Timing of treatment for opioid use disorder among birthing people.

BACKGROUND: The number of pregnant women with opioid use disorder (OUD) has increased over time. Although effective treatment options exist, little is known about the extent to which women receive treatment during pregnancy and at what stage of pregnancy care is initiated. METHODS: Using a national private health insurance claims database, we identified women aged 13-49 who gave birth in 2006-2019 and had an OUD or nonfatal opioid overdose (NFOO) diagnosis during the year prior to or at delivery. We then identified women who received their first OUD treatment prior to or during pregnancy. In this cross-sectional study, we investigated how rates and timing of the initial OUD treatment changed over time. Furthermore, we examined factors associated with early initiation of OUD treatment among birthing people. RESULTS: Of the 7057 deliveries from 6747 women with OUD or NFOO, 63.3 % received any OUD treatment. Rates of OUD treatment increased from 42.9 % in 2006 to 69 % in 2019. Of those treated, in 2006, 54.5 % received their first treatment prior to conception and 24.2 % initiated care during the 1st trimester. In 2019, 68.9 % received their first treatment prior to conception, and 15.1 % initiated care during the 1st trimester. The percentage of women who were first treated in the 2nd trimester or later decreased from 21.2 % in 2006 to 16.1 % in 2019. Factors associated with early treatment initiation include being 25 years or older (age 25-34: aOR, 1.51, 95 % CI, 1.28-1.78; age 35-49: aOR, 1.82, 95 % CI, 1.39-2.37), living in urban areas (aOR, 1.28; 95 % CI, 1.05-1.56), having pre-existing behavioral health comorbidities such as anxiety disorders (aOR, 1.8; 95 % CI, 1.40-2.32), mood disorders (aOR, 1.63; 95 % CI, 1.02-2.61), and substance use disorder other than OUD (aOR, 2.56; 95 % CI, 2.03-3.32). CONCLUSION: Overall, rates of OUD treatment increased over time, and more women initiated OUD treatment prior to conception. Despite these improvements, over one-third of pregnant women with OUD/NFOO either received no treatment or did not initiate care until the 3rd trimester in 2019. Future research should examine barriers to OUD treatment initiation among pregnant women.

Receipt of Electroconvulsive Therapy in Outpatient Settings in a National Sample of Privately Insured Patients With Mood Disorders.

PURPOSE: Electroconvulsive therapy (ECT), an effective treatment for bipolar and major depressive disorder, is underused. Little information is available on use of ECT in potentially less costly outpatient settings, possibly reducing cost barriers. METHODS: Insurance claims from the 2008 to 2017 MarketScan Commercial Database for patients diagnosed with mood disorders were used to compare 4 groups of ECT users in each year: those receiving (1) exclusively outpatient ECT, (2) first inpatient and subsequently outpatient, (3) outpatient and subsequently inpatient, and (4) exclusively inpatient ECT. Groups were compared on the proportion receiving ECT in each group over time as well as on the total numbers of treatments received along with group differences in sociodemographic and diagnostic characteristics and health care costs. RESULTS: Among 2.9 million patients diagnosed with mood disorders, the proportion who received ECT (n = 8859) was small (0.30%) and declined over the decade to 0.17%. Among those who received ECT, most did so exclusively as outpatients (52.3%), the group with fewest comorbidities and lowest costs. This proportion increased by 19.7% over the decade, whereas the proportion receiving ECT exclusively in an inpatient setting (12.1%) fell by 30.6%. The total number of treatments per patient averaged 11.7 per year and increased by 28.0% over the decade, with outpatients decreasing to slightly less than average. Health care costs were greatest for those who started ECT as inpatients. CONCLUSIONS: Although the proportion of privately insured patients receiving ECT in outpatient settings has increased, reducing cost barriers, the use of ECT continued to be extremely limited and declining.

Medical marijuana access and prolonged opioid use among adolescents and young adults.

BACKGROUND AND OBJECTIVES: Laws liberalizing access to medical marijuana are associated with reduced opioid analgesic use among adults, but little is known about the impact of such policies on adolescents and young adults. METHODS: This retrospective cohort study used 2005 to 2014 claims from MarketScan® Commercial database, which covers all 50 states and Washington D.C. The sample included 195,204 adolescent and young adult patients (aged 12-25) who underwent one of 13 surgical procedures. RESULTS: Of the 195,204 patients, 4.8% had prolonged opioid use. Several factors were associated with a higher likelihood of prolonged opioid use, including being female (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.21-1.33), longer hospital stay (aOR, 1.04; 95% CI, 1.02-1.06), greater days of index opioid supply (8-14 days: aOR, 1.39, 95% CI, 1.33-1.45; greater than 14 days: aOR, 2.42, 95% CI, 2.26-2.59), rural residence (aOR, 1.07; 95% CI, 1.01-1.14), and cholecystectomy (aOR, 1.16; 95% CI, 1.08-1.25). There was not a significant association of medical marijuana dispensary laws on prolonged opioid use (aOR, 0.98; 95% CI, 0.81-1.18). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Medical marijuana has been suggested as a substitute for opioids, but our results focusing on adolescents and young adults provide new evidence that this particularly vulnerable population does not exhibit reductions in prolonged use of opioids after surgery when they have legal access to medical marijuana. These findings are the first to demonstrate potentially important age differences in sustained use of opioids, and point to the need for prescriber oversight and management with this vulnerable population.

The Implementation of the Tennessee Fetal Assault Law and Its Association With Out-of-State Births Among Residents of Tennessee.

INTRODUCTION: This study analyzed the association between the implementation of the Tennessee Fetal Assault Law (TFAL), which allowed prosecutors to incarcerate people who used substances during pregnancy, and out-of-state births among residents of Tennessee. METHODS: The main data source is vital records on singleton births in hospitals to people aged 15-44 years during the period January 2010 to June 2016. We include data from 33 states and the District of Columbia where birth certificate data are comparable over this time period. The statistical significance of the difference in outcomes observed before and after TFAL implementation was tested using a difference-in-differences analysis between Tennessee and the comparison group. RESULTS: After TFAL implementation, the odds of having an out-of-state birth increased by 13% for residents of Tennessee (odds ratio, 1.13; 95% confidence interval, 1.09-1.16) relative to residents of the comparison states. When we adopted different thresholds for travel distances to the birth hospital, the odds of residents of Tennessee having an out-of-state birth more than 75 miles away increased by 17% (odds ratio, 1.17; 95% confidence interval, 1.13-1.21) after TFAL implementation. CONCLUSION: The results of this study suggest that the implementation of a policy allowing incarceration of people who use substances during pregnancy is associated with an increase in out-of-state births, potentially putting pregnant people and their infants at greater risk.

Cost assessment of allergy procedures to improve high-value care implementation.

Background: Oral challenges and desensitizations are regularly performed by allergy/immunology physicians. However, there is limited research that has evaluated their cost-effectiveness and overall health-care-related value. Objective: The objective was to analyze the costs of oral challenges and desensitizations by clinician type (including allergy/immunology physicians, other physicians, and certified registered nurse practitioners [CRNP] and physician assistants [PA]), and by geographic distribution in the United States. Methods: By using a de-identified commercial database of medical encounters, we identified all claims for outpatient oral challenges and desensitizations in 2017 and grouped them separately by clinician type and by U.S. Census region. We used analysis of variance to test for cost differences between these two groupings. Results: Allergy/immunology physicians performed the majority of oral challenges (74.36%) with a mean cost of $161, significantly less than that of other physicians ($280). Allergy/immunology physicians also performed the majority of desensitizations (84.48%) with a mean cost of $335, significantly higher than that of CRNPs/PAs ($280); other physicians were reimbursed significantly more than both groups ($410). By geographic region, the mean costs of oral challenges in the Northeast ($212) and the West ($210) were significantly higher than those of other regions, whereas the mean cost of desensitizations was significantly highest in the West ($381). Conclusion: Allergy/immunology physicians and CRNPs/PAs cost the least with respect to oral challenges, whereas CRNPs/PAs cost the least with respect to desensitizations. The Northeast and the West regions provided the highest cost for oral challenges, whereas the West was most expensive in terms of desensitizations. Further knowledge and examination of these reimbursement patterns are crucial in understanding their relative value and the impact on delivery of high-value care.

Incidence of Midurethral Sling Revision or Removal by Its Timing With Prolapse Surgery.

OBJECTIVE: The aim of the study was to evaluate incidence of midurethral sling removal/revision based on timing with surgery for pelvic organ prolapse. METHODS: This was a retrospective cohort study of women who underwent midurethral sling placement in a claims-based database of women 65 years or older. Three groups were identified using the Current Procedural Terminology codes: (1) isolated sling, (2) concomitant sling, and (3) prolapse surgery and staged sling after prolapse surgery. In the staged group, placement of sling was identified within 18 months after index prolapse surgery. Fascial grafts were excluded. Sling removal/revision was identified across 3 years after sling surgery using Current Procedural Terminology code 57287. Rates of sling removal/revision were calculated by group. Comparisons were made using the χ2 test and analysis of variance. Cumulative incidence of removal/revision was evaluated using the Kaplan-Meier curves. Cox proportional hazards was performed to evaluate factors influencing removal/revision. RESULTS: We identified 39,381 isolated MUSs, 25,389 concomitant, and 886 staged. The rate of sling removal/revision was 3.52%. Rates of removal/revision differed between groups (7% staged vs 3.94% concomitant vs 3.17% isolated sling, P < 0.001). Compared with the staged group, the rate of removal/revision was lower in the isolated sling group (relative risk, 0.4550; 95% confidence interval [CI], 0.358-0.568) and the concomitant group (relative risk, 0.5666; 95% CI, 0.4450-0.7287). After adjusting for patient characteristics, sling revision or removal remained significantly less in the isolated MUS (hazard ratio, 0.50; 95% CI, 0.39-0.65) and concomitant (odds ratio, 0.55; 95% CI, 0.43-0.71) groups. CONCLUSIONS: Sling removal/revision is higher when it is staged after prolapse surgery compared with isolated and concomitant placement. Future studies are needed to confirm these findings in a controlled population.

Mental Health Conditions and Substance Use Disorders Among Youth Subsequently Diagnosed With Opioid Use Disorder or Opioid Poisoning.

PURPOSE: This study examined receipt of services for mental health conditions and non-opioid substance use disorders (SUDs) among privately insured adolescents and young adults (ie, youth) with subsequent clinically diagnosed opioid use disorder (OUD) or opioid poisoning. METHODS: Among individuals aged 12 to 25 years (N = 4926), healthcare service utilization claims for the 2 years before a newly clinically diagnosed OUD or opioid poisoning were assessed for mental health and nonopioid SUD service visits. RESULTS: Over half (60.6%) of the youth with clinically diagnosed OUD or opioid poisoning received mental health or nonopioid SUD services in the 2 years before the opioid poisoning or OUD diagnosis. CONCLUSION: Many adolescents and young adults with clinically diagnosed OUD or opioid poisoning interacted with the healthcare system to receive services for mental health conditions and nonopioid SUDs before the OUD or opioid poisoning being diagnosed. Opportunities exist to design better intervention strategies to prevent OUD or opioid poisoning among adolescents and young adults.

Does Electroconvulsive Therapy for Patients with Mood Disorders Extend Hospital Length of Stays and Increase Inpatient Costs?

Although randomized trials have shown that electroconvulsive therapy (ECT) is an effective and underused treatment for mood disorders, its impact on inpatient length of stay (LOS) and hospital costs are not fully understood. We analyzed private insurance claims of patients hospitalized for mood disorders who had continuous insurance for three months prior to an index hospitalization and six months after discharge (N = 24,249). Propensity score weighted linear models were used to examine the association of any ECT use, the number of ECT treatments, and time to first ECT treatment, with LOS and hospital costs adjusting for potential confounders. Three months prior to the index hospitalization, patients who subsequently received ECT had more than double the total healthcare costs and bed days ($12,669 vs. $6,333 and 4.5 vs. 0.92 days, p < .001) of the other group. During their index admission, patients receiving ECT had longer LOS (16.1 vs. 5.8 days, p < .001) and three times greater hospital costs ($28,607 vs. $8,708, p < .001). Analyses adjusted for other group differences showed a dose-response relationship between the number of ECT treatments and LOS and hospital costs. Receipt of ECT was associated with increased LOS by 4 to 29 days depending on the number of ECT treatments and increasing total hospital costs from $5,767 to $52,717. Receipt of any ECT and the number of treatments during hospitalization were associated with markedly increased LOS, hospital admission costs, and post-discharge costs. Cost-effectiveness of ECT may be enhanced by shifting treatments to outpatient settings when possible.

Cervical cancer screening varies by HPV vaccination status among a National Cohort of privately insured young women in the United States 2006-2016.

ABSTRACT: Human papillomavirus (HPV) vaccination in young women is low. Women aged 21 to 65 years in the United States (U.S.) have not reached the Healthy People 2020 objective of 93% for cervical cancer screening. The main aim of this study was to investigate the association between HPV vaccination status and cervical cancer screening among privately insured women aged 21 to 26 years in the U.S.This was a retrospective cohort study using the IBM MarketScan database (2006-2016). The study population included 190,982 HPV-vaccinated women and 763,928 matched unvaccinated women. Adjusted incidence rate ratio (IRR) and the 95% confidence intervals (CIs) were obtained using the generalized estimating equations models with a Poisson distribution.Among a total of 954,910 women included in the analysis, age (mean [SD]) was 23.3 [1.6] years. During 967,317 person-years of follow-up, a total of 475,702 incidents of cervical cancer screening were identified. The incidence density rates of cervical cancer screening were 461 per 1000 person-years (PY) for unvaccinated women and 787 per 1000 PY for those who received 3 doses of the HPV vaccine. After adjusting for other covariates, the IRR of cervical cancer screening was 34% higher among HPV-vaccinated women with at least one vaccine dose than unvaccinated women (adjusted IRR = 1.34, 95% CI: 1.33-1.35; P < .0001). The IRR of cervical cancer screening varied by the dose of HPV vaccination. There was evidence of a linear dose-response relationship between the number of HPV vaccine doses and cervical cancer screening (P-trend < .0001). Compared with unvaccinated women, the IRR of cervical cancer screening were 14%, 39%, and 60% higher among those who received 1, 2, and 3 doses of the HPV vaccine, respectively.In this large retrospective cohort study of privately insured women, HPV-vaccinated women were more likely to be screened for cervical cancer compared with unvaccinated women.

Prevalence and determinants of cervical cancer screening in five sub-Saharan African countries: A population-based study.

BACKGROUND: Cervical cancer is the fourth most common cancer among women worldwide, with an estimate of 570,000 new cases and about 311,000 deaths annually. Low-resource countries, including those in sub-Saharan Africa, have the highest-burden with an estimate of 84 % of all cervical cancers. This study examines the prevalence and socio-demographic-economic factors associated with cervical cancer screening in sub-Saharan Africa. METHODS: A weighted population-based cross-sectional study using Demographic and Health Surveys data. We used available data on cervical cancer screening between 2011 and 2018 from the Demographic and Health Surveys for five sub-Saharan African countries (Benin, Ivory Coast, Kenya, Namibia, and Zimbabwe). The study population included women of childbearing age, 21-49 years (n = 28,976). We fit a multivariable Poisson regression model to identify independent factors associated with cervical cancer screening. RESULTS: The overall weighted prevalence of cervical cancer screening was 19.0 % (95 % CI: 18.5 %-19.5 %) ranging from 0.7 % in Benin to 45.9 % in Namibia. Independent determinants of cervical cancer screening were: older age (40-49 years) adjusted prevalence ratio (aPR) = 1.77 (95 % CI: 1.64, 1.90) compared with younger age (21-29 years), secondary/higher education (aPR = 1.51, 95 CI: 1.28-1.79) compared with no education, health insurance (aPR = 1.53, 95 % CI: 1.44-1.61) compared with no insurance, and highest socioeconomic status (aPR = 1.39, 95 % CI: 1.26-1.52) compared with lowest. CONCLUSION: The prevalence of cervical cancer screening is substantially low in sub-Saharan Africa countries and shows a high degree of between-country variation. Interventions aimed at increasing the uptake of cervical cancer screening in sub-Saharan Africa are critically needed.

Prevalence and determinants of breast cancer screening in four sub-Saharan African countries: a population-based study.

OBJECTIVES: Breast cancer is the most prevalent cancer and the second leading cause of cancer-related deaths among women after cervical cancer in much of sub-Saharan Africa. This study aims to examine the prevalence and sociodemographic-socioeconomic factors associated with breast cancer screening among women of reproductive age in sub-Saharan Africa. DESIGN: A weighted population-based cross-sectional study using Demographic and Health Surveys (DHS) data. We used all available data on breast cancer screening from the DHS for four sub-Saharan African countries (Burkina Faso, Ivory Coast, Kenya and Namibia). Breast cancer screening was the outcome of interest for this study. Multivariable Poisson regression was used to identify independent factors associated with breast cancer screening. SETTING: Four countries participating in the DHS from 2010 to 2014 with data on breast cancer screening. PARTICIPANTS: Women of reproductive age 15-49 years (N=39 646). RESULTS: The overall prevalence of breast cancer screening was only 12.9% during the study period, ranging from 5.2% in Ivory Coast to 23.1% in Namibia. Factors associated with breast cancer screening were secondary/higher education with adjusted prevalence ratio (adjusted PR)=2.33 (95% CI: 2.05 to 2.66) compared with no education; older participants, 35-49 years (adjusted PR=1.73, 95% CI : 1.56 to 1.91) compared with younger participants 15-24 years; health insurance coverage (adjusted PR=1.57, 95% CI: 1.47 to 1.68) compared with those with no health insurance and highest socioeconomic status (adjusted PR=1.33, 95% CI : 1.19 to 1.49) compared with lowest socioeconomic status. CONCLUSION: Despite high breast cancer mortality rates in sub-Saharan Africa, the prevalence of breast cancer screening is substantially low and varies gradually across countries and in relation to factors such as education, age, health insurance coverage and household wealth index level. These results highlight the need for increased efforts to improve the uptake of breast cancer screening in sub-Saharan Africa.

Early Discontinuation of Buprenorphine Therapy for Opioid Use Disorder Among Privately Insured Adults.

OBJECTIVE: This study examined the temporal relationship between early discontinuation of buprenorphine treatment and health care expenditures before and after treatment initiation. METHODS: MarketScan commercial claims for patients who initiated buprenorphine for opioid use disorder in 2013 and had continuous insurance for the subsequent 12 months (N=6,444) were used to examine the relationship between treatment retention and health care expenditures before and after buprenorphine initiation. Analysis of covariance and generalized linear models (with gamma distribution/log link) were used to compare expenditures across four buprenorphine-retention groups (0-3, 3-6, 6-12, and 12 or more months). RESULTS: Average total health care expenditures in the 3 months prior to buprenorphine initiation ranged from a high of $7,588 among those with the shortest retention to $4,929 among those with the longest retention (p<0.001). In the 12 months after buprenorphine initiation, total health care expenditures averaged $26,332 per year, with $2,916 (11.1%) in out-of-pocket expenditures. Average annual expenditures for medication were highest among patients with the longest buprenorphine retention, and total health care expenditures were highest among those with the shortest retention. Expenditures for health care services other than medication were highest among those with early discontinuation both before the initiation of buprenorphine and during the initial period after initiation but not in subsequent quarters. CONCLUSIONS: Poorer treatment retention among privately insured adults was associated with greater clinical and financial burdens that preceded and continued during the period shortly following treatment initiation, suggesting that cost burdens may contribute to poor retention among privately insured adults.

Performance of Pain Interventionalists From Different Specialties in Treating Degenerative Disk Disease-Related Low Back Pain.

OBJECTIVES: To examine the utilization of current common treatments by providers from different specialties and the effect on delaying spinal surgery in patients with disk degenerative disease (DDD) related low back pain. DESIGN: Retrospective observational study using data from the MarketScan Commercial Claims and Encounters database (2005-2013). SETTING: Not applicable. PARTICIPANTS: Patients (N=6229) newly diagnosed with DDD-related low back pain who received interventional treatments from only 1 provider specialty and continuously enrolled in the database for 3 years after diagnosis. MAIN OUTCOME MEASURES: Measures of treatment utilization and cost were constructed for patients who received spinal surgery within 3 years after diagnosis. Cox proportional hazards models were used to examine time to surgery among provider specialties and generalized linear models were used to examine cost differences among provider specialties. RESULTS: Of the 6229 patients, 427 (6.86%) underwent spinal surgery with unadjusted mean interventional treatment costs ranging from $555 to $851. Although the differences in mean costs across provider specialties were large, they were not statistically significant. Cox proportional hazards models showed that there was no significant difference between provider specialties in the time from DDD diagnosis to spinal surgery. However, patients diagnosed with DDD at a younger age and receiving physical therapy had significantly delayed time to surgery (hazard ratio, 0.66; 95% confidence interval [CI], 0.54-0.81 and hazard ratio, 0.77; 95% CI, 0.62-0.96, respectively). CONCLUSIONS: Although there were no statistically significant differences among provider specialties for time to surgery and cost, patients receiving physical therapy had significantly delayed time to surgery.

Prevalence and predictors of contraceptive use among women of reproductive age in 17 sub-Saharan African countries: A large population-based study.

OBJECTIVE: To measure the prevalence of contraceptive use among women of reproductive age in 17 sub-Saharan Africa countries and identify factors associated with contraceptive use in these countries. STUDY DESIGN: We conducted a population-based cross-sectional study using data on contraceptive use from the Demographic and Health Surveys (DHS) for 17 sub-Saharan Africa countries (Angola, Benin, Burkina Faso, Burundi, Cameroon, Congo, Gambia, Ghana, Guinea, Ivory Coast, Liberia, Mali, Niger, Nigeria, Senegal, Togo, and Uganda). We restricted our sample to women aged 15-49 years and used generalized estimating equations to identify factors associated with contraceptive use while controlling for other covariates. RESULTS: The overall prevalence of current contraceptive use among women of reproductive age was only 17%, with rates ranging from 7% in Gambia to 29% in Uganda. After adjusting for potential confounders, we found that women were more likely to use a method of contraception if they were sexually active (adjusted prevalence ratio (aPR) 2.17 [95% confidence interval (CI) 2.11, 2.24]); had 5-7 living children (aPR 2.19 [95% CI 1.89, 2.55] compared to no children); had secondary or higher education (aPR 1.71 [95% CI 1.63, 1.78] compared to no education); and were wealthy (aPR 1.34 [95% CI 1.29, 1.40] compared to poor). CONCLUSION: The use of contraceptives is low in sub-Saharan Africa, but varies substantially across countries. Use of contraception is associated with both personal and socioeconomic factors.

The economic burden of the opioid epidemic on states: the case of Medicaid.

The societal burden of opioid use disorder (OUD) is considerable and contributes to increased healthcare costs and overdose deaths. However, the burden is not well understood. The purpose of this analysis is to estimate the state Medicaid programs' costs for treating OUD and how these costs have changed over time. We used data from the Medicaid Analytic eXtract files from 17 states between 1999 and 2013 to examine the healthcare costs associated with OUD. Inpatient, outpatient, and prescription medication costs related to the treatment of OUD were included, as were excess costs for other healthcare services (eg, general medical care) for individuals with OUD relative to a comparison group of individuals without OUD matched on age, sex, and state. We then extrapolated our results to the entire US Medicaid population using population-based sample weights. All costs were adjusted for inflation and are reported in 2017 US dollars. During our study period, the number of patients who were diagnosed with OUD increased 378%, from 39,109 (0.21% of total Medicaid enrollment) in 1999 to 186,979 (0.60% of total Medicaid enrollment) in 2013 in our 17-state sample. Even after adjusting for inflation, total Medicaid costs associated with OUD more than tripled during this time, reaching more than $3 billion in 2013, from $919 million in 1999. Most of this growth was due to excess non-OUD treatment costs for patients with OUD, which increased 363% over the period; the rate of growth is triple the expenditures for OUD treatment services. When the results were extrapolated to the entire United States, the Medicaid costs associated with OUD increased from more than $2 billion in 1999 to more than $8 billion in 2013. The total cumulative costs that were associated with OUD for this extrapolated 50-state sample over a 15-year time period amounts to more than $72.4 billion. OUD imposes considerable financial burden on state Medicaid programs, and the burden is increasing over time.

Three-Year Retention in Buprenorphine Treatment for Opioid Use Disorder Among Privately Insured Adults.

OBJECTIVE: This study examined factors related to retention in buprenorphine treatment for opioid use disorder (OUD) among privately insured patients. METHODS: Patients with OUD who were newly started on buprenorphine during federal fiscal year (FY) 2011 were identified in a national private insurance claims database (MarketScan), and treatment retention (filled buprenorphine prescriptions) was evaluated through FY 2014. Proportional hazards models were used to examine demographic, clinical, and service use characteristics in FY 2011, including ongoing insurance coverage, associated with discontinuation of treatment. RESULTS: Of 16,190 patients with OUD newly started on buprenorphine in FY 2011, 45.0% were retained in treatment for more than one year, and 13.7% for more than three years (mean±SD duration of retention=1.23±1.16 years). During the first three years after buprenorphine initiation, 49.3% (N=7,988) disenrolled from their insurance plan. Cox proportional hazards models showed that for every 30 days of enrollment, the risk of discontinuation declined by 10% (hazard ratio [HR]=.90, 95% confidence interval [CI]=.90-.91). FY 2011 factors reducing discontinuation risk were age greater than the median (HR=.90, CI=.87-.93) and receipt of outpatient psychotherapy (HR=.90, CI=.86-.92); increased risk was associated with psychiatric hospitalization (HR=1.30, CI=1.24-1.36), emergency department visits (HR=1.07, CI=1.04-1.14), and additional substance use disorders (HR=1.05, CI=1.01-1.10). CONCLUSIONS: Buprenorphine treatment retention declined markedly in the first year and was substantially lower than in comparable studies from publicly funded health care systems, apparently largely due to disenrollment. The association of psychotherapy with greater retention suggests that it may be an important complement to opioid agonist treatment.

Identifying Recipients of Electroconvulsive Therapy: Data From Privately Insured Americans.

OBJECTIVE: Despite the effectiveness of electroconvulsive therapy (ECT), limited epidemiologic research has been conducted to identify rates of ECT use and characteristics of patients who receive ECT. Sociodemographic and clinical characteristics associated with ECT use were examined among patients with mood disorders in the MarketScan commercial insurance claims database. METHODS: Among individuals with major depressive disorder or bipolar disorder, sociodemographic and clinical characteristics of those who received ECT and those who did not were compared by using bivariate effect size comparisons and multivariate logistic regression. RESULTS: Among unique individuals in the 2014 MarketScan database (N=47,258,528), the ECT utilization rate was 5.56 ECT patients per 100,000 in the population. Of the 969,277 patients with a mood disorder, 2,471 (.25%) received ECT. Those who received ECT had substantially higher rates of additional comorbid psychiatric disorders (risk ratio [RR]=5.70 for any additional psychiatric disorder), numbers of prescription fills for any psychotropic medication (Cohen's d=.77), rates of any substance use disorder (RR=1.97), and total outpatient psychotherapy visits (Cohen's d=.49). The proportion of patients with a mood disorder who received ECT in the West (.19%) was substantially lower than in other U.S. regions (.28%). This difference was almost entirely accounted for by one western state comprising 59.1% of patients in that region. CONCLUSIONS: Use of ECT is exceptionally uncommon and limited to patients with extensive multimorbidity and high levels of service use. ECT utilization is most limited in areas of the country where regulatory restrictions are greatest.

Medicaid Waivers Targeting Children With Autism Spectrum Disorder Reduce The Need For Parents To Stop Working.

Several states have passed Medicaid home and community-based services waivers that expand eligibility criteria and available services for children with autism spectrum disorder. Although previous research has shown considerable variation in these waivers, little is known about the programs' impact on parents' workforce participation. We used nationally representative survey data combined with detailed information on state Medicaid waiver programs to determine the effects of waivers on whether parents of children with autism spectrum disorder had to stop working because of the child's condition. Increases in the Medicaid home and community-based services waiver cost limit and enrollment limit significantly reduced the likelihood that a parent had to stop working, although the results varied considerably by household income level. These findings suggest that the Medicaid waivers are effective policies to address the care-related needs of children with autism spectrum disorder.

The Effects of Medicaid Home and Community-based Services Waivers on Unmet Needs Among Children With Autism Spectrum Disorder.

BACKGROUND: Several states have passed Medicaid Home and Community-based Services (HCBS) waivers that expand eligibility criteria and available services for children with autism spectrum disorder (ASD). Previous research has shown considerable variation in these waivers, but little is known about the extent to which they address the health care needs of children with ASD. OBJECTIVE: To determine the effects of Medicaid HCBS waivers, and their characteristics, on unmet health care needs among children with ASD. METHODS: We used data from the 2003, 2007, and 2011 waves of the National Survey of Children's Health with detailed information on the Medicaid HCBS waiver programs of 35 states. Quasi-difference-in-difference-in-differences models were used to determine the effects of waivers and their characteristics on parent report of unmet health care needs of children with ASD compared with children without ASD. RESULTS: Greater waiver cost limits per child, estimated costs of services, and enrollment limits were associated with significant decreases in the adjusted rate of unmet health care needs, with considerable variation by household income level. CONCLUSIONS: These findings suggest that Medicaid HCBS waivers significantly decrease the unmet need for health care among children with ASD, most substantially among those who would not otherwise qualify for Medicaid. The findings regarding the effects of specific aspects of these waivers can inform the development of insurance policies in other states to address the needs of children with ASD.

Medicaid 1915(c) Home- and Community-Based Services waivers for children with autism spectrum disorder.

This research aims to describe the characteristics of 1915(c) Home- and Community-Based Services waivers for children with autism spectrum disorder across states and over time. While increasingly popular, little is known about these Medicaid waivers. Understanding the characteristics of these programs is important to clinicians and policymakers in designing programs to meet the needs of this vulnerable population and to set the stage for evaluating changes that occur with the implementation of health-care reform. Home- and Community-Based Services waiver applications that included children with autism spectrum disorder as a target population were collected from the Centers for Medicare and Medicaid Services website, state websites, and state administrators. A data extraction tool was used to document waiver inclusions and restrictions, estimated service provision and institutional costs, and the inclusion of four core autism spectrum disorder services: respite, caregiver support and training, personal care, and evidence-based treatments. Investigators identified 50 current or former waivers across 29 states that explicitly included children with autism spectrum disorder in their target populations. Waivers differed substantially across states in the type and breadth of autism spectrum disorder coverage provided. Specifically, waivers varied in the populations they targeted, estimated cost of services, cost control methods employed, and services offered to children with autism spectrum disorder. Home- and Community-Based Services waivers for children with autism spectrum disorder are very complex and are not consistent across states or over time. Further efforts are needed to examine the characteristics of programs that are associated with improved access to care and clinical outcomes to maximize the benefits to individuals with autism spectrum disorder and their families.