Decoding Suicide Decedent Profiles and Signs of Suicidal Intent Using Latent Class Analysis

Importance

Suicide rates in the US increased by 35.6% from 2001 to 2021. Given that most individuals die on their first attempt, earlier detection and intervention are crucial. Understanding modifiable risk factors is key to effective prevention strategies.

Objective

To identify distinct suicide profiles or classes, associated signs of suicidal intent, and patterns of modifiable risks for targeted prevention efforts.

Design, Setting, and Participants

This cross-sectional study used data from the 2003-2020 National Violent Death Reporting System Restricted Access Database for 306 800 suicide decedents. Statistical analysis was performed from July 2022 to June 2023.

Exposures

Suicide decedent profiles were determined using latent class analyses of available data on suicide circumstances, toxicology, and methods.

Main Outcomes and Measures

Disclosure of recent intent, suicide note presence, and known psychotropic usage.

Results

Among 306 800 suicide decedents (mean [SD] age, 46.3 [18.4] years; 239 627 males [78.1%] and 67 108 females [21.9%]), 5 profiles or classes were identified. The largest class, class 4 (97 175 [31.7%]), predominantly faced physical health challenges, followed by polysubstance problems in class 5 (58 803 [19.2%]), and crisis, alcohol-related, and intimate partner problems in class 3 (55 367 [18.0%]), mental health problems (class 2, 53 928 [17.6%]), and comorbid mental health and substance use disorders (class 1, 41 527 [13.5%]). Class 4 had the lowest rates of disclosing suicidal intent (13 952 [14.4%]) and leaving a suicide note (24 351 [25.1%]). Adjusting for covariates, compared with class 1, class 4 had the highest odds of not disclosing suicide intent (odds ratio [OR], 2.58; 95% CI, 2.51-2.66) and not leaving a suicide note (OR, 1.45; 95% CI, 1.41-1.49). Class 4 also had the lowest rates of all known psychiatric illnesses and psychotropic medications among all suicide profiles. Class 4 had more older adults (23 794 were aged 55-70 years [24.5%]; 20 100 aged ≥71 years [20.7%]), veterans (22 220 [22.9%]), widows (8633 [8.9%]), individuals with less than high school education (15 690 [16.1%]), and rural residents (23 966 [24.7%]).

Conclusions and Relevance

This study identified 5 distinct suicide profiles, highlighting a need for tailored prevention strategies. Improving the detection and treatment of coexisting mental health conditions, substance and alcohol use disorders, and physical illnesses is paramount. The implementation of means restriction strategies plays a vital role in reducing suicide risks across most of the profiles, reinforcing the need for a multifaceted approach to suicide prevention.

Conjoint Analysis of Telemedicine Preferences for Hypertension Management Among Adult Patients

Background: Telemedicine has been differentially utilized by different demographic groups during COVID-19, exacerbating inequities in health care. We conducted conjoint and latent class analyses to understand factors that shape patient preferences for hypertension management telemedicine appointments. Methods: We surveyed 320 adults, oversampling participants from households that earned <$50K per year (77.2%) and speak a language other than English at home (68.8%). We asked them to choose among 2 hypothetical appointments through 12 conjoint tasks measuring 6 attributes. Individual utilities for attributes were constructed using logit estimation, and latent classes were identified and compared by demographic and clinical characteristics. Results: Respondents preferred in-person visits (0.353, standard error [SE] = 0.039) and video appointments conducted through a secure patient portal (0.002, SE = 0.040). Respondents also preferred seeing a clinician with whom they have an established relationship (0.168, SE = 0.021). We found four latent classes: "in-person" (26.5% of participants) who strongly weighted in-person appointments, "cost conscious" (8.1%) who prioritized the lowest copay ($0 to $10), "expedited" (19.7%) who prioritized getting the earliest appointment possible (same/next day or at least within the next week), and "comprehensive" (45.6%) who had preferences for in-person care and telemedicine appointments through a secure portal, low copayments, and the ability to see a familiar clinician. Conclusions: Appointment preferences for hypertension management can be segmented into four groups that prioritize (1) in-person care, (2) low copayments, (3) expedited care, and (4) balanced preferences for in-person and telemedicine appointments. Evidence is needed to clarify whether aligning appointment offerings with patients' preferences can improve care quality, equity, and efficiency.

White matter and literacy: A dynamic system in flux

Cross-sectional studies have linked differences in white matter tissue properties to reading skills. However, past studies have reported a range of, sometimes conflicting, results. Some studies suggest that white matter properties act as individual-level traits predictive of reading skill, whereas others suggest that reading skill and white matter develop as a function of an individual's educational experience. In the present study, we tested two hypotheses: a) that diffusion properties of the white matter reflect stable brain characteristics that relate to stable individual differences in reading ability or b) that white matter is a dynamic system, linked with learning over time. To answer these questions, we examined the relationship between white matter and reading in a five-year longitudinal dataset and a series of large-scale, single-observation, cross-sectional datasets (N = 14,249 total participants). We find that gains in reading skill correspond to longitudinal changes in the white matter. However, in the cross-sectional datasets, we find no evidence for the hypothesis that individual differences in white matter predict reading skill. These findings highlight the link between dynamic processes in the white matter and learning.

Linguistic Disparities in Diabetes Care Quality in California Community Health Centers Before and During the COVID-19 Pandemic

BACKGROUND

Disparities in diabetes care quality may have increased for patients with limited English language proficiency (LEP) compared to non-LEP patients during the COVID-19 pandemic. Changes in diabetes care quality for adult LEP and non-LEP patients of community health centers (CHCs) were examined from 2019 to 2020.

METHODS

Adults with Type 2 diabetes (n = 15 965) of 88 CHC sites in California and with 1+ visit/year in 2019 and 2020 from OCHIN electronic health record data were included. Multivariable regression models estimated the association of LEP status and changes in diabetes care quality from 2019 to 2020, controlling for patient sociodemographic and clinical characteristics. Interaction terms (LEP × 2020) were used to estimate differential over time changes in (1) blood pressure screening, (2) blood pressure control (<140/90 mm Hg), and (3) hemoglobin A1c control (HbA1c <8%) for LEP versus non-LEP patients.

RESULTS

LEP and non-LEP patients with diabetes had comparable blood pressure screening and control in 2019 and in 2020. LEP patients were less likely than non-LEP patients to have their HbA1c under control in 2019 (OR = 0.85, 95% CI = 0.77, 0.96, P = .006) and 2020 (OR = 0.83, 95% CI = 0.75, 0.92, P = .001). There were no differential changes in HbA1c control over time for LEP and non-LEP patients.

DISCUSSION

Although LEP patients were less likely than non-LEP patients to have their HbA1c under control, CHCs maintained quality of care equally for LEP and non-LEP patients with diabetes during the early pandemic period.

Patterns of Social Determinants of Health and Child Mental Health, Cognition, and Physical Health

Importance

Social determinants of health (SDOH) influence child health. However, most previous studies have used individual, small-set, or cherry-picked SDOH variables without examining unbiased computed SDOH patterns from high-dimensional SDOH factors to investigate associations with child mental health, cognition, and physical health.

Objective

To identify SDOH patterns and estimate their associations with children's mental, cognitive, and physical developmental outcomes.

Design, Setting, and Participants

This population-based cohort study included children aged 9 to 10 years at baseline and their caregivers enrolled in the Adolescent Brain Cognitive Development (ABCD) Study between 2016 and 2021. The ABCD Study includes 21 sites across 17 states.

Exposures

Eighty-four neighborhood-level, geocoded variables spanning 7 domains of SDOH, including bias, education, physical and health infrastructure, natural environment, socioeconomic status, social context, and crime and drugs, were studied. Hierarchical agglomerative clustering was used to identify SDOH patterns.

Main Outcomes and Measures

Associations of SDOH and child mental health (internalizing and externalizing behaviors) and suicidal behaviors, cognitive function (performance, reading skills), and physical health (body mass index, exercise, sleep disorder) were estimated using mixed-effects linear and logistic regression models.

Results

Among 10 504 children (baseline median [SD] age, 9.9 [0.6] years; 5510 boys [52.5%] and 4994 girls [47.5%]; 229 Asian [2.2%], 1468 Black [14.0%], 2128 Hispanic [20.3%], 5565 White [53.0%], and 1108 multiracial [10.5%]), 4 SDOH patterns were identified: pattern 1, affluence (4078 children [38.8%]); pattern 2, high-stigma environment (2661 children [25.3%]); pattern 3, high socioeconomic deprivation (2653 children [25.3%]); and pattern 4, high crime and drug sales, low education, and high population density (1112 children [10.6%]). The SDOH patterns were distinctly associated with child health outcomes. Children exposed to socioeconomic deprivation (SDOH pattern 3) showed the worst health profiles, manifesting more internalizing (β = 0.75; 95% CI, 0.14-1.37) and externalizing (β = 1.43; 95% CI, 0.83-2.02) mental health problems, lower cognitive performance, and adverse physical health.

Conclusions

This study shows that an unbiased quantitative analysis of multidimensional SDOH can permit the determination of how SDOH patterns are associated with child developmental outcomes. Children exposed to socioeconomic deprivation showed the worst outcomes relative to other SDOH categories. These findings suggest the need to determine whether improvement in socioeconomic conditions can enhance child developmental outcomes.

Leveraging the Adolescent Brain Cognitive Development Study to improve behavioral prediction from neuroimaging in smaller replication samples

Magnetic resonance imaging (MRI) is a popular and useful non-invasive method to map patterns of brain structure and function to complex human traits. Recently published observations in multiple large scale studies cast doubt upon these prospects, particularly for prediction of cognitive traits from structural and resting state functional MRI, which seems to account for little behavioral variability. We leverage baseline data from thousands of children in the Adolescent Brain Cognitive DevelopmentSM (ABCD®) Study to inform the replication sample size required with both univariate and multivariate methods across different imaging modalities to detect reproducible brain-behavior associations. We demonstrate that by applying multivariate methods to high-dimensional brain imaging data, we can capture lower dimensional patterns of structural and functional brain architecture that correlate robustly with cognitive phenotypes and are reproducible with only 41 individuals in the replication sample for working memory-related functional MRI, and ~100 subjects for structural MRI. Even with 100 random re-samplings of 50 subjects in the discovery sample, prediction can be adequately powered with 98 subjects in the replication sample for multivariate prediction of cognition with working memory task functional MRI. These results point to an important role for neuroimaging in translational neurodevelopmental research and showcase how findings in large samples can inform reproducible brain-behavior associations in small sample sizes that are at the heart of many investigators' research programs and grants.

Collaborative Learning Among Health Care Organizations to Improve Quality and Advance Racial Equity

Background

The study examined stakeholder experiences of a statewide learning collaborative, sponsored and led by Blue Cross Blue Shield of Massachusetts (BCBSMA) and facilitated by the Institute for Healthcare Improvement (IHI) to reduce racial and ethnic disparities in quality of care.

Methods

Interviews of key stakeholders (n=44) were analyzed to assess experiences of collaborative learning and interventions to reduce racial and ethnic disparities in quality of care. The interviews included BCBSMA, IHI, provider groups, and external experts.

Results

Breast cancer screening, colorectal cancer screening, hypertension management, and diabetes management were focal areas for reducing disparities. Collaborative learning methods involved expert coaching, group meetings, and sharing of best practices. Interventions tested included pharmacist-led medication management, strategies to improve the collection of race, ethnicity, and language (REaL) data, transportation access improvement, and community health worker approaches. Stakeholder experiences highlighted three themes: (1) the learning collaborative enabled the testing of interventions by provider groups, (2) infrastructure and pilot funding were foundational investments, but groups needed more resources than they initially anticipated, and (3) expertise in quality improvement and health equity were critical for the testing of interventions and groups anticipated needing this expertise into the future.

Conclusions

BCBSMA's learning collaborative and intervention funding supported contracted providers in enhancing REaL data collection, implementing equity-focused interventions on a small scale, and evaluating their feasibility and impact. The collaborative facilitated learning among groups on innovative approaches for reducing racial disparities in quality. Concerns about sustainability underscore the importance of expertise for implementing initiatives to reduce racial and ethnic disparities.

Frontline work and racial disparities in social and economic pandemic stressors during the first COVID-19 surge

OBJECTIVE

To assess the magnitude of racial-ethnic disparities in pandemic-related social stressors and examine frontline work's moderating relationship on these stressors.

DATA SOURCES

Employed Californians' responses to the Institute for Governmental Studies (IGS) poll from April 16-20, 2020, were analyzed. The Pandemic Stressor Scale (PSS) assessed the extent to which respondents experienced or anticipated problems resulting from the inability to pay for basic necessities, job instability, lacking paid sick leave, unavailability of childcare, and reduced wages or work hours due to COVID-19.

STUDY DESIGN

Mixed-effects generalized linear models estimated (1) racial-ethnic disparities in pandemic stressors among workers during the first COVID-19 surge, adjusting for covariates, and (2) tested the interaction between race-ethnicity and frontline worker status, which includes a subset of essential workers who must perform their job on-site, to assess differential associations of frontline work by race-ethnicity.

DATA COLLECTION

The IGS poll data from employed workers (n = 4795) were linked to the 2018 Centers for Disease Control and Prevention Social Vulnerability Index at the zip code level (N = 1068).

PRINCIPAL FINDINGS

The average PSS score was 37.34 (SD = 30.49). Whites had the lowest PSS score (29.88, SD = 26.52), and Latinxs had the highest (50.74, SD = 32.61). In adjusted analyses, Black frontline workers reported more pandemic-related stressors than White frontline workers (PSS = 47.73 vs. 36.96, p < 0.001). Latinxs reported more pandemic stressors irrespective of frontline worker status. However, the 5.09-point difference between Latinx frontline and non-frontline workers was not statistically different from the 4.6-point disparity between White frontline and non-frontline workers.

CONCLUSION

Latinx workers and Black frontline workers disproportionately reported pandemic-related stressors. To reduce stress on frontline workers during crises, worker protections like paid sick leave, universal access to childcare, and improved job security are needed, particularly for those disproportionately affected by structural inequities, such as racially minoritized populations.

Shared Decision-making Lowers Medical Expenditures and the Effect Is Amplified in Racially-Ethnically Concordant Relationships

BACKGROUND

Racial-ethnic disparities are pervasive in health care. One mechanism that may underlie disparities is variation in shared decision-making (SDM), which encompasses high-quality clinician-patient communication, including deliberative discussions about treatment options.

OBJECTIVES

To determine whether SDM has causal effects on outcomes and whether these effects are stronger within racial-ethnic concordant clinician-patient relationships.

RESEARCH DESIGN

We use instrumental variables to estimate the causal effect of SDM on outcomes.

SUBJECTS

A total of 60,584 patients from the 2003-2017 Integrated Public Use Microdata Series Medical Expenditure Panel Survey. Years 2018 and 2019 were excluded due to changes in the Medical Expenditure Panel Survey that omitted essential parts of the SDM index.

MEASURES

Our key variable of interest is the SDM index. Outcomes included total, outpatient, and drug expenditures; physical and mental health; and the utilization of inpatient and emergency services.

RESULTS

SDM lowers annual total health expenditures for all racial-ethnic groups, but this effect is only moderated among Black patients seen by Black clinicians, more than doubling in size relative to Whites. A similar SDM moderation effect also occurs for both Black patients seen by Black clinicians and Hispanic patients seen by Hispanic clinicians with regard to annual outpatient expenditures. There was no significant effect of SDM on self-reported physical or mental health.

CONCLUSIONS

High-quality SDM can reduce health expenditures without negatively impacting overall physical or mental health, supporting a business case for health care organizations and systems to improve racial-ethnic clinician-patient concordance for Black and Hispanic patients.

Hospital Characteristics Associated With Clinically Integrated Network Participation

BACKGROUND

Increased integration of physician organizations and hospitals into health systems has not necessarily improved clinical integration or patient outcomes. However, federal regulators have issued favorable opinions for clinically integrated networks (CINs) as a way to pursue coordination between hospitals and physicians. Hospital organizational affiliations, including independent practice associations (IPA), physician-hospital organizations (PHOs), and accountable care organizations (ACOs), may support CIN participation. No empirical evidence, however, exists about factors associated with CIN participation.

METHODS

Data from the 2019 American Hospital Association survey (n = 4405) were analyzed to quantify hospital CIN participation. Multivariable logistic regression models were estimated to examine whether IPA, PHO, and ACO affiliations were associated with CIN participation, controlling for market factors and hospital characteristics.

RESULTS

In 2019, 34.6% of hospitals participated in a CIN. Larger, not-for-profit, and metropolitan hospitals were more likely to participate in CINs. In adjusted analyses, hospitals participating in CINs were more likely to have an IPA (9.5% points, P < 0.001), a PHO (6.1% points, P < 0.001), and ACO (19.3% points, P < 0.001) compared with hospitals not participating in a CIN.

CONCLUSIONS

Over one-third of hospitals participate in a CIN, despite limited evidence about their effectiveness in delivering value. Results suggest that CIN participation may be a response to integrative norms. Future work should attempt to better define CIN participation and strive to disentangle overlapping organizational participation.

Impact of a selective narrow network with comprehensive patient navigation on access, utilization, expenditures, and enrollee experiences

OBJECTIVE

To examine the effect of enrollee switching from a broad-network accountable care organization (ACO) health maintenance organization (HMO) to a "high performance" ACO-HMO with a selective narrow network and comprehensive patient navigation system on access, utilization, expenditures, and enrollee experiences.

DATA SOURCES

Secondary administrative data were obtained for 2016-2020, and primary interview and survey data in 2021.

STUDY DESIGN

Fixed-effects instrumental variable analyses of administrative data and regression analyses of survey data. Outcomes included access, utilization, expenditures, and enrollee experience. Background information was gathered via interviews.

DATA COLLECTION/EXTRACTION METHODS

We obtained medical expenditure/enrollment and access data on continuously enrolled members in a broad-network ACO-HMO (n = 24,555), a subset of those who switched to a high-performance ACO-HMO in 2018 (n = 7664); interviews of organizational leaders (n = 13); and an enrollee survey (n = 512).

PRINCIPAL FINDINGS

Health care effectiveness data and information Set (HEDIS) access measures were not different across plans. However, annual utilization dropped by 15.5 percentage points (95% CI: 18.1, 12.9) more in the high-performance ACO-HMO, with relative annual expenditures declining by $1251 (95% CI: $1461, $1042) per person per year. High-performance ACO-HMO enrollees were 10.1 percentage points (95% CI 0.001, 0.201) more likely to access primary care usually or always as soon as needed and 11.2 percentage points (95% CI 0.007, 0.217) more likely to access specialty care usually or always as soon as needed. Plan satisfaction was 7.1 percentage points (95% CI: -0.001, 0.138) higher in the high-performance ACO-HMO. Interviewees noted the comprehensive patient navigation system was designed to ensure patients remained in the narrow network to receive care.

CONCLUSIONS

ACO and HMO contracts with selective narrow networks supported by comprehensive patient navigation can reduce expenditures and improve specialty access and patient satisfaction compared to broad-network plans that lack these features. Payers should consider implementing narrow networks with comprehensive support systems.

Telehealth Use, Care Continuity, and Quality: Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic

BACKGROUND

Community health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients' experiences, it is unclear whether telehealth supported this relationship.

OBJECTIVE

We examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth.

RESEARCH DESIGN

This was a cohort study.

PARTICIPANTS

Electronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020.

METHODS

Multivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020.

RESULTS

MMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P<0.001; 2020: OR=1.50, marginal effect=0.63, z=147.73, P<0.001] and telehealth use (2019: OR=1.50, marginal effect=0.85, z=122.87, P<0.001; 2020: OR=10.00, marginal effect=0.90, z=155.57, P<0.001) were associated with higher odds of A1c testing. MMCI was associated with lower systolic (β=-2.90, P<0.001) and diastolic blood pressure (β=-1.44, P<0.001) in 2020, and lower A1c values (2019: β=-0.57, P=0.007; 2020: β=-0.45, P=0.008) in both years. In 2020, telehealth use mediated 38.7% of the relationship between MMCI and A1c testing.

CONCLUSIONS

Higher care continuity is associated with telehealth use and A1c testing, and lower A1c and blood pressure. Telehealth use mediates the association of care continuity and A1c testing. Care continuity may facilitate telehealth use and resilient performance on process measures.

COVID-19 Policies, Pandemic Disruptions, and Changes in Child Mental Health and Sleep in the United States

IMPORTANCE

The adverse effects of COVID-19 containment policies disrupting child mental health and sleep have been debated. However, few current estimates correct biases of these potential effects.

OBJECTIVES

To determine whether financial and school disruptions related to COVID-19 containment policies and unemployment rates were separately associated with perceived stress, sadness, positive affect, COVID-19-related worry, and sleep.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was based on the Adolescent Brain Cognitive Development Study COVID-19 Rapid Response Release and used data collected 5 times between May and December 2020. Indexes of state-level COVID-19 policies (restrictive, supportive) and county-level unemployment rates were used to plausibly address confounding biases through 2-stage limited information maximum likelihood instrumental variables analyses. Data from 6030 US children aged 10 to 13 years were included. Data analysis was conducted from May 2021 to January 2023.

EXPOSURES

Policy-induced financial disruptions (lost wages or work due to COVID-19 economic impact); policy-induced school disruptions (switches to online or partial in-person schooling).

MAIN OUTCOMES AND MEASURES

Perceived stress scale, National Institutes of Health (NIH)-Toolbox sadness, NIH-Toolbox positive affect, COVID-19-related worry, and sleep (latency, inertia, duration).

RESULTS

In this study, 6030 children were included in the mental health sample (weighted median [IQR] age, 13 [12-13] years; 2947 [48.9%] females, 273 [4.5%] Asian children, 461 [7.6%] Black children, 1167 [19.4%] Hispanic children, 3783 [62.7%] White children, 347 [5.7%] children of other or multiracial ethnicity). After imputing missing data, experiencing financial disruption was associated with a 205.2% [95% CI, 52.9%-509.0%] increase in stress, a 112.1% [95% CI, 22.2%-268.1%] increase in sadness, 32.9% [95% CI, 3.5%-53.4%] decrease in positive affect, and a 73.9 [95% CI, 13.2-134.7] percentage-point increase in moderate-to-extreme COVID-19-related worry. There was no association between school disruption and mental health. Neither school disruption nor financial disruption were associated with sleep.

CONCLUSIONS AND RELEVANCE

To our knowledge, this study presents the first bias-corrected estimates linking COVID-19 policy-related financial disruptions with child mental health outcomes. School disruptions did not affect indices of children's mental health. These findings suggest public policy should consider the economic impact on families due to pandemic containment measures, in part to protect child mental health until vaccines and antiviral drugs become available.

The effect of social network strain on suicidal ideation among middle-aged adults with adverse childhood experiences in the US: A twelve-year nationwide study

Objective

Building on literature that measured the association between social network strain (SNS) and suicidal ideation using conventional regression analyses, we examined the effect of SNS, due to adverse childhood experiences (ACEs), on suicidal ideation using instrumental variables (IV) to eliminate the potential biases that may have occurred in earlier studies due to residual confounding.

Methods

This retrospective cohort study linked longitudinal data from the National Survey of Midlife Development in the United States (MIDUS) Refresher Biomarker Project (2012–2016), the MIDUS Refresher Project (2011–2014), the MIDUS 2 Biomarker Project (2004–2009), and the MIDUS 2 Project (2004–2006). Participants completed a phone interview, self-administered survey, and biomarker data collection. Exposure indicators included self-reported suicidal ideation, ACEs, and SNS from family, spouse, and friends. IV analysis was used to evaluate the continuous local average treatment effect of SNS on suicidal ideation when SNS only varied due to variation in ACEs.

Results

Our sample included 1703 middle-aged adults (52.9% females), which were followed up for 12 years. An IV probit model controlling for sociodemographic characteristics found a one-standard-deviation reduction in SNS reduced suicidal ideation by 22.6% (p < 0.01). A comprehensively controlled IV probit model found that a one-standard-deviation reduction in SNS is associated with a 21.4% (p = 0.05) decrease in suicidal ideation.

Conclusions

The causal pathway from SNS (due to ACEs) to suicidal ideation among middle-aged adults was established using IV analysis in this large-scale longitudinal study. The magnitude of this effect is sufficient to warrant the development of programs to improve social network relationships among family, friends, and spouses/partners. Suicide prevention programs addressing SNS may significantly reduce suicidal ideation among middle-aged Americans who have experienced ACEs.

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Social Network Strain (SNS) from family, spouse, and friends is common.

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SNS derives from demands, criticisms, disappointments, and irritations.

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SNS varies strongly with Adverse Childhood Experiences (ACEs).

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Reductions in SNS due to fewer ACEs decrease suicidal ideation.

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A one standard-deviation reduction in SNS lowers suicidal ideation by 20%.

Do aggregate, multimodal structural neuroimaging measures replicate regional developmental differences observed in highly cited cellular histological studies?

Influential investigations of postmortem human brain tissue showed regional differences in tissue properties at early phases of development, such as between prefrontal and primary sensory cortical regions. Large-scale neuroimaging studies enable characterization of age-related trajectories with much denser sampling of cortical regions, assessment ages, and demographic variables than postmortem tissue analyses, but no single imaging measure perfectly captures what is measured with histology. Using publicly available data from the Pediatric Imaging, Neurocognition, and Genetics (PING) study, including 951 participants with ages ranging from 3 to 21 years, we characterized cortical regional variability in developmental trajectories of multimodal brain imaging measures. Multivariate analyses integrated morphometric and microstructural cortical surface measures. To replicate foundational histological work showing delayed synapse elimination in middle frontal gyrus relative to primary sensory areas, we tested whether developmental trajectories differ between prefrontal and visual or auditory cortex. We extended this to a whole-cortex analysis of interregional differences, producing cortical parcellations with maximally different developmental trajectories. Consistent with the general conclusions of postmortem analyses, our imaging results suggest that prefrontal regions show a protracted period of greater developmental change; however, they also illustrate the challenges of drawing conclusions about the relative maturational phases of different brain regions.

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Multimodal, multivariate, nonlinear modeling, integrating morphometric and microstructural measures.

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Tested regional developmental differences previously found in highly influential cellular histological studies.

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Produced cortical parcellations with maximally different, multimodal, developmental trajectories.

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Findings converge with evidence from histological studies showing delayed prefrontal cortical development.

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Interregional differences vary by measure and illustrate complexities of defining which regions mature first.

Differences in Muscle Quantity and Quality by HIV Serostatus and Sex

OBJECTIVE

People with HIV (PWH) experience greater declines in both muscle function and muscle mass with aging. Whether changes in muscle quality and quantity with aging differ between men and women with HIV and the implications on muscle function are not established.

DESIGN

In coordinated substudies of the Multicenter AIDS Cohort Study and Women's Interagency HIV Study, participants completed physical function and falls assessments; total trunk/thigh density, inversely related to fatty infiltration, and area were quantified from computed tomography (CT) scans.

METHODS

Generalized linear models were used to explore variables affecting density/area, and associations between area/density and physical function and falls.

RESULTS

CT scans were available on 387 men (198 PWH) and 184 women (118 PWH). HIV serostatus was associated with greater lateralis, paraspinal, and hamstring area, but lower psoas area and density. Older age and female sex were associated with smaller trunk muscle area and lower density. Both lower muscle area and muscle density were associated with several measures of impaired physical function. The odds of falling were lower with greater hamstring density, but not associated with other measurers of muscle area or density.

CONCLUSIONS

In summary, older adults with HIV appear to have smaller and less dense (fattier) psoas, a key component in truncal stability and hip flexion that could have implications on physical function. The longitudinal associations of muscle area and density with physical function require careful investigation, with a particular focus on characteristics and interventions that can preserve muscle area, density, and function over time.

Association of patient engagement strategies with utilisation and spending for musculoskeletal problems in the USA: a cross-sectional analysis of Medicare patients and physician practices

OBJECTIVE

Musculoskeletal problems like hip and knee osteoarthritis and low-back pain are preference sensitive conditions. Patient engagement strategies (PES), such as shared decision-making and motivational interviewing, can help align patients' preferences with treatment options and potentially reduce spending. We assess the association of physician practice-level adoption of PES with utilisation and spending.

DESIGN

Cross-sectional study in which patients were matched across low, moderate and high levels of PES via coarsened exact matching.

SETTING

Primary and secondary care in 2190 physician practices.

PARTICIPANTS

39 336 hip, 48 362 knee and 67 940 low-back patients who were Medicare beneficiaries were matched to the 2017-2018 National Survey of Healthcare Organizations and Systems.

PRIMARY AND SECONDARY OUTCOME MEASURES

Total hip replacement (THR), total knee replacement (TKR), 1-2 level posterior lumbar fusion (LF), total annual spending, components of total annual spending.

RESULTS

Total annual spending for patients with musculoskeletal problems did not differ for practices with low versus moderate PES, low versus high PES or moderate versus high PES, but spending was significantly lower in some categories for practices with relatively higher PES adoption. For hospital-owned and health system-owned practices, the ORs of receiving LF were 0.632 (95% CI 0.396 to 1.009) for patients attributed to practices with high PES compared with patients attributed to practices with moderate PES. For independent practices, the odds of receiving THR were 1.403 (95% CI 1.035 to 1.902) for patients attributed to practices with moderate PES compared with patients attributed to practices with low PES.

CONCLUSIONS

Practice-level adoption of PES for patients with musculoskeletal problems was generally not associated with total spending. PES, however, may steer patients toward evidence-based treatments. Opportunities for overall spending reduction exist as indicated by the variation in the subcomponents of total spending by PES adoption.

Understanding the distributional impacts of health insurance reform: Evidence from a consumer cost-sharing program

We examine the heterogeneous effects of reference pricing, a health insurance reform introduced by the California Public Employees' Retirement System (CalPERS), on the distribution of spending by patients and insurers. Using medical claims data for CalPERS and a comparison group not subject to reference pricing, we use the changes-in-changes approach to estimate the quantile treatment effects of the program across different medical procedures. We find that the quantile treatment effects vary across the patient spending distributions, with a range of positive and negative estimates of the QTE, depending on the medical procedure considered. However, across all procedures, the insurer's spending distributions tend to shift left, with the largest reductions occurring in the right-tail of the spending distributions. These effects are not captured by mean estimates but have important policy implications.

Price Differences To Insurers For Infused Cancer Drugs In Hospital Outpatient Departments And Physician Offices

The prices paid in 2019 by Blue Cross Blue Shield health plans in hospital outpatient departments were double those paid in physician offices for biologics, chemotherapies, and other infused cancer drugs (99-104 percent higher) and for infused hormonal therapies (68 percent higher). Had these plans excluded hospital clinics from their networks, channeling all of the infusions to physician offices, they would have saved $1.28 billion per year, or 26 percent of what they actually paid. Had they relied on cost-sharing incentives to channel infusions to physician offices-with either uniform 20 percent coinsurance or reference pricing-they would have realized savings but increased the financial burden on patients who received care at the higher-price hospital clinics. Under 20 percent coinsurance, patients' payment obligations for care at hospital clinics would have exceeded those for care in physician offices by a median of 67 percent for biologics, 72 percent for chemotherapies, 87 percent for hormonal therapies, and 75 percent for other cancer drugs. Large savings are potentially available to commercial insurers from shifting cancer infusion care to nonhospital settings, but cost-sharing burdens could become very high for patients.

Testosterone use and shorter electrocardiographic QT interval duration in men living with and without HIV

OBJECTIVES

Testosterone usage (T-use) may alter risk factors for sudden cardiac death in men living with HIV (MLWH). Electrocardiographic QT interval prolongation, which could potentiate ventricular arrhythmias, has previously been associated with HIV infection and, separately, with low testosterone levels. We investigated whether T-use shortens the QT interval duration in MLWH and HIV-uninfected men.

METHODS

We utilized data from the Multicenter AIDS Cohort Study, a prospective, longitudinal study of HIV infection among men who have sex with men. Multivariable linear regression analyses were used to evaluate associations between T-use and corrected QT interval (QTc) duration.

RESULTS

Testosterone usage was more common in MLWH compared with HIV-uninfected men (19% vs. 9%). In a multivariable regression analysis, T-use was associated with a 5.7 ms shorter QT interval [95% confidence interval (CI): -9.5 to -1.9; P = 0.003). Furthermore, stronger associations were observed for prolonged duration of T-use and recent timing of T-use.

CONCLUSIONS

This study is the first known analysis of T-use and QTc interval in MLWH. Overall, our data demonstrate that recent T-use is associated with a shorter QTc interval. Increased T-use duration above a threshold of ≥ 50% of visits in the preceding 5 years was associated with a shorter QTc interval while lesser T-use duration was not.

Reducing the prevalence of low-back pain by reducing the prevalence of psychological distress: Evidence from a natural experiment and implications for health care providers

OBJECTIVE

To determine whether exogenously reduced psychological distress reduces reported low-back pain (LBP) and is associated with reduced medical visits for LBP.

DATA SOURCES

National Health Interview Survey, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, 1998-2004.

STUDY DESIGN

We estimate a fuzzy regression discontinuity model in which a discontinuity in the prevalence of psychological distress is identified by exogenous national events. We examine whether this discontinuity induced a corresponding discontinuity in the prevalence of LBP. We additionally estimate a regression discontinuity model to determine associated changes in medical visits with LBP as the primary complaint.

PRINCIPAL FINDINGS

The prevalence of LBP was discontinuously reduced by one-fifth due to the exogenous national discontinuous reduction in psychological distress. This discontinuity in LBP cannot be explained by discontinuities in employment, insurance, injuries/poisoning, general health status, or other factors. We find an associated three-fifth discontinuous reduction in medical visits with LBP as the primary complaint.

CONCLUSIONS

On a monthly basis, 2.1 million (P < .01) adults ceased to suffer LBP due to the national reduction in psychological distress, and associated medical visits with LBP as the primary complaint declined by 685 000 (P < .01).

Does the Implementation of Reference Pricing Result in Reduced Utilization? Evidence From Inpatient and Outpatient Procedures

Reference pricing (RP) is an insurance design that can be used to incentivize patients to use low-price settings. While RP is not intended to affect overall utilization, it could unintentionally reduce utilization. We examined whether utilization was reduced when a large employer adopted RP for selected elective surgeries, including inpatient joint replacement surgery and outpatient cataract surgery, colonoscopy, and arthroscopic surgery. Data included a treatment group subject to RP implementation and a comparison group that was not. We applied autoregressive integrated moving average analysis as comparison-population interrupted time-series analysis to determine whether there were procedure reductions following RP implementation. We find no evidence of short-term decreases (within 3 months of RP implementation). However, we find very modest declines of approximately 14 (20%) fewer arthroscopic knee surgeries 6 months after RP implementation and 129 (17.2%) fewer colonoscopies 8 months after RP implementation. There were no declines in the other procedures examined.

Low Urologist Density Predicts High-Cost Surgical Treatment of Stone Disease

Introduction and Objectives: Lack of access to urologic specialists is approaching crisis levels as the number of urologists is decreasing, while the demand for urologic care is increasing. The financial implications of this have not been explored. The objective of this study is to examine the impact of access and other patient factors on cost to treat urolithiasis. We hypothesized that markers of poor access would associate with higher costs of surgical encounters for patients presenting with urolithiasis. Methods: A retrospective review of prospectively collected data from the Registry for Stones of the Kidney and Ureter (ReSKU) from September 2015 to July 2018 was conducted to investigate characteristics of surgical patients treated for urinary stone disease. Univariate analysis was performed using the Welch two-sample t-test. Multivariate analysis was performed using logistic regression. Statistical analysis was performed in R version 3.5. Results: When taking into account age, delayed presentation, procedure type, stone size >20 mm, American Society of Anesthesiologists (ASA) code, gender, race, income, distance, urologist density, body mass index, diabetes, infection, education, language, insurance, and stone complexity, patients undergoing percutaneous nephrolithotomy procedure (p < 0.001; odds ratio [OR] 12.9, confidence interval [CI] 4.05-48.5), urologist density in the bottom quartile (p = 0.014; OR 4.66, CI 1.40-16.9), diabetes (p = 0.018; OR 4.38, CI 1.32-15.6), and infection (p = 0.007; OR 4.51, CI 1.55-14.0) were the only variables statistically significant for association with top quartile of total cost. Conclusions: Surgical encounter costs are largely dictated by patient clinical factors, but low regional urologist density appears to independently predicted for high-cost stone surgery. Increasing patients' access to a urologist may prove to be financially beneficial in the longitudinal reduction in health care costs for stone disease.

The FUTUREPAIN study: Validating a questionnaire to predict the probability of having chronic pain 7-10 years into the future

OBJECTIVES

The FUTUREPAIN study develops a short general-purpose questionnaire, based on the biopsychosocial model, to predict the probability of developing or maintaining moderate-to-severe chronic pain 7-10 years into the future.

METHODS

This is a retrospective cohort study. Two-thirds of participants in the National Survey of Midlife Development in the United States were randomly assigned to a training cohort used to train a predictive machine learning model based on the least absolute shrinkage and selection operator (LASSO) algorithm, which produces a model with minimal covariates. Out-of-sample predictions from this model were then estimated using the remaining one-third testing cohort to determine the area under the receiver operating characteristic curve (AUROC). An optimal cut-point that maximized sensitivity and specificity was determined.

RESULTS

The LASSO model using 82 variables in the training cohort, yielded an 18-variable model with an out-of-sample AUROC of 0.85 (95% Confidence Interval (CI): 0.80, 0.91) in the testing cohort. The sum of sensitivity (0.88) and specificity (0.76) was maximized at a cut-point of 17 (95% CI: 15, 18) on a 0-100 scale where the AUROC was 0.82.

DISCUSSION

We developed a short general-purpose questionnaire that predicts the probability of an adult having moderate-to-severe chronic pain in 7-to-10 years. It has diagnostic ability greater than 80% and can be used regardless of whether a patient is currently experiencing chronic pain. Knowing which patients are likely to have moderate-to-severe chronic pain in the future allows clinicians to target preventive treatment.

Reference-Based Benefits for Colonoscopy and Arthroscopy: Large Differences in Patient Payments Across Procedures but Similar Behavioral Responses

This study examines how reference-based benefits (RBB) affect patient out-of-pocket payments across outpatient procedures. The California Public Employees' Retirement System (CalPERS) implemented RBB asymmetrically for outpatient procedures in 2012, only applying RBB to outpatient procedures performed in a hospital outpatient department (HOPD), and not applying RBB to outpatient procedures performed in a lower cost ambulatory surgery center. Using claims data (2009-2013) on arthroscopy and colonoscopy services, we found that for colonoscopy, CalPERS patients paid an average of 63.9% (p < .01) more for HOPDs than ambulatory surgery centers in 2012. For arthroscopy, no statistically different cost sharing was found on average. However, high-priced HOPDs were 17.3% and 17.9% less likely to be chosen by CalPERS patients in 2012 for colonoscopy and arthroscopy, respectively. These magnitudes increased in 2013 to 25.2% and 24.2% less, respectively. Overall, responsiveness to RBB with regard to the most expensive HOPDs was similar despite varying cost sharing by procedure.

Physician and Patient Adjustment to Reference Pricing for Drugs

IMPORTANCE

Reference pricing has been shown to reduce drug spending in Europe and has been adopted by some employers and labor unions in the United States. Its association with patient cost sharing depends on whether and how quickly physicians adjust their prescribing patterns to favor the least costly alternatives within each therapeutic class.

OBJECTIVE

To examine whether the implementation of reference pricing is associated with physicians and patients shifting to lower-cost drugs, thereby reducing consumer cost sharing and the prices paid by employers.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation included employees of Catholic organizations who purchased health insurance through the Reta Trust and a random sample of employees of public sector organizations who purchased insurance through the California Public Employees' Retirement System (CalPERS) as a comparison group between July 1, 2010, and December 31, 2017. Data analysis was performed from January 1, 2019, to September 1, 2019.

EXPOSURES

The Reta Trust implemented reference pricing in July 2013; CalPERS did not adopt reference pricing during the study period.

MAIN OUTCOMES AND MEASURES

Probability that the drug prescribed was the least costly alternative within its therapeutic class, price paid per prescription, and patient cost sharing per prescription. Multivariable, difference-in-differences regression analysis of drug insurance claims was performed for patients before and after implementation of reference pricing, adjusted for patient characteristics, each drug's therapeutic class, and the month and year of the prescription.

RESULTS

During the study period, a total of 1.2 million prescriptions were submitted by 34 319 individuals covered by Reta Trust and 2.1 million prescriptions were submitted by 738 159 individuals covered by CalPERS. In the first 2.5 years after implementation of reference pricing, the percentage of prescriptions made for the low-priced drug within each therapeutic class increased by 5.1 percentage points (95% CI, 1.8 to 8.4 percentage points), patient cost sharing increased by 10.3% (95% CI, -1.6% to -23.6%; this difference was not statistically significant), and prices paid decreased by 19.1% (95% CI, -30.2% to -6.2%) for Reta Trust patients compared with CalPERS patients. During the subsequent 2-year postimplementation period, the percentage of prescriptions made for the low-priced drug increased an additional 6.2 percentage points (95% CI, 2.3 to 10.1 percentage points), patient cost sharing decreased by 21.3% (95% CI, -31.2% to -9.9%), and prices paid increased by 7.2% (95% CI, -12.6% to 31.4%; this difference was not statistically significant). Relative to the change experienced by the CalPERS population, during the study period, the share of prescriptions for lower-priced drugs increased by 6.3 percentage points (8.9% relative increase), the mean prescription drug price decreased by $9.5 (12.1% relative decrease), and the mean patient cost sharing decreased by $1.8 (4.3% relative decrease).

CONCLUSIONS AND RELEVANCE

In this study, reference pricing was associated with a combination of lower prices paid by employers and lower cost sharing by employees but with a time lag in prescribing habits by physicians.

Impact of Reference Pricing on Cost and Quality in Total Joint Arthroplasty

BACKGROUND

Prices for total joint arthroplasty vary widely. Insurers have experimented with reference-based benefit designs (reference pricing) to control costs by setting a contribution limit that covers lower-priced facilities but necessitates higher out-of-pocket payments at higher-priced facilities. The purpose of this study was to evaluate the impact of reference pricing on the cost and quality of care for total joint arthroplasty.

METHODS

The California Public Employees' Retirement System (CalPERS) implemented reference pricing for total joint arthroplasty in January 2011. We obtained data on 2,023 CalPERS patients who underwent total joint arthroplasty from January 2009 to December 2013 and comparison group data on 8,024 non-CalPERS patients from the same time period. Trends in 9 cost and quality-related metrics were compared between the CalPERS group and the comparison group: patient choice of a lower-priced hospital, insurer payment, consumer payment, 90-day complication rate, 90-day readmission rate, annual surgical volume of the chosen hospital, length of stay, travel distance, and rate of discharge to home. The impact of reference pricing was estimated with difference-in-differences multivariable regressions, adjusting for covariates.

RESULTS

An increase of 19 percentage points (95% confidence interval [CI], 13.0 to 25.6 percentage points; p < 0.01) in the selection of lower-priced hospitals was attributable to reference pricing, with a concurrent mean savings for the insurer of $5,067 (95% CI, $2,315 to $7,819; p < 0.01) and an increase in the mean patient out-of-pocket payment of $1,991 (95% CI, $1,053 to $2,929; p < 0.01). No significant change in any quality indicator was attributable to reference pricing, with the exception of an 8% reduction (95% CI, 3.3% to 12.7% reduction; p < 0.01) in the length of stay for hip replacement.

CONCLUSIONS

Reference pricing motivates patients to choose lower-priced hospitals for total joint arthroplasty, with no measurable adverse impact on quality. Reference pricing represents a viable strategy in the shift toward value-based care.

Variations in brain morphometry among healthy preschoolers born preterm

BACKGROUND

Preterm birth is associated with an increased risk of neonatal brain injury, which can lead to alterations in brain maturation. Despite being born without the most significant medical consequences of preterm birth, infants born early remain at increased risk for subtle brain injury that affects future neurodevelopment and functioning.

AIMS

To investigate the gray matter morphometry measures of cortical thickness, cortical surface area, and sulcal depth using MRI at 5 years of age in healthy children born preterm.

STUDY DESIGN

Cohort study.

SUBJECTS

Participants were 52 children born preterm (<33 weeks gestational age) and 37 children born full term.

OUTCOME MEASURES

Cortical segmentation and calculation of morphometry measures were completed using FreeSurfer version 5.3.0 and compared between groups using surface-based, voxel-wise analyses.

RESULTS

The preterm group had a significantly thinner cortex in temporal and parietal regions while cortical thickness was significantly larger within occipital and inferior frontal regions. Surface area was significantly reduced within the fusiform gyrus. Sulcal depth was significantly lower within the posterior parietal and inferior temporal regions but greater in the middle temporal and medial parietal regions.

CONCLUSIONS

Regional differences were found between preschoolers born preterm and full term in cortical thickness, surface area, and sulcal depth. Cortical thickness differences primarily overlapped with regions found in previous studies of older children and adults. Differences in sulcal depth may represent additional areas of maturational differences in preterm children. These findings likely represent a combination of delayed maturation and permanent alterations caused by the perinatal processes associated with preterm birth.

Associations between subcutaneous fat density and systemic inflammation differ by HIV serostatus and are independent of fat quantity

OBJECTIVES

Adipose tissue (AT) density measurement may provide information about AT quality among people living with HIV. We assessed AT density and evaluated relationships between AT density and immunometabolic biomarker concentrations in men with HIV.

DESIGN

Cross-sectional analysis of men enrolled in the Multicenter AIDS Cohort Study.

METHODS

Abdominal visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) density (Hounsfield units, HU; less negative = more dense) were quantified from computed tomography (CT) scans. Multivariate linear regression models described relationships between abdominal AT density and circulating biomarker concentrations.

RESULTS

HIV+ men had denser SAT (-95 vs -98 HU HIV-, P < 0.001), whereas VAT density was equivalent by HIV serostatus men (382 HIV-, 462 HIV+). Historical thymidine analog nucleoside reverse transcriptase inhibitor (tNRTI) use was associated with denser SAT but not VAT. In adjusted models, a 1 s.d. greater SAT or VAT density was associated with higher levels of adiponectin, leptin, HOMA-IR and triglyceride:HDL cholesterol ratio and lower hs-CRP concentrations in HIV- men. Conversely, in HIV+ men, each s.d. greater SAT density was not associated with metabolic parameter improvements and was significantly (P < 0.05) associated with higher systemic inflammation. Trends toward higher inflammatory biomarker concentrations per 1 s.d. greater VAT density were also observed among HIV+ men.

CONCLUSIONS

Among men living with HIV, greater SAT density was associated with greater systemic inflammation independent of SAT area. AT density measurement provides additional insight into AT density beyond measurement of AT quantity alone, and may have implications for metabolic disease risk.

The Growth Hormone Releasing Hormone Analogue, Tesamorelin, Decreases Muscle Fat and Increases Muscle Area in Adults with HIV

BACKGROUND

Tesamorelin, a growth hormone-releasing hormone analogue, decreases visceral adipose tissue in people living with HIV, however, the effects on skeletal muscle fat and area are unknown.

OBJECTIVES

The goals of this exploratory secondary analysis were to determine the effects of tesamorelin on muscle quality (density) and quantity (area).

DESIGN

Secondary, exploratory analysis of two previously completed randomized (2:1), clinical trials.

SETTING

U.S. and Canadian sites.

PARTICIPANTS

People living with HIV and with abdominal obesity. Tesamorelin participants were restricted to responders (visceral adipose tissue decrease ≥8%).

INTERVENTION

Tesamorelin or placebo.

MEASUREMENTS

Computed tomography scans (at L4-L5) were used to quantify total and lean density (Hounsfield Units, HU) and area (centimeters2) of four trunk muscle groups using a semi-automatic segmentation image analysis program. Differences between muscle area and density before and after 26 weeks of tesamorelin or placebo treatment were compared and linear regression models were adjusted for baseline and treatment arm.

RESULTS

Tesamorelin responders (n=193) and placebo (n=148) participants with available images were similar at baseline; most were Caucasian (83%) and male (87%). In models adjusted for baseline differences and treatment arm, tesamorelin was associated with significantly greater increases in density of four truncal muscle groups (coefficient 1.56-4.86 Hounsfield units; all p<0.005), and the lean anterolateral/abdominal and rectus muscles (1.39 and 1.78 Hounsfield units; both p<0.005) compared to placebo. Significant increases were also seen in total area of the rectus and psoas muscles (0.44 and 0.46 centimeters2; p<0.005), and in the lean muscle area of all four truncal muscle groups (0.64-1.08 centimeters2; p<0.005).

CONCLUSIONS

Among those with clinically significant decrease in visceral adipose tissue on treatment, tesamorelin was effective in increasing skeletal muscle area and density. Long term effectiveness of tesamorelin among people with and without HIV, and the impact of these changes in daily life should be further studied.

Influence of Socioeconomic Factors on Stone Burden at Presentation to Tertiary Referral Center: Data From the Registry for Stones of the Kidney and Ureter

OBJECTIVE

To determine social factors associated with advanced stone disease (defined as unilateral stone burden >2 cm) at time of presentation to a regional stone referral center. Little is known about social determinants of urolithiasis. We hypothesize that socioeconomic factors impact kidney stone severity at intake to referral centers.

METHODS

A retrospective review of the prospectively collected data from the Registry for Stones of the Kidney and Ureter from 2015 to 2018 was conducted to evaluate patient characteristics predictive of having a large (>2 cm) unilateral kidney stone. Data on patient age, gender, body mass index, diabetes, race, language, education level, infection, distance, income, referring regional urologist density, American Society of Anesthesiologists score, and stone analysis were evaluated.

RESULTS

Complete imaging and patient variable data was present in 650 of 1142 patients including 197 patients with unilateral stone burden >2 cm. On multivariate analysis, obesity, lower education level, increased distance from the referral center, and symptoms of infection predicted for unilateral stone burden greater than 2 cm. Among 191 patients with stone analysis data present, stone type, income, and urologist density predicted for unilateral stone burden greater than 2 cm.

CONCLUSION

In addition to known biological risk factors, patients with lower education levels and from regions of lower mean income were found to be more likely to present to our tertiary care center with stone burden greater than 2 cm. More research is needed to elucidate the social and societal determinants of advanced stone disease and the impact this has on population costs for stone treatment.

Reference pricing: The case of screening colonoscopies

We study the introduction of reference pricing to the California Public Employees' Retirement System. Reference pricing changes the relative price of using a hospital versus an ambulatory surgery center (ASC) for patients receiving a colonoscopy, leading to as good as random variation in patients' use of ASCs. We find a 10 percentage point increase in the share of patients using an ASC, leading to a $2300 to $1700 reduction in prices paid for patients who switch to ASCs. Our results suggest that the use of ASCs has a causal effect on prices paid and has no negative effect on patient health outcomes.

Neuroanatomical correlates of emotion-processing in children with unilateral brain lesion: A preliminary study of limbic system organization

In this study, MRI and DTI were employed to examine subcortical volume and microstructural properties (FA, MD) of the limbic network, and their relationships with affect discrimination in 13 FL (6 right FL, M = 10.17 years; 7 left FL; M = 10.09) and 13 typically-developing children (TD; M = 10.16). Subcortical volume of the amygdala, hippocampus and thalamus and FA and MD of the fornix and anterior thalamic radiation (ATR) were examined. Results revealed no group differences across emotion-perception tasks or amygdalar volume. However, contrasting neuroanatomical patterns were observed in right versus left FL youth. Right FL participants showed increased left hippocampal and thalamic volume relative to left FL participants; whereas, the latter group showed increased right thalamic volume. DTI findings also indicated right FL children show greater MD of right fornix than other groups, whereas, left FL youth showed greater MD of left fornix. Right FL youth also showed lower FA of right fornix than left FL children, whereby the latter showed greater FA of left fornix and ATR. Differential associations between DTI indices and auditory/visual emotion-perception were observed across FL groups. Findings indicate diverging brain-behavioral relationships for emotion-perception among right and left FL children.

Developmental differentiation of executive functions on the NIH Toolbox Cognition Battery

OBJECTIVE

The NIH Toolbox Cognition Battery (NTCB) is a brief computerized method for evaluating neuropsychological functions in children, adolescents, and adults. We examined how performance on the 2 executive function measures of cognitive flexibility and inhibitory control was related to performance on the other NTCB measures across development.

METHOD

Participants were 1,020 typically developing individuals between the ages of 3 and 21 from the Pediatric Imaging, Neurocognition, and Genetics Study who were divided into 5 age groups (3-6, 7-9, 10-13, 14-17, and 18-21). Scores were adjusted for sex, level of parental education, and family income.

RESULTS

Although the correlations between the 2 executive function measures were moderate and consistent across age groups, their correlations with the other 5 cognitive measures were highest in the youngest age group and decreased across the older age groups. Exploratory factor analysis revealed that all NTCB measures loaded onto a single factor for the 3- to 6-year-olds. Across the older age groups, the executive function and processing speed measures loaded onto one factor, and the vocabulary knowledge, oral reading, and working memory measures loaded onto a second factor.

CONCLUSIONS

These results indicate that younger children's performance on the NTCB is more intercorrelated and less differentiated, while performance on the NTCB executive function measures becomes more differentiated from performance on the other measures with development. These results support the hypothesis that executive functions become increasingly differentiated from other cognitive functions with development as the functional specialization of neural systems progresses throughout childhood and young adulthood. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

California's Drug Transparency Law: Navigating The Boundaries Of State Authority On Drug Pricing

The California drug transparency bill (SB-17), signed into law in October 2017, seeks to promote transparency in pharmaceutical pricing, enhance understanding about pharmaceutical pricing trends, and assist in managing pharmaceutical costs. This article examines the legal and regulatory aspects of SB-17, explores legal challenges to the law, compares it to other state efforts to address rising drug prices, and discusses how California can maximize the impact of SB-17 by coupling the law with other incentives. While SB-17 might not significantly reduce drug prices, the new law represents a meaningful step for one state seeking to negotiate the political and legal boundaries of state action to rein in drug prices.

Firm responses to targeted consumer incentives: Evidence from reference pricing for surgical services

This paper examines how health care providers respond to a reference pricing insurance program that increases consumer cost sharing when consumers choose high-priced surgical providers. We use geographic variation in the population covered by the program to estimate supply-side responses. We find limited evidence of market segmentation and price reductions for providers with baseline prices above the reference price. Finally, approximately 75% of the reduction in provider prices is in the form of a positive externality that benefits a population not subject to the program.

To T or not to T: Differences in Testosterone Use and Discontinuation by HIV Serostatus among Men who Have Sex with Men

OBJECTIVES

The aim of the study was to characterize contemporary patterns and correlates of testosterone therapy (TTh) use and discontinuation by HIV serostatus among men in the Multicenter AIDS Cohort Study (MACS).

METHODS

Self-reported testosterone use data were collected semiannually from 2400 (1286 HIV-infected and 1114 HIV-uninfected) men who have sex with men. Multivariable Poisson regression was used to estimate prevalence ratios for TTh use and predictors of TTh discontinuation (2012-2015).

RESULTS

Use was higher among HIV-infected compared with HIV-uninfected men in all age strata, with an age-adjusted prevalence of 17% vs. 5%, respectively (adjusted prevalence ratio 3.7; P < 0.001). Correlates of use in the multivariable model were similar by HIV serostatus: white race, the Los Angeles (LA) site, more than one recent sexual partner, non-smoking status, and higher American Heart Association/American College of Cardiology (AHA/ACC) cardiovascular disease (CVD) risk score category (approximately 70% of testosterone users were in the high-risk category). Compared with HIV-uninfected men, HIV-infected men more frequently reported building muscle mass as a motivation for testosterone use. The TTh discontinuation rate was 20.9/100 person-years [95% confidence interval (CI) 17.3, 25.0/100 person-years]. Relative to HIV-uninfected men, HIV-infected men were half as likely to discontinue (adjusted incidence rate ratio 0.4; P < 0.001). Discontinuation was 40% higher in the period after the US Food and Drug Administration (FDA) safety communication for testosterone in 2014, independent of co-factors (P = 0.06).

CONCLUSIONS

Given the high prevalence of both TTh use and CVD risk among HIV-infected men, the benefits and risks of TTh should be examined in future studies of aging HIV-infected men and monitored routinely in clinical practice.

Williams Syndrome neuroanatomical score associates with GTF2IRD1 in large-scale magnetic resonance imaging cohorts: a proof of concept for multivariate endophenotypes

Despite great interest in using magnetic resonance imaging (MRI) for studying the effects of genes on brain structure in humans, current approaches have focused almost entirely on predefined regions of interest and had limited success. Here, we used multivariate methods to define a single neuroanatomical score of how William's Syndrome (WS) brains deviate structurally from controls. The score is trained and validated on measures of T1 structural brain imaging in two WS cohorts (training, n = 38; validating, n = 60). We then associated this score with single nucleotide polymorphisms (SNPs) in the WS hemi-deleted region in five cohorts of neurologically and psychiatrically typical individuals (healthy European descendants, n = 1863). Among 110 SNPs within the 7q11.23 WS chromosomal region, we found one associated locus (p = 5e-5) located at GTF2IRD1, which has been implicated in animal models of WS. Furthermore, the genetic signals of neuroanatomical scores are highly enriched locally in the 7q11.23 compared with summary statistics based on regions of interest, such as hippocampal volumes (n = 12,596), and also globally (SNP-heritability = 0.82, se = 0.25, p = 5e-4). The role of genetic variability in GTF2IRD1 during neurodevelopment extends to healthy subjects. Our approach of learning MRI-derived phenotypes from clinical populations with well-established brain abnormalities characterized by known genetic lesions may be a powerful alternative to traditional region of interest-based studies for identifying genetic variants regulating typical brain development.

Polygenic risk for psychiatric disorders correlates with executive function in typical development

Executive functions are a diverse and critical suite of cognitive abilities that are often disrupted in individuals with psychiatric disorders. Despite their moderate to high heritability, little is known about the molecular genetic factors that contribute to variability in executive functions and how these factors may be related to those that predispose to psychiatric disorders. We examined the relationship between polygenic risk scores built from large genome-wide association studies of psychiatric disorders and executive functioning in typically developing children. In our discovery sample (N = 417), consistent with previous reports on general cognitive abilities, polygenic risk for autism spectrum disorder was associated with better performance on the Dimensional Change Card Sort test from the NIH Cognition Toolbox, with the largest effect in the youngest children. Polygenic risk for major depressive disorder was associated with poorer performance on the Flanker test in the same sample. This second association replicated for performance on the Penn Conditional Exclusion Test in an independent cohort (N = 3681). Our results suggest that the molecular genetic factors contributing to variability in executive function during typical development are at least partially overlapping with those associated with psychiatric disorders, although larger studies and further replication are needed.

Through Thick and Thin: a Need to Reconcile Contradictory Results on Trajectories in Human Cortical Development

Understanding how brain development normally proceeds is a premise of understanding neurodevelopmental disorders. This has sparked a wealth of magnetic resonance imaging (MRI) studies. Unfortunately, they are in marked disagreement on how the cerebral cortex matures. While cortical thickness increases for the first 8-9 years of life have repeatedly been reported, others find continuous cortical thinning from early childhood, at least from age 3 or 4 years. We review these inconsistencies, and discuss possible reasons, including the use of different scanners, recording parameters and analysis tools, and possible effects of variables such as head motion. When tested on the same subsample, 2 popular thickness estimation methods (CIVET and FreeSurfer) both yielded a continuous thickness decrease from 3 years. Importantly, MRI-derived measures of cortical development are merely our best current approximations, hence the term "apparent cortical thickness" may be preferable. We recommend strategies for reaching consensus in the field, including multimodal neuroimaging to measure phenomena using different techniques, for example, the use of T1/T2 ratio, and data sharing to allow replication across analysis methods. As neurodevelopmental origins of early- and late-onset disease are increasingly recognized, resolving inconsistencies in brain maturation trajectories is important.

A multisample study of longitudinal changes in brain network architecture in 4-13-year-old children

Recent advances in human neuroimaging research have revealed that white-matter connectivity can be described in terms of an integrated network, which is the basis of the human connectome. However, the developmental changes of this connectome in childhood are not well understood. This study made use of two independent longitudinal diffusion-weighted imaging data sets to characterize developmental changes in the connectome by estimating age-related changes in fractional anisotropy (FA) for reconstructed fibers (edges) between 68 cortical regions. The first sample included 237 diffusion-weighted scans of 146 typically developing children (4-13 years old, 74 females) derived from the Pediatric Longitudinal Imaging, Neurocognition, and Genetics (PLING) study. The second sample included 141 scans of 97 individuals (8-13 years old, 62 females) derived from the BrainTime project. In both data sets, we compared edges that had the most substantial age-related change in FA to edges that showed little change in FA. This allowed us to investigate if developmental changes in white matter reorganize network topology. We observed substantial increases in edges connecting peripheral and a set of highly connected hub regions, referred to as the rich club. Together with the observed topological differences between regions connecting to edges showing the smallest and largest changes in FA, this indicates that changes in white matter affect network organization, such that highly connected regions become even more strongly imbedded in the network. These findings suggest that an important process in brain development involves organizing patterns of inter-regional interactions. Hum Brain Mapp 39:157-170, 2018. © 2017 Wiley Periodicals, Inc.

The moral hazard effects of consumer responses to targeted cost-sharing

This paper examines the effects of the reference pricing program implemented by the California Public Employees Retirement System (CalPERS) in 2012. The program uses targeted cost-sharing to incentivize patient price shopping. We find that the program leads to a 10.3% increase in the use of low-price providers and reduces the average cost per procedure by 12.5%. We further estimate that the program reduces medical spending by $218.8 per procedure, which we estimate is approximately 53.7% of the excessive spending that is due to patient choice of higher price providers caused by insurance coverage, at the expense of a $94.3 (or 12.5%) reduction in consumer surplus. The cost savings from the reference pricing program is about two to three times as large as the reduction from implementing a high-deductible health plan, while the accompanying consumer surplus reduction is much smaller under reference pricing.

Association of Reference Pricing with Drug Selection and Spending

Background In the United States, prices for therapeutically similar drugs vary widely, which has prompted efforts by public and private insurers to steer patients toward the lower-priced options. Under reference pricing, the insurer or employer establishes a maximum contribution it will make toward the price of a drug or procedure, and the patient pays the remainder. Methods We used difference-in-differences multivariable regression methods to analyze changes in prescriptions and pricing for 1302 drugs in 78 therapeutic classes in the United States, before and after implementation of reference pricing by an alliance of private employers. We assessed trends for the study group relative to those for an employee group that was not subject to reference pricing. The study included 1,122,741 prescriptions that were reimbursed during the period from 2010 through 2014. Results Implementation of reference pricing was associated with a higher percentage of prescriptions that were filled for the lowest-priced reference drug within its therapeutic class (difference in probability, 7.0 percentage points; 95% confidence interval [CI], 4.0 to 9.9), a lower average price paid per prescription (-13.9%; 95% CI, -23.8 to -2.7), and a higher rate of copayment by patients (5.2%; 95% CI, 0.2 to 10.4) than in the comparison group. During the first 18 months after implementation, spending for employers was $1.34 million lower and the amount of copayments for employees was $0.12 million higher than in the comparison group. Conclusions Implementation of reference pricing was associated with significant changes in drug selection and spending for a population of patients covered by employment-based insurance in the United States. (Funded by the Agency for Healthcare Research and Quality and the Genentech Foundation.).

Fall frequency and associated factors among men and women with or at risk for HIV infection

OBJECTIVES

Falls and fall-related injuries are a major public health concern. HIV-infected adults have been shown to have a high incidence of falls. Identification of major risk factors for falls that are unique to HIV infection or similar to those in the general population will inform development of future interventions for fall prevention.

METHODS

HIV-infected and uninfected men and women participating in the Hearing and Balance Substudy of the Multicenter AIDS Cohort Study and Women's Interagency HIV Study were asked about balance symptoms and falls during the prior 12 months. Falls were categorized as 0, 1, or ≥ 2; proportional odds logistic regression models were used to investigate relationships between falls and demographic and clinical variables and multivariable models were created.

RESULTS

Twenty-four per cent of 303 HIV-infected participants reported at least one fall compared with 18% of 233 HIV-uninfected participants (P = 0.27). HIV-infected participants were demographically different from HIV-uninfected participants, and were more likely to report clinical imbalance symptoms (P ≤ 0.035). In univariate analyses, more falls were associated with hepatitis C, female sex, obesity, smoking, and clinical imbalance symptoms, but not age, HIV serostatus or other comorbidities. In multivariable analyses, female sex and imbalance symptoms were independently associated with more falls. Among HIV-infected participants, smoking, a higher number of medications, and imbalance symptoms remained independent fall predictors, while current protease inhibitor use was protective.

CONCLUSIONS

Similar rates of falls among HIV-infected and uninfected participants were largely explained by a high prevalence of imbalance symptoms. Routine assessment of falls and dizziness/imbalance symptoms should be considered, with interventions targeted at reducing symptomatology.

Cortical morphology of the pars opercularis and its relationship to motor-inhibitory performance in a longitudinal, developing cohort

This study investigates the relationship between variability in cortical surface area and thickness of the pars opercularis of the inferior frontal gyrus and motor-inhibitory performance on a stop-signal task in a longitudinal, typically developing cohort of children and adolescents. Linear mixed-effects models were used to investigate the hypotheses that (1) cortical thinning and (2) a relatively larger cortical surface area of the bilateral pars opercularis of the inferior frontal gyrus would predict better performance on the stop-signal task in a cohort of 110 children and adolescents 4-13 years of age, with one to four observations (totaling 232 observations). Cortical thickness of the bilateral opercular region was not related to inhibitory performance. However, independent of age, gender, and total cortical surface area, relatively larger cortical surface area of the bilateral opercular region of the inferior frontal gyrus was associated with better motor-inhibitory performance. Follow-up analyses showed a significant effect of surface area of the right pars opercularis, but no evidence for an effect of area of left pars opercularis, on motor-inhibitory performance. These findings are consistent with the previous work in adults showing that cortical morphology of the pars opercularis is related to inhibitory functioning. It also expands upon this literature by showing that, in contrast to earlier work highlighting the importance of cortical thickness of this region in adults, relative cortical surface area of the pars opercularis may be related to developing motor-inhibitory functions during childhood and adolescence. Relationships between cortical phenotypes and individual differences in behavioral measures may vary across the lifespan.

Williams syndrome-specific neuroanatomical profile and its associations with behavioral features

Williams Syndrome (WS) is a rare genetic disorder with unique behavioral features. Yet the rareness of WS has limited the number and type of studies that can be conducted in which inferences are made about how neuroanatomical abnormalities mediate behaviors. In this study, we extracted a WS-specific neuroanatomical profile from structural magnetic resonance imaging (MRI) measurements and tested its association with behavioral features of WS. Using a WS adult cohort (22 WS, 16 healthy controls), we modeled a sparse representation of a WS-specific neuroanatomical profile. The predictive performances are robust within the training cohort (10-fold cross-validation, AUC = 1.0) and accurately identify all WS individuals in an independent child WS cohort (seven WS, 59 children with diverse developmental status, AUC = 1.0). The WS-specific neuroanatomical profile includes measurements in the orbitofrontal cortex, superior parietal cortex, Sylvian fissures, and basal ganglia, and variability within these areas related to the underlying size of hemizygous deletion in patients with partial deletions. The profile intensity mediated the overall cognitive impairment as well as personality features related to hypersociability. Our results imply that the unique behaviors in WS were mediated through the constellation of abnormalities in cortical-subcortical circuitry consistent in child WS and adult WS. The robustness of the derived WS-specific neuroanatomical profile also demonstrates the potential utility of our approach in both clinical and research applications.

The association between physical activity and cognition in men with and without HIV infection

OBJECTIVES

HIV-associated neurocognitive disorders are highly prevalent, and physical activity (PA) is a modifiable behaviour that may affect neurocognitive function. Our objective was to determine the association between PA and neurocognitive function and the effect of HIV on this association.

METHODS

PA was assessed in the Multicenter AIDS Cohort Study with the International Physical Activity Questionnaire. A neuropsychological test battery assessed global impairment and domain-specific impairment (executive function, speed of processing, working memory, learning, memory, and motor function) every 2 years. Semiannually, the Symbol Digit Modalities Test and Trail Making Test Parts A and B were performed. Adjusted logistic regression models were used to assess the PA-neurocognitive function association. Using longitudinal data, we also assessed the PA category-decline of neurocognitive function association with multivariate simple regression.

RESULTS

Of 601 men, 44% were HIV-infected. Low, moderate, and high PA was reported in 27%, 25%, and 48% of the HIV-infected men vs. 19%, 32% and 49% of the HIV-uninfected men, respectively. High PA was associated with lower odds of impairment of learning, memory, and motor function [odds ratio (OR) ranging from 0.52 to 0.57; P < 0.05 for all]. The high PA-global impairment association OR was 0.63 [95% confidence interval (CI) 0.39, 1.02]. Among HIV-infected men only, across multiple domains, the high PA-impairment association was even more pronounced (OR from 0.27 to 0.49). Baseline high/moderate PA was not associated with decline of any domain score over time. HIV infection was marginally associated with a higher speed of decline in motor function.

CONCLUSIONS

A protective effect of high PA on impairment in neurocognitive domains was observed cross-sectionally. Longitudinal PA measurements are needed to elucidate the PA-neurocognitive function relationship over time.

Reference Pricing Changes The 'Choice Architecture' Of Health Care For Consumers

Reference pricing in health insurance creates incentives for patients to select for nonemergency services providers that charge relatively low prices and still offer high quality of care. It changes the "choice architecture" by offering standard coverage if the patient chooses cost-effective providers but requires considerable consumer cost sharing if more expensive alternatives are selected. The short-term impact of reference pricing has been to shift patient volumes from hospital-based to freestanding surgical, diagnostic, imaging, and laboratory facilities. This article summarizes reference pricing's impacts to date on patient choice, provider prices, surgical complications, and employer spending and estimates its potential impacts if expanded to more services and a broader population. Reference pricing induces consumers to select lower-price alternatives for all of the forms of care studied, leading to significant reductions in prices paid and spending incurred by insurers and employers. The impact on consumer cost sharing is mixed, with some studies finding higher copayments and some lower. We conclude with a discussion of the incentives created for providers to redesign their clinical processes and for efficient providers to expand into price-sensitive markets. Over time, reference pricing may increase pressures for price competition and lead to further cost-reducing innovations in health care products and processes.