Contraceptive Use Among Traditional Medicare And Medicare Advantage Enrollees

Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.

Enrollee characteristics and receipt of colorectal cancer testing in Pennsylvania after adoption of the Affordable Care Act Medicaid expansion

BACKGROUND

Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer-related death in the U.S. Despite increased CRC screening rates, they remain low among low-income non-older adults, including Medicaid enrollees who are more likely to be diagnosed at advanced stages.

OBJECTIVES

Given limited evidence regarding CRC screening service use among Medicaid enrollees, we examined multilevel factors associated with CRC testing among Medicaid enrollees in Pennsylvania after Medicaid expansion in 2015.

RESEARCH DESIGN

Using the 2014-2019 Medicaid administrative data, we performed multivariable logistic regression models to assess factors associated with CRC testing, adjusting for enrollment length and primary care services use.

SUBJECTS

We identified 15,439 adults aged 50-64 years newly enrolled through Medicaid expansion.

MEASURES

Outcome measures include receiving any CRC testing and by modality.

RESULTS

About 32% of our study population received any CRC testing. Significant predictors for any CRC testing include being male, being Hispanic, having any chronic conditions, using primary care services ≤4 times annually, and having a higher county-level median household income. Being 60-64 years at enrollment, using primary care services >4 times annually, and having higher county-level unemployment rates were significantly associated with a decreased likelihood of receiving any CRC tests.

CONCLUSIONS

CRC testing rates were low among adults newly enrolled in Medicaid under the Medicaid expansion in Pennsylvania relative to adults with high income. We observed different sets of significant factors associated with CRC testing by modality. Our findings underscore the urgency to tailor strategies by patients' racial, geographic, and clinical conditions for CRC screening.

Sex-related differences in the prevalence of substance use disorders, treatment, and overdose among parents with young children

Introduction

Risk factors and treatment rates for substance use disorders (SUDs) differ by sex. Females often have greater childcare and household responsibilities than males, which may inhibit SUD treatment. We examined how SUD, medication for opioid use disorder (MOUD) receipt, and overdose rates differ by sex among parents with young children (<5 years).

Methods

Using deidentified national administrative healthcare data from Optum's Clinformatics® Data Mart Database version 8.1 (2007-2021), we identified parents aged 26-64 continuously enrolled in commercial insurance for ≥ 30 days and linked to ≥ 1 dependent child < 5 years from January 1, 2016-February 29, 2020. We used generalized estimating equations to estimate the average predicted prevalence of SUD diagnosis, MOUD receipt after opioid use disorder (OUD) diagnosis, and overdose by parent sex in any month, adjusting for age, race/ethnicity, state of residence, enrollment month, and mental health conditions.

Results

From 2016 to 2020, there were 2,241,795 parents with a dependent child < 5 years, including 1,155,252 (51.5%) females and 1,086,543 (48.5%) males. Male parents had a higher average predicted prevalence of an SUD diagnosis (11.1% [11, 11.16]) than female parents (5.5% [5.48, 5.58]). Among parents with OUD, the average predicted prevalence of receiving MOUD was 27.4% [26.1, 28.63] among male and 19.7% [18.34, 21.04] among female parents, with no difference in overdose rates by sex.

Conclusion

Female parents are less likely to be diagnosed with an SUD or receive MOUD than male parents. Removing policies that criminalize parental SUD and addressing childcare-related barriers may improve SUD identification and treatment.

Prevalence of Testing for Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Among Medicaid Enrollees Treated With Medications for Opioid Use Disorder in 11 States, 2016-2019

BACKGROUND

Limited information exists about testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among Medicaid enrollees after starting medication for opioid use disorder (MOUD), despite guidelines recommending such testing. Our objectives were to estimate testing prevalence and trends for HIV, HBV, and HCV among Medicaid enrollees initiating MOUD and examine enrollee characteristics associated with testing.

METHODS

We conducted a serial cross-sectional study of 505 440 initiations of MOUD from 2016 to 2019 among 361 537 Medicaid enrollees in 11 states. Measures of MOUD initiation; HIV, HBV, and HCV testing; comorbidities; and demographics were based on enrollment and claims data. Each state used Poisson regression to estimate associations between enrollee characteristics and testing prevalence within 90 days of MOUD initiation. We pooled state-level estimates to generate global estimates using random effects meta-analyses.

RESULTS

From 2016 to 2019, testing increased from 20% to 25% for HIV, from 22% to 25% for HBV, from 24% to 27% for HCV, and from 15% to 19% for all 3 conditions. Adjusted rates of testing for all 3 conditions were lower among enrollees who were male (vs nonpregnant females), living in a rural area (vs urban area), and initiating methadone or naltrexone (vs buprenorphine). Associations between enrollee characteristics and testing varied across states.

CONCLUSIONS

Among Medicaid enrollees in 11 US states who initiated medications for opioid use disorder, testing for human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and all 3 conditions increased between 2016 and 2019 but the majority were not tested.

Duration of medication treatment for opioid-use disorder and risk of overdose among Medicaid enrollees in 11 states: a retrospective cohort study

BACKGROUND AND AIMS

Medication for opioid use disorder (MOUD) reduces harms associated with opioid use disorder (OUD), including risk of overdose. Understanding how variation in MOUD duration influences overdose risk is important as health-care payers increasingly remove barriers to treatment continuation (e.g. prior authorization). This study measured the association between MOUD continuation, relative to discontinuation, and opioid-related overdose among Medicaid beneficiaries.

DESIGN

Retrospective cohort study using landmark survival analysis. We estimated the association between treatment continuation and overdose risk at 5 points after the index, or first, MOUD claim. Censoring events included death and disenrollment.

SETTING AND PARTICIPANTS

Medicaid programs in 11 US states: Delaware, Kentucky, Maryland, Maine, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia and Wisconsin. A total of 293 180 Medicaid beneficiaries aged 18-64 years with a diagnosis of OUD and had a first MOUD claim between 2016 and 2017.

MEASUREMENTS

MOUD formulations included methadone, buprenorphine and naltrexone. We measured medically treated opioid-related overdose within claims within 12 months of the index MOUD claim.

FINDINGS

Results were consistent across states. In pooled results, 5.1% of beneficiaries had an overdose, and 67% discontinued MOUD before an overdose or censoring event within 12 months. Beneficiaries who continued MOUD beyond 60 days had a lower relative overdose hazard ratio (HR) compared with those who discontinued by day 60 [HR = 0.39; 95% confidence interval (CI) = 0.36-0.42; P < 0.0001]. MOUD continuation was associated with lower overdose risk at 120 days (HR = 0.34; 95% CI = 0.31-0.37; P < 0.0001), 180 days (HR = 0.31; 95% CI = 0.29-0.34; P < 0.0001), 240 days (HR = 0.29; 95% CI = 0.26-0.31; P < 0.0001) and 300 days (HR = 0.28; 95% CI = 0.24-0.32; P < 0.0001). The hazard of overdose was 10% lower with each additional 60 days of MOUD (95% CI = 0.88-0.92; P < 0.0001).

CONCLUSIONS

Continuation of medication for opioid use disorder (MOUD) in US Medicaid beneficiaries was associated with a substantial reduction in overdose risk up to 12 months after the first claim for MOUD.

Follow-up after ED visits for opioid use disorder: Do they reduce future overdoses?

INTRODUCTION

Follow-up visits within 7 days of an emergency department (ED) visit related to opioid use disorder (OUD) is a key measure of treatment quality, but we know little about its protective effect on future opioid-related overdoses. The objective this paper is to examine the rate of 7-day follow-up after an OUD-related ED visit and the association with future overdoses.

METHODS

Retrospective analysis of Medicaid enrollees in 11 states that had an OUD-related ED visit from 2016 through 2018. Each state used Cox proportional hazard models to estimate the association between having a follow-up visit within 7 days of an OUD-related ED visit, and an overdose within 6 months of the ED visit. State analyses were pooled to generate global estimates using random effects meta-analysis.

RESULTS

Among 114,945 Medicaid enrollees with an OUD-related ED visit, 15.7% had a follow-up visit within 7 days. State-specific rates varied from 7.2% to 22.4% across the 11 states. Compared to those with no follow-up visit, enrollees with a follow-up visit were more likely to be female, non-Hispanic White, less likely to have had an overdose or other substance use disorder at the time of the ED visit, and much more likely to have been receiving MOUD treatment prior to the ED visit. Global estimates based on multivariate analysis showed that having a 7-day follow-up visit was associated with a lower likelihood of overdose within 6 months of the index ED visit (HR = 0.91, CI = 0.84, 0.99). However, states had considerable heterogeneity in this association, with only two states having statistically significant results.

CONCLUSIONS

Among Medicaid enrollees with OUD, having a follow-up visit 7 days after an ED visit is protective against fatal or nonfatal overdose within 6 months, although the association varies considerably across states. Although the association with future overdoses was relatively modest, both practitioners and policymakers should seek to increase the number of Medicaid enrollees with OUD who receive follow-up care within 7 days after an ED visit.

Association of Cannabis Use With Nausea and Vomiting of Pregnancy

Our objective was to evaluate whether cannabis use was associated with nausea and vomiting in early pregnancy. Participants from nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be) enrolled from October 2010 through September 2013 with a PUQE (Pregnancy-Unique Quantification of Emesis) questionnaire and an available stored urine sample from the first study visit (median gestational age 12 weeks) were included. Cannabis exposure was ascertained by urine immunoassay for 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH); positive results were confirmed with liquid chromatography tandem mass spectrometry. The primary outcome was moderate-to-severe nausea by the PUQE score. Overall, 9,250 participants were included, and 5.8% (95% CI 5.4-6.3%) had detectable urine THC-COOH. In adjusted analyses, higher THC-COOH levels were associated with greater odds of moderate-to-severe nausea (20.7% in the group with THC-COOH detected vs 15.5% in the group with THC-COOH not detected, adjusted odds ratio 1.6, 95% CI 1.1-2.2 for a 500 ng/mg Cr THC-COOH increment).

Adverse Cardiovascular Events Following Severe Maternal Morbidity

Severe maternal morbidity (SMM) affects 50,000 women annually in the United States, but its consequences are not well understood. We aimed to estimate the association between SMM and risk of adverse cardiovascular events during the 2 years postpartum. We analyzed 137,140 deliveries covered by the Pennsylvania Medicaid program (2016-2018), weighted with inverse probability of censoring weights to account for nonrandom loss to follow-up. SMM was defined as any diagnosis on the Centers for Disease Control and Prevention list of SMM diagnoses and procedures and/or intensive care unit admission occurring at any point from conception through 42 days postdelivery. Outcomes included heart failure, ischemic heart disease, and stroke/transient ischemic attack up to 2 years postpartum. We used marginal standardization to estimate average treatment effects. We found that SMM was associated with increased risk of each adverse cardiovascular event across the follow-up period. Per 1,000 deliveries, relative to no SMM, SMM was associated with 12.1 (95% confidence interval (CI): 6.2, 18.0) excess cases of heart failure, 6.4 (95% CI: 1.7, 11.2) excess cases of ischemic heart disease, and 8.2 (95% CI: 3.2, 13.1) excess cases of stroke/transient ischemic attack at 26 months of follow-up. These results suggest that SMM identifies a group of women who are at high risk of adverse cardiovascular events after delivery. Women who survive SMM may benefit from more comprehensive postpartum care linked to well-woman care.

Outcomes associated with the use of medications for opioid use disorder during pregnancy

AIM

To test the effect of the duration of medication for opioid use disorder (MOUD) use during pregnancy on maternal, perinatal and neonatal outcomes.

DESIGN

Retrospective cohort analysis of claims, encounter and pharmacy data.

SETTING

Pennsylvania, USA.

PARTICIPANTS

We analyzed 13 320 pregnancies among 10 741 women with opioid use disorder aged 15-44 years enrolled in Pennsylvania Medicaid between 2009 and 2017.

MEASUREMENTS

We examined five outcomes during pregnancy and for 12 weeks postpartum: (1) overdose, (2) postpartum MOUD continuation, (3) preterm birth (< 37 weeks gestation), (4) term low birth weight (< 2500 g at ≥ 37 weeks) and (5) neonatal abstinence syndrome (NAS). Our primary exposure was the duration (count of weeks) of any MOUD use, including methadone or buprenorphine, during pregnancy.

FINDINGS

Among 13 320 pregnancies, 306 (2.3%) were complicated by an overdose, 1753 (13.2%) resulted in a preterm birth and 6787 (50.9%) continued MOUD postpartum. Among infants, 874 (7.6%) were low birth weight at term and 7706 (57.9%) were diagnosed with NAS. As the duration of MOUD use increased, we found a statistically significant decrease in the rate of overdose and preterm birth, a statistically significant increase in the rate of postpartum MOUD continuation and NAS and a decline in term low birth weight. Specifically, for each additional week of MOUD, the adjusted odds of overdose decreased by 2% [adjusted odds ratio (aOR) = 0.98; 95% confidence interval (CI) = 0.97, 0.99], preterm birth decreased by 1% (aOR = 0.99; 95% CI = 0.99, 1.00), postpartum MOUD continuation increased by 95% (aOR = 1.95; 95% CI = 1.87, 2.04) and NAS increased by 41% (aOR = 1.41; 95% CI = 1.35, 1.47). The odds of term low birth weight did not change (aOR = 1.00; 95% CI = 0.99, 1.00), although the rate declined with a longer duration of MOUD use during pregnancy.

CONCLUSIONS

Longer duration of medication for opioid use disorder use during pregnancy appears to be associated with improved maternal and perinatal outcomes.

Use of Medications for Treatment of Opioid Use Disorder Among US Medicaid Enrollees in 11 States, 2014-2018

Importance

There is limited information about trends in the treatment of opioid use disorder (OUD) among Medicaid enrollees.

Objective

To examine the use of medications for OUD and potential indicators of quality of care in multiple states.

Design, Setting, and Participants

Exploratory serial cross-sectional study of 1 024 301 Medicaid enrollees in 11 states aged 12 through 64 years (not eligible for Medicare) with International Classification of Diseases, Ninth Revision (ICD-9 or ICD-10) codes for OUD from 2014 through 2018. Each state used generalized estimating equations to estimate associations between enrollee characteristics and outcome measure prevalence, subsequently pooled to generate global estimates using random effects meta-analyses.

Exposures

Calendar year, demographic characteristics, eligibility groups, and comorbidities.

Main Outcomes and Measures

Use of medications for OUD (buprenorphine, methadone, or naltrexone); potential indicators of good quality (OUD medication continuity for 180 days, behavioral health counseling, urine drug tests); potential indicators of poor quality (prescribing of opioid analgesics and benzodiazepines).

Results

In 2018, 41.7% of Medicaid enrollees with OUD were aged 21 through 34 years, 51.2% were female, 76.1% were non-Hispanic White, 50.7% were eligible through Medicaid expansion, and 50.6% had other substance use disorders. Prevalence of OUD increased in these 11 states from 3.3% (290 628 of 8 737 082) in 2014 to 5.0% (527 983 of 10 585 790) in 2018. The pooled prevalence of enrollees with OUD receiving medication treatment increased from 47.8% in 2014 (range across states, 35.3% to 74.5%) to 57.1% in 2018 (range, 45.7% to 71.7%). The overall prevalence of enrollees receiving 180 days of continuous medications for OUD did not significantly change from the 2014-2015 to 2017-2018 periods (-0.01 prevalence difference, 95% CI, -0.03 to 0.02) with state variability in trend (90% prediction interval, -0.08 to 0.06). Non-Hispanic Black enrollees had lower OUD medication use than White enrollees (prevalence ratio [PR], 0.72; 95% CI, 0.64 to 0.81; P < .001; 90% prediction interval, 0.52 to 1.00). Pregnant women had higher use of OUD medications (PR, 1.18; 95% CI, 1.11-1.25; P < .001; 90% prediction interval, 1.01-1.38) and medication continuity (PR, 1.14; 95% CI, 1.10-1.17, P < .001; 90% prediction interval, 1.06-1.22) than did other eligibility groups.

Conclusions and Relevance

Among US Medicaid enrollees in 11 states, the prevalence of medication use for treatment of opioid use disorder increased from 2014 through 2018. The pattern in other states requires further research.

Five-Year Outcomes Among Medicaid-Enrolled Children With In Utero Opioid Exposure

The health of women and children affected by opioid use disorder is a priority for state Medicaid programs. Little is known about longer-term outcomes among Medicaid-enrolled children exposed to opioids in utero. We examined well-child visit use and diagnoses of pediatric complex chronic conditions in the first five years of life among children with opioid exposure, tobacco exposure, or neither exposure in utero. The sample consisted of 82,329 maternal-child dyads in the Pennsylvania Medicaid program in which the children were born in the period 2008-11 and followed up for five years. Children with in utero opioid exposure had a lower predicted probability of recommended well-child visit use at age fifteen months (42.1 percent) compared to those with tobacco exposure (54.1 percent) and those with neither exposure (55.7 percent). Children with in utero opioid exposure had a predicted probability of being diagnosed with a pediatric complex chronic condition similar to that among children with tobacco exposure and those with neither exposure (20.4 percent, 18.7 percent, and 20.2 percent, respectively). Our findings were consistent when we examined a subgroup of opioid-exposed children identified as having neonatal opioid withdrawal symptoms.

Association of Chain Restaurant Advertising Spending With Obesity in US Adults

IMPORTANCE

Restaurants spend billions of dollars on marketing. However, little is known about the association between restaurant marketing and obesity risk in adults.

OBJECTIVE

To examine associations between changes in per capita county-level restaurant advertising spending over time and changes in objectively measured body mass index (BMI) for adult patients.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used regression models with county fixed effects to examine associations between changes in per capita county-level (370 counties across 44 states) restaurant advertising spending over time with changes in objectively measured body mass index (BMI) for US adult patients from 2013 to 2016. Different media types and restaurant types were analyzed together and separately. The cohort was derived from deidentified patient data obtained from athenahealth. The final analytic sample included 5 987 213 patients, and the analysis was conducted from March 2018 to November 2019.

EXPOSURE

Per capita county-level chain restaurant advertising spending.

MAIN OUTCOMES AND MEASURES

Individual-level mean BMI during the quarter.

RESULTS

The included individuals were generally older (37.1% older than 60 years), female (56.8%), and commercially insured (53.5%). For the full population of 29 285 920 person-quarters, there was no association between changes in all restaurant advertising per capita (all media types, all restaurants) and changes in BMI. However, restaurant advertising spending was positively associated with weight gain for patients in low-income counties but not in high-income counties. A $1 increase in quarterly advertising per capita across all media and restaurant types was associated with a 0.053-unit increase in BMI (95% CI, 0.001-0.102) for patients in low-income counties, corresponding to a 0.12% decrease in BMI at the 10th percentile of changes in county advertising spending vs a 0.12% increase in BMI at the 90th percentile.

CONCLUSIONS AND RELEVANCE

The results of this study suggest that restaurant advertising is associated with modest weight gain among adult patients in low-income counties. To date, there has been no public policy action or private sector action to limit adult exposure to unhealthy restaurant advertising. Efforts to decrease restaurant advertising in low-income communities should be intensified and rigorously evaluated to understand their potential for increasing health equity.

Polysubstance Use Among Pregnant Women With Opioid Use Disorder in the United States, 2007-2016

OBJECTIVE

To assess trends in polysubstance use among pregnant women with opioid use disorder in the United States.

METHODS

We conducted a time trend analysis of pooled, cross-sectional data from the National Inpatient Sample, an annual nationally representative sample of U.S. hospital discharge data. Among 38.0 million females aged 15-44 years with a hospitalization for delivery from 2007 to 2016, we identified 172,335 pregnant women with an International Classification of Diseases, Ninth Revision, Clinical Modification or International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of opioid use disorder. Polysubstance use among pregnant women with opioid use disorder was defined as at least one co-occurring diagnosis of other substance use, including alcohol, amphetamine, cannabis, cocaine, sedative, or tobacco. We fit weighted multivariable logistic regression models to produce nationally representative estimates, including an interaction between year and rural compared with urban county of residence; controlled for age, race, and insurance type. Average predicted probabilities and 95% CIs were derived from regression results.

RESULTS

Polysubstance use among women with opioid use disorder increased from 60.5% (95% CI 58.3-62.8%) to 64.1% (95% CI 62.8%-65.3%). Differential time trends in polysubstance use among women with opioid use disorder were found in rural compared with urban counties. Large increases in amphetamine use occurred among those in both rural and urban counties (255.4%; 95% CI 90.5-562.9% and 150.7%; 95% CI 78.2-52.7%, respectively), similarly to tobacco use (30.4%; 95% CI 16.9-45.4% and 23.2%; 95% CI 15.3-31.6%, respectively). Cocaine use diagnoses declined among women with opioid use disorder at delivery in rural (-70.5%; 95% CI -80.4% to -55.5%) and urban (-61.9%; 95% CI -67.6% to -55.1%) counties. Alcohol use diagnoses among those with opioid use disorder declined -57% (95% CI -70.8% to -37.7%) in urban counties but did not change among those in rural counties.

CONCLUSION

Over the past decade, polysubstance use among pregnant women with opioid use disorder has increased more rapidly in rural compared with urban counties in the United States, with amphetamines and tobacco use increasing most rapidly.

Impact of Changes in Chain Restaurant Calories over Time on Obesity Risk

BACKGROUND

Prior research on the restaurant environment and obesity risk is limited by cross-sectional data and a focus on specific geographic areas.

OBJECTIVE

To measure the impact of changes in chain restaurant calories over time on body mass index (BMI).

DESIGN

We used a first-difference model to examine whether changes from 2012 to 2015 in chain restaurant calories per capita were associated with percent changes in BMI. We also examined differences by race and county income, restaurant type, and initial body weight categories.

SETTING

USA (207 counties across 39 states).

PARTICIPANTS

447,873 adult patients who visited an athenahealth medical provider in 2012 and 2015 where BMI was measured.

MAIN OUTCOMES MEASURED

Percent change in objectively measured BMI from 2012 to 2015.

RESULTS

Across all patients, changes in chain restaurant calories per capita were not associated with percent changes in BMI. For Black or Hispanic adults, a 10% increase in exposure to chain restaurant calories per capita was associated with a 0.16 percentage-point increase in BMI (95% CI 0.03, 0.30). This translates into a predicted weight increase of 0.89 pounds (or a 0.53% BMI increase) for an average weight woman at the 90th percentile of increases in the restaurant environment from 2012 to 2015 versus an increase 0.39 pounds (or 0.23% BMI increase) at the 10th percentile. Greater increases in exposure to chain restaurant calories also significantly increased BMI for Black or Hispanic adults receiving healthcare services in lower-income counties (0.26, 95% CI 0.04, 0.49) and with overweight/obesity (0.16, 95% CI 0.04, 0.29).

LIMITATIONS

Generalizability to non-chain restaurants is unknown and the sample of athenahealth patients is relatively homogenous.

CONCLUSIONS

Increased exposure to chain restaurant calories per capita was associated with increased weight gain among Black or Hispanic adults.

Sugary Drink Consumption Among Children by Supplemental Nutrition Assistance Program Status

INTRODUCTION

The Supplemental Nutrition Assistance Program is the largest U.S. federally funded nutrition assistance program, providing food assistance to more than 40 million low-income Americans, half of whom are children. This paper examines trends in sugar-sweetened beverage consumption among U.S. children and adolescents by Supplemental Nutrition Assistance Program participation status.

METHODS

Dietary data from 15,645 participants (aged 2-19 years) were obtained from the 2003-2014 National Health and Nutrition Examination surveys. Supplemental Nutrition Assistance Program participation was categorized as: Supplemental Nutrition Assistance Program participant, income-eligible nonparticipant, lower income-ineligible nonparticipant, and higher income-ineligible nonparticipant. Survey-weighted logistic regressions estimated predicted probabilities of daily sugar-sweetened beverage consumption, and negative binomial regressions estimated predicted per capita daily consumption of sugar-sweetened beverage calories. Data were analyzed in 2019.

RESULTS

From 2003 to 2014, there were significant declines across all Supplemental Nutrition Assistance Program participation categories for sugar-sweetened beverage consumption (participants: 84.2% to 75.6%, p=0.009; income-eligible nonparticipants: 85.8% to 67.5%, p=0.004; lower income-ineligible nonparticipants: 84.3% to 70.6%, p=0.026; higher income-ineligible nonparticipants: 82.2% to 67.7%, p=0.001) and per capita daily sugar-sweetened beverage calories (participants: 267 to 182 kilocalories, p<0.001; income-eligible nonparticipants: 269 to 168 kilocalories, p<0.001; lower income-ineligible nonparticipants: 249 to 178 kilocalories, p=0.008; higher income-ineligible nonparticipants: 244 to 161 kilocalories, p<0.001). Per capita sports/energy drink consumption increased among Supplemental Nutrition Assistance Program participants (2 to 15 kilocalories, p=0.007).

CONCLUSIONS

Sugar-sweetened beverage consumption has declined for children and adolescents in all Supplemental Nutrition Assistance Program participation categories, but current levels remain high. There were fewer favorable trends over time for consumption of sugar-sweetened beverage subtypes among Supplemental Nutrition Assistance Program participants relative to other participant categories.

Medication-Assisted Treatment Use Among Pregnant Women With Opioid Use Disorder

OBJECTIVE

To evaluate temporal trends in medication-assisted treatment use among pregnant women with opioid use disorder.

METHODS

We conducted a retrospective cohort study using Pennsylvania Medicaid administrative data. Trends in medication-assisted treatment use, opioid pharmacotherapy (methadone and buprenorphine) and behavioral health counselling, were calculated using pharmacy records and procedure codes. Cochrane-Armitage tests evaluated linear trends in characteristics of pregnant women using methadone compared with buprenorphine.

RESULTS

In total, we evaluated 12,587 pregnancies among 10,741 women with opioid use disorder who had a live birth between 2009 and 2015. Across all years, 44.1% of pregnant women received no opioid pharmacotherapy, 27.1% used buprenorphine, and 28.8% methadone. Fewer than half of women had any behavioral health counseling during pregnancy. The adjusted prevalence of methadone use declined from 31.6% (95% CI 29.3-33.9%) in 2009 to 25.2% (95% CI 23.3-27.1%) in 2015, whereas the adjusted prevalence of buprenorphine use increased from 15.8% (95% CI 13.9-17.8%) to 30.9% (95% CI 28.8-33.0%). Greater increases in buprenorphine use were found in geographic regions with large metropolitan centers, such as the Southwest (plus 24.9%) and the Southeast (plus 12.0%), compared with largely rural regions, such as the New West (plus 5.2%). In 2015, the adjusted number of behavioral health counseling visits during pregnancy was 3.4 (95% CI 2.6-4.1) among women using buprenorphine, 4.0 (95% CI 3.3-4.7) among women who did not use pharmacotherapy, and 6.4 (95% CI 4.9-7.9) among women using methadone.

CONCLUSION

Buprenorphine use among Medicaid-enrolled pregnant women with opioid use disorder increased significantly over time, with a small concurrent decline in methadone use. Behavioral health counseling use was low, but highest among women using methadone.

Adherence trajectories of buprenorphine therapy among pregnant women in a large state Medicaid program in the United States

PURPOSE

Little is known about the longitudinal patterns of buprenorphine adherence among pregnant women with opioid use disorder, especially when late initiation, nonadherence, or early discontinuation of buprenorphine during pregnancy may increase the risk of adverse outcomes. We aimed to identify distinct trajectories of buprenorphine use during pregnancy, and factors associated with these trajectories in Medicaid-enrolled pregnant women.

METHODS

A retrospective cohort study included 2361 Pennsylvania Medicaid enrollees aged 15 to 46 having buprenorphine therapy during pregnancy and a live birth between 2008 and 2015. We used group-based trajectory models to identify buprenorphine use patterns in the 40 weeks prior to delivery and 12 weeks postdelivery. Multivariable multinomial logistic regression models were used to identify factors associated with specific trajectories.

RESULTS

Six distinct trajectories were identified. Four groups initiated buprenorphine during the first trimester of the pregnancy (early initiators): 31.6% with persistently high adherence, 15.1% with moderate-to-high adherence, 10.5% with declining adherence, and 16.7% with early discontinuation. Two groups did not initiate buprenorphine until midsecond or third trimester (late initiators): 13.5% had moderate-to-high adherence and 12.6% had low-to-moderate adherence. Factors significantly associated with late initiation and discontinuation were younger age, non-white race, residents of rural counties, fewer outpatient visits, more frequent emergency department visits and hospitalizations, and lower buprenorphine daily dose.

CONCLUSIONS

Six buprenorphine treatment trajectories during pregnancy were identified in this population-based Medicaid cohort, with 25% of women initiating buprenorphine late during pregnancy. Understanding trajectories of buprenorphine use and factors associated with discontinuation/nonadherence may guide integration of behavioral treatment with obstetrical/gynecological care to improve buprenorphine treatment during pregnancy.

Higher-Calorie Menu Items Eliminated in Large Chain Restaurants

INTRODUCTION

Large chain restaurants have reduced calories in their new menu items. No research has examined the calorie content of items eliminated from these menus.

METHODS

Data are from the MenuStat project (2012-2015), which includes 66 of the 100 largest U.S. chain restaurants (n=27,238 items), to compare: (1) mean calories for items on the menu in all years compared with those dropped after 2012 and (2) mean calories for items new in 2013 or 2014 that stayed on the menu compared with items new in 2013 or 2014 that were dropped. The data were analyzed in 2016.

RESULTS

Menu items that were dropped from the menu relative to those on the menu in all years had 71 more calories (p=0.02). New items that were dropped relative to new items that stayed on the menu had 52 more calories (p=0.04).

CONCLUSIONS

Items dropped from chain restaurant menus are significantly higher in calories than items that remain on the menu. Eliminating higher-calorie items from restaurant menus may have a significant and positive impact on population health by reducing calorie intake without relying on individual behavior, which is very resistant to change.

Trends in Sodium Content of Menu Items in Large Chain Restaurants in the U.S

INTRODUCTION

Consuming too much sodium is associated with increased risk for cardiovascular disease, and restaurant foods are a primary source of sodium. This study assessed recent trends in sodium content of menu items in U.S. chain restaurants.

METHODS

Data from 21,557 menu items in 66 top-earning chain restaurants available from 2012 to 2016 were obtained from the MenuStat project and analyzed in 2017. Generalized linear models were used to examine changes in calorie-adjusted, per-item sodium content of menu items offered in all years (2012-2016) and items offered in 2012 only compared with items newly introduced in 2013, 2014, 2015, and 2016.

RESULTS

Overall, calorie-adjusted sodium content in newly introduced menu items declined by 104 mg from 2012 to 2016 (p<0.02). However, the magnitude and direction of these changes varied by menu category and restaurant type; sodium content, particularly for main course items, was high. Sodium declined by 83 mg in fast food restaurants, 19 mg in fast casual restaurants, and 163 mg in full service restaurants. Sodium in appetizer and side items newly introduced in 2016 increased by 266 mg compared with items on the menu in 2012 only (p<0.01). Sodium in main courses newly introduced in 2016 declined by 124 mg compared with items on the menu in 2012 only (p=0.01), with the greatest decline, 207 mg (p=0.03), among salads.

CONCLUSIONS

Average, adjusted, per-item sodium content was lower in newly introduced items in large chain restaurants. However, sodium content of core and new menu items remain high, and reductions are inconsistent across menu categories and restaurant types.

Calorie changes in large chain restaurants from 2008 to 2015

No prior studies examining changes in the calorie content of chain restaurants have included national data before and after passage of federal menu labeling legislation, required by the 2010 Affordable Care Act. This paper describes trends in calories available in large U.S. chain restaurants in 2008 and 2012 to 2015 using data were obtained from the MenuStat project (2012 to 2015) and from the Center for Science in the Public Interest (2008). This analysis included 44 of the 100 largest U.S. restaurants which are available in all years of the data (2008 and 2012-2015) (N=19,391 items). Generalized linear models were used to examine 1) per-item calorie changes from 2008 to 2015 among items on the menu in all years and 2) mean calories in new items in 2012, 2013, 2014 and 2015 compared to items on the menu in 2008 only. We found that Among items common to the menu in all years, overall calories declined from 327kcal in 2008 to 318kcal in 2015 (p-value for trend=0.03). No differences in mean calories among menu items newly introduced in 2012, 2013, 2014, and 2015 relative to items only on the menu in 2008 were found. These results suggest that the federal menu labeling mandate (to be implemented in May 2017) appears to be influencing restaurant behavior towards lower average calories for menu items.

Restaurants With Calories Displayed On Menus Had Lower Calorie Counts Compared To Restaurants Without Such Labels

Beginning in December 2016, calorie labeling on menus will be mandatory for US chain restaurants and many other establishments that serve food, such as ice cream shops and movie theaters. But before the federal mandate kicks in, several large chain restaurants have begun to voluntarily display information about the calories in the items on their menus. This increased transparency may be associated with lower overall calorie content of offered items. This study used data for the period 2012-14 from the MenuStat project, a data set of menu items at sixty-six of the largest US restaurant chains. We compared differences in calorie counts of food items between restaurants that voluntarily implemented national menu labeling and those that did not. We found that the mean per item calorie content in all years was lower for restaurants that voluntarily posted information about calories (the differences were 139 calories in 2012, 136 in 2013, and 139 in 2014). New menu items introduced in 2013 and 2014 showed a similar pattern. Calorie labeling may have important effects on the food served in restaurants by compelling the introduction of lower-calorie items.

Macronutrient Composition of Menu Offerings in Fast Food Restaurants in the U.S

INTRODUCTION

A high intake of fast food is associated with increased obesity risk. This study assessed recent changes in caloric content and macronutrient composition in large U.S. fast food restaurants.

METHODS

Data from the MenuStat project included 11,737 menu items in 37 fast food restaurants from 2012 to 2014. Generalized linear models were used to examine changes in the caloric content and corresponding changes in the macronutrient composition (non-sugar carbohydrates, sugar, unsaturated fat, saturated fat, and protein) of menu items over time. Additionally, macronutrient composition was compared in menu items newly introduced in 2013 and 2014, relative to 2012. Analyses, conducted in January 2016, controlled for restaurant and were stratified by menu categories.

RESULTS

Overall, there was a 22-calorie reduction in food items from 2012 to 2014. Beverages had a 46-calorie increase, explained by an increase in calories from sugar (12 calories) and saturated fat (16 calories). Newly introduced main courses in 2014 had 59 calories fewer than those on 2012 menus, explained by a 54-calorie reduction in unsaturated fat, while other macronutrient content remained fairly constant. Newly introduced dessert items in 2014 had 90 calories more than those on 2012 menus, explained primarily by an increase of 57 calories of sugar.

CONCLUSIONS

Overall, there were relatively minor changes in menu items' caloric and macronutrient composition. Although declines in caloric content among newly introduced fast food main courses may improve the public's caloric intake, it appears that the macronutrient composition of newly introduced items did not shift to a healthier profile.

Calorie Changes in Large Chain Restaurants: Declines in New Menu Items but Room for Improvement

INTRODUCTION

Large chain restaurants reduced the number of calories in newly introduced menu items in 2013 by about 60 calories (or 12%) relative to 2012. This paper describes trends in calories available in large U.S. chain restaurants to understand whether previously documented patterns persist.

METHODS

Data (a census of items for included restaurants) were obtained from the MenuStat project. This analysis included 66 of the 100 largest U.S. restaurants that are available in all three of the data years (2012-2014; N=23,066 items). Generalized linear models were used to examine: (1) per-item calorie changes from 2012 to 2014 among items on the menu in all years; and (2) mean calories in new items in 2013 and 2014 compared with items on the menu in 2012 only. Data were analyzed in 2014.

RESULTS

Overall, calories in newly introduced menu items declined by 71 (or 15%) from 2012 to 2013 (p=0.001) and by 69 (or 14%) from 2012 to 2014 (p=0.03). These declines were concentrated mainly in new main course items (85 fewer calories in 2013 and 55 fewer calories in 2014; p=0.01). Although average calories in newly introduced menu items are declining, they are higher than items common to the menu in all 3 years. No differences in mean calories among items on menus in 2012, 2013, or 2014 were found.

CONCLUSIONS

The previously observed declines in newly introduced menu items among large restaurant chains have been maintained, which suggests the beginning of a trend toward reducing calories.

Use of pharmacotherapies for smoking cessation: analysis of pregnant and postpartum Medicaid enrollees

BACKGROUND

The Affordable Care Act requires state Medicaid programs to cover pharmacotherapies for smoking cessation without cost sharing for pregnant women. Little is known about use of these pharmacotherapies among Medicaid-enrolled women.

PURPOSE

To describe the prevalence of prescription fills for smoking-cessation pharmacotherapies during pregnancy and postpartum among Medicaid-enrolled women and to examine whether certain pregnancy complications or copayments are associated with prescription fills.

METHODS

Insurance claims data for women enrolled in a Medicaid managed care plan in Maryland and who used tobacco during pregnancy from 2003 to 2010 were obtained (N=4,709) and analyzed in 2014. Descriptive statistics were used to calculate the prevalence of smoking-cessation pharmacotherapy use during pregnancy and postpartum. Generalized estimating equations were employed to examine the relationship of pregnancy complications and copayments with prescription fills of smoking-cessation pharmacotherapies during pregnancy and postpartum.

RESULTS

Few women filled any prescription for a smoking-cessation pharmacotherapy during pregnancy or postpartum (2.6% and 2.0%, respectively). Having any smoking-related pregnancy complication was positively associated with filling a smoking-cessation pharmacotherapy prescription during pregnancy (OR=1.69, 95% CI=1.08, 2.65) but not postpartum. Copayments were associated with significantly decreased odds of filling any prescription for smoking-cessation pharmacotherapies in the postpartum period (OR=0.38, 95% CI=0.22, 0.66).

CONCLUSIONS

Smoking-related pregnancy complications and substance use are predictive of filling a prescription for pharmacotherapies for smoking cessation during pregnancy. Low use of pharmacotherapies during pregnancy is consistent with clinical guidelines; however, low use postpartum suggests an unmet need for cessation aids in Medicaid populations.

Calorie changes in chain restaurant menu items: implications for obesity and evaluations of menu labeling

BACKGROUND

Supply-side reductions to the calories in chain restaurants are a possible benefit of upcoming menu labeling requirements.

PURPOSE

To describe trends in calories available in large U.S. restaurants.

METHODS

Data were obtained from the MenuStat project, a census of menu items in 66 of the 100 largest U.S. restaurant chains, for 2012 and 2013 (N=19,417 items). Generalized linear models were used to calculate (1) the mean change in calories from 2012 to 2013, among items on the menu in both years; and (2) the difference in mean calories, comparing newly introduced items to those on the menu in 2012 only (overall and between core versus non-core items). Data were analyzed in 2014.

RESULTS

Mean calories among items on menus in both 2012 and 2013 did not change. Large restaurant chains in the U.S. have recently had overall declines in calories in newly introduced menu items (-56 calories, 12% decline). These declines were concentrated mainly in new main course items (-67 calories, 10% decline). New beverage (-26 calories, 8% decline) and children's (-46 calories, 20% decline) items also had fewer mean calories. Among chain restaurants with a specific focus (e.g., burgers), average calories in new menu items not core to the business declined more than calories in core menu items.

CONCLUSIONS

Large chain restaurants significantly reduced the number of calories in newly introduced menu items. Supply-side changes to the calories in chain restaurants may have a significant impact on obesity prevention.

Mammography use among women ages 40-49 after the 2009 U.S. Preventive Services Task Force recommendation

BACKGROUND

In 2009, the U.S. Preventive Service Task Force changed its recommendation regarding screening mammography in average-risk women aged 40-49 years.

OBJECTIVE

To evaluate the effects of the 2009 recommendation on reported mammogram use in a population-based survey.

DESIGN

Secondary data analysis of data collected in the 2006, 2008, and 2010 Behavioral Risk Factor Surveillance System surveys.

PARTICIPANTS

Women ages 40-74 years in the 50 states and Washington, DC who were not pregnant at time of survey and reported data on mammogram use during the 2006, 2008, or 2010 survey.

MAIN MEASURES

Mammogram use was compared between women ages 40-49 and women ages 50-74 before and after the recommendation. We performed a difference-in-difference estimation adjusted for access to care, education, race, and health status, and stratified analyses by whether women reported having a routine checkup in the prior year.

KEY RESULTS

Reported prevalence of mammogram use in the past year among women ages 40-49 and 50-74 was 53.2 % and 65.2 %, respectively in 2008, and 51.7 % and 62.4 % in 2010. In 2010, mammography use did not significantly decline from 2006-2008 in women ages 40-49 relative to women ages 50-74.

CONCLUSION

There was no reduction in mammography use among younger women in 2010 compared to older women and previous years. Patients and providers may have been hesitant to comply with the 2009 recommendation.

How does physician BMI impact patient trust and perceived stigma?

OBJECTIVE

The objective is to evaluate whether physician body mass index (BMI) impacts their patients' trust or perceptions of weight-related stigma.

METHODS

We used a national cross-sectional survey of 600 non-pregnant overweight and obese patients conducted between April 5 and April 13, 2012. The outcome variables were patient trust (overall and by type of advice) and patient perceptions of weight-related stigma. The independent variable of interest was primary care physician (PCP) BMI. We conducted multivariate regression analyses to determine whether trust or perceived stigma differed by physician BMI, adjusting for covariates.

RESULTS

Patients reported high levels of trust in their PCPs, regardless of the PCPs body weight (normal BMI=8.6; overweight=8.3; obese=8.2; where 10 is the highest). Trust in diet advice was significantly higher among patients seeing overweight PCPs as compared to normal BMI PCPs (87% vs. 77%, p=0.04). Reports of feeling judged by their PCP were significantly higher among patients seeing obese PCPs (32%; 95% confidence interval (CI): 23-41) as compared to patients seeing normal BMI PCPs (14%; 95% CI: 7-20).

CONCLUSION

Overweight and obese patients generally trust their PCP, but they more strongly trust diet advice from overweight PCPs as compared to normal BMI PCPs.

Insurance coverage for weight loss: overweight adults' views

BACKGROUND

Given the prevalence of obesity and associated chronic conditions among U.S. adults, wellness benefits are an increasingly popular approach to promoting weight loss.

PURPOSE

The goal of the study was to assess overweight and obese adults' beliefs about the helpfulness of insurance coverage of weight loss-related benefits, their willingness to pay for such benefits, and whether these opinions differ by individuals' weight or health insurance type.

METHODS

A national survey was fielded in 2012 among non-pregnant, overweight, and obese adults who had seen a primary care provider in the past year (n=600). Descriptive statistics summarized beliefs about which weight loss-related benefits would be helpful, willingness to pay for such benefits, and agreement about whether health insurers should be able to charge more to obese individuals. Multivariable logistic regression was employed to determine whether beliefs differed by weight category or health insurance type. Analyses were conducted in July 2012.

RESULTS

The majority (83%) of respondents cited a specific benefit as helpful. Those with private health insurance had a higher probability (89%, 95% CI=86%, 93%) of endorsing any benefit as helpful relative to those with other types of health insurance. Being obese relative to overweight was associated with greater support (57% vs 39%, p<0.05) for preventing health insurers from charging higher premiums to obese individuals.

CONCLUSIONS

In this sample of overweight adults, a large proportion endorsed the value of weight loss-related benefits offered by health plans. However, only about one third were willing to pay extra for them, and half disagreed with the notion that health plans should charge more to obese individuals. Given evidence of their effectiveness, wellness benefits should be offered to all individuals.

News coverage of sugar-sweetened beverage taxes: pro- and antitax arguments in public discourse

OBJECTIVES

We examined news coverage of public debates about large taxes on sugar-sweetened beverages (SSBs) to illuminate how the news media frames the debate and to inform future efforts to promote obesity-related public policy.

METHODS

We conducted a quantitative content analysis in which we assessed how frequently 30 arguments supporting or opposing SSB taxes appeared in national news media and in news outlets serving jurisdictions where SSB taxes were proposed between January 2009 and June 2011.

RESULTS

News coverage included more discrete protax than antitax arguments on average. Supportive arguments about the health consequences and financial benefits of SSB taxes appeared most often. The most frequent opposing arguments focused on how SSB taxes would hurt the economy and how they constituted inappropriate governmental intrusion.

CONCLUSIONS

News outlets that covered the debate on SSB taxes in their jurisdictions framed the issue in largely favorable ways. However, because these proposals have not gained passage, it is critical for SSB tax advocates to reach audiences not yet persuaded about the merits of this obesity prevention policy.

Health inequalities: trends, progress, and policy

Health inequalities, which have been well documented for decades, have more recently become policy targets in developed countries. This review describes time trends in health inequalities (by sex, race/ethnicity, and socioeconomic status), commitments to reduce health inequalities, and progress made to eliminate health inequalities in the United States, United Kingdom, and other OECD countries. Time-trend data in the United States indicate a narrowing of the gap between the best- and worst-off groups in some health indicators, such as life expectancy, but a widening of the gap in others, such as diabetes prevalence. Similarly, time-trend data in the United Kingdom indicate a narrowing of the gap between the best- and worst-off groups in some indicators, such as hypertension prevalence, whereas the gap between social classes has increased for life expectancy. More research and better methods are needed to measure precisely the relationships between stated policy goals and observed trends in health inequalities.