Social and economic cost of eating disorders in the United States: Evidence to inform policy action.

OBJECTIVE: To estimate one-year costs of eating disorders in the United States (U.S.) from a societal perspective, including the costs to the U.S. health system, individual and family productivity costs, lost wellbeing, and other societal economic costs, by setting and payer. Findings will inform needed policy action to mitigate the impact of eating disorders in the U.S. METHOD: Costs of eating disorders were estimated using a bottom-up cost-of-illness methodology, based on the estimated one-year prevalence of eating disorders. Intangible costs of reduced wellbeing were also estimated using disability-adjusted life years. RESULTS: Total economic costs associated with eating disorders were estimated to be $64.7 billion (95% CI: $63.5-$66.0 billion) in fiscal year 2018-2019, equivalent to $11,808 per affected person (95% CI: $11,754-$11,863 per affected person). Otherwise Specified Feeding or Eating Disorder accounted for 35% of total economic costs, followed by Binge Eating Disorder (30%), Bulimia Nervosa (18%) and Anorexia Nervosa (17%). The substantial reduction in wellbeing associated with eating disorders was further valued at $326.5 billion (95% CI: $316.8-$336.2 billion). DISCUSSION: The impact of eating disorders in the U.S. is substantial when considering both economic costs and reduced wellbeing (nearly $400 billion in fiscal year 2018-2019). Study findings underscore the urgency of identifying effective policy actions to reduce the impact of eating disorders, such as through primary prevention and screening to identify people with emerging or early eating disorders in primary care, schools, and workplaces and ensuring access to early evidence-based treatment.

Effect of School Integrated Pest Management or Classroom Air Filter Purifiers on Asthma Symptoms in Students With Active Asthma: A Randomized Clinical Trial.

Importance: School and classroom allergens and particles are associated with asthma morbidity, but the benefit of environmental remediation is not known. Objective: To determine whether use of a school-wide integrated pest management (IPM) program or high-efficiency particulate air (HEPA) filter purifiers in the classrooms improve asthma symptoms in students with active asthma. Design, Setting, and Participants: Factorial randomized clinical trial of a school-wide IPM program and HEPA filter purifiers in the classrooms was conducted from 2015 to 2020 (School Inner-City Asthma Intervention Study). There were 236 students with active asthma attending 41 participating urban elementary schools located in the Northeastern US who were randomized to IPM by school and HEPA filter purifiers by classroom. The date of final follow-up was June 20, 2020. Interventions: The school-wide IPM program consisted of application of rodenticide, sealing entry points, trap placement, targeted cleaning, and brief educational handouts for school staff. Infestation was assessed every 3 months, with additional treatments as needed. Control schools received no IPM, cleaning, or education. Classroom portable HEPA filter purifiers were deployed and the filters were changed every 3 months. Control classrooms received sham HEPA filters that looked and sounded like active HEPA filter purifiers. Randomization was done independently (split-plot design), with matching by the number of enrolled students to ensure a nearly exact 1:1 student ratio for each intervention with 118 students randomized to each group. Participants, investigators, and those assessing outcomes were blinded to the interventions. Main Outcomes and Measures: The primary outcome was the number of symptom-days with asthma during a 2-week period. Symptom-days were assessed every 2 months during the 10 months after randomization. Results: Among the 236 students who were randomized (mean age, 8.1 [SD, 2.0] years; 113 [48%] female), all completed the trial. At baseline, the 2-week mean was 2.2 (SD, 3.9) symptom-days with asthma and 98% of the classrooms had detectable levels of mouse allergen. The results were pooled because there was no statistically significant difference between the 2 interventions (P = .18 for interaction). During a 2-week period, the mean was 1.5 symptom-days with asthma after use of the school-wide IPM program vs 1.9 symptom-days after no IPM across the school year (incidence rate ratio, 0.71 [95% CI, 0.38-1.33]), which was not statistically significantly different. During a 2-week period, the mean was 1.6 symptom-days with asthma after use of HEPA filter purifiers in the classrooms vs 1.8 symptom-days after use of sham HEPA filter purifiers across the school year (incidence rate ratio, 1.47 [95% CI, 0.79-2.75]), which was not statistically significantly different. There were no intervention-related adverse events. Conclusions and Relevance: Among children with active asthma, use of a school-wide IPM program or classroom HEPA filter purifiers did not significantly reduce symptom-days with asthma. However, interpretation of the study findings may need to consider allergen levels, particle exposures, and asthma symptoms at baseline. Trial Registration: ClinicalTrials.gov Identifier: NCT02291302.

The association of disordered eating with health-related quality of life in U.S. young adults and effect modification by gender.

PURPOSE: To examine the relationship of disordered eating behaviors and eating disorder (ED) diagnosis in young adults with health-related quality of life (HRQL) and to assess the presence of effect modification by gender. METHODS: In 2013, participants (N = 9440, ages 18-31 years) in the U.S. Growing Up Today Study cohort reported use of disordered eating behaviors (dieting, diet pills, laxatives, or vomiting to control weight; binge eating with loss of control) over the past year, plus a lifetime history of ED diagnosis. The relative risk (RR) of less-than-full health (EQ-5D-5L health utility score < 1) and of any impairment (score > 1 on EQ-5D-5L dimensions) were compared across participants with and without disordered eating or ED diagnosis, using cross-sectional multivariable regression controlling for confounders. The association between HRQL and disordered eating or ED diagnosis was assessed using multivariable linear regression with the subsample reporting less-than-full health. The presence of effect modification by gender was also examined. RESULTS: Disordered eating behaviors and ED diagnosis were associated with significantly increased risk of less-than-full health. A significant gender interaction was found for only one variable-ED diagnosis; men who reported ever having received a diagnosis experienced worse decrements in HRQL than did women. Inclusion of BMI in estimation models revealed small attenuations. Across the weight spectrum, the presence of ED was associated with impairment across all EQ-5D-5L dimensions, except self-care. CONCLUSION: Disordered eating behaviors and a lifetime history of ED diagnosis are associated with significant decrements in HRQL, but only ED diagnosis is associated with a significant effect modification by gender.

Reoperation following lumbar spinal surgery: costs and outcomes in a UK population cohort study using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES).

PURPOSE: To assess the likelihood of persistent postoperative pain (PPP) following reoperation after lumbar surgery and to estimate associated healthcare costs. METHODS: This is a retrospective cohort study using two linked UK databases: Hospital Episode Statistics and UK Clinical Practice Research Datalink. Costs and outcomes associated with reoperation were evaluated over a 2-year postoperative period using multivariate logistic regression for cases who underwent reoperation and controls who did not, based on demographics, index surgery type, smoking status, and pre-index comorbidities using propensity score matching. RESULTS: Risk factors associated with reoperation included younger age and the presence of diabetes with complications or rheumatic disease. The rate of PPP after reoperation was much higher than after index surgery, with 79 of 200 (39.5%; 95% CI 32.5%, 46.5%) participants experiencing ongoing pain compared with 983 of 5022 (19.5%; 95% CI 18.5%, 20.7%) after index surgery. Mean costs in the 2 years following reoperation were £1889 higher (95% CI £2, £3809) than for patients with PPP who did not undergo repeat surgery over an equivalent follow-up period. With the cost of reoperation itself included, the mean cost difference for patients who underwent reoperation compared with matched controls rose to £7221 (95% CI £5273, £9206). CONCLUSIONS: High rates of PPP and associated healthcare costs suggest that returning to the operating room is a complex and challenging decision. Spinal surgeons should review whether the potential benefits of additional surgery are justified when other approaches to managing and relieving chronic pain have demonstrated superior outcomes. These slides can be retrieved under Electronic Supplementary Material.

Short- and long-term cost and utilization of health care resources in Parkinson's disease in the UK.

BACKGROUND: There is currently no robust long-term data on costs of treating patients with Parkinson's disease. The objective of this study was to report levels of health care utilization and associated costs in the 10 years after diagnosis among PD patients in the United Kingdom. METHODS: We undertook a retrospective population-based cohort study using linked data from the UK Clinical Practice Research Datalink and Hospital Episode Statistics databases. Total health care costs of PD patients were compared with those of a control group of patients without PD selected using 1:1 propensity score matching based on age, sex, and comorbidity. RESULTS: Between 1994 and 2013, 7271 PD patients who met study inclusion criteria were identified in linked Clinical Practice Research Datalink-Hospital Episode Statistics; 7060 were matched with controls. The mean annual health care cost difference (at 2013 costs) between PD patients and controls was £2471 (US$3716) per patient in the first year postdiagnosis (P < 0.001), increasing to £4004 (US$6021) per patient (P < 0.001) 10 years following diagnosis because of higher levels of use across all categories of health care utilization. Costs in patients with markers of advanced PD (ie, presence of levodopa-equivalent daily dose > 1100 mg, dyskinesias, falls, dementia, psychosis, hospital admission primarily due to PD, or nursing home placement) were on average higher by £1069 (US$1608) per patient than those with PD without these markers. CONCLUSIONS: This study provides comprehensive estimates of health care costs in PD patients based on routinely collected data. Health care costs attributable to PD increase in the year following diagnosis and are higher for patients with indicators of advanced disease. © 2018 International Parkinson and Movement Disorder Society.

Analysis of Healthcare Institutional Costs of Pediatric Home Parenteral Nutrition Central Line Infections.

BACKGROUND: Although previous literature suggests home parenteral nutrition (HPN)-dependent children experience frequent complications like community-acquired central line-associated bloodstream infections (CLABSI), few studies have characterized the cost. OBJECTIVE: The aim of this study was to evaluate institutional cost of community-acquired CLABSI in pediatric patients with HPN. METHODS: This is a single-center retrospective review of institutional costs for patients with HPN with community-acquired CLABSI at a tertiary care children's hospital. Inclusion was age 18 years or less between October 2011 and April 2016. Exclusions were death during hospitalization and readmission within 2 days of discharge. Patient-level factors were compared between high-cost group and all others using Welch 2-sample t test and analysis of variance. Multivariable logistic regression was used to determine predictors of higher cost. RESULTS: There were 176 CLABSI admissions among 68 patients during the study period (median 2 hospitalizations per patients). The mean cost and length of stay per hospital admission are $28,375 (2015 US dollars) and 8 days, and both were associated with intensive care unit admission (ICU), central venous catheter removal, private insurance, and age <2 years at admission. Nine percent of patients were classified as "super-utilizers" whose 54 hospitalizations accounted for 28% of total institutional costs. CONCLUSIONS: Among pediatric patients with HPN, community-acquired CLABSI is associated with significant cost and length of stay. Healthcare utilization is disproportionately concentrated in a small number of patients. These study findings may help inform cost analysis for future CLABSI prevention strategies.

Decrements in health-related quality of life associated with gender nonconformity among U.S. adolescents and young adults.

PURPOSE: Gender nonconformity, that is, transgressing conventionally "masculine" vs. "feminine" characteristics, is often stigmatized. Stigmatization and discrimination are social stressors that raise risk of adverse mental and physical health outcomes and may drive health inequities. However, little is known about the relationship between such social stressors and health-related quality of life (HRQOL). This paper aimed to examine associations between perceived gender nonconformity and HRQOL in a cohort of U.S. adolescents and young adults. METHODS: Using data from 8408 participants (18-31 years) in the U.S. Growing Up Today Study (93% white, 88% middle-to-high income), we estimated risk ratios (RRs) for the association of gender nonconformity (three levels: highly gender conforming, moderately conforming, and gender nonconforming) and HRQOL using the EuroQol questionnaire (EQ-5D-5L). Models were adjusted for demographic characteristics, including sexual orientation identity. RESULTS: Gender nonconformity was independently associated with increased risk of having problems with mobility [RR (95% confidence interval): 1.76 (1.16, 2.68)], usual activities [2.29 (1.67, 3.13)], pain or discomfort [1.59, (1.38, 1.83)], and anxiety or depression [1.72 (1.39, 2.13)], after adjusting for sexual orientation and demographic characteristics. Decrements in health utility by gender nonconformity were observed: compared to persons who were highly gender conforming, mean health utility was lower for the moderately gender conforming [beta (SE): -0.011 (.002)] and lowest for the most gender nonconforming [-0.034 (.005)]. CONCLUSIONS: In our study, HRQOL exhibited inequities by gender nonconformity. Future studies, including in more diverse populations, should measure the effect of gender-related harassment, discrimination, and violence victimization on health and HRQOL.

Adherence to Buprenorphine Treatment Guidelines in a Medicaid Program.

BACKGROUND: Buprenorphine is the most frequently prescribed medication for treating substance use disorders in the United States, but few studies have evaluated the structure of treatment delivered in real-world settings. The purpose of this study is to investigate adherence to current buprenorphine treatment guidelines using administrative data for Massachusetts Medicaid. METHODS: We identified buprenorphine treatment episodes beginning in 2009 through pharmacy claims. We then used service claims to identify treatment-related physician, behavioral, and laboratory services received in the induction, stabilization, and maintenance phases of these treatment episodes. Rates of service utilization were compared with those recommended in treatment guidelines. RESULTS: A total of 3674 treatment episodes met inclusion criteria, representing 3005 unique Medicaid beneficiaries. Liver enzymes were tested in 47.3% of episodes, but testing for hepatitis C (23.2%), hepatitis B (19.6%), and human immunodeficiency virus (HIV; 13.7%) was less frequent. Adherence to recommended physician visit frequency was 37.6% during induction, 39.7% during stabilization, and 51.2% during maintenance. For behavioral care, adherence rates were 40.0% during induction, 41.2% during stabilization, and 41.0% during maintenance. Rates of toxicology testing met or exceeded recommendations in just over 60% of episodes in the induction (61.1%), stabilization (62.1%), and maintenance (61.4%) phases. Although rates varied by treatment phase, substantial proportions of episodes showed no evidence of physician visits (27.2-42.8%), behavioral care (44.3-60.0%), and toxicology screening (25.3-39.0%). CONCLUSIONS: Our data suggest that there is significant variability in the structure of buprenorphine treatment provided to Massachusetts Medicaid beneficiaries, and that half or less of episodes include physician and behavioral visits at recommended frequencies. The use of administrative data for this type of analysis is limited by the potential for missing or inaccurate data. More research is needed to establish the levels of services most closely associated with positive outcomes to help guide providers in offering the highest-quality care.

Economic evaluation of cell salvage in pediatric surgery.

BACKGROUND: Red blood cells are a scarce resource with demand outstripping supply. Use of intraoperative red cell salvage (CS) - the process of collecting shed blood during surgery and reinfusing it to patients - is often used as an effective blood conservation strategy. However, little is known about the economic impact of CS during pediatric surgery. METHODS: A decision tree model was used to estimate the transfusion-related costs per patient (2010 USD) from a healthcare system perspective of four transfusion strategies among children undergoing elective orthopedic or cardiac surgery: (i) CS followed by allogeneic transfusion, (ii) CS followed by autologous transfusion, (iii) allogeneic transfusion alone, and (iv) autologous transfusion alone. RESULTS: Cell salvage and allogeneic transfusion was the least expensive strategy (USD 883.3) followed by CS and autologous blood transfusion (USD 1,269.7), allogeneic transfusion alone (USD 1,443.0), and autologous transfusion alone (USD 1,824.7). Savings associated with CS use persisted in separate analyses of orthopedic and cardiac surgery, as well as in one-way and probabilistic sensitivity analyses. CONCLUSIONS: Use of CS, particularly along with allogeneic blood transfusion, appears cost-saving and cost-effective in pediatric surgery.

Adverse Outcomes, Healthcare Resource Utilization, and Costs Associated with Systemic Corticosteroid use Among Adults with Systemic Lupus Erythematosus in the UK.

INTRODUCTION: This analysis was conducted to assess the incidence of adverse clinical outcomes, healthcare resource use (HCRU), and the costs associated with systemic corticosteroid (SCS) use in adults with systemic lupus erythematosus (SLE) in the UK. METHODS: We identified incident SLE cases using the Clinical Practice Research Datalink GOLD, Hospital Episode Statistics-linked healthcare, and Office for National Statistics mortality databases from January 1, 2005, to June 30, 2019. Adverse clinical outcomes, HCRU, and costs were captured for patients with and without prescribed SCS. RESULTS: Of 715 patients, 301 (42%) had initiated SCS use (mean [standard deviation (SD)] 3.2 [6.0] mg/day) and 414 (58%) had no recorded SCS use post-SLE diagnosis. Cumulative incidence of any adverse clinical outcome over 10-year follow-up was 50% (SCS group) and 22% (non-SCS group), with osteoporosis diagnosis/fracture most frequently reported. SCS exposure in the past 90 days was associated with an adjusted hazard ratio of 2.41 (95% confidence interval 1.77-3.26) for any adverse clinical outcome, with increased hazard for osteoporosis diagnosis/fracture (5.26, 3.61-7.65) and myocardial infarction (4.52, 1.16-17.71). Compared to low-dose SCS (< 7.5 mg/day), patients on high-dose SCS (≥ 7.5 mg/day) had increased hazard for myocardial infarction (14.93, 2.71-82.31), heart failure (9.32, 2.45-35.43), osteoporosis diagnosis/fracture (5.14, 2.82-9.37), and type 2 diabetes (4.02 1.13-14.27). Each additional year of SCS use was associated with increased hazard for any adverse clinical outcome (1.15, 1.05-1.27). HCRU and costs were greater for SCS users than non-SCS users. CONCLUSIONS: Among patients with SLE, there is a higher burden of adverse clinical outcomes and greater HCRU in SCS versus non-SCS users.

Healthcare Resource Use and Costs Associated with Organ Damage in Newly Diagnosed Adults with Systemic Lupus Erythematosus in the UK.

INTRODUCTION: This analysis compared healthcare resource use (HCRU) and costs associated with incident organ damage in a cohort of adult patients with systemic lupus erythematosus (SLE). METHODS: Incident SLE cases were identified (Clinical Practice Research Datalink [CPRD] and Hospital Episode Statistics-linked healthcare databases; January 1, 2005-June 30, 2019). Annual incidence of 13 organ damage domains was calculated from SLE diagnosis through follow-up. Annualized HCRU and costs were compared between organ damage and non-organ damage patient groups using generalized estimating equations. RESULTS: A total of 936 patients met the inclusion criteria for SLE. Mean age was 48.0 (standard deviation [SD] 15.7) years and 88% were female. Over a median follow-up period of 4.3 (interquartile range [IQR] 1.9-7.0) years, 59% (315/533) had evidence of post-SLE diagnosis incident organ damage (≥ 1 type), which was greatest for musculoskeletal (146/819 [18%]), cardiovascular (149/842 [18%]), and skin (148/856 [17%]) domains. Patients with organ damage had greater resource use for all organ systems, excluding gonadal, versus those without it. Overall, mean (SD) annualized all-cause HCRU was greater in patients with organ damage versus those without it (inpatient, 1.0 versus 0.2; outpatient, 7.3 versus 3.5; accident and emergency, 0.5 versus 0.2 days; primary care contacts, 28.7 versus 16.5; prescription medications, 62.3 versus 22.9). Adjusted mean annualized all-cause costs were significantly greater in both post- and pre-organ damage index periods for patients with organ damage versus those without it (all P < 0.05, excluding gonadal). Overall organ damage was associated with significantly increased adjusted mean annualized per-patient cost (£4442 greater [P < 0.0001]) ranging between £2709 and £7150 greater depending on the organ damage type. CONCLUSION: Organ damage was associated with higher HCRU and healthcare costs, before and after SLE diagnosis. More effective SLE management may slow disease progression, prevent organ damage onset, improve clinical outcomes, and reduce healthcare costs.

Budget Impact Analysis of Intensification with iGlarLixi Compared to Alternative Treatment Strategies Among Patients with Type 2 Diabetes Mellitus.

INTRODUCTION: The clinical benefits of treating patients with type 2 diabetes mellitus (T2DM) with fixed-ratio combination of insulin iGlar (iGlar) plus lixisenatide (iGlarLixi) were demonstrated in clinical trials and real-world evidence studies; however, its cost impact to healthcare payers is unknown. METHODS: A budget impact model was developed from a United States (US) payer's perspective for a hypothetical healthcare plan of 1 million people over a 1-year time horizon. In scenario analysis, patients with uncontrolled glycated hemoglobin (HbA1c) treated with 60 units or less of daily insulin (insulin cohort) or oral antidiabetic drugs (OADs) only (OAD cohort) were intensified to iGlarLixi/rapid-acting insulin (RAI)/glucagon-like peptide 1 receptor agonists (GLP-1RA) or iGlarLixi/iGlar/GLP-1RA, respectively. Model inputs from real-world data (RWD) included baseline market shares, proportion of patients intensifying to respective treatments, and dosing inputs; unit costs were obtained from published literature. One-way sensitivity analyses assessed the impact of individual parameters. RESULTS: Intensification with iGlarLixi resulted in the lowest incremental per member per month (PMPM) budget impact compared to other intensifying drugs (iGlar, RAI, and GLP-1RA). In the insulin cohort, the incremental PMPM cost for intensification with iGlarLixi ($0.03) was the lowest among intensifying drugs; GLP-1RA ($72.20) and RAI ($4.81). Similarly, the incremental PMPM cost for intensification with iGlarLixi was the lowest ($1.25) in the OAD cohort among intensifying drugs; GLP-1RA ($321.65) and iGlar ($114.82). In scenario analyses, when equal market intensification shares for iGlarLixi and GLP-1RA were explored, the incremental PMPM cost for iGlarLixi ($0.03) remained lower than GLP-1RA ($2.28) and RAI ($10.44) in the insulin cohort. CONCLUSIONS: Intensification with iGlarLixi was associated with lower costs compared to other treatment intensifications, as well as overall budget reductions compared to pre-intensification when considering cost savings attributable to reduction in HbA1c; therefore, its inclusion for the treatment of T2DM would represent a budget saving.

Clinical Benefits of Treating Patients with Type 2 Diabetes Mellitus with iGlarLixi: A Patient-Level Simulation Study.

INTRODUCTION: The fixed-ratio combination of insulin glargine (iGlar) plus lixisenatide (iGlarLixi) has proven efficacious in clinical trials; however, there is limited evidence of its benefits in a variety of real-world patients with type 2 diabetes mellitus (T2DM) who present in routine clinical practice. METHODS: A large integrated claims and EHR database was used to identify two real-world (RW) cohorts (ages ≥ 18) with T2DM who were eligible for treatment with iGlarLixi. At baseline, the first cohort (insulin cohort) received insulin with or without oral antidiabetic drugs (OADs), and the second cohort (OAD-only cohort) received OADs only. A Monte Carlo patient-level simulation was applied to each cohort based on treatment strategies and efficacies from the LixiLan-L and LixiLan-O trials to estimate reductions in glycated hemoglobin A1C (A1C) and the percentage achieving age-based A1C goals (≤ 7% for ages < 65 and ≤ 8% for ages ≥ 65) at 30 weeks. RESULTS: The RW insulin (N = 3797) and OAD-only (N = 17,633) cohorts differed considerably in demographics, age, clinical characteristics, baseline A1C levels, and background OAD therapies compared to the populations in the Lixilan-L and Lixilan-O trials. Regardless of the cohort description, A1C goals were achieved among 52.6% vs. 31.6% (p < 0.001) of patients in the iGlarLixi vs. the iGlar arms in the insulin cohort simulation, while A1C goals were achieved among 59.9% vs. 49.3% and 32.8% (p < 0.001) of patients in the OAD-only cohort simulation in the iGlarLixi vs. the iGlar and lixisenatide arms, respectively. CONCLUSIONS: Irrespective of the treatment regimen at baseline (insulin vs. OAD only), this patient-level simulation demonstrated that a greater proportion of patients achieved their A1C goals with iGlarlixi compared to iGlar or lixisenatide alone. These findings suggest that the benefits of iGlarLixi extend to clinically distinct RW populations.

Electronic surveillance of patient safety events using natural language processing.

OBJECTIVE: We describe our approach to surveillance of reportable safety events captured in hospital data including free-text clinical notes. We hypothesize that a) some patient safety events are documented only in the clinical notes and not in any other accessible source; and b) large-scale abstraction of event data from clinical notes is feasible. MATERIALS AND METHODS: We use regular expressions to generate a training data set for a machine learning model and apply this model to the full set of clinical notes and conduct further review to identify safety events of interest. We demonstrate this approach on peripheral intravenous (PIV) infiltrations and extravasations (PIVIEs). RESULTS: During Phase 1, we collected 21,362 clinical notes, of which 2342 were reviewed. We identified 125 PIV events, of which 44 cases (35%) were not captured by other patient safety systems. During Phase 2, we collected 60,735 clinical notes and identified 440 infiltrate events. Our classifier demonstrated accuracy above 90%. CONCLUSION: Our method to identify safety events from the free text of clinical documentation offers a feasible and scalable approach to enhance existing patient safety systems. Expert reviewers, using a machine learning model, can conduct routine surveillance of patient safety events.

Assessing Variations in Sexual Orientation- and Gender Identity-Related U.S. State Laws for Sexual and Gender Minority Health Research and Action, 1996-2016.

Purpose: We developed a multiyear database of sexual orientation- and gender identity-related U.S. state laws to advance sexual and gender minority (SGM) health research and practice and assessed variability in U.S. state laws from 1996 through 2016 across all U.S. states and D.C. Methods: Between 2014 and 2016, a multidisciplinary group of SGM health researchers and legal experts used secondary and primary legal sources and policy surveillance methods to systematically develop a state-level legal database of 30 sexual orientation- and gender identity-related U.S. state laws in 9 legal domains from 1996 through 2016. We calculated descriptive statistics and created maps to observe the distribution of these laws over both time and space. Results: Although progress has occurred in some domains, such as same-sex marriage, adoption, and employment discrimination, significant challenges to SGM rights remain, especially with regard to HIV criminalization, transgender rights, and discrimination in health care settings. Further, notable variation exists in the presence of protective lesbian, gay, bisexual, transgender, queer (LGBTQ) state laws across U.S. states and D.C. Conclusion: Efforts to repeal harmful U.S. state laws are needed, as are new laws, policies, regulations, practices, and norms that advance social justice and health equity for all SGM people.

Seeking racial and ethnic equity among neonatologists.

OBJECTIVE: Racial and ethnic inequities in leadership achievement, compensation, scholarly productivity, and grant funding exists among physicians. This study explores whether similar inequities exist among neonatologists within the United States. STUDY DESIGN: A voluntary anonymous survey was distributed to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine with 560 respondents. Logistic regression and ordinary least squares were used to assess whether racial and ethnic identity is associated with clinical time, leadership, compensation, publication, grant funding, or academic rank. RESULTS: As compared to non-Hispanic White neonatologists, statistical differences were found for underrepresented minorities in medicine in: regions of the country where they worked, total cash compensation received, being awarded an NIH grant, and location of graduate medical education. Fewer differences were found for Asian neonatologists and included location of graduate medicine education. CONCLUSION: Racial and ethnic identity remains a significant independent factor influencing professional achievement and compensation.

Pediatric Primary Care-Based Social Needs Services and Health Care Utilization.

OBJECTIVE: To evaluate the relationship between use of primary care-based social needs services and subsequent utilization of ambulatory, emergency, and inpatient services. METHODS: This retrospective 2012 to 2015 cohort study uses electronic medical record data from an academic pediatric primary care practice that screens universally for social needs and delivers services via in-house social work staff. Logistic regression (N = 7300) examines how patient characteristics relate to practice-based social service use. Negative binomial models with inverse probability of treatment weights (N = 4893) estimate adjusted incidence rate ratios for ambulatory, emergency, and inpatient service use among those who used social services compared to those who did not. RESULTS: Forty-five percent of patients used primary care-based social needs services. This use was significantly greater among those with disabling or complex medical conditions than those without (adjusted odds ratio and 95% confidence interval (CI) of 9.81 [7.39-13.01] and 2.76 [2.44-3.13], respectively); those from low-income versus high-income backgrounds (1.40 [1.21-1.61]); and Blacks and Latinos than Whites (1.33 [1.09-1.62] and 1.29 [1.05-1.59], respectively). Patients who used social services subsequently utilized ambulatory, emergency, and inpatient services at significantly higher rates than those who did not (adjusted incidence rate ratios and 95% CI of 1.54 [1.45-1.63], 1.50 [1.36-1.65], and 3.23 [2.31-4.51], respectively). CONCLUSIONS: Primary care-based social needs service use was associated with increased utilization of ambulatory services without reductions in emergency or inpatient admissions. This pattern suggests increased health care needs or access and could have payment model-dependent financial implications for practices.

Equity for women in medicine-neonatologists identify issues.

OBJECTIVE: Inequity between genders with regards to leadership achievement, compensation, scholarly productivity, and grant funding exist among physicians. This study explores whether similar inequities exist among board certified neonatologists within the USA. STUDY DESIGN: A voluntary anonymous survey was distributed to 3575 members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine with 560 respondents (15.7% response rate). The survey contained questions assessing clinician characteristics, work environment, compensation, professional productivity, and social factors. Statistical analysis was done using JMP Pro 15.0.0 by SAS. RESULTS: Female neonatologists, compared to male peers, were less likely to hold leadership positions (OR 0.36, p = 0.005), received lower compensation by an average of $34,916 or 12.47% (p < 0.001), and had 6.71 fewer primary authored publications (p = 0.025) after adjusting for several confounding factors. CONCLUSION: Gender remains a significant independent factor influencing leadership attainment, compensation, and academic productivity in this cohort of neonatologists.

Health-care utilization and costs in adults with systemic lupus erythematosus in the United Kingdom: a real-world observational retrospective cohort analysis.

OBJECTIVE: The aim was to describe direct health-care costs for adults with SLE in the UK over time and by disease severity and encounter type. METHODS: Patients aged ≥18 years with SLE were identified using the linked Clinical Practice Research Datalink-Hospital Episode Statistics database from January 2005 to December 2017. Patients were classified as having mild, moderate or severe disease using an adapted claims-based algorithm based on prescriptions and co-morbid conditions. We estimated all-cause health-care costs and incremental costs associated with each year of follow-up compared with a baseline year, adjusting for age, sex, disease severity and co-morbid conditions (2017 UK pounds). RESULTS: We identified 802 patients; 369 (46.0%) with mild, 345 (43.0%) moderate and 88 (11.0%) severe disease. The mean all-cause cost increased in the 3 years before diagnosis, peaked in the first year after diagnosis and remained high. The adjusted total mean annual increase in costs per patient was £4476 (95% CI: £3809, £5143) greater in the year of diagnosis compared with the baseline year (P < 0.0001). The increase in costs per year was 4.7- and 1.6-fold higher among patients with severe SLE compared with those with mild and moderate SLE, respectively. Primary care utilization was the leading component of costs during the first year after diagnosis. CONCLUSION: The health-care costs for patients with SLE in the UK are substantial, remain high after diagnosis and increase with increasing severity. Future research should assess whether earlier diagnosis and treatment might reduce disease severity and associated high health-care costs.

Disease severity, flares and treatment patterns in adults with systemic lupus erythematosus in the UK: a real-world observational retrospective cohort analysis.

OBJECTIVES: The aim was to characterize disease severity, clinical manifestations, treatment patterns and flares in a longitudinal cohort of adults with SLE in the UK. METHODS: Adults with SLE were identified in the Clinical Practice Research Datalink-Hospital Episode Statistics database (1 January 2005-31 December 2017). Patients were required to have ≥12 months of data before and after the index date (earliest SLE diagnosis date available). SLE disease severity and flares were classified using adapted claims-based algorithms, which are based on SLE-related conditions, medications and health-service use. RESULTS: Of 802 patients, 369 had mild, 345 moderate and 88 severe SLE at baseline. A total of 692 initiated treatment in the first year after diagnosis. Five hundred and fifty-seven received antimalarials, 203 immunosuppressants and 416 oral CSs. Information on biologic use in hospitals was unavailable. The mean (S.d.) time to initiating any medication was 177 (385.3) days. The median time to first flare was 63 days (95% CI: 57, 71). At least one flare was experienced by 750 of 802 patients during follow-up; the first flare was mild for 549 of 750, moderate for 116 of 750 and severe for 85 of 750. The mean (S.d.) annual overall flare rate (year 1) was 3.5 (2.5). A shorter median time to first flare was significantly associated with moderate/severe disease (P < 0.001) and clinical manifestations (P < 0.001). CONCLUSION: Our findings suggest some delay in the initiation of SLE treatment. Most patients experience a flare within 2 months of diagnosis. Early treatment might delay or reduce the severity of the first SLE flare and might translate to slower disease progression, lower accrual of organ damage and better outcomes.