JAMA Health Forum最新文献

Importance: Parental substance use is a primary driver of child welfare system involvement, and child welfare services primarily seek to address caregiver challenges, including connecting parents to treatment. Although research highlights that formal child welfare services connect children to health care professionals, less is known about how the system affects caregivers' substance use treatment.

Objective: To examine the prevalence of maternal substance use disorder (SUD) in the Pennsylvania child welfare system and the association between formal child welfare system response and mothers' take-up of SUD treatment.

Design, setting, and participants: This cohort study used linked Medicaid claims and child welfare system records for mothers enrolled in Medicaid and involved in the Pennsylvania child welfare system between 2015 and 2018, followed by 12 months postsystem contact. The study applied a difference-in-differences framework to estimate associations between child welfare system intervention and maternal SUD treatment utilization. Data were analyzed from January to September 2024.

Exposure: Child welfare system intervention was defined in 3 categories: no formal services, in-home services, and foster care services.

Main outcomes and measures: Maternal SUD was defined by International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes. Dependent variables were mothers' monthly and cumulative use of inpatient and outpatient SUD treatment, defined by procedure and service location codes.

Results: Among 46 484 mothers, the prevalence of maternal SUD was estimated at 62% within the child welfare system population, predominantly involving opioid and polysubstance use. Compared with mothers who did not receive a formal child welfare system response, those who received a formal intervention had a statistically significant higher probability of monthly outpatient (in-home services: 24%; 95% CI, 18%-28%; foster care: 63%; 95% CI, 55%-75%) and inpatient (in-home services: 36%; 95% CI, 23%-48%; foster care: 130%; 95% CI, 103%-156%) SUD treatment in the 12 months after referral.

Conclusions and relevance: This cohort study demonstrates that formal child welfare services can facilitate substance use treatment for caregivers. As states seek to reduce the role of formal child welfare system responses in responding to parental substance use, alternative strategies to engage and retain parents in treatment are needed.

Importance: Hemoglobin disorders are a considerable public health issue with more than 500 000 affected infants born annually worldwide. First introduced in the 1970s, newborn screening (NBS) for sickle cell disease (SCD) was included in the Recommended Uniform Screening Panel (RUSP) in 2006, a successful public health promotion and prevention practice that has led to improved childhood survival. Although SCD is the primary target, the screening process also detects many other hemoglobinopathies.

Observations: NBS programs, administered by individual states, vary in their practices for hemoglobinopathy screening, creating health inequities and compromising public health efforts. There is a lack of uniformity in the choice of primary screening test, reporting, and follow-up of abnormal results, exacerbated by inconsistent access to genetic confirmation. Consequently, newborns diagnosed through protein-based screening alone may have diverse genotypes that alter the clinical expression of hemoglobinopathies. This Special Communication considers how the universal adoption of molecular testing for hemoglobinopathy newborn screening can overcome these current shortcomings. Simultaneously, the considerable challenges of primary screening with molecular methods and how these can be overcome are evaluated. Screening with targeted genetic testing of the hemoglobin genes (HbA1, HBA2, HBB) is especially well suited to hemoglobinopathies because there exists an extensive database of variants for the prediction of pathogenicity, averting the need for secondary or multiple testing. Importantly, it would eliminate the health disparities created by location and health insurance on the access to confirmatory testing and facilitate timely referral for definitive care. Standardization of the screening platform with diagnostic specificity has vast implications for public health surveillance and resource allocation. The adoption of molecular testing requires bringing new technology online, training and changes to workflow, potentially increased cost, and concerns for genetic data protection. Some of these barriers can be overcome using high-throughput methods with the potential to multiplex with other disease conditions that use genetic testing for primary screening through the consolidation of platforms.

Conclusions and relevance: The time has come for a paradigm shift in newborn screening for hemoglobinopathies through the adoption of universal molecular genetic testing.