JAMA Network Open最新文献

Importance: In randomized trials, early prophylactic hydrocortisone improved survival without bronchopulmonary dysplasia (BPD) with few adverse effects in extremely preterm infants. Large scale implementation data are needed to evaluate clinical effects and safety.

Objective: To examine the association between early prophylactic hydrocortisone and survival without BPD at 36 weeks' postmenstrual age (PMA) in extremely preterm infants in Sweden after guideline implementation and to assess treatment safety.

Design, setting, and participants: A national historical cohort study with prospectively collected data from the Swedish Neonatal Quality register from 4 Swedish centers where hydrocortisone prophylaxis was implemented. The study included infants born between 22 and 27 weeks' gestation between 2018 and 2023. Infants were divided into exposed and nonexposed groups according to the intention-to-treat principle.

Exposure: Hydrocortisone, 1 mg/kg/d, for the first 7 days of life, followed by 0.5 mg/kg/d from days 8 through 10.

Main outcomes and measures: The primary outcome was survival without BPD at 36 weeks' PMA. A predefined statistical analysis plan with logistic regression was used to calculate unadjusted and adjusted odds ratios.

Results: Among 1106 infants (median [IQR] gestational age, 25 weeks, 6 days [24 weeks, 3 days to 27 weeks]; median [IQR] birth weight, 780 [610-964] g), 474 received hydrocortisone prophylaxis and 632 did not. Survival without BPD occurred in 154 of 474 exposed (32.5%) and 185 of 632 nonexposed (29.3%) infants (adjusted odds ratio, 1.62; 95% CI, 1.16-2.27). BPD occurred in 233 exposed (49.2%) and 345 nonexposed (54.6%) infants (adjusted odds ratio, 0.65; 95% CI, 0.49-0.86). Death before 36 weeks' PMA occurred in 87 exposed (18.4%) and 102 nonexposed (16.1%) infants. Late-onset bacterial infection was more common in exposed infants, but not significant after adjustment. No other severe neonatal morbidities differed significantly between the 2 groups.

Conclusions and relevance: In this cohort study of extremely preterm infants, the introduction of prophylactic hydrocortisone was associated with increased survival without BPD, after adjusting for covariates. There was no significant increase in severe neonatal morbidities, except that late-onset bacterial infection was more common in the exposed group before adjustments.

Importance: Despite strong guideline support, single maintenance and reliever therapy (SMART) for asthma is underused in the US. Limited insurance coverage of SMART-compatible inhalers remains a major barrier to its adoption.

Objective: To compare the annual asthma management costs of SMART vs traditional therapy from a US health care payer perspective.

Design, setting, and participants: This economic evaluation used a probabilistic decision-tree model with Monte Carlo simulations to compare the total asthma management costs for patients prescribed SMART vs traditional therapy, conducting analyses from September 1, 2024, to March 13, 2025. Input data were extracted through a systematic review of 6 randomized clinical trials as well as current asthma guidelines.

Exposures: SMART vs traditional therapy.

Main outcomes and measures: The main outcome was annual asthma-related costs to health care payers. Model inputs, including exacerbation rates and expected inhaler utilization, were extracted from prior randomized clinical trials. Morbidity data and medication costs were obtained from national databases and inflated to 2024 US dollars. Analyses used a 1-year time horizon and were repeated with and without quality-adjusted life-years (QALYs) considered.

Results: The model includes 11 988 individuals with moderate to severe asthma who participated in the randomized clinical trials. For patients prescribed SMART, the estimated total annual cost of asthma management was $2181 (95% CI, $1606-$2939) per patient compared with $2235 (95% CI, $1595-$3267) for traditional therapy. SMART was associated with an incremental gain of 0.0006 QALYs (95% CI, 0.0003-0.0011 QALYs) per patient. SMART was less costly in 57% of simulations when QALYs were excluded, was more cost-effective in 67% of simulations when QALYs were included, and produced a mean incremental net monetary benefit of $118 (95% CI, -$344 to $663) per patient per year.

Conclusions and relevance: The findings of this economic analysis suggest that SMART was associated with modest cost savings and improved health outcomes compared with traditional asthma therapy. Given its cost-effectiveness, demonstrated effectiveness, and strong guideline endorsement, expanding insurance coverage of SMART may reduce asthma-related morbidity while lowering costs to US health care payers.

Importance: The requirement for in-person, often daily, attendance at opioid treatment programs (OTPs) makes travel times a barrier to methadone treatment. Research on methadone accessibility has primarily focused on travel via personal vehicle, and there is uncertainty about public transit travel time to methadone treatment.

Objective: To estimate travel time via personal vehicle vs public transit to methadone treatment in the state of Connecticut.

Design, setting, and participants: This cross-sectional study included geospatial analysis of median travel time to nearest OTP via personal vehicle and public transit from all census block groups (CBGs). This study took place in the state of Connecticut in 2023. Participants were all CBGs in Connecticut.

Exposures: Participants were characterized by racial and ethnic demographics; household income; car ownership; urban, suburban, or rural designations; and per-capita opioid overdose deaths.

Main outcomes and measures: The primary outcome was the median travel time to nearest OTP by via personal vehicle and public transit. Spatial error models using k-nearest neighbor spatial weight matrices were estimated to assess the associations between sociodemographic characteristics and travel times for each transportation mode (personal vehicle vs public transit) at the CBG level.

Results: From the centroids of the 2702 CBGs in Connecticut, the median (IQR) travel time to the closest OTP was 11.0 (7.5-16.3) minutes by personal vehicle and 41.7 (31.0-49.5) minutes via public transit, with 1431 CBGs (53%) lacking access to public transit or having high public transit times (>60 minutes or no trip available). Travel times via public transit increased along the urban-rural gradient and across CBGs with an increasing percentage of non-Hispanic White residents. Median (IQR) travel times to an OTP from the 489 CBGs with the highest per-capita overdose death rates were 8.2 (5.9-11.7) minutes by personal vehicle and 37.6 (27.8-48.5) minutes by public transit, with 166 (34%) lacking public transit access.

Conclusions and relevance: The findings of this cross-sectional study of barriers to access to methadone treatment suggest that areas with high overdose death rates, low car ownership, and high public transit travel times should be targets for interventions (eg, mobile services or greater use of take-home doses for patients) to lower travel-based barriers to methadone. Current federal statutes and regulations governing methadone provision are the greatest barrier, as they directly require often daily transit to opioid treatment clinics. Reducing this barrier requires policy changes.