Medicaid Policy Changes in Mental Health Care and Their Effect on Mental Health Outcomes

In recent years, Medicaid has experienced a dramatic increase in spending on prescription drugs in general and psychotropic medications in particular. The purpose of this study is to examine the effects of increased Medicaid spending on psychotropic drugs on improving the mental health and well-being of participants at the population level. Specifically, we study the effect on outcomes that are strongly correlated with mood disorders, including depression, and Attention Deficit/Hyperactivity disorder, controlling for concomitant increases in Medicaid eligibility thresholds and expansion into managed care for mental health services. Knowledge of the effects of changes in the Medicaid program is crucial to policymakers as they consider implementing and expanding mental health services. Our results show that increased spending on antidepressants and stimulants are associated with improvements in some outcomes, but not in others.

How Do Youth with Mental Disorders Fare in the Juvenile Justice System?

The purpose of this paper is to examine the relationship between mental health problems and justice outcomes. Several studies have documented that individuals with a variety of mental disorders are overrepresented in the justice system. This pattern could result if persons with mental disorders are more likely to commit crimes, or more likely to commit serious crimes, than persons without disorders. In addition, individuals with mental disorders may be more likely than those without disorders to be sanctioned conditional on committing a particular crime. The major public policy concern is around the latter possibility, which has been interpreted as the justice system being biased against those with mental disorders. In this paper we explore several channels through which mental health problems, measured as ADHD and depression, may lead to over-representation in the criminal justice system. Using a large sample of adolescents, our findings show that youth with ADHD fare worse in the juvenile justice system in terms of the probability of being arrested and the probability of conviction once arrested. We find that elevated ADHD symptoms during adolescence are associated with statistically significant and meaningful increases in the probability of arrest and conviction after controlling for preexisting factors and mechanisms that may arise from the disorder itself.

Evaluating Commonwealth Coordinated Care: The Experiences of Individuals Dually Eligible for Medicare and Medicaid

Objectives 1. To understand Virginia’s rationale for implementing the Commonwealth Coordinated Care Program and its approach to evaluating it. 2. To provide a framework for examining the health care experiences of individuals with behavioral health and/or long-term service and support needs who are enrolled in the Commonwealth Coordinated Care Program. 3. To inform policy on future options for improving the quality and health care experiences of similar groups of individuals in Virginia and other states

Promoting Sustainable Responses to the US Opioid Epidemic With Community-Academic Partnerships: Qualitative Outcomes From a Statewide Program

Background: Drug overdose deaths in the United States have continued to increase at an alarming rate. The United States is facing two devastating public health crises– the opioid epidemic and the COVID-19 pandemic. Within this context, one of the most ambitious implementation studies in addiction research is moving forward. Launched in May 2019, the HEALing Communities Study (HCS) was developed by the National Institutes of Health (NIH) and the Substance Abuse and Mental Health Services Administration (SAMHSA) as part of the Helping to End Addiction Long-termSM Initiative (National Institutes of Health, 2020). The goal for this research was to reduce opioid overdose deaths by 40 % in three years by enhancing and integrating the delivery of multiple evidence-based practices (EBPs) with proven effectiveness in reducing opioid overdose deaths across health care, justice, and community settings. This paper describes the initial vision, goals, and objectives of this initiative; the impact of COVID-19; and the potential for knowledge to be generated from HCS at the intersection of an unrelenting epidemic of opioid misuse and overdoses and the ravishing COVID-19 pandemic.. The Substance Abuse and Mental Health Services Administration distributed more than $7 billion between January 2016 and June 2020 to address the drug overdose crisis. The funds were intended to support evidence-based responses, including medications for opioid use disorder, and other prevention, treatment and recovery activities. Although the SOR grants support much-needed community level interventions, many of the services they support may not be sustainable. Methods: This paper describes a statewide effort to support local entities through SAMHSA’s State Opioid Response (SOR) grants in Virginia. Our investigators conducted detailed needs assessment exercises with community agencies across the state, and collaboratively developed requests for proposals (RFPs) to sustain their SOR programs. We distributed the RFPs to prospective partners at universities across the state, and provided all responsive proposals to local agencies who selected the proposal most likely to meet their needs. Our investigators also conducted an inductive, three-phase content analysis approach to examine the RFPs submitted to the VHEOC to identify nominal categories of support requested of the academic partners. Results: Our investigators received and coded 27 RFPs from ten community agencies representing four of five regions of the state. We identified six nominal categories of academic support with high inter-coder agreement. The six categories of support requested of the academic partners were program development and support, literature review and best practices, outreach and education, data analysis and interpretation, program evaluation, and grant writing assistance. Several RFPs requested up to three categories of support in a single project. Conclusions: Our analysis of the requests received by the consortium identified several categories of academic support for SOR-grantees addressing the drug overdose crisis. The most common requests related to development and maintenance of supportive collaborations, which existing research has demonstrated is necessary for the long-term sustainability of SOR-funded services. In this way, the academic partners served as a source of support for sustainable SOR-funded programs. As the state opioid response program is implemented nationally, we hope that other states will consider similar models in response to the opioid crisis

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years

Background Enhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time. Objective To test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits. Design We compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity. Participants A total of 1,433,297 adults aged 18–64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013. Intervention CareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support. Measures Outcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits. Results By the third intervention year, annual adjusted total claims payments were $109 per participating member (95$192, −$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services. Conclusions A PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization

RELATO DE CASO: SÍNDROME DO DESFILADEIRO TORÁCICO

Abstract Introduction: Thoracic Outlet Syndrome (TOS) is a clinical entity with diverse symptomatology due to abnormal compression of brachial plexus in the thoracic outlet region. This compression is often carried out by the anterior scalene muscle, but it may be a result from the presence of musculofibrotic bands, alteration of the first rib morphology, cervical ribs and anomalous muscles. TOS can be classified into vascular and neurogenic types. Case description: Patient, female, 27 years old, with pain and paresthesia, since two years ago, insidious onset, in 4th and 5th fingers, and later with progression to all left upper limb (LUL). She looked for Emergency Care Unit, and only analgesic medication was prescribed. After three days, she presented pain intensification, associated with pallor and paresthesia of LUL, looking for care at the General Hospital of Palmas. Discussion: The TOS affects more women between 20-50 years old, with several contributing factors, limiting daily activities and work. The clinical treatment, often, is the initial conduct, seeking to relieve symptoms. In general, the surgical treatment is indicated in 15% of cases, when the syndrome is due to symptomatic bone anomalies and vascular complications. Keywords: Thoracic Outlet Syndrome; Cervical Rib; Brachial Plexus.RESUMO Introdução: A Síndrome do Desfiladeiro Torácico (SDT) é uma entidade clínica com sintomatologia diversa, decorrente de compressão anormal do plexo braquial, na região do desfiladeiro torácico. Esta compressão é exercida, na maioria das vezes, pelo músculo escaleno anterior, mas pode resultar também da existência de bandas musculofibróticas, alteração da morfologia da primeira costela, costelas cervicais e músculos anômalos. A SDT pode ser classificada nos tipos vascular e neurogênico. Descrição do caso: Paciente, sexo feminino, 27 anos, com quadro de dor e parestesia, há dois anos, de início insidioso, em 4º e 5º quirodáctilos e, posteriormente, com progressão para todo membro superior esquerdo (MSE). Procurou Unidade de Pronto Atendimento, sendo prescrito apenas medicação analgésica. Após três dias, apresentou intensificação da dor, associada a palidez e parestesia de MSE procurando atendimento no Hospital Geral de Palmas. Discussão: A SDT acomete mais mulheres entre 20-50 anos, com vários fatores contribuintes, chegando a limitar as atividades diárias e laborais. O tratamento clínico, frequentemente, é a conduta inicial, procurando aliviar os sintomas. Em geral, o tratamento cirúrgico tem indicação em 15 % dos casos, quando a síndrome é decorrente de anomalias ósseas sintomáticas e complicações vasculares.   Palavras-chave: Síndrome do Desfiladeiro Torácico; Costela Cervical; Plexo Braquial. ABSTRACT Introduction: Thoracic Outlet Syndrome (TOS) is a clinical entity with diverse symptomatology due to abnormal compression of brachial plexus in the thoracic outlet region. This compression is often carried out by the anterior scalene muscle, but it may be a result from the presence of musculofibrotic bands, alteration of the first rib morphology, cervical ribs and anomalous muscles. TOS can be classified into vascular and neurogenic types. Case description: Patient, female, 27 years old, with pain and paresthesia, since two years ago, insidious onset, in 4th and 5th fingers, and later with progression to all left upper limb (LUL). She looked for Emergency Care Unit, and only analgesic medication was prescribed. After three days, she presented pain intensification, associated with pallor and paresthesia of LUL, looking for care at the General Hospital of Palmas. Discussion: The TOS affects more women between 20-50 years old, with several contributing factors, limiting daily activities and work. The clinical treatment, often, is the initial conduct, seeking to relieve symptoms. In general, the surgical treatment is indicated in 15% of cases, when the syndrome is due to symptomatic bone anomalies and vascular complications. Keywords: Thoracic Outlet Syndrome; Cervical Rib; Brachial Plexus

Multi-ancestry genome-wide association meta-analysis of Parkinson’s disease

Although over 90 independent risk variants have been identified for Parkinson’s disease using genome-wide association studies, most studies have been performed in just one population at a time. Here we performed a large-scale multi-ancestry meta-analysis of Parkinson’s disease with 49,049 cases, 18,785 proxy cases and 2,458,063 controls including individuals of European, East Asian, Latin American and African ancestry. In a meta-analysis, we identified 78 independent genome-wide significant loci, including 12 potentially novel loci (MTF2, PIK3CA, ADD1, SYBU, IRS2, USP8, PIGL, FASN, MYLK2, USP25, EP300 and PPP6R2) and fine-mapped 6 putative causal variants at 6 known PD loci. By combining our results with publicly available eQTL data, we identified 25 putative risk genes in these novel loci whose expression is associated with PD risk. This work lays the groundwork for future efforts aimed at identifying PD loci in non-European populations

The genetic architecture of dog ownership: large-scale genome-wide association study in 97,552 European-ancestry individuals

Dog ownership has been associated with several complex traits, and there is evidence of genetic influence. We performed a genome-wide association study of dog ownership through a meta-analysis of 31,566 Swedish twins in 5 discovery cohorts and an additional 65,986 European-ancestry individuals in 3 replication cohorts from Sweden, Norway, and the United Kingdom. Association tests with >7.4 million single-nucleotide polymorphisms were meta-analyzed using a fixed effect model after controlling for population structure and relatedness. We identified 2 suggestive loci using discovery cohorts, which did not reach genome-wide significance after meta-analysis with replication cohorts. Single-nucleotide polymorphism-based heritability of dog ownership using linkage disequilibrium score regression was estimated at 0.123 (CI 0.038–0.207) using the discovery cohorts and 0.018 (CI −0.002 to 0.039) when adding in replication cohorts. Negative genetic correlation with complex traits including type 2 diabetes, depression, neuroticism, and asthma was only found using discovery summary data. Furthermore, we did not identify any genes/gene-sets reaching even a suggestive level of significance. This genome-wide association study does not, by itself, provide clear evidence on common genetic variants that influence dog ownership among European-ancestry individuals.publishedVersio

World guidelines for falls prevention and management for older adults: a global initiative

Background falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. Objectives to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. Methods a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. Recommendations all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. Conclusions the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception