American Journal of Preventive Medicine最新文献

Introduction: In 2021, the USPSTF lowered the recommended age of colorectal cancer (CRC) screening initiation from 50 to 45 years. We assessed clinician response to the updated guideline in a major health system.

Methods: This was a retrospective cohort study of average-risk, CRC screening-naïve adults aged 45-50 years with a primary care appointment between July 2018 and February 2023. We defined the pre-guideline change period as July 2018-February 2020 (pre-period) and the post-guideline change period as July 2021-February 2023 (post-period). Clinician ordering of any CRC screening type was assessed. Mixed effects Poisson regression was used to model the incidence rate ratio (IRR) of a patient receiving a screening order, including an interaction between age (45-49 years versus 50 years) and time-period (pre- versus post-guideline change.) Variation in screening orders were also described by calendar quarter and clinician.

Results: There were 28,114 patients in the pre-period and 22,509 in the post-period. Compared to patients aged 40-49 years in the pre-period, those in the post-period were more likely to have screening ordered (IRR:12.1; 95%CI:11.3-13.0). The screening ordering rate increased for 50-year-olds from the pre- to the post-period (IRR:1.08;95%CI:1.01-1.16) and was slightly higher than that of 45-49-year-olds in the post-period (IRR:1.08; 95%CI:1.02-1.14). All clinicians increased their ordering rate for patients aged 45-49 years. Within five months of the guideline change, the ordering rate for 45-49-year-olds and 50-year-olds was nearly the same.

Conclusions: Rapidly following the guideline change, clinicians increased their screening ordering rate for 45-49-year-olds, indicating almost complete uptake of the recommendation.

Introduction: In 2016, Oregon developed an innovative policy to improve care for Medicaid patients with back pain. The objective of this study was to identify factors associated with dose reduction and discontinuation among Medicaid patients using chronic opioid therapy following implementation of this policy.

Methods: Using Medicaid administrative claims data, this was a retrospective cohort of patients on chronic stable opioid therapy between July and December 2016. Outcomes assessed were 1) 30% reduction in opioid dose and 2) an absolute discontinuation between January to December 2017. Multivariable logistic regressions evaluated association between dose reduction outcomes and clinical and demographic factors.

Results: Of 4,643 Medicaid patients on chronic opioid therapy, 3853 (83%) had a dose reduction and 651 (14%) discontinued opioids; patients with back pain were more likely to have a dose reduction (adjusted odds ratio [aOR] 1.19; 95% 1.01 to 1.41). Factors associated with discontinuation included having a mental health diagnosis (aOR 1.30; 95% CI 1.08 to 1.56), substance use disorder (aOR 1.90; 95% CI 1.41 to 2.56), opioid use disorder (aOR 1.55; 95% CI 1.21 to 1.99), and receipt of buprenorphine (aOR 2.82; 95% CI 1.30 to 6.15). Discontinuation was less likely in Black patients (aOR 0.50; 95% CI 0.29 to 0.85), in older age groups, and in those with a higher opioid dose at baseline.

Conclusions: Most Medicaid beneficiaries had a dose reduction following implementation of Oregon's back pain policy. Opioid discontinuation was associated with factors that suggest providers pursue this strategy for patients at higher overdose risk.

Introduction: Polycystic ovary syndrome (PCOS) is associated with hypertension in women, but few population studies have examined findings among adolescents. This retrospective study examines PCOS and hypertensive blood pressure (BP) in a large adolescent population receiving routine healthcare.

Methods: Among females aged 13-17 years who had a well-child visit with systolic/diastolic BP measured in a Northern California healthcare system (2013-2019), the outcome of hypertensive BP (≥130/80 mmHg) was examined. PCOS was based on clinical diagnosis (ICD-9/10 256.4/E28.2) within one year of the visit. Overweight and obesity were defined by body mass index 85^th to <95^th percentile and ≥95^th percentile, respectively; 1.7% with underweight (<5^th percentile) were excluded. Multivariable logistic regression was used to examine the association of PCOS and hypertensive BP, adjusting for age, race/ethnicity, BMI category, and estimated neighborhood deprivation index. Analyses were conducted in 2023-2024.

Results: The cohort included 224,418 females (mean age 14.9±1.4 years; 34.3% non-Hispanic White, 30.1% Hispanic, 19.5% Asian/Pacific Islander, and 9.7% Black. Overall, 18.7% had overweight and 15.8% had obesity. The prevalence of hypertensive BP was 7.2%, much higher for those with PCOS (18.2%) versus no PCOS (7.1%, p<0.001). In adjusted analyses, PCOS was associated with 1.25-fold greater odds of hypertensive BP [95% confidence interval 1.10-1.42]). Similar findings were seen among the subset with obesity (odds ratio 1.23 [1.06-1.42]).

Conclusions: Nearly 1 in 5 adolescents with PCOS had hypertensive BP. PCOS was associated with 25% increased adjusted odds of hypertensive BP, emphasizing the importance of BP surveillance in this population with higher cardiometabolic risk.

Introduction: Although posttraumatic stress disorder (PTSD) and depression are prominent mental health conditions affecting United States service members, only a subset of individuals with these conditions utilize mental healthcare services. Identifying factors associated with mental healthcare utilization may elucidate military subgroups with unmet mental healthcare needs.

Methods: Cross-sectional survey data from the 2019-2021 Millennium Cohort Study assessment were used to examine correlates of unmet mental healthcare needs among military personnel who screened positive for PTSD or depression symptoms (n=18,420) using modified Poisson regression models. Data analyses for this study were conducted between 2023 and 2024.

Results: Approximately 32-43% of service members reported receiving any mental healthcare in the past 12 months. Hispanic and Asian or Pacific Islander personnel, and those with certain service characteristics (higher pay grade, recent deployment, experienced discrimination) had a lower likelihood of mental healthcare utilization. Female sex, greater symptom severity, experiencing bullying, and other psychosocial factors were associated with greater likelihood of mental healthcare utilization.

Conclusions: One-third of service members with PTSD or depression symptoms reported any mental healthcare use, highlighting the need to identify factors that may impede or delay treatment. Racial and ethnic disparities in treatment utilization persist as do differences in utilization by military characteristics. Further research and initiatives are necessary to identify potential service-specific or cultural barriers and provide equitable quality and access to needed mental health services within the Military Health System.

Introduction: The mortality, long-term morbidity, and exacerbated healthcare needs due to firearm injury in the US are significant and growing. However, the relationship between exposure to a nonfatal firearm injury and long-term ED utilization is poorly understood. This study estimates the association between exposure to a nonfatal firearm injury and ED utilization in the subsequent year.

Methods: Using all-payer ED data among non-elderly adults in Georgia and New York, all ED visits for nonfatal firearm injuries from 2017-2018 were identified. Sociodemographic, clinical, and contextual characteristics between nonfatal firearm injury ED patients and the broader population of ED users were compared. ED utilization in the year following a nonfatal firearm injury relative to ED use in the year before, and compared to ED use by a propensity score matched control group was examined, using Poisson and negative binomial multivariable regressions. Analyses were performed in 2024.

Results: Nonfatal firearm injury ED patients were disproportionately male, younger, non-Hispanic Black, uninsured, and residents of areas with low median income and high firearm ownership. Compared to a matched control group, multivariable analyses indicated that nonfatal firearm injury ED patients had significantly higher risks of having hospital admissions through the ED (aRR: 1.42), all-cause injury-related ED visits (aRR: 1.47), non-firearm injury-related ED visits (aRR: 1.26), and additional nonfatal firearm injury-related ED visits (aRR: 325.45) in the subsequent year (p<0.001 for all). About one in every eight ED users with a firearm-related injury at index also sought ED care for another nonfatal firearm injury within one year.

Conclusions: Nonfatal firearm-related injuries contribute to preventable harm, health inequity and increased ED utilization.

Introduction: High tobacco smoking prevalence in people with low SES or serious psychological distress (SPD) in the U.S. may increase cardiovascular disease (CVD) risk among these marginalized subpopulations. We estimate how smoking disparities contribute to CVD disparities.

Methods: Using the Simulation of Tobacco and Nicotine Outcomes and Policy model, a validated microsimulation model of tobacco use and clinical outcomes, we used 2004-2019 data from the National Health Interview Survey to first compare 20-year cumulative CVD incidence for 40-year-olds by sex, smoking status, and marginalized subpopulation membership. Second, we simulated the marginalized subpopulations with representative age, sex, and smoking status distributions to estimate 20-year cumulative CVD incidence under status quo and counterfactual scenarios. In the counterfactual scenario, smoking prevalence and trends in the low SES and SPD subpopulations match those in the higher SES and non-SPD subpopulations, respectively.

Results: The model-projected impact of smoking on 20-year cumulative CVD incidence is considerably larger than the impact of low SES or SPD; for example, among 40-year-old males, cumulative CVD incidence is 28.3% for low SES people who currently smoke, 13.0% for low SES people who never smoke, and 26.2% for higher SES people who currently smoke. In the second analysis, in the status quo scenario, model-projected 20-year cumulative CVD incidence is 19.3% for low SES and 22.1% for SPD; in the counterfactual scenario, it is 18.1% for low SES and 19.6% for SPD.

Conclusions: Interventions focused on reducing smoking disparities could substantially reduce CVD in marginalized subpopulations.

Introduction: The US has required chain food establishments-including supermarkets-to display calorie labels on prepared (i.e., ready-to-eat) foods since 2018. Implementation of this supermarket calorie labeling policy reduced purchases of prepared foods from supermarkets, but it remains unknown whether the policy is cost-effective.

Methods: In 2023-2024, this study applied the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model to estimate the effects of the supermarket calorie labeling policy on health, costs, and cost-effectiveness over 10 years (2018-2027) for the US population. The model projected benefits overall and among racial, ethnic, and income subgroups. Sensitivity analyses varied assumptions about the extent to which consumers replace calorie reductions from prepared foods with calories from other sources (i.e., caloric compensation).

Results: From 2018-2027, the supermarket calorie labeling policy was projected to save $348 million in healthcare costs (95% Uncertainty Interval [UI]: $263-426 million), prevent 21,700 cases of obesity (95% UI: 18,200-25,400), including 3,890 cases of childhood obesity (95% UI: 2,680-5,120), and lead to 15,100 quality-adjusted life years (QALYs) gained across the US population (95% UI: 10,900-20,500). The policy was projected to prevent cases of obesity and childhood obesity across all racial, ethnic, and income groups. The policy was projected to be cost-saving when assuming low and moderate caloric compensation and cost-effective when assuming very high caloric compensation.

Conclusions: A policy requiring calorie labels on prepared foods in supermarkets was projected to be cost-saving or cost-effective and lead to reductions in obesity across all racial, ethnic, and income groups.

Introduction: Although health insurance is a critical tool for wellbeing across the life course, few studies have explored the long-term health implications of shifts in insurance coverage. This study examined whether changes in insurance types from adolescence to early midlife were associated with early midlife self-rated health.

Methods: This study used data from Wave I (1994-1995; average age 15.7 years), Wave IV (2008-2009; average age 28.7 years), and Wave V (2016-2018; average age 37.6 years) of Add Health, including 6,765 respondents from 1994-2018. Logistic regression was used to examine the association between health insurance status from adolescence to early midlife and early midlife self-rated health. The analyses were conducted from March - August 2024.

Results: Relative to having private insurance in adolescence and early midlife, the following health insurance statuses in adolescence and early midlife were significantly associated with poorer early midlife self-rated health: public in adolescence and early midlife (AOR=3.34; 95% CI=1.89, 5.91); uninsured in adolescence to public at early midlife (AOR=3.29; 95% CI=1.85, 5.85); private in adolescence to public at early midlife (AOR=3.36; 95% CI=2.46, 4.58), and private in adolescence to uninsured at early midlife (AOR=1.68; 95% CI=1.10, 2.55).

Conclusions: Health insurance statuses from adolescence to early midlife, specifically having or switching into public insurance, may be associated with poorer health in early midlife among individuals who were adolescents in the early 1990s. More research is needed to explore how insurance reform such as the Children's Health Insurance Program may have mitigated this association in future cohorts.

Introduction: Cardiovascular disease (CVD) is a leading cause of death among transgender women and people with HIV. Exogenous estrogen and psychosocial stressors are known risk factors for CVD. Yet, few studies have used biomarkers to examine the role of stress in CVD risk among transgender women with HIV (TWHIV). This analysis examined whether stress moderates relationships between gender-affirming hormone therapy (GAHT) duration and CVD risk among TWHIV.

Methods: This cross-sectional analysis of baseline data from an observational cohort of 108 Black and Latina TWHIV in Boston, New York, and Washington, DC, enrolled December 2020 - June 2022, measured socio-demographics, medical diagnoses, medications, smoking history, and perceived stress via interviewer-administered surveys. Physiological stress was measured with 14 biomarkers to calculate allostatic load indices (ALI). Forty participants provided saliva samples used to calculate cortisol awakening response and cortisol daily decline. The 2018 American College of Cardiology revised pooled cohort equation estimated 10-year CVD risk. Data were analyzed in 2024.

Results: GAHT duration was positively associated with CVD risk scores in bivariate regression. In multivariable linear regression models (adjusting for age, income, education), only age and ALI remained significantly associated with CVD risk scores [β 1.13, CI: 1.05, 1.21]. No stress measure significantly interacted with GAHT duration to affect CVD risk scores. In visual plots, GAHT duration increased CVD risk scores only for TWHIV experiencing the highest ALI.

Conclusions: Stress plays an important role in CVD in TWHIV. More research is needed on non-GAHT factors, which influence CVD health among transgender women.

Introduction: In guidance published in February 2020, the FDA described their intent to prioritize enforcement against the sale of flavored cartridge-based electronic nicotine delivery systems (ENDS) except tobacco and menthol flavors. This guidance was specific to cartridge-based ENDS and did not apply to other ENDS types or e-liquids sold in the United States (U.S.). It remains unknown if use of certain types of ENDS devices and flavors changed following the publication of this guidance.

Methods: This analysis includes PATH Study data from Wave 5 (W5, 2018-2019) and Wave 6 (W6, 2021) and examines cross-sectional estimates of 1) use of flavored ENDS and 2) use of different device types. All analyses in this study were stratified by self-reported age (youth - aged 12-17 years at W5 and aged 14-17 years at W6, and adults - aged 18-20, 21-24, and 25+). Analyses were conducted in 2023-2024.

Results: Among adults aged 21 years and over, there were significant increases in the use of menthol or mint flavored ENDS. There were no substantial changes in flavors of ENDS used among youth or adults aged 18-20 years. Among all age groups, the use of cartridge-based ENDS was lower in 2021 than 2018-2019, with a notable shift to disposable-style ENDS.

Conclusions: Federal-level tobacco control actions taken in the U.S. in early 2020 prioritized enforcement against "any flavored, cartridge-based ENDS product (other than a tobacco- or menthol-flavored ENDS product)". Based on this analysis, there was a shift following the policy to menthol or mint-flavored ENDS and disposable-style ENDS.