JAMA Network Open最新文献

Importance: Current evidence of the association between prenatal exposure to glucocorticoids and long-term mental disorders is scarce and has limitations.

Objective: To investigate the association between prenatal exposure to systemic glucocorticoids and mental disorders in offspring at the age of 15 years, comparing exposed vs unexposed offspring born to mothers with the same underlying disease (risk of preterm delivery and autoimmune or inflammatory disorders).

Design, setting, and participants: This nationwide population-based cohort study used data from registries in Denmark with follow-up until December 31, 2018. Participants included all Danish infants born alive from 1996 to 2016. Analyses were performed from January to December 2023.

Exposures: Prenatal exposure to systemic glucocorticoids.

Main outcomes and measures: Fifteen-year crude and adjusted risks, risk differences, and risk ratios (RR) for mental disorders using Kaplan-Meier estimator comparing exposed vs unexposed offspring born to mothers with the same underlying disease.

Results: A total of 1 061 548 infants (52% male) were included in the final study cohort, including 31 518 born to mothers at risk of preterm delivery and 288 747 born to mothers with autoimmune or inflammatory disorders. Among offspring born to mothers at risk of preterm delivery, the adjusted risks for exposed vs unexposed were 6.6% vs 4.3% (RR, 1.5 [95% CI, 1.2-1.9]) for autism spectrum disorders; 1.6% vs 1.3% (RR, 1.3 [95% CI, 0.8-1.8]) for intellectual disabilities; 5.8% vs 4.3% (RR, 1.3 [95% CI, 1.0-1.7]) for attention-deficit hyperactivity disorder (ADHD); and 7.2% vs 4.6% (RR, 1.5 [95% CI, 1.1-2.0]) for mood, anxiety, and stress-related disorders. Among offspring born to mothers with autoimmune or inflammatory disorders, the adjusted risks for exposed vs unexposed were 4.8% vs 3.8% (RR, 1.3 [95% CI, 1.1-1.5]) for autism spectrum disorders; 1.1% vs 0.8% (RR 1.4, [95% CI, 0.9-2.0]) for intellectual disabilities; 5.5% vs 4.4% (RR, 1.3 [95% CI, 1.0-1.5]) for ADHD; and 6.6% vs 4.6% (RR, 1.4 [95% CI, 1.2-1.8]) for mood, anxiety, and stress-related disorders. Findings were confirmed through an active comparator and sibling design. However, confounding by disease severity could not be ruled out.

Conclusions and relevance: In this cohort study, prenatal exposure to glucocorticoids was associated with higher risk of some mental disorders. These data support continued caution in the use of glucocorticoids in pregnant people.

Importance: Nearly all Medicare Advantage (MA) plans offer dental, vision, and hearing benefits not covered by traditional Medicare (TM). However, little is known about MA enrollees' use of those benefits or how much they cost MA insurers or enrollees.

Objective: To estimate use, out-of-pocket (OOP) spending, and insurer payments for dental, hearing, and vision services among Medicare beneficiaries.

Design, setting, and participants: This cross-sectional analysis used pooled 2017-2021 Medical Expenditure Panel Survey (MEPS) and Medicare Current Beneficiary Survey (MCBS) data for MA and TM beneficiaries (excluding those also covered by Medicaid). The analysis was performed from September 10, 2023, to June 30, 2024.

Exposures: MA compared with TM coverage.

Main outcomes and measures: The main outcome was receipt of eye examinations, corrective lenses, hearing aids, optometry and dental visits, and MA and TM enrollees' and insurers' spending for such services. MEPS and MCBS data were weighted to be nationally representative.

Results: We included 76 557 non-dually eligible Medicare beneficiaries, including 23 404 from the MEPS and 53 153 from the MCBS. Weighted demographic characteristics of MA and TM beneficiaries were similar (54.7% and 51.9% female; 39.8% and 35.2% older than 75 years, respectively). Only 54.2% (95% CI, 52.4%-55.9%) and 54.3% (95% CI 52.2%-56.3%) of MA beneficiaries were aware of having MA dental and vision coverage, respectively. MA enrollees were no more likely to receive eye examinations, hearing aids, or eyeglasses than TM enrollees. After adjustment for demographic differences, MA and TM enrollees paid OOP $205.86 (95% CI, $192.44-$219.27) and $226.12 (95% CI, $212.02-$240.23), respectively, for eyeglasses (MA - TM difference, -$20.27 [95% CI, -$33.77 to -$6.77] or -9.0% [95% CI, -14.9% to -3.0%]); $226.82 (95% CI, $202.24-$251.40) and $249.98 (95% CI, $226.22-$273.74) for dental visits, respectively (MA - TM difference, -$23.16 [95% CI, -$43.15 to -$3.17] or -9.3% [95% CI, -17.3% to -1.3%]); and no less for optometry visits or durable medical equipment (a proxy for hearing aids). Nationwide, MA plans' annual spending on vision, dental services, and durable medical equipment totaled $3.9 billion (95% CI, $3.3-$4.4 billion), while enrollees spent OOP $9.2 billion (95% CI, $8.2-$10.2 billion) annually for these services and other private insurers covered $2.8 billion (95% CI, $2.7-$3.0 billion).

Conclusions and relevance: In this cross-sectional study of 2 nationally representative surveys, MA beneficiaries did not receive more supplemental services than TM beneficiaries, possibly because of cost-sharing and limited awareness of benefit coverage.

Importance: Pregnant people with opioid use disorder (OUD) are at high risk for potentially avoidable maternal morbidity. The majority of pregnant people with OUD receive health insurance through state Medicaid programs, but there is little comprehensive data on the burden of severe maternal morbidity (SMM)-a composite measure of adverse maternal health outcomes-among this high-risk group.

Objective: To estimate rates of SMM among Medicaid-enrolled pregnant people with OUD from 2016 to 2018.

Design, setting, and participants: Using the Transformed Medicaid Statistical Information System Analytic Files, this cross-sectional study identified 96 309 pregnant people with OUD enrolled in Medicaid in 47 states with 108 975 deliveries between March 1, 2016, and November 16, 2018. Data were analyzed from August 1, 2023, to September 1, 2024.

Main outcome and measures: SMM was identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis and procedure codes for 20 relevant conditions and was measured per 10 000 live births nationally and by state. Rates of SMM were also stratified by the timing of Medicaid enrollment before delivery.

Results: From 2016 to 2018, 96 309 Medicaid enrollees had a diagnosis of OUD before a live birth (108 975 deliveries). The mean (SD) age of Medicaid-enrolled pregnant people with OUD was 28.8 (5.0) years. The mean (SD) rate of OUD among pregnant people enrolled in Medicaid was 324.8 (260.9) per 10 000 live births across states. Among this group, the mean (SD) unadjusted rate of SMM excluding blood transfusions among those with OUD was 292.1 (112.3) per 10 000 live births, with these rates varying substantially across states, from 101.0 per 10 000 live births in South Dakota to 682.2 per 10 000 live births in California. Adjustment for enrollee characteristics and comorbidities did not meaningfully alter the estimated rate of SMM (305.6 [95% CI, 245.2-408.2] per 10 000 live births). Rates of SMM generally increased with decreased durations of Medicaid enrollment.

Conclusions and relevance: This cross-sectional study of pregnant people enrolled in Medicaid found that the rate of OUD among this group was more than twice as high as previous estimates. Pregnant people with OUD face a disproportionately high risk of SMM, particularly those who enroll in Medicaid later in pregnancy. Targeted interventions that facilitate early Medicaid enrollment and coverage continuity may be needed to reduce the burden of adverse outcomes in this group.