Timing of perinatal mental health needs: data to inform policy

BACKGROUND

The policies pertaining to perinatal healthcare should be informed by medical needs. The windows of standard obstetrical care and mandated Medicaid coverage eligibility typically end approximately 8 weeks postpartum, even though women may have perinatal health concerns, including suicidal ideation, which are identified beyond this period.

OBJECTIVE

To evaluate the timing of mental health needs across the perinatal period with a focus on how frequently the initial referral and suicidal ideation occur outside of standard obstetrical care windows.

STUDY DESIGN

This retrospective cohort study included all women during pregnancy or up to one year postpartum referred to a perinatal mental health collaborative care program (COMPASS) between September 2017 and September 2019. The timing of initial referral to COMPASS was identified, with women referred postpartum categorized by whether the referral was made after 8 weeks postpartum. The characteristics of the women were compared according to the timing of the initial mental health referral with receiver operating characteristic curves to identify whether patient characteristics could accurately classify women whose initial mental health needs were not recognized until after 8 weeks postpartum. Similarly, the assessment of suicidal ideation, either at or after referral, was ascertained, with the evaluation of the timing at which suicidal ideation was first expressed.

RESULTS

Of 1421 women referred for mental healthcare during the study period, 774 (54%) were initially referred antenatally and 647 (46%) were initially referred postpartum. The women who were referred antenatally exhibited no clustering in the timing of referral. Of the women referred postpartum, 203 (31%) were referred after 8 weeks postpartum. Sociodemographic and medical characteristics were unable to accurately classify which women were referred for mental health care after 8 weeks postpartum (area under the curve, 0.64; 95% confidence interval, 0.58-0.68). A total of 215 (16%) women reported suicidal ideation at or after the time of initial referral: 129 (17%) antenatally and 86 (14%) postpartum. The incidence of suicidal ideation was not significantly different before vs 8 weeks postpartum.

CONCLUSION

Perinatal mental health needs, including suicidal ideation, are often first recognized beyond 8 weeks postpartum. These data should be taken into consideration in policymaking discussions pertaining to the approach to medical care continuity and postpartum healthcare coverage.

Provider Attitudes toward the Use of Hepatitis C Virus-Positive Organs in Kidney Transplantation

BACKGROUND

Direct-acting antivirals have changed the landscape of hepatitis C virus (HCV) care. While transplantation with HCV-positive donor organs is increasing, little is known about providers' attitudes toward this topic. The aim of this study is to determine providers' attitudes toward HCV-positive kidney transplantation.

METHODS

Willing transplant and nontransplant nephrologists, transplant surgeons, and mid-level providers completed an online survey from April through May 2018. The survey asked about HCV knowledge and willingness to transplant HCV-positive antibody, nucleic acid testing-positive kidneys into HCV-negative recipients. Descriptive analyses including mean and median for continuous variables and frequencies for categorical variables were calculated.

RESULTS

Seven-hundred surveys were emailed and 99 providers (62 transplant nephrologists, 28 nontransplant nephrologists, 7 transplant surgeons, and 2 advanced practice providers) completed the survey (participation rate 14.1%). All providers knew that HCV was curable, with 60% believing that it had no effect on transplant success and 32% thinking it reduced transplant success. Providers were significantly more likely to offer a HCV-positive organ to HCV-positive recipients compared to HCV-negative recipients in all queried circumstances (p < 0.005 in all cases), especially with increasing impact on patient's quality of life. While only 39% of providers would offer a HCV-positive organ for transplant to a patient without HCV if it reduced the waitlist time by 1 year, 92% would offer a HCV-positive organ if it reduced the waitlist time by 4 years. However, only 47% thought that the use of HCV-positive kidneys should be for routine care, while 38% believed it should be reserved for research purposes only. There were no significant differences between transplant and nontransplant nephrologists in attitudes toward HCV-positive kidney transplantation. Providers believed that donor organs from those who were obese, >50 years old, or had died from a cardiac arrest were significantly more likely to reduce the likelihood of a successful transplant 1-year posttransplant when compared with a HCV-positive organ (p < 0.005 in all cases). Eighty-six percent of providers had concerns about HCV curability posttransplant.

CONCLUSION

Although 92% of providers were willing to offer a HCV-positive kidney for transplant as patient waitlist time increases, less than half supported offering HCV-positive transplantation for routine care rather than for research. The results underscore the need for further education and data about the efficacy and safety of HCV-positive kidney transplantation.

Self-reported Black race predicts significant prostate cancer independent of clinical setting and clinical and socioeconomic risk factors

INTRODUCTION AND OBJECTIVE

Studies have linked Black race to prostate cancer (CaP) risk but most fail to account for established risk factors such as 5-ARI use, prostate volume, socioeconomic status, and hospital setting. We assess whether Black race remains associated with CaP and Gleason ≥3 + 4 CaP, after adjusting for clinical setting and socioeconomic and clinical factors at prostate biopsy, with a focus on men aged 40-54 years, who may be excluded from current screening guidelines.

METHODS

We recruited 564 men age 40-79 undergoing initial prostate biopsy for abnormal PSA or digital rectal examination (DRE) from three publicly funded and two private hospitals from 2009-2014. Univariate and multivariate analyses examined the associations between hospital type, race, West African Ancestry (WAA), clinical, and sociodemographic risk factors with CaP diagnosis and Gleason ≥3 + 4 CaP. Given changes in CaP screening recommendations, we also assess the multivariate analyses for men aged 40-54.

RESULTS

Black and White men had similar age, BMI, and prostate volume. Black men had higher PSA (8.10 ng/mL vs. 5.63 ng/mL) and PSA density (0.22 ng/mL/cm³ vs. 0.15 ng/mL/cm³, all p < 0.001). Blacks had higher frequency of CaP (63.1% vs. 41.5%, p<0.001) and Gleason ≥3+4 CaP relative to Whites in both public (27.7% vs 11.6%, p<0.001) and private (48.4% vs 21.6%, p = 0.002) settings. In models adjusted for age, first degree family history, prostate volume, 5-ARI use, hospital type, income, marital and educational status, Black race was independently associated with overall CaP diagnosis (OR = 2.13, p = 0.002). There was a significant multiplicative interaction with Black race and abnormal DRE for Gleason ≥3 + 4 CaP (OR = 2.93, p = 0.01). WAA was not predictive of overall or significant CaP among Black men. Black race (OR = 5.66, p = 0.02) and family history (OR = 4.98, p = 0.01) were independently positively associated with overall CaP diagnosis for men aged 40 to 54.

CONCLUSIONS

Black race is independently associated with CaP and Gleason ≥3+4 CaP after accounting for clinical and socioeconomic risk factors including clinical setting and WAA, and has a higher odds ratio of CaP diagnosis in younger men. Further investigation into optimizing screening in Black men aged 40 to 54 is warranted.