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6.
J Neurointerv Surg ; 13(4): 304-307, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33408256

RESUMO

BACKGROUND: The coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT). METHODS: We used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020). RESULTS: We identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004). CONCLUSION: The COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.


Assuntos
Afro-Americanos/etnologia , Disparidades em Assistência à Saúde/tendências , Pandemias , Acidente Vascular Cerebral/etnologia , Trombectomia/tendências , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar/tendências , Hospitalização/tendências , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Resultado do Tratamento
7.
J Urol ; 205(1): 257-263, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32716676

RESUMO

PURPOSE: Among some populations access to neonatal circumcision has become increasingly limited despite evidence of its benefits. This study examines national neonatal circumcision trends before and after the 2012 American Academy of Pediatrics recommendation for neonatal circumcision reimbursement. MATERIALS AND METHODS: A retrospective cohort study of boys aged 28 days or less was conducted using data from the Kids' Inpatient Database (2003 to 2016). Boys who underwent neonatal circumcision prior to discharge were compared to boys who did not. Boys with coagulopathies, penile anomalies or a history of prematurity were excluded. RESULTS: An estimated 8,038,289 boys comprised the final cohort. Boys were primarily White (53.7%), privately insured (49.1%) and cared for at large (60.8%) teaching (49.4%) hospitals in metropolitan areas (84.1%). While 55.0% underwent circumcision prior to discharge, neonatal circumcision rates decreased significantly over time (p <0.0001). Black (68.0%) or White (66.0%) boys, boys in the highest income quartile (60.7%) and Midwestern boys (75.0%) were most likely to be circumcised. Neonatal circumcision was significantly more common among privately (64.9%) than publicly (44.6%) insured boys after controlling for demographics, region, hospital characteristics and year (p <0.0001). The odds of circumcision over time were not significantly different in the years before vs after 2012 (p=0.28). CONCLUSIONS: Among approximately 8 million boys sampled over a 13-year period 55.0% underwent neonatal circumcision. The rate of neonatal circumcision varied widely by region, race and socioeconomic status. The finding that boys with public insurance have lower circumcision rates in all years may be related to lack of circumcision access for boys with public insurance.


Assuntos
Circuncisão Masculina/tendências , Acesso aos Serviços de Saúde/economia , Disparidades em Assistência à Saúde/economia , Afro-Americanos/estatística & dados numéricos , Circuncisão Masculina/economia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Geografia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/tendências , Humanos , Recém-Nascido , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Classe Social , Estados Unidos
8.
Health Psychol ; 40(1): 51-61, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33370152

RESUMO

OBJECTIVE: To better understand mechanisms influencing health in African Americans (AAs), the aims of this study were (a) to identify longitudinal cigarette smoking classes among AAs across adolescence and into young adulthood; (b) to identify risk factors for smoking and how cardiometabolic health in adulthood differs by smoking class; and (c) to investigate whether smoking mediates the relation between adolescent risk factors and adult cardiometabolic health. METHOD: This study used 4 waves of nationally representative data, restricted to an AA subsample (N = 2,009). Participants self-reported on multilevel risk factors in adolescence and smoking across adolescence and young adulthood; cardiometabolic risk was assessed in adulthood. Growth mixture modeling and structural equation modeling were conducted. RESULTS: Five classes emerged: nonsmoker; early onset, heavier smoking; later onset; early onset, light smoking; and maturing out or declining smoking. Predictors of class membership included living with individuals who smoke, having friends who smoke, and limited access to medical care. The early onset, light smoking class had the greatest cardiometabolic risk. Smoking class mediated the relation between living with people who smoke in adolescence and adult cardiometabolic risk. CONCLUSIONS: Nuanced smoking patterns among AAs were identified, and 23% fell into classes characterized by an early onset and persistent smoking trajectory. The early onset, light smoking class had the greatest cardiometabolic risk in adulthood. The results suggest unique protective factors may be present for youth who remain nonsmokers even when their family smokes. Results have implications for health promotion and tobacco prevention efforts among AA families. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Assuntos
Afro-Americanos/psicologia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Disparidades em Assistência à Saúde/tendências , Fumar/epidemiologia , Adolescente , Adulto , Criança , Feminino , Humanos , Estudos Longitudinais , Masculino , Fatores de Risco , Adulto Jovem
9.
J Diabetes Sci Technol ; 14(6): 1107-1110, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33050727

RESUMO

With the recent pivot to telehealth as a direct result of the COVID-19 pandemic, there is an imperative to ensure that access to affordable devices and technologies with remote monitoring capabilities for people with diabetes becomes equitable. In addition, expanding the use of remote Diabetes Self-Management Education and Support (DSMES) and Medical Nutrition Therapy (MNT) services will require new strategies for achieving long-term, effective, continuous, data-driven care. The current COVID-19 pandemic has especially impacted underserved US communities that were already disproportionately impacted by diabetes. Historically, these same communities have faced barriers in accessing timely and effective diabetes care including access to DSMES and MNT services, and diabetes technologies. Our call to action encourages all involved to urge US Federal representatives to widen access to the array of technologies necessary for successful telehealth-delivered care beyond COVID-19.


Assuntos
Computação em Nuvem/tendências , Infecções por Coronavirus/epidemiologia , Diabetes Mellitus/terapia , Acesso aos Serviços de Saúde/tendências , Pneumonia Viral/epidemiologia , Telemedicina/tendências , Assistência de Saúde Universal , Infecções por Coronavirus/terapia , Democracia , Complicações do Diabetes/epidemiologia , Complicações do Diabetes/terapia , Diabetes Mellitus/epidemiologia , Acesso aos Serviços de Saúde/organização & administração , Disparidades em Assistência à Saúde/organização & administração , Disparidades em Assistência à Saúde/tendências , Humanos , Invenções/tendências , Área Carente de Assistência Médica , Pandemias , Educação de Pacientes como Assunto/métodos , Educação de Pacientes como Assunto/organização & administração , Educação de Pacientes como Assunto/tendências , Pneumonia Viral/terapia , Autogestão/métodos , Autogestão/tendências , Telemedicina/métodos , Telemedicina/organização & administração
11.
J Stroke Cerebrovasc Dis ; 29(11): 105209, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33066926

RESUMO

BACKGROUND AND PURPOSE: Testing for thrombophilic disorders is often performed in patients after cryptogenic ischemic stroke in an attempt to identify a hematologic explanation for the event. However, the role of commonly tested thrombophilias in ischemic stroke is poorly defined. There is limited evidence to quantify how these disorders affect ischemic stroke risk and testing practices are highly variable. METHODS: Retrospective evaluation of thrombophilia testing practices and clinical outcomes was performed in hospitalized patients with acute ischemic stroke (n = 1898) at a large academic hospital over a two-year period. Variables assessed included testing components, timing of testing, number of abnormal results, and frequency of change in clinical management prompted by abnormal results. A provider survey was also performed to assess perceptions of current testing practices and provider understanding of testing indications. RESULTS: Thrombophilia testing was performed in 190 (10%) patients admitted for acute ischemic stroke. Of those tested, 137 (72.1%) had at least one abnormal result, but this decreased to 37.4% when elevated factor VIII activity was excluded. An abnormal result prompted initiation of anticoagulation in only 4 patients (2%). The provider survey indicated that all providers (100%) were selecting thrombophilia tests using a pre-existing order set and were interested in additional education on testing indications and interpretation. Comparison to similar studies at other institutions revealed significant variation in testing practices, and a small proportion of patients in which testing prompted a change in management (1-8%). CONCLUSIONS: Thrombophilia testing is frequently obtained in hospitalized patients with acute ischemic stroke, yet testing only changed management in 2% of patients. Efforts to improve provider education and the stewardship of testing are needed to ensure appropriate evaluation and treatment of patients with acute ischemic stroke.


Assuntos
Testes de Coagulação Sanguínea/tendências , Coagulação Sanguínea , Isquemia Encefálica/etiologia , Hospitalização , Padrões de Prática Médica/tendências , Acidente Vascular Cerebral/etiologia , Trombofilia/diagnóstico , Adulto , Idoso , Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Isquemia Encefálica/diagnóstico , Tomada de Decisão Clínica , Feminino , Disparidades em Assistência à Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Trombofilia/sangue , Trombofilia/complicações , Trombofilia/tratamento farmacológico
13.
J Med Vasc ; 45(5): 288-293, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32862987

RESUMO

BACKGROUND: The incidence of upper extremity deep vein thrombosis (UEDVT) is increasing. Its management is sometimes complex and difficult due to its complications and the lack of strong recommendations. The aim was to describe the practice of vascular physicians in Occitanie region in the management of upper extremity deep vein thrombosis. MATERIAL AND METHODS: We used a descriptive observational study in the form of a declarative survey by means of a questionnaire from April to May 2019 among vascular physicians. RESULTS: Of the 142 physicians contacted, 84 responded, with a reply rate of 59.1%. The majority of physicians introduced low-molecular-weight heparin treatment (60.71%) and 29.76% direct oral anticoagulation after a diagnosis of UEDVT. Three months of anticoagulation was chosen by 69% of physicians against 27.4% for a duration of 6 months. Diagnostic work-up included biological risk factors, chest and/or cervical radiography and ultrasonography with dynamic maneuvers. Three quarters of doctors recommended venous compression. A control ultrasonography was performed for 67.86% of patients at one month and at the end of treatment. After the acute phase, 63% of physicians introduced direct oral anticoagulation and 11% recommended venous revascularization. DISCUSSION AND CONCLUSIONS: The mobilization of vascular physicians reflects their interest for this pathology. The management of UEDVT requires specific studies to address therapeutic modalities, the duration of anticoagulation or the place of venous compression in the acute phase.


Assuntos
Anticoagulantes/administração & dosagem , Bandagens Compressivas/tendências , Heparina de Baixo Peso Molecular/administração & dosagem , Padrões de Prática Médica/tendências , Trombose Venosa Profunda de Membros Superiores/terapia , Procedimentos Cirúrgicos Vasculares/tendências , Administração Oral , Adulto , Esquema de Medicação , Inibidores do Fator Xa/administração & dosagem , França/epidemiologia , Pesquisas sobre Serviços de Saúde , Disparidades em Assistência à Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento , Trombose Venosa Profunda de Membros Superiores/diagnóstico por imagem , Trombose Venosa Profunda de Membros Superiores/epidemiologia
14.
J Pregnancy ; 2020: 7864816, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32802511

RESUMO

Hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide, constituting one of the most significant causes of maternal morbidity and mortality. Hypertensive disorders, specifically gestational hypertension, chronic hypertension, and preeclampsia, throughout pregnancy are contributors to the top causes of maternal mortality in the United States. Diagnosis of hypertensive disorders throughout pregnancy is challenging, with many disorders often remaining unrecognized or poorly managed during and after pregnancy. Moreover, the research has identified a strong link between the prevalence of maternal hypertensive disorders and racial and ethnic disparities. Factors that influence the prevalence of maternal hypertensive disorders among racially and ethnically diverse women include maternal age, level of education, United States-born status, nonmetropolitan residence, prepregnancy obesity, excess weight gain during pregnancy, and gestational diabetes. Examination of the factors that increase the risk for maternal hypertensive disorders along with the current interventions utilized to manage hypertensive disorders will assist in the identification of gaps in prevention and treatment strategies and implications for future practice. Specific focus will be placed on disparities among racially and ethnically diverse women that increase the risk for maternal hypertensive disorders. This review will serve to promote the development of interventions and strategies that better address and prevent hypertensive disorders throughout a pregnant woman's continuum of care.


Assuntos
Disparidades em Assistência à Saúde/tendências , Hipertensão/epidemiologia , Hipertensão/prevenção & controle , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/prevenção & controle , Fatores Etários , Grupos de Populações Continentais , Diabetes Gestacional , Escolaridade , Feminino , Humanos , Hipertensão/etnologia , Hipertensão/etiologia , Gravidez , Complicações na Gravidez/etnologia , Complicações na Gravidez/etiologia , Prevalência , Risco , Estados Unidos/epidemiologia , Ganho de Peso
17.
J Stroke Cerebrovasc Dis ; 29(9): 104954, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807414

RESUMO

BACKGROUND/PURPOSE: Racial/ethnic and sex disparity may occur in stroke throughout the continuum of care. Endovascular therapy (EVT) became standard of care in 2015 for eligible patients with acute ischemic stroke (AIS). We evaluated for racial and sex differences in t-PA and EVT utilization and outcomes in 2016 in the National Inpatient Sample. METHODS: Treatment rates for t-PA, EVT, and t-PA+EVT and outcomes including home discharge, in-hospital mortality and prolonged length of stay (pLOS) were evaluated by sex and race. Multivariate survey-logistic regression was performed to evaluate outcomes. RESULTS: The study had 468,630 patients - 49.3% men, 50.7% women; 69.3% whites, and 30.7% non-whites. There was no difference in treatment utilization by sex, women vs men for t-PA (7.65% vs 7.76%; aOR:1.02; 95% CI:0.97-1.07), EVT (1.74% vs 1.67%; aOR:1.09; 95% CI:0.99-1.20) and t-PA+EVT (0.57% vs 0.57%; aOR:1.01; 95% CI:0.85-1.21); and by race, non-white vs white for t-PA (7.62% vs 7.74%; aOR:0.98; 95% CI:0.93-1.05), EVT (1.62% vs 1.74%; aOR:0.91; 95% CI:0.78-1.07), and t-PA+EVT(0.59% vs 0.56%; aOR:1.05; 95% CI:0.84-1.30). Compared to men, women treated with t-PA had less home discharge (37.2% vs 46.3%; aOR:0.81; 95% CI:0.72-0.90), more in-hospital mortality (5.7% vs 3.9%; aOR:1.37; 95% CI:1.06-1.77) and less pLOS (8.3% vs 9.6%; aOR:0.82; 95% CI:0.69-0.98); women treated with EVT had less home discharge (15.8% vs 23.7%; aOR:0.69; 95% CI:0.52-0.91). Compared to whites, non-whites treated with t-PA had lower odds of home discharge (42.1% vs 41.6%; aOR:0.79; 95% CI:0.69-0.90), less in-hospital mortality (3.7% vs 5.3%; aOR:0.65; 95% CI:0.49-0.87), and higher pLOS (11.4% vs 7.9%; aOR:1.3; 95% CI:1.07-1.56); non-whites treated with EVT had less home discharge (18%vs 20.2%; aOR:0.70; 95% CI:0.51-0.97) and higher pLOS (35.1% vs 24%; aOR:1.52; 95% CI:1.16-1.99). CONCLUSION: Sex and racial disparity exists for outcomes of t-PA and EVT despite no difference in utilization rates.


Assuntos
Isquemia Encefálica/terapia , Fibrinolíticos/administração & dosagem , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/tendências , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Acidente Vascular Cerebral/terapia , Trombectomia/tendências , Terapia Trombolítica/tendências , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etnologia , Isquemia Encefálica/mortalidade , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Disparidades em Assistência à Saúde/etnologia , Mortalidade Hospitalar/tendências , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Alta do Paciente/tendências , Complicações Pós-Operatórias/etnologia , Prevalência , Fatores Raciais , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores Sexuais , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etnologia , Acidente Vascular Cerebral/mortalidade , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Estados Unidos/epidemiologia
18.
J Stroke Cerebrovasc Dis ; 29(9): 104938, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807412

RESUMO

BACKGROUND AND PURPOSE: The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic. METHODS: This is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center. CONCLUSION: The proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/epidemiologia , Hospitalização/tendências , Pneumonia Viral/epidemiologia , Padrões de Prática Médica/tendências , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Comorbidade , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Disparidades em Assistência à Saúde/tendências , Mortalidade Hospitalar/tendências , Interações Hospedeiro-Patógeno , Humanos , Incidência , Análise de Séries Temporais Interrompida , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
20.
PLoS Med ; 17(8): e1003247, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32764761

RESUMO

BACKGROUND: Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD. METHODS AND FINDINGS: We utilized the 2016 National Inpatient Sample-a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59-0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33-0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57-2.17; p < 0.001) or patient-directed discharge (also referred to as "discharge against medical advice") (aOR 3.47; 95% CI 2.80-4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts. CONCLUSIONS: Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.


Assuntos
Disparidades em Assistência à Saúde/tendências , Hospitalização/tendências , Infecções/epidemiologia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Índice de Gravidade de Doença , Adulto , Idoso , Estudos Transversais , Feminino , Disparidades em Assistência à Saúde/economia , Hospitalização/economia , Humanos , Infecções/economia , Infecções/terapia , Cobertura do Seguro/economia , Cobertura do Seguro/tendências , Masculino , Medicare/economia , Medicare/tendências , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/terapia , Estados Unidos/epidemiologia
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