Amie Goodin

Rural and Appalachian Disparities in Neonatal Abstinence Syndrome Incidence and Access to Opioid Abuse Treatment

OBJECTIVEnIncidence of neonatal abstinence syndrome (NAS) is increasing due to the rise in opioid use. Rural states like Kentucky have been disproportionally impacted by opioid abuse, and this study determines NAS burden nationally and in Kentucky while quantifying differences in access to care between Appalachian and non-Appalachian counties.nnnMETHODSnNAS rates were calculated using National (2013) and Kentucky (2008-2014) National Inpatient Sample discharge data. Births were identified using International Classification of Diseases v9 code 779.5 and live birth codes V30.x-V38.x. Counties were classified as rural, micropolitan, or metropolitan using census data. Proximity analysis was conducted via mapping from ZIP code centroid to nearest opioid treatment facility. Distance to treatment facilities was calculated and then compared using nonparametric testing for counties by rural and Appalachian status.nnnRESULTSnNAS cases tripled from 2008 to 2014 in Kentucky counties, with a 2013 NAS rate more than double the national NAS rate. Rural and Appalachian counties experienced an NAS increase per 1,000 births that was 2-2.5 times higher than urban/non-Appalachian counties, with a greater number of NAS births overall in Appalachian counties. All opioid treatment facility types were further from rural patients than micropolitan/metropolitan patients (P < .001), as well as further for Appalachians versus non-Appalachians (P < .001, all facility types).nnnCONCLUSIONSnNAS burden disparately affects rural and Appalachian Kentucky counties, while treatment options are disproportionately further away for these residents. Policy efforts to increase NAS prevention and encourage opioid abuse treatment uptake in pregnant women should address rural and Appalachian disparities.

Risk Stratification for Bleeding Complications in Patients With Venous Thromboembolism: Application of the HAS‐BLED Bleeding Score During the First 6 Months of Anticoagulant Treatment

Background The Hypertension, Abnormal renal/liver function, Stroke, Bleeding, Labile International Normalized Ratio (INR), Elderly, Drugs or alcohol use (HAS‐BLED) score has strong predictive validity for major bleeding complications, but limited validation has been conducted in venous thromboembolism (VTE). This study evaluates the HAS‐BLED score in a large cohort of VTE patients. Methods and Results A retrospective cohort of adults ≥18 years with primary diagnosis of VTE between January 1, 2010 and November 31, 2013 were identified in an insurance claims database. Patients were tracked until death, any bleed event, or end of study period. HAS‐BLED score and components were evaluated via proportional hazard models. Cumulative incidence functions were reported at 30, 60, 90, and 180 days. N=132 280 patients with a VTE were identified, with 73.8% having HAS‐BLED scores of 0 to 2, 3.6% score ≥4, and 4789 bleeding events (3.6% all patients). A 1‐point HAS‐BLED score increase was associated with 20% to 30% bleeding rate increase overall, but in a cancer cohort only the increase from 3‐ to 4‐points was significant for all bleeds (csHR=1.41, 95% CI: 1.17–1.69; sdHR=1.40, 95% CI: 1.17–1.69) and major bleeds (csHR=1.66, 95% CI: 1.26–2.20; sdHR=1.66, 95% CI: 1.25–2.19). Adding cancer to the model as an independent covariate provided the strongest association among all covariates, with csHR=2.25 (95% CI: 1.98–2.56) and sdHR=2.11 (95% CI: 1.85–2.41) in the model for major bleeds. Conclusions The HAS‐BLED score has good predictive validity for bleeding risks in patients with VTE. The addition of cancer as an independent bleeding risk factor merits consideration, possibly as part of the “B” criterion (“bleeding tendency or predisposition”).

The American College of Chest Physician score to assess the risk of bleeding during anticoagulation in patients with venous thromboembolism: comment

In patients with venous thromboembolism (VTE), the goal of anticoagulation is to treat the current VTE and to prevent recurrent VTE. However, anticoagulation also imposes an increased risk for bleeding events and this risk must be assessed to determine appropriateness of a given treatment plan for each patient. The American College of Chest Physicians (ACCP) guidelines for VTE management presented a set of 18 risk factors and scoring system to distinguish patients with a low, moderate, or high risk of bleeding. Having two or more of these risk factors was deemed high risk based on bleeding rate estimates from several studies and the scoring system was used to make recommendations for time-limited or extended treatment courses. This article is protected by copyright. All rights reserved.

Pharmacists’ role in harm reduction: a survey assessment of Kentucky community pharmacists’ willingness to participate in syringe/needle exchange

BackgroundPharmacists’ role in harm reduction is expanding in many states, yet there are limited data on pharmacists’ willingness to participate in harm reduction activities. This study assessed community pharmacists’ willingness to participate in one harm reduction initiative: syringe/needle exchange.MethodsIn 2015, all Kentucky pharmacists with active licenses were emailed a survey that examined attitudes towards participation in syringe/needle exchange. Response frequencies were calculated for community pharmacist respondents. Ordinal logistic regression estimated the impact of community pharmacist characteristics and attitudes on willingness to provide clean needles/syringes to people who inject drugs and to dispose of used syringes/needles, where both dependent variables were defined as Likert-type questions on a scale of 1 (not at all willing) to 6 (very willing).ResultsOf 4699 practicing Kentucky pharmacists, 1282 pharmacists responded (response rateu2009=u200927.3%); the majority (nu2009=u2009827) were community pharmacists. Community pharmacists were divided on willingness to provide clean needles/syringes, with 39.1% not willing (score 1 or 2 of 6) and 30% very willing (score 5 or 6 of 6). Few were willing to dispose of used needles/syringes, with only 18.7% willing. Community pharmacists who agreed that pharmacists could have significant public health impact by providing access to clean needles expressed 3.56 times more willingness to provide clean needles (95% CI 3.06–4.15), and 2.04 times more willingness to dispose of used needles (95% CI 1.77–2.35). Chain/supermarket pharmacists (nu2009=u2009485, 58.6% of community pharmacies) were 39% less likely to express willingness to dispose of used needles (95% CI 0.43–0.87) when compared with independent community pharmacists (nu2009=u2009342, 41.4% of community pharmacies). Independent pharmacists reported different barriers (workflow) than their chain/supermarket pharmacist colleagues (concerns of clientele).ConclusionsKentucky community pharmacists were more willing to provide clean needles than to dispose of used needles. Strategies to mitigate barriers to participation in syringe/needle exchange are warranted.

A Review of Interventions to Increase Vena Cava Filter Retrieval Rates

BACKGROUNDnInferior vena cava filters (IVCFs) are indicated for therapeutic and prophylactic treatment of venous thromboembolism in patients when anticoagulation has failed or is contraindicated. Retrievable IVCFs are not always retrieved despite clinical recommendations. The purpose of this review is to compare results in the literature regarding interventions and to improve IVCF retrieval rates.nnnMETHODSnArticles were identified via the search terms vena cava filters and inferior vena cava filters in conjunction with retrieval. Searches were repeated in MEDLINE/PubMed, Google Scholar, and Cochrane database. Exclusion criteria included duplicates, misidentified subject matter, study period before 2008, and lack of control group. Two independent reviewers screened key elements in the identified manuscripts, including the targeted intervention population, study design, IVCF retrieval rates, and other outcomes. A third reviewer corroborated results and consolidated findings.nnnRESULTSnSeventeen articles were identified for review. Of these, 12 were physician-targeted interventions, and 8 were patient-targeted interventions (3 studies included both). IVCF retrieval rates varied substantially for each study, but all reviewed studies reported improvement in retrieval rate following intervention. Only 5 studies reported decreased IVCF indwell times in intervention groups. Reported complication rates from IVCF retrievals were low, ranging from 0 to 2%.nnnCONCLUSIONSnIVCF retrieval rates were improved by all interventions in the reviewed studies. Findings suggest that IVCF retrieval rates can be best improved by tracking patients typically lost to follow-up. Literature suggests that successful tracking requires an individual or team of individuals who have been assigned dedicated clinical responsibility for coordinating care following IVCF placement.

Mass Casualty Shooting Venues, Types of Firearms, and Age of Perpetrators in the United States, 1982–2018

Objectives To evaluate the association between mass casualty shooting venues, types of firearms, and the age of perpetrators in the United States. Methods We analyzed data on mass casualty (≥u20093 fatalities) shootings for August 1982 through February 14, 2018. We describe data overall, specifically by school venues and the weapons used. We categorized perpetrators by ages of younger than 18 years, 18 to 20 years, and 21 years and older. We described the number of victims (fatalities plus injuries) by medians and average per event. Results Of 97 events, the median perpetrator age was 35 years and 21 years for school shootings. Four of 16 school events were committed by those aged 18 to 20 years, and all of those events included long guns. Victims of perpetrators aged 18 to 20 years made up 9.0% of all victims and 31.1% of victims of school shootings. Conclusions Persons aged 18 to 20 years perpetrated about 1 in 8 shootings, accounting for about 1 in 3 victims of school shootings. Public Health Implications. Legislation to prevent mass casualty events must be multifaceted, including age restrictions, restrictions on certain types of firearms, and improved resources for mental health, with particular emphasis on mental health and firearm restrictions for young adults.

We Cannot Treat the Dead

An introduction to an article applying an epidemiological tool for modeling infectious disease trajectories is presented. Opioid policy and the opioid epidemic in the U.S. is also discussed, which focuses upon death and overdose prevention, harm reduction, and governmental public health policy on the issue.

The Power and Pitfalls of Big Data Research in Obstetrics and Gynecology: A Consumerʼs Guide

Supplemental digital content is available in the text.

An investigation of factors predicting the type of bladder antimuscarinics initiated in Medicare nursing homes residents

BackgroundTo examine factors predicting type of bladder antimuscarinics (BAM) initiated in nursing home (NH) residents.MethodsIncident BAM initiators following NH admission were identified by constructing a retrospective cohort from Medicare files and Minimum Data Set (MDS). Participants included all residents 65xa0years and older admitted in Medicare-certified NH between January 1, 2007 and December 31, 2008 who were prescribed BAM and had continuous Medicare (Part A, B, and D) enrollment. Patient characteristics, medications, and comorbidities were derived from Medicare enrollment and claims. NH characteristics and health status were derived from MDS assessments. The outcome was defined as type of BAM initiated after admission (selective, non-selective extended release, non-selective immediate release). Multinomial logistic regression using generalized estimating equation methodology determined which factors predicted the type of BAM initiated.ResultsTwelve thousand eight hundred ninety-nine NH residents initiating BAM therapy were identified; 13.38% of new users were prescribed selective BAM, 45.56% non-selective extended release, and 41.07% non-selective immediate release medications. In both sexes, significant predictors of BAM included region of nursing home, body mass index, cognitive performance score, frailty measures, activities of daily living, and measures of bladder continence. In women, history of fracture and fall-related injuries were significant predictors of type of BAM use, while race and indicators of balance were significant predictors of type of BAM use in men. Non-pharmacological continence management strategies were not predictive of type of BAM initiation.ConclusionsSeveral factors are important in predicting type of BAM initiation in both women and men, but other factors are sex-specific. Some observed factors predicting the type of BAM initiated, such as other medications use, body mass index, or provider-related factors are potentially modifiable and could be used in targeted interventions to help optimize BAM use in this population.Trial registrationNot applicable.