pregnancy status. Chi-square tests were used to identify statistical differences. RESULTS: Only 42 % of calls reached a treatment provider in Florida. Pregnant and non-pregnant women were less likely to obtain an appointment with Medicaid coverage by a BWP than an OTP (p < 0.01). Nearly 40 % of OTPs offered appointments to callers with Medicaid compared to only 17 % of BWPs. Both types of providers denied appointments more often for pregnant women. Thirty-eight percent of BWP's and 12 % of OTP's denied appointments to pregnant women using cash or Medicaid payment. CONCLUSIONS: Our study demonstrates logistical and financial barriers to treatment for OUD among pregnant and non-pregnant women with Medicaid in Florida and highlights the need for improved systems of care.

Trends in Neonatal Extracorporeal Membrane Oxygenation During a Venovenous Cannula Shortage.

OBJECTIVES: To report temporal trends in venovenous extracorporeal membrane oxygenation (ECMO) use for neonatal respiratory failure in U.S. centers before and after functional venovenous cannula shortage due to withdrawal of one dual lumen venovenous cannula from the market in 2018. DESIGN: Retrospective cohort study. SETTING: ECMO registry of the Extracorporeal Life Support Organization. PATIENTS: Infants who received neonatal (cannulated prior to 29 d of age) respiratory ECMO at a U.S. center and had a record available in the ECMO registry from January 1, 2010 to July 20, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was receipt of venovenous ECMO (vs venoarterial or other), and secondary outcomes were survival to hospital discharge and adverse neurologic outcomes. Using an interrupted time series design, we fit multivariable mixed effects logistic regression models with receipt of venovenous ECMO as the dependent variable, treatment year modeled as a piecewise linear variable using three linear splines (pre shortage: 2010-2014, 2014-2018; shortage: 2018-2021), and adjusted for center clustering and multiple covariates. We evaluated trends in venovenous ECMO use by primary diagnosis including congenital diaphragmatic hernia, meconium aspiration, pulmonary hypertension, and other. Annual neonatal venovenous ECMO rates decreased after 2018: from 2010 to 2014, adjusted odds ratio (aOR) for yearly trend 0.98 (95% CI 0.92-1.04), from 2014 to 2018, aOR for yearly trend 0.90 (95% CI 0.80-1.01), and after 2018, aOR for yearly trend 0.46 (95% CI 0.37-0.57). We identified decreased venovenous ECMO use after 2018 in all diagnoses evaluated, and we failed to identify differences in temporal trends between diagnoses. Survival and adverse neurologic outcomes were unchanged across the study periods. CONCLUSIONS: Venovenous ECMO for neonatal respiratory failure in U.S. centers decreased after 2018 even after accounting for temporal trends, coincident with withdrawal of one of two venovenous cannulas from the market.

"The Problem's Bigger than We Are": Understanding How Local Factors Influence Child Welfare Responses to Substance Use in Pregnancy, A Qualitative Study.

State eligibility for certain federal child welfare funding requires a gubernatorial assurance that infants affected by substances receive plans of safe care (POSC). We conducted 18 interviews with state and county child welfare staff to understand how POSC has been implemented and found variability in practice driven by vague policy, challenges of cross-system collaboration, and a lack of knowledge about substance use disorder. Policy improvements should align requirements with POSC practice and create shared accountability with key partners.

Family Care Plans for Infants with Prenatal Substance Exposure.

The federal Child Abuse Prevention and Treatment Act (CAPTA) requires that a plan of safe care, called a family care plan (FCP) in Connecticut, be developed for all newborns identified as being affected by substance abuse and their caregivers. In Connecticut, FCPs are developed in treatment or hospital settings, not by child protective services. Analyzing data from Connecticut from 2019-2021, we found robust yet uneven implementation of FCPs that may have resulted in inadequate support for some affected caregiver-infant dyads. Additional implementation strategies may be needed to ensure that all dyads receive comprehensive FCPs.

The Association between NICU Admission and Mental Health Diagnoses among Commercially Insured Postpartum Women in the US, 2010-2018.

Maternal mental health (MH) conditions represent a leading cause of preventable maternal death in the US. Neonatal Intensive Care Unit (NICU) hospitalization influences MH symptoms among postpartum women, but a paucity of research uses national samples to explore this relationship. Using national administrative data, we examined the rates of MH diagnoses of anxiety and/or depression among those with and without an infant admitted to a NICU between 2010 and 2018. Using generalized estimating equation models, we explored the relationship between NICU admission and MH diagnoses of anxiety and/or depression, secondarily examining the association of NICU length of stay and race/ethnicity with MH diagnoses of anxiety and/or depression post NICU admission. Women whose infants became hospitalized in the NICU for <2 weeks had 19% higher odds of maternal MH diagnoses (aOR: 1.19, 95% CI: 1.14%−1.24%) and those whose infants became hospitalized for >2 weeks had 37% higher odds of maternal MH diagnoses (aOR: 1.37 95% CI: 1.128%−1.47%) compared to those whose infants did not have a NICU hospitalization. In adjusted analyses, compared to white women, all other race/ethnicities had significantly lower odds of receiving a maternal MH condition diagnosis [Black (aOR = 0.76, 0.73−0.08), Hispanic (aOR = 0.69, 0.67−0.72), and Asian (aOR: 0.32, 0.30−0.34)], despite higher rates of NICU hospitalization. These findings suggest a need to target the NICU to improve maternal MH screening, services, and support while acknowledging the influence of social determinants, including race and ethnicity, on health outcomes.