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1.
Contraception ; 2021 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-33939984

RESUMO

OBJECTIVES: We measured women's preferences for avoiding an unintended pregnancy. We determined if young age (<25) was associated with lowest utility with an unintended pregnancy. METHODS: We conducted a cross sectional study of women presenting for hormonal contraception who did not desire a pregnancy. We used four techniques to elicit health prefences and calculate utilities for an unintended pregnancy: visual analog scale (VAS), and willingness to pay (WTP), time-tradeoff (TTO), and standard gamble (SG). We dichotomized each measure to define lowest utility for each measure. We used predicted probabilities and multivariable logistic regression to estimate the association between age (≤25 vs ≥26 years) and lowest utility with an unintended pregnancy. RESULTS: Our sample included 419 participants from four states. We found that younger age (≤25) was positively associated with reporting the lowest utility for unintended pregnancy. In absolute terms, with the VAS, the probability that a woman 25 years or younger would have lower preference for an unintended pregnancy was 26.8% (95% CI 20.4 - 33.2%) versus (21.7% (95% CI 14.3 - 29.0%). Using the WTP, the probability of the younger group having lower preference was 84.9% (CI 80.3 - 89.4%) compared to 57.3% (CI 49.3 - 65.3). With the TTO, Women 25 years old and younger had a 78.3% probability (CI 72.6 - 84.0%) of low utility on the TTO versus 48.9% (CI 40.9 - 56.9%) in the older group. With SG, younger women had a 47.0% probability (CI 36.8 - 50.6%) versus 18.0% (CI 14.7 - 27.5%). CONCLUSIONS: Women of all ages report a decrease in health utility with unintended pregnancy. This decrease in health utility is greater among young women (age <25). IMPLICATIONS: Health utilities for unintended pregnancy can be used to guide cost effectiveness research and health policy.

3.
Contraception ; 2021 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-33781759

RESUMO

OBJECTIVE: We describe provision of contraception to adolescents at Oregon school-based health centers (SBHCs). We examine trends over time, by race/ethnicity, and by Title X clinic status and test whether these factors are associated with provision of long-acting reversible contraception (LARC; intrauterine devices/IUDs and implants). STUDY DESIGN: We conducted a retrospective cohort study of 33 SBHCs participating in a shared electronic health record 2012-2016. We identified 20,339 contraception provision visits to 5,934 adolescent females ages 14-19 using diagnosis and procedure codes. We used logistic regression to evaluate the association of clinic Title X status, race/ethnicity, and year with receipt of LARC, controlling for individual-, clinic-, and residence-level factors. We calculated adjusted probabilities. RESULTS: Provision of IUDs and implants increased at Oregon SBHCs between 2012 and 2016. IUD provision increased almost 5-fold, (from 0.9% to 4.4% of contraception provision visits), and implants increased approximately 6.5-fold (from 1.1% to 7.2%). More adolescent contraception provision visits occurred at Title X SBHCs, which had greater than twice the adjusted probability of providing LARCs than non-Title X SBHCs (4.4% versus 1.7%). After adjusting for adolescent-, clinic-, and residence-level covariates, non-white adolescents had lower probabilities of receiving LARC methods than white adolescents. CONCLUSIONS: SBHCs play an important role in providing access to contraceptive services to adolescents in Oregon. Access to IUDs and implants is increasing over time in SBHCs, particularly those that participate in the Title X program. IMPLICATIONS: Adolescents have expanding access to IUDs and implants in SBHCs over time in Oregon. Participation in the Title X program can help further increase access to effective contraception in SBHCs.

4.
J Am Pharm Assoc (2003) ; 61(2): e140-e144, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33446459

RESUMO

BACKGROUND: Pharmacist prescription of contraception is becoming increasingly common in the United States (US). Limited information exists on whether this is improving access to contraception in underserved areas, including rural America. OBJECTIVE: We sought to determine whether there were differences by rural location in pharmacists' willingness to prescribe hormonal contraception and perceived barriers to doing so. METHODS: We conducted a cross-sectional survey of pharmacists eligible to prescribe hormonal contraception in New Mexico in March and May 2020. The survey consisted of demographic data, pharmacists' experience prescribing hormonal contraception, and questions regarding perceived barriers to pharmacist-prescribed hormonal contraception. Descriptive statistics assessed differences in survey responses between rural and urban pharmacists. We used multivariable logistic regression to estimate the association between rural practice and prescribing hormonal contraception. RESULTS: Our sampling frame consisted of 822 licensed pharmacists. We received 256 responses, for a response rate of 31.1%. We found that rural pharmacists were as likely as their urban counterparts to prescribe hormonal contraception (adjusted odds ratio 1.22 [95% CI 0.56-2.68], P = 0.50). Five main barriers included a need for additional training, reimbursement for services, liability concerns, corporate policies, and shortage of staff. No difference in barriers were identified by rural location or staff role. CONCLUSION: Pharmacy access has the potential to improve access to contraception across New Mexico, including underserved rural areas.

5.
Ann Fam Med ; 19(1): 38-40, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33431389

RESUMO

One-half of women in the United States use Medicaid during pregnancy. Women living in states that did not expand Medicaid under the Patient Protection and Affordable Care Act (ACA) are at risk of losing coverage post partum. We analyzed Medicaid claims and vital statistics for the state of North Carolina for the period 2011 to 2017. North Carolina did not expand Medicaid but did alter Medicaid enrollment to meet ACA requirements. After implementation, enrollment in full Medicaid during pregnancy almost doubled, and enrollment in Medicaid for pregnant women decreased. Full Medicaid offers more comprehensive coverage and does not expire at 60 days post partum, allowing for access to crucial preventive health services including contraception and primary care.

6.
J Hypertens ; 2020 Nov 18.
Artigo em Inglês | MEDLINE | ID: mdl-33230021

RESUMO

OBJECTIVES: The aim of this study was to understand the associations between hypertensive disorders of pregnancy (HDP) and postpartum complications throughout the newly defined 12-week postpartum transition. STUDY DESIGN: We conducted a retrospective cohort study of the associations of HDP (any/subtype) with postpartum complications among 2.5 million California births, 2008-2012. We identified complications from discharge diagnoses from maternal hospital encounters (emergency department visits and readmissions) in the 12 weeks after giving birth. We compared rates of complications, overall and by diagnostic category, between groups defined by HDP. In survival analyses, we calculated the adjusted hazard ratios of postpartum complications associated with HDP. We adjusted for maternal age, race/ethnicity, prepregnancy obesity, chronic diabetes, gestational diabetes, insurance, delivery mode, gestational age and birth outcome (term and size). RESULTS: Among women with and without HDP, 12.8 and 7.7%, respectively, had a hospital encounter within 12 weeks of giving birth [adjusted hazard ratio 1.5, 95% confidence interval (95% CI): 1.5-1.5]. HDP was associated with increased risk across all major categories of complications: hypertension-related, adjusted hazard ratio 11.8 (95% CI: 11.2-12.3); childbirth-related, 1.4 (1.3-1.4); and other, 1.4 (1.4-1.4). Risk of any complication differed by hypertensive subtype: chronic hypertension with super-imposed preeclampsia, adjusted hazard ratio 1.8 (95% CI: 1.7-1.8); chronic hypertension, 1.6 (1.6-1.7); preeclampsia/eclampsia, 1.3 (1.3-1.4); and gestational hypertension, 1.2 (1.2-1.3). Over a quarter (28.9%) of maternal hospital encounters occurred more than 6 weeks after giving birth; this did not differ substantially by HDP status. CONCLUSION: Women with HDP are at an increased risk for virtually all postpartum complications, including those not related to hypertension, and may benefit from enhanced and comprehensive postpartum care.

8.
Obstet Gynecol ; 136(5): 876-881, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33030862

RESUMO

BACKGROUND: Postpartum hemorrhage is a leading cause of maternal mortality globally. A tamponade agent that can be quickly and easily placed in a range of settings could advance the treatment of atonic hemorrhage. METHOD: We adapted a highly effective trauma dressing for use in postpartum hemorrhage. This mini-sponge tamponade device is comprised of two components: compressed mini-sponges contained within a strong mesh pouch and a tubular applicator. Compressed mini-sponges rapidly absorb blood, expand within seconds, and exert sustained pressure uniformly to bleeding sites. The sponges are deployed within a mesh pouch to facilitate simple vaginal removal. EXPERIENCE: We successfully placed the mini-sponge device in nine patients experiencing postpartum hemorrhage after vaginal birth, with resolution of bleeding within 1 minute. The mean time to place the device was 62 seconds. Uterine fill was documented in all cases by ultrasound scan, and device placement was rated as "easy" to "very easy." Mini-sponges were left in place on average for 1 hour (0.5 hours-14 hours). Bleeding did not recur. There were no adverse events; all patients remained afebrile and did not require subsequent surgical intervention. CONCLUSION: This study supports further evaluation of the mini-sponge device for the management of postpartum hemorrhage. FUNDING: This study was funded by OBSTETRX, Inc.


Assuntos
Hemorragia Pós-Parto/terapia , Tampões de Gaze Cirúrgicos , Tamponamento com Balão Uterino/instrumentação , Adulto , Dispositivos Anticoncepcionais Femininos , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Humanos , Gravidez , Resultado do Tratamento , Tamponamento com Balão Uterino/métodos , Vagina , Adulto Jovem
10.
JAMA Netw Open ; 3(8): e2012540, 2020 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-32756928

RESUMO

Importance: Reducing unintended pregnancy is a national public health priority. Incentive metrics are increasingly used by health systems to improve health outcomes and reduce costs, but limited data exist on the association of incentive metrics with contraceptive use. Objective: To evaluate whether an association exists between implementing an incentive metric and effective contraceptive use within the Oregon Medicaid program. Design, Setting, and Participants: In this state-level, claims-based cohort study, a comparative interrupted time series design was used to evaluate whether the implementation of an effective contraceptive use incentive metric on January 1, 2015, was associated with changes in contraceptive use among Oregon Medicaid adult enrollees when compared with commercially insured women. The participants were adult women at risk of pregnancy (18-50 years of age) living in Oregon from January 1, 2012, through December 31, 2017, and enrolled in Medicaid (532 337 person-years) or in commercial health insurance (1 131 738 person-years). Exposure: Implementation of an effective contraceptive use incentive metric as defined using the 2019 Oregon Health Authority specifications. Main Outcomes and Measures: International Classification of Diseases, Ninth Revision codes; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes; and Current Procedural Terminology codes were used to identify contraceptive use. Annual rates of effective contraceptive use were measured through health insurance claims. Results: The final analyses included 532 337 Medicaid person-years and 1 131 738 privately insured person-years. Women enrolled in Medicaid were younger than those with private insurance (47.5% vs 33.2% of women in 2013 younger than 30 years), and approximately 40% of Medicaid enrollees (vs fewer than 10% of women with private insurance) resided in rural locations. Demographic characteristics within each group remained similar before and after the incentive metric was implemented. In the comparative interrupted time series model, relative to the commercially insured comparison group, effective contraceptive use among Medicaid enrollees for all ages combined increased 3.6% (95% CI, 3.1%-4.1%) 1 year after the start of the incentive metric, 7.5% (95% CI, 6.8%-8.2%) at the end of 2 years, and 11.5% (95% CI, 10.5%-12.4%) at the end of 3 years. Prior to the introduction of the incentive, contraceptive use rates among the youngest cohort of Medicaid enrollees (18-24 years of age) were decreasing; following the introduction of the incentive, contraceptive use increased steadily among all enrollees. Among women aged 18 to 24 years, the effective contraceptive use rate increased 16.5 percentage points (95% CI, 14.4-18.6 percentage points) after 3 years. The largest initial increase in contraceptive use was among women enrolled in Medicaid who were 30 to 34 years of age (4.9%; 95% CI, 3.4%-6.3%). Conclusions and Relevance: Implementation of the effective contraceptive use incentive metric was associated with a significant increase in contraceptive use among Medicaid enrollees relative to a commercially insured comparison group. This finding is relevant given national efforts aimed at adopting a similar metric for widespread use.

11.
BMC Womens Health ; 20(1): 142, 2020 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-32635921

RESUMO

BACKGROUND: A wide range of drugs have been studied for first trimester medical abortion. Studies evaluating different regimens, including combination mifepristone and misoprostol and misoprostol alone regimens, show varying results related to safety, efficacy and other outcomes. Thus, the objectives of this systematic review were to compare the safety, effectiveness and acceptability of medical abortion and to compare medical with surgical methods of abortion ≤63 days of gestation. METHODS: Pubmed and EMBASE were systematically searched from database inception through January 2019 using a combination of MeSH, keywords and text words. Randomized controlled trials on induced abortion at ≤63 days that compared different regimens of medical abortion using mifepristone and/or misoprostol and trials that compared medical with surgical methods of abortion were included. We extracted data into a pre-designed form, calculated effect estimates, and performed meta-analyses where possible. The primary outcomes were ongoing pregnancy and successful abortion. RESULTS: Thirty-three studies composed of 22,275 participants were included in this review. Combined regimens using mifepristone and misoprostol had lower rates of ongoing pregnancy, higher rates of successful abortion and satisfaction compared to misoprostol only regimens. In combined regimens, misoprostol 800 µg was more effective than 400 µg. There was no significant difference in dosing intervals between mifepristone and misoprostol and routes of misoprostol administration in combination or misoprostol alone regimens. The rate of serious adverse events was generally low. CONCLUSION: In this systematic review, we find that medical methods of abortion utilizing combination mifepristone and misoprostol or misoprostol alone are effective, safe and acceptable. More robust studies evaluating both the different combination and misoprostol alone regimens are needed to strengthen existing evidence as well as assess patient perspectives towards a particular regimen.


Assuntos
Abortivos não Esteroides/uso terapêutico , Abortivos Esteroides/uso terapêutico , Aborto Induzido/métodos , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Feminino , Humanos , Gravidez , Primeiro Trimestre da Gravidez
12.
Leukemia ; 34(10): 2722-2735, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32576963

RESUMO

Mutations in genes encoding subunits of the SWI/SNF chromatin remodeling complex are frequently found in different human cancers. While the tumor suppressor function of this complex is widely established in solid tumors, its role in hematologic malignancies is largely unknown. Recurrent point mutations in BCL7A gene, encoding a subunit of the SWI/SNF complex, have been reported in diffuse large B-cell lymphoma (DLBCL), but their functional impact remains to be elucidated. Here we show that BCL7A often undergoes biallelic inactivation, including a previously unnoticed mutational hotspot in the splice donor site of intron one. The splice site mutations render a truncated BCL7A protein, lacking a portion of the amino-terminal domain. Moreover, restoration of wild-type BCL7A expression elicits a tumor suppressor-like phenotype in vitro and in vivo. In contrast, splice site mutations block the tumor suppressor function of BCL7A by preventing its binding to the SWI/SNF complex. We also show that BCL7A restoration induces transcriptomic changes in genes involved in B-cell activation. In addition, we report that SWI/SNF complex subunits harbor mutations in more than half of patients with germinal center B-cell (GCB)-DLBCL. Overall, this work demonstrates the tumor suppressor function of BCL7A in DLBCL, and highlights that the SWI/SNF complex plays a relevant role in DLBCL pathogenesis.


Assuntos
Genes Supressores de Tumor , Linfoma Difuso de Grandes Células B/genética , Proteínas dos Microfilamentos/genética , Mutação , Proteínas Oncogênicas/genética , Domínios e Motivos de Interação entre Proteínas/genética , Animais , Linfócitos B/imunologia , Linfócitos B/metabolismo , Linfócitos B/patologia , Cromatografia Líquida , Proteínas Cromossômicas não Histona/metabolismo , Análise Mutacional de DNA , Modelos Animais de Doenças , Regulação Neoplásica da Expressão Gênica , Estudos de Associação Genética , Predisposição Genética para Doença , Humanos , Ativação Linfocitária/imunologia , Linfoma Difuso de Grandes Células B/diagnóstico , Linfoma Difuso de Grandes Células B/terapia , Camundongos , Proteínas dos Microfilamentos/química , Imagem Molecular , Complexos Multiproteicos , Proteínas Oncogênicas/química , Ligação Proteica , Espectrometria de Massas em Tandem , Ensaios Antitumorais Modelo de Xenoenxerto
13.
JAMA Netw Open ; 3(6): e206874, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32496568

RESUMO

Importance: Use of effective contraception decreases unintended pregnancy. It is not known whether Medicaid expansion under the Affordable Care Act increased use of contraception for women who are underserved in the US health care safety net. Objective: To evaluate the association of Medicaid expansion under the Affordable Care Act with changes in use of contraception among patients at risk of pregnancy at US community health centers, with the hypothesis that Medicaid expansion would be associated with increases in use of the most effective contraceptive methods (long-acting reversible contraception). Design, Setting, and Participants: This was a participant-level retrospective cross-sectional study comparing receipt of contraception before (2013) vs immediately after (2014) and a longer time after (2016) Medicaid expansion. Electronic health record data from a clinical research network of community health centers across 24 states were included. The sample included all female patients ages 15 to 44 years at risk for pregnancy, with an ambulatory care visit at a participating community health center during the study period (315 clinics in expansion states and 165 clinics in nonexpansion states). Exposures: Medicaid expansion status (by state). Main Outcomes and Measures: Two National Quality Forum-endorsed contraception quality metrics, calculated annually: the proportion of women at risk of pregnancy who received (1) either a moderately effective or most effective method (hormonal and long-acting reversible contraception) methods and (2) the most effective method (long-acting reversible contraception). Results: The sample included 310 132 women from expansion states and 235 408 women from nonexpansion states. The absolute adjusted increase in use of long-acting reversible contraceptive methods was 0.58 (95% CI, 0.13-1.05) percentage points greater among women in expansion states compared with nonexpansion states in 2014 and 1.19 (95% CI, 0.41-1.96) percentage points larger in 2016. Among adolescents, the association was larger, particularly in the longer term (2014 vs 2013: absolute difference-in-difference, 0.80 [95% CI, 0.30-1.30] percentage points; 2016 vs 2013: absolute difference, 1.79 [95% CI, 0.88-2.70] percentage points). Women from expansion states who received care at a Title X clinic had the highest percentage of women receiving most effective contraceptive methods compared with non-Title X clinics and nonexpansion states. Conclusions and Relevance: In this study, Medicaid expansion was associated with an increase in use of long-acting reversible contraceptive methods among women at risk of pregnancy seeking care in the US safety net system, and gains were greatest among adolescents.


Assuntos
Centros Comunitários de Saúde/estatística & dados numéricos , Anticoncepção/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Medicaid/organização & administração , Patient Protection and Affordable Care Act , Adolescente , Adulto , Estudos Transversais , Registros Eletrônicos de Saúde , Serviços de Planejamento Familiar/estatística & dados numéricos , Serviços de Planejamento Familiar/provisão & distribução , Feminino , Humanos , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
14.
Contraception ; 102(4): 259-261, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32502494

RESUMO

OBJECTIVE: To describe reasons for and experiences with obtaining contraception from pharmacists. STUDY DESIGN: Cross-sectional survey. RESULTS: Our sample included 426 women presenting for hormonal contraception (n = 150 pharmacist prescribers). The most common reasons women chose to obtain their contraception from a pharmacist were because no appointment was required (25%) or their prescription had lapsed (24%). Women receiving contraception from pharmacists were highly satisfied (95.3% vs 100.0%; p = 0.007). Women recalled similar side-effects counseling points regardless of prescriber type (p = 0.30). CONCLUSION: Women chose to obtain contraceptive care at the pharmacy because it was timely and convenient.

15.
JAMA Netw Open ; 3(5): e205252, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32432710

RESUMO

Importance: Since 2016, 11 states have expanded the scope of pharmacists to include direct prescription of hormonal contraception. Dispensing greater than 1 month's supply is associated with improved contraceptive continuation rates and fewer breaks in coverage. Scant data exist on the practice of pharmacist prescription of contraception and its outcomes compared with traditional, clinic-based prescriptions. Objective: To compare the amount of hormonal contraceptive supply dispensed between pharmacists and clinic-based prescriptions. Prescribing patterns were assessed by describing prescribing practices for women with contraindications to combined hormonal contraception. Characteristics of women seeking hormonal contraception directly from pharmacists were also described. Design, Setting, and Participants: This cohort study surveyed women aged 18 to 50 years who presented to pharmacies in California, Colorado, Hawaii, and Oregon for hormonal contraception prescribed by a clinician or a pharmacist between January 30 and November 1, 2019. Exposures: Pharmacist or clinic-based prescription of contraception. Main Outcomes and Measures: Months of contraceptive supply dispensed. Results: Four hundred ten women (mean [SD] age, 27.1 [7.7] years) were recruited who obtained contraception directly from a pharmacist (n = 144) or by traditional clinician prescription (n = 266). Women obtaining contraception from a pharmacist were significantly younger (82 [56.9%] vs 115 [43.2%] participants aged 18-24 years; P = .03), had less education (38 [26.4%] vs 100 [37.6%] with a bachelor degree; P = .002), and were more likely to be uninsured (16 [11.1%] vs 8 [3.0%] participants; P = .001) compared with women with a prescription from a clinician. Pharmacists were significantly more likely to prescribe a 6-month or greater supply of contraceptives than clinicians (6.9% vs 1.5%, P < .001) and significantly less likely to only prescribe a 1-month supply (42 [29.2%] vs 118 [44.4%] prescriptions; P < .001). Controlling for all covariates, women seen by pharmacists had higher odds of receipt of a 6-month or greater supply of contraceptives compared with those seen by clinicians (odds ratio = 3.55; 95% CI, 1.88-6.70). Pharmacists were as likely as clinicians to prescribe a progestin-only method to women with a potential contraindication to estrogen (n = 60 women; 8 [20.0%] vs 6 [30.0%], P = .52). Conclusions and Relevance: These findings suggest that pharmacist prescription of contraception may be associated with improved contraceptive continuation by preventing breaks in coverage through the provision of a greater supply of medication. Efforts are needed to educate prescribing providers on the importance of dispensing 6 months or greater contraceptive supply.


Assuntos
Contraceptivos Hormonais/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Farmacêuticos , Adolescente , Adulto , Feminino , Humanos , Farmacêuticos/estatística & dados numéricos , Médicos/estatística & dados numéricos , Gravidez , Gravidez não Planejada , Fatores de Tempo , Estados Unidos , Adulto Jovem
16.
Womens Health Issues ; 30(4): 240-247, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32253056

RESUMO

OBJECTIVE: To compare the outcomes and cost effectiveness of two alternate policy strategies for prenatal care among low-income, immigrant women: coverage for delivery only (the federal standard) and prenatal care with delivery coverage (state option under the Children's Health Insurance Program). METHODS: A decision-analytic model was developed to determine the cost effectiveness of two alternate policies for pregnancy coverage. All states currently provide coverage for delivery, and 19 states also provide coverage for prenatal care. An estimated 84,000 unauthorized immigrant women have pregnancies where no prenatal care is covered. Our outcomes were costs, quality-adjusted life-years, and cases of cerebral palsy and infant death before age 1. Model inputs were obtained from a database of Oregon Medicaid claims and the literature. Univariate and bivariate sensitivity analyses, as well as a Monte Carlo simulation, were performed. RESULTS: Extending prenatal coverage is a cost-effective strategy. Providing prenatal care for the 84,000 women annually who are currently uninsured could prevent 117 infant deaths and 34 cases of cerebral palsy. Prenatal care coverage costs $380 more per woman than covering the delivery only. For every 865 additional women receiving prenatal care, one infant death would be averted, at an average cost of $328,700. Cost-effectiveness acceptability curve analyses suggest a 99% probability that providing prenatal care is more cost effective at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year. CONCLUSIONS: Extending prenatal care to low-income, immigrant women, regardless of citizenship status, is a cost-effective strategy.


Assuntos
Emigrantes e Imigrantes/estatística & dados numéricos , Cobertura do Seguro/economia , Seguro Saúde/economia , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pobreza , Cuidado Pré-Natal/economia , Criança , Análise Custo-Benefício , Feminino , Humanos , Lactente , Mortalidade Infantil , Cobertura do Seguro/estatística & dados numéricos , Oregon , Gravidez , Cuidado Pré-Natal/métodos , Anos de Vida Ajustados por Qualidade de Vida , Estados Unidos
17.
Health Aff (Millwood) ; 39(4): 595-602, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32250679

RESUMO

Children born to women with substance use disorders are at high risk for early foster care placement, which is associated with long-term adverse outcomes for children and places additional pressure on state budgets. Poor outcomes for drug-dependent mothers and their children may be further exacerbated by a lack of coordination between the health care and human services sectors. Project Nurture is an innovative model in Portland, Oregon, that integrates maternity care, substance use treatment, and social service coordination for Medicaid beneficiaries. This study assessed the impact of Project Nurture on a range of patient and child welfare outcomes. Among the "treatment" population of opioid-dependent women enrolled in Medicaid, Project Nurture was associated with reductions in child maltreatment, placement of children in foster care, and increases in both prenatal visits and maternal lengths-of-stay in the hospital, compared to opioid-dependent women enrolled in Medicaid in Oregon counties not served by the project. These results suggest that models based in a clinical setting that engage the human services sector may improve overall outcomes, even though the difficulty in sharing savings across sectors presents challenges to sustainability.

18.
Med Care ; 58(5): 453-460, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32049877

RESUMO

OBJECTIVES: We describe payor for contraceptive visits 2013-2014, before and after Medicaid expansion under the Affordable Care Act (ACA), in a large network of safety-net clinics. We estimate changes in the proportion of uninsured contraceptive visits and the independent associations of the ACA, Title X, and state family planning programs. METHODS: Our sample included 237 safety net clinics in 11 states with a common electronic health record. We identified contraception-related visits among women aged 10-49 years using diagnosis and procedure codes. Our primary outcome was an indicator of an uninsured visit. We also assessed payor type (public/private). We included encounter, clinic, county, and state-level covariates. We used interrupted time series and logistic regression, and calculated multivariable absolute predicted probabilities. RESULTS: We identified 162,666 contraceptive visits in 219 clinics. There was a significant decline in uninsured contraception-related visits in both Medicaid expansion and nonexpansion states, with a slightly greater decline in expansion states (difference-in-difference: -1.29 percentage points; confidence interval: -1.39 to -1.19). The gap in uninsured visits between expansion and nonexpansion states widened after ACA implementation (from 2.17 to 4.1 percentage points). The Title X program continues to fill gaps in insurance in Medicaid expansion states. CONCLUSIONS: Uninsured contraceptive visits at safety net clinics decreased following Medicaid expansion under the ACA in both expansion and nonexpansion states. Overall, levels of uninsured visits are lower in expansion states. Title X continues to play an important role in access to care and coverage. In addition to protecting insurance gains under the ACA, Title X and state programs should continue to be a focus of research and advocacy.


Assuntos
Anticoncepção/economia , Pessoas sem Cobertura de Seguro de Saúde , Provedores de Redes de Segurança , Adolescente , Adulto , Criança , Estudos de Coortes , Serviços de Planejamento Familiar/legislação & jurisprudência , Feminino , Humanos , Medicaid , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act , Planos Governamentais de Saúde , Estados Unidos/epidemiologia , Adulto Jovem
20.
Am J Obstet Gynecol ; 222(4S): S886.e1-S886.e9, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31846612

RESUMO

BACKGROUND: In 2012, South Carolina revised the Medicaid policy to cover reimbursement for immediate postpartum long-acting reversible contraception. Immediate postpartum long-acting reversible contraception may improve health outcomes for populations at risk with a subsequent short-interval pregnancy. OBJECTIVES: We examined the impact of the Medicaid policy change on the initiation of long-acting and reversible contraception (immediate postpartum and postpartum) within key populations. We determined whether immediate postpartum long-acting and reversible contraception use varied by adequate prenatal care (>7 visits), metropolitan location, and medical comorbidities. We also tested the association of immediate postpartum and postpartum long-acting, reversible contraception on interpregnancy interval of less than 18 months. STUDY DESIGN: We conducted a historical cohort study of live births among Medicaid recipients in South Carolina between 2010 and 2017, 2 years before and 5 years after the policy change. We used birth certificate data linked with Medicaid claims. Our primary outcome was immediate postpartum long-acting and reversible contraception, and our secondary outcome was short interpregnancy interval. We characterize trends in long-acting and reversible contraception use and interpregnancy interval over the study period. We used logistic regression models to test the association of key factors (rural, inadequate prenatal care, and medical comorbidities) with immediate and outpatient postpartum long-acting and reversible contraception following the policy change and to test the association of immediate postpartum and postpartum long-acting and reversible contraception with short interpregnancy interval. RESULTS: Our sample included 187,438 births to 145,973 women. Overall, 44.7% of the sample was white, with a mean age of 25.0 years. A majority of the sample (61.5%) was multiparous and resided in metropolitan areas (79.5%). The odds of receipt of immediate postpartum long-acting and reversible contraception use increased after the policy change (adjusted odds ratio, 1.39, 95% confidence interval, 1.34-1.43). Women with inadequate prenatal care (adjusted odds ratio, 1.50, 95% confidence interval, 1.31-1.71) and medically complex pregnancies had higher odds of receipt of immediate postpartum long-acting and reversible contraception following the policy change (adjusted odds ratio, 1.47, 95% confidence interval, 1.29-1.67) compared with women with adequate prenatal care and normal pregnancies. Women residing in rural areas were less likely to receive immediate postpartum long-acting and reversible contraception (adjusted odds ratio, 0.36, 95% confidence interval, 0.30-0.44) than women in metropolitan areas. Utilization of immediate postpartum long-acting and reversible contraception was associated with a decreased odds of a subsequent short interpregnancy interval (adjusted odds ratio, 0.62, 95% confidence interval, 0.44-0.89). CONCLUSION: Women at risk of a subsequent pregnancy and complications (inadequate prenatal care and medical comorbidities) are more likely to receive immediate postpartum long-acting and reversible contraception following the policy change. Efforts are needed to improve access in rural areas.


Assuntos
Intervalo entre Nascimentos/estatística & dados numéricos , Política de Saúde , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Medicaid , Cuidado Pós-Natal/estatística & dados numéricos , Adulto , Estudos de Coortes , Feminino , Humanos , Reembolso de Seguro de Saúde , Modelos Logísticos , Razão de Chances , Gravidez , Complicações na Gravidez/epidemiologia , Cuidado Pré-Natal/estatística & dados numéricos , População Rural/estatística & dados numéricos , South Carolina/epidemiologia , Estados Unidos , População Urbana/estatística & dados numéricos , Adulto Jovem
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