Antidepressant Prescriptions Increased For Privately Insured People With Perinatal Mood And Anxiety Disorder, 2008-20.

We aimed to determine whether antidepressant prescriptions for perinatal mood and anxiety disorder (PMAD) increased after several professional organizations issued clinical recommendations in 2015 and 2016. This serial, cross-sectional, logistic regression analysis evaluated changes in antenatal and postpartum antidepressant prescriptions among commercially insured people who had a live-birth delivery as well as a PMAD diagnosis during the period 2008-20. For people with antenatal PMAD, the odds of an antenatal antidepressant prescription decreased 3 percent annually from 2008 to 2016 and increased by 32 percent in 2017, and the annual rate of change increased 5 percent for 2017-20 compared with 2008-16. For people with postpartum PMAD, the odds of a postpartum antidepressant prescription decreased 2 percent annually from 2008 to 2016 and experienced no significant change in 2017, but the annual rate of change increased 3 percent for 2017-20 compared with 2008-16. The clinical recommendations issued in 2015 and 2016 were associated with increased antidepressant prescriptions for PMAD, particularly for antenatal PMAD. These findings indicate that clinical recommendations represent an effective tool for changing prescribing patterns.

Perinatal Mood And Anxiety Disorders Rose Among Privately Insured People, 2008-20.

Nationwide, perinatal mood and anxiety disorder (PMAD) diagnoses among privately insured people increased by 93.3 percent from 2008 to 2020, growing faster in 2015-20 than in 2008-14. Most states and demographic subgroups experienced increases, suggesting worsening morbidity in maternal mental health nationwide. PMAD-associated suicidality and psychotherapy rates also increased nationwide from 2008 to 2020. Relative to 2008-14, psychotherapy rates continued to rise in 2015-20, whereas suicidality rates declined.

Diagnosed behavioral health conditions during the perinatal period among a commercially insured population by race/ethnicity, 2008-2020.

Objective: We sought to examine trends in diagnosed behavioral health (BH) conditions [mental health (MH) disorders or substance use disorders (SUD)] among pregnant and postpartum individuals between 2008-2020. We then explored the relationship between BH conditions and race/ethnicity, acknowledging race/ethnicity as a social construct that influences health disparities. Methods: This study included delivering individuals, aged 15-44 years, and continuously enrolled in a single commercial health insurance plan for 1 year before and 1 year following delivery between 2008-2020. We used BH conditions as our outcome based on relevant ICD 9/10 codes documented during pregnancy or the postpartum year. Results: In adjusted analyses, white individuals experienced the highest rates of BH conditions, followed by Black, Hispanic, and Asian individuals, respectively. Asian individuals had the largest increase in BH rates, increasing 292%. White individuals had the smallest increase of 192%. The trend remained unchanged even after adjusting for age and Bateman comorbidity score, the trend remained unchanged. Conclusions: The prevalence of diagnosed BH conditions among individuals in the perinatal and postpartum periods increased over time. As national efforts continue to work toward improving perinatal BH, solutions must incorporate the needs of diverse populations to avert preventable morbidity and mortality.

The impact of the affordable care act on perinatal mood and anxiety disorder diagnosis and treatment rates among Michigan Medicaid enrollees 2012-2018.

BACKGROUND: Perinatal Mood and Anxiety Disorders (PMADs) affect one in five birthing individuals and represent a leading cause of maternal mortality. While these disorders are associated with a variety of poor outcomes and generate significant societal burden, underdiagnosis and undertreatment remain significant barriers to improved outcomes. We aimed to quantify whether the Patient Protection Affordable Care Act (ACA) improved PMAD diagnosis and treatment rates among Michigan Medicaid enrollees. METHODS: We applied an interrupted time series framework to administrative Michigan Medicaid claims data to determine if PMAD monthly diagnosis or treatment rates changed after ACA implementation for births 2012 through 2018. We evaluated three treatment types, including psychotherapy, prescription medication, and either psychotherapy or prescription medication. Participants included the 170,690 Medicaid enrollees who had at least one live birth between 2012 and 2018, with continuous enrollment from 9 months before birth through 3 months postpartum. RESULTS: ACA implementation was associated with a statistically significant 0.76% point increase in PMAD diagnosis rates (95% CI: 0.01 to 1.52). However, there were no statistically significant changes in treatment rates among enrollees with a PMAD diagnosis. CONCLUSION: The ACA may have improved PMAD detection and documentation in clinical settings. While a higher rate of PMAD cases were identified after ACA Implementation, Post-ACA cases were treated at similar rates as Pre-ACA cases.

Racial Disparities in Diagnosis of Postpartum Mood and Anxiety Disorders Among Symptomatic Medicaid Enrollees, 2012-2015.

OBJECTIVE: This study quantified the prevalence of postpartum mood and anxiety disorder (PMAD) diagnoses among symptomatic Michigan Medicaid enrollees and explored factors associated with receiving a diagnosis. METHODS: Data sources comprised Michigan Medicaid administrative claims and Phase 7 Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS) survey responses, linked at the individual level. Participants were continuously enrolled in Michigan Medicaid, delivered a live birth (2012-2015), responded to the survey, and screened positive for PMAD symptoms on the adapted two-item Patient Health Questionnaire. Unadjusted and adjusted weighted logistic regression analyses were used to predict the likelihood of having a PMAD diagnosis (for the overall sample and stratified by race). RESULTS: The weighted analytic cohort represented 24,353 deliveries across the 4-year study. Only 19.8% of respondents with symptoms of PMAD had a PMAD diagnosis between delivery and 3 months afterward. Black respondents were less likely to have PMAD diagnoses (adjusted odds ratio [AOR]=0.23, 95% CI=0.11-0.49) compared with White respondents. Among White respondents, no covariates were significantly associated with having a diagnosis. However, among Black respondents, more comorbid conditions and more life stressors were statistically significantly associated with having a diagnosis (AOR=3.18, 95% CI=1.27-7.96 and AOR=3.12, 95% CI=1.10-8.88, respectively). CONCLUSIONS: Rate of PMAD diagnosis receipt differed by race and was low overall. Black respondents were less likely than White respondents to receive a diagnosis. Patient characteristics influencing diagnosis receipt also differed by race, indicating that strategies to improve detection of these disorders require a tailored approach.

Relationship between Depression and Anxiety during Pregnancy, Delivery-Related Outcomes, and Healthcare Utilization in Michigan Medicaid, 2012-2021.

To evaluate associations between depression and/or anxiety disorders during pregnancy (DAP), delivery-related outcomes, and healthcare utilization among individuals with Michigan Medicaid-funded deliveries. We conducted a retrospective delivery-level analysis comparing delivery-related outcomes and healthcare utilization among individuals with and without DAP between January 2012 and September 2021. We used generalized estimating equation models assessing cesarean and preterm delivery; 30-day readmission after delivery; severe maternal morbidity within 42 days of delivery; and ambulatory, inpatient, emergency department or observation (ED), psychotherapy, or substance use disorders (SUD) visits during pregnancy. We adjusted models for age, race/ethnicity, urbanicity, federal poverty level, and obstetric comorbidities. Among 170,002 Michigan Medicaid enrollees with 218,890 deliveries, 29,665 (13.6%) had diagnoses of DAP. Compared to those without DAP, individuals with DAP were more often White, rural dwelling, had lower income, and had more comorbidities. In adjusted models, deliveries with DAP had higher odds of cesarean and preterm delivery OR = 1.02, 95% CI: [1.00, 1.05] and OR = 1.15, 95% CI: [1.11, 1.19] respectively), readmission within 30 days postpartum (OR = 1.14, 95% CI: [1.07, 1.22]), SMM within 42 days (OR = 1.27, 95% CI: [1.18, 1.38]), and utilization compared to those without DAP diagnoses (ambulatory: OR = 7.75, 95% CI: [6.75, 8.88], inpatient: OR = 1.13, 95% CI: [1.11, 1.15], ED: OR = 1.86, 95% CI: [1.80, 1.92], psychotherapy: OR = 172.8, 95% CI: [160.10, 186.58], and SUD: OR = 5.6, 95% CI: [5.37, 5.85]). Among delivering individuals in Michigan Medicaid, DAP had significant associations with adverse delivery-related outcomes and greater healthcare use. Early detection and intervention to address mental illness during pregnancy may help mitigate burdens of these complex yet treatable disorders.

Trends in chronic pain conditions among delivering women with and without mood and anxiety disorders.

OBJECTIVE: The co-existence of chronic pain conditions with anxiety and/or depression is common in the general population but poorly described during pregnancy. In this study, we sought to describe trends in chronic pain among a sample of delivering people and describe the co-existence of chronic pain with anxiety and/or depression among delivering people. METHODS: This cross-sectional study used data from Optum's de-identified Clinformatics® Data Mart Database between 2008 and 2021, for delivering persons with coverage by single employer-based health plan. We computed predicted margins from generalized estimating equations to determine the marginal predicted probability of chronic pain among all delivering and non-delivering persons who identify as women with and without diagnosed anxiety and/or depression. RESULTS: Musculoskeletal and pelvic pain occurred most often regardless of delivering status. Delivering persons with anxiety and/or depression had higher marginal predicted probabilities of chronic pain compared to all delivering persons. Between 2008 and 2021, the predicted probabilities ranged from 0.400 to 0.527 and 0.221-0.261, respectively. CONCLUSION: Chronic pain conditions are common in pregnancy and nearly two times higher among individuals with anxiety and/or depression. The frequency of comorbid depression and/or anxiety with pain disorders among delivering persons highlights the importance of proper detection, coordination of care, and safe treatment options for this population.

Pregnancy Outcomes in a US Cohort of Transgender People.

This study assesses severe parental morbidity, cesarean deliveries, and preterm births among commercially and publicly insured trans people compared with cisgender people.

Factors associated with mental health treatment among Michigan medicaid enrollees with perinatal mood and anxiety disorders, 2012-2015.

OBJECTIVE: Perinatal mood and anxiety disorders (PMADs) represent the most prevalent pregnancy-related comorbidity and a leading cause of maternal mortality. Effective treatments exist, but remain underutilized. We sought to identify factors associated with receipt of prenatal and postpartum mental health treatment. METHODS: This observational, cross-sectional analysis used self-reported survey data from the Michigan Pregnancy Risk Assessment Monitoring System linked to Michigan Medicaid administrative claims for births from 2012 to 2015. We used survey-weighted multinomial logistic regression to predict prescription medication and psychotherapy utilization among respondents with PMADs. RESULTS: Only 28.0% of respondents with prenatal PMAD and 17.9% of respondents with postpartum PMAD received both prescription medication and psychotherapy. During pregnancy, Black respondents were 0.33 (95%CI: 0.13-0.85, p = 0.022) times less likely to receive both treatments while more comorbidities were associated with receipt of both treatments (adjRR = 1.31, 95%CI: 1.02-1.70, p = 0.036). In the first three months postpartum, respondents with four or more stressors were 6.52 times more likely to receive both treatments (95%CI: 1.62-26.24, p = 0.008) and those satisfied with prenatal care were 16.25 times more likely to receive both treatments (95%CI: 3.35-78.85, p = 0.001). DISCUSSION: Race, comorbidities, and stress are critical factors in PMAD treatment. Satisfaction with perinatal healthcare may facilitate access to care.

Determining the Sex Assigned at Birth of Transgender and Nonbinary Populations in Administrative Claims Databases Utilizing Diagnostic and Procedure Codes.

Purpose: Widespread conflation of sex assigned at birth and gender has hindered the identification of transgender and nonbinary people in large datasets. The study objective was to develop a method of determining the sex assigned at birth of transgender and nonbinary patients utilizing sex-specific diagnostic and procedural codes, for future use in administrative claims databases, with a goal of expanding the available datasets for exploring sex-specific conditions among transgender and nonbinary people. Methods: Authors reviewed indexes of International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and medical record data from a single institution's gender-affirming clinics. Sex-specific ICD and CPT codes were identified through author review and consultation with subject experts. Patient's sex assigned at birth determined by chart review, as a gold standard, was compared with sex assigned at birth determined by querying their electronic health records for natal sex-specific codes. Results: Sex-specific codes correctly identified 53.5% (n=364) of transgender and nonbinary patients assigned female sex at birth, and 17.3% (n=108) of those assigned male sex at birth. Codes were 95.7% and 98.3% specific for assigned female and male sex at birth, respectively. Conclusions: ICD and CPT codes can be used to specifically determine the sex assigned at birth in databases where this information is not recorded. This methodology has novel potential for use in exploring sex-specific conditions among transgender and nonbinary patients in administrative claims data.

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.

Reduction in Rates of Symptomatic Urinary Tract Infection After Pelvic Reconstructive Surgery: A Quality Improvement Analysis.

IMPORTANCE: Urinary tract infections contribute to high health care costs. OBJECTIVE: This study aimed to determine if a combination of interventions was successful at reducing the rate of postoperative symptomatic urinary tract infections (SUTIs) in a female pelvic medicine and reconstructive surgery (FPMRS) practice. STUDY DESIGN: Observational, retrospective quality improvement analysis looking at the rate of postoperative SUTI within 30 days of surgery in women who underwent gynecologic surgery performed by an FPMRS surgeon from October 2015 to October 2019. Symptomatic urinary tract infection was defined by symptoms and urinalysis, positive urine culture, or treatment for cystitis or urethritis within 30 days of surgery. Interventions were implemented between 2015 and 2016: perioperative cranberry use, intraoperative protocols for catheterization, and postoperative protocols for urinary retention management. In 2018, we added metronidazole to cefazolin for antibiotic prophylaxis. We developed a multivariable logistic regression to determine if postoperative SUTI rates decreased over the study period with adjustment for clustering by surgeons, patient factors, and surgery type. RESULTS: Of 2,389 procedures performed, 284 (11.8%) involved patients who had an SUTI within 30 days of surgery. The annual infection rate decreased 50% (year 1, 14.7%; year 4, 7.3%). Adjusting for age, race, body mass index, length of stay, surgery type, and surgeon, the odds of SUTI decreased 19% each year (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.72-0.91; P < 0.001). Compared with women who had other gynecologic procedures, those who underwent vaginal prolapse surgery with or without incontinence procedures (OR, 2.75; 95% CI, 1.35-5.54; P = 0.01) or incontinence surgery alone (OR, 2.65; 95% CI, 1.25-5.62; P = 0.01) were more likely to have an SUTI. CONCLUSION: Combining interventions can be highly effective in reducing postoperative SUTI rates.

Leveraging Administrative Claims to Understand Disparities in Gender Minority Health: Contraceptive Use Patterns Among Transgender and Nonbinary People.

Purpose: Transgender people face disparities in access to reproductive and sexual health services; however, differences in receipt of contraceptive services have not been quantified. We compare contraceptive patterns between cisgender women and trans masculine people in insurance claims databases. Methods: We analyzed 2014-2018 Truven MarketScan data, using diagnostic and procedural codes to identify sex assigned at birth, and existing coding methodology to identify transgender and nonbinary people. We compared contraceptive patterns between cisgender women and trans masculine people aged 15-49 in Medicaid and commercial databases. Results: We identified 4700 people in the commercial and 1628 people in the Medicaid databases as trans masculine. Trans masculine people were prescribed fewer oral contraceptive pills (Medicaid: 17.44%, commercial: 16.62%) compared to cisgender women (Medicaid: 24.96%, commercial: 27.85%), less long-acting reversible contraception (LARC) use (Medicaid: 7.62%, commercial: 7.49% vs. Medicaid: 12.79%, commercial: 8.51%), had more hysterectomies (Medicaid: 5.77%, commercial: 8.45% vs. Medicaid: 2.15%, commercial: 2.48%), and less evidence of any contraception (Medicaid: 34.21%, commercial: 32.28% vs. Medicaid: 46.80%, commercial: 39.81%). Hysterectomies and LARC use varied by insurance type. Conclusion: We found significant differences in contraceptive patterns between trans masculine people and cisgender women. Data suggest potential differences in hysterectomy occurrences by trans masculine people, and long-acting reversible contraceptive use by cisgender women, in Medicaid versus commercial insurance cohorts. Appropriate counseling, insurance coverage, and removal of structural barriers are needed to ensure adequate access to contraception methods for people of all genders-regardless of whether they are being employed for contraception, menstrual management, or gender affirmation.

Continuous Renal Replacement Therapy among Patients with COVID-19 and Acute Kidney Injury.

BACKGROUND AND OBJECTIVES: Acute kidney injury (AKI) is a common complication among patients with COVID-19 and acute respiratory distress syndrome. Reports suggest that COVID-19 confers a pro-thrombotic state, which presents challenges in maintaining hemofilter patency and delivering continuous renal replacement therapy (CRRT). We present our initial experience with CRRT in critically ill patients with COVID-19, emphasizing circuit patency and the association between fluid balance during CRRT and respiratory parameters. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Retrospective chart review of 32 consecutive patients with COVID-19 and AKI managed with continuous venovenous hemodiafiltration with regional citrate anticoagulation (CVVHDF-RCA) according to the University of Michigan protocol. Primary outcome was mean CRRT circuit life per patient during the first 7 days of CRRT. We used simple linear regression to assess the relationship between patient characteristics and filter life. We also explored the relationship between fluid balance on CRRT and respiratory parameters using repeated measures modeling. RESULTS: Patients' mean age was 54.8 years and majority were Black (75%). Comorbidities included hypertension (90.6%), obesity (70.9%) diabetes (56.2%), and chronic kidney disease (40.6%). Median CRRT circuit life was 53.5 [interquartile range 39.1-77.6] hours. There was no association between circuit life and inflammatory or pro-thrombotic laboratory values (ferritin p = 0.92, C-reactive protein p = 0.29, D-dimer p = 0.24), or with systemic anticoagulation (p = 0.37). Net daily fluid removal during the first 7 days of CRRT was not associated with daily (closest recorded values to 20:00) PaO2/FIO2 ratio (p = 0.21) or positive end-expiratory pressure requirements (p = 0.47). CONCLUSIONS: We achieved adequate CRRT circuit life in COVID-19 patients using an established CVVHDF-RCA protocol. During the first 7 days of CRRT therapy, cumulative fluid balance was not associated with improvements in respiratory parameters, even after accounting for baseline fluid balance.