To assess the availability of oral emergency contraception in southwestern Pennsylvania pharmacies.We conducted a simulated patient study to assess on-the-shelf availability of levonorgestrel emergency contraception and immediate availability of ulipristal acetate emergency contraception.Only 44% of pharmacies stocked levonorgestrel on-the-shelf and only 5% of pharmacies had ulipristal acetate immediately available.We found significant barriers to obtaining timely oral emergency contraception in southwestern Pennsylvania.Timely access to emergency contraception is important for people's ability to determine if, when, how, and under what circumstances to have children. Pharmacies in southwestern Pennsylvania need to expand access to oral emergency contraception.
Cigarette smoking during pregnancy is an important cause of poor maternal and infant health outcomes in the population eligible for Medicaid. These outcomes may be avoided or attenuated by timely, high-quality prenatal care. Using data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System for the period 2004-10, we examined the effects of two optional state Medicaid enrollment policies on smoking cessation, preterm birth, and having an infant who was small for gestational age. We used a natural experiment to compare outcomes before and after nineteen states adopted either of the two policies. The first policy, presumptive eligibility, permits women to receive prenatal care while their Medicaid application is pending. Its adoption led to a 7.7-percentage-point increase in smoking cessation but did not reduce adverse birth outcomes. The second policy, the unborn-child option, permits states to provide coverage to pregnant women who cannot document their citizenship or residency. Its adoption was not significantly associated with any of the three outcomes. The presumptive-eligibility enrollment policy will continue to be an important tool for promoting timely prenatal care and smoking cessation.
Objectives: State Medicaid programs are the largest single provider of healthcare for pregnant persons with opioid use disorder (OUD). Our objective was to provide comparable, multistate measures estimating the burden of OUD in pregnancy, medication for OUD (MOUD) in pregnancy, and related neonatal and child outcomes. Methods: Drawing on the Medicaid Outcomes Distributed Research Network (MODRN), we accessed administrative healthcare data for 1.6 million pregnancies and 1.3 million live births in 9 state Medicaid populations from 2014 to 2017. We analyzed within- and between-state prevalences and time trends in the following outcomes: diagnosis of OUD in pregnancy, initiation, and continuity of MOUD in pregnancy, Neonatal Opioid Withdrawal Syndrome (NOWS), and well-child visit utilization among children with NOWS. Results: OUD diagnosis increased from 49.6 per 1000 to 54.1 per 1000 pregnancies, and the percentage of those with any MOUD in pregnancy increased from 53.4% to 57.9%, during our study time period. State-specific percentages of 180-day continuity of MOUD ranged from 41.2% to 84.5%. The rate of neonates diagnosed with NOWS increased from 32.7 to 37.0 per 1000 live births. State-specific percentages of children diagnosed with NOWS who had the recommended well-child visits in the first 15 months ranged from 39.3% to 62.5%. Conclusions: Medicaid data, which allow for longitudinal surveillance of care across different settings, can be used to monitor OUD and related pregnancy and child health outcomes. Findings highlight the need for public health efforts to improve care for pregnant persons and children affected by OUD.
Introduction: Black adults are disproportionately burdened by poor cardiovascular health, and Black women bear the brunt of this disparity. Cardiovascular disease (CVD) disparities among Black women have been attributed to chronic exposure to psychosocial stressors and the cumulative “wear and tear” of these stressors on the body (i.e., allostatic load). Financial strain has been linked to both higher allostatic load and CVD risk. We aimed to determine whether allostatic load (AL) mediates the relationship between financial strain and cumulative CVD risk among Black women. Methods: This study utilized longitudinal data from the Black participants in the Study of Women's Health Across the Nation (SWAN). We conducted a causal mediation analysis with fourfold decomposition to determine if the relationship between long-term financial strain and subclinical CVD was mediated by AL. The study outcome was defined as the presence of any indicator of subclinical CVD from carotid ultrasounds conducted in visit 12/13: carotid artery intima-media thickness (cIMT) ≥ 75 th percentile of the study sample, carotid adventitial diameter (cAD) ≥ 75 th percentile of the study sample, or plaque index (a measure of number and size of plaques) >2. Long-term financial strain was defined as reporting “money problems” or “difficulty paying for basics” at >50% of the 6 most recent visits prior to the carotid ultrasound. AL was calculated using a validated summary score method based on 10 component measures from visit 12: systolic and diastolic blood pressure, serum glucose, BMI, triglycerides, C-reactive protein, HDL-C, total cholesterol, waist-to-hip ratio, and dehydroepiandrosterone sulfate. AL was considered “high” if the score was ≥75 th percentile of the study sample. Results: Of the 390 Black women in our sample [Mean (SD) age at subclinical CVD visit = 60.0 (2.7)], 42.3% had subclinical CVD (24.9% with cIMT or cAD, 9.7% with plaque), 56.9% reported long-term financial strain, and 38.0% had high AL. Both long-term financial strain (β=0.132, p <0.01) and high AL (β=0.134, p <0.01) were associated with a significantly higher likelihood of subclinical CVD. However, causal mediation analysis indicated that the effect of long-term financial strain on subclinical CVD was not mediated by AL (β=0.004, p =0.66). Conclusions: Though higher AL is associated with higher CVD risk among Black women, it did not mediate the causal relationship between long-term financial strain and CVD risk in these midlife women. Future research should examine the pathways by which financial strain and AL influence premature cardiovascular weathering among midlife Black women and explore potential large-scale interventions.
To assess changes in cervical cancer screening after the 2009 American College of Obstetricians and Gynecologists' guideline change and to determine predictors associated with underscreening and overscreening among Medicaid-enrolled women.We performed an observational cohort study of Pennsylvania Medicaid claims from 2007 to 2013. We evaluated guideline adherence of 18- to 64-year-old continuously enrolled women before and after the 2009 guideline change. To define adherence, we categorized intervals between Pap tests as longer than (underscreening), within (appropriate screening), or shorter than (overscreening) guideline-recommended intervals (±6-month). We stratified results by age and assessed predictors of underscreening and overscreening through logistic regression.Among 29,650 women, appropriate cervical cancer screening significantly decreased after the guideline change (from 45% [95% confidence interval (CI) 44-46%] to 11% [95% CI 11-12%] among 17,360 younger than 30 year olds and from 27% [95% CI 26-28%] to 6% [95% CI 6-7%] among 12,290 women 30 years old or older). Overscreening significantly increased (from 6% [95% CI 5-6%] to 67% [95% CI 66-68%] in those younger than 30 years old and from 54% [95% CI 52-55%] to 65% [95% CI 64-67%] in those 30 years old or older), whereas underscreening significantly increased only in those 30 years old or older (from 20% [95% CI 19-21%] to 29% [95% CI 27-30%]). Pap tests after guideline change, pregnancy, Managed Care enrollment (in those younger than 30 years old), and black race (in those younger than 30 years old) were associated with underscreening. Pap tests after guideline change, more visits, more sexually transmitted infection testing, and white race (in those 30 years old or older) were associated with overscreening.We observed high rates of cervical cancer overscreening and underscreening and low rates of appropriate screening after the guideline change. Interventions should target both underscreening and overscreening to address these separate yet significant issues.
Abstract Background Limited information exists about testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among Medicaid enrollees after starting medication for opioid use disorder (MOUD), despite guidelines recommending such testing. Our objectives were to estimate testing prevalence and trends for HIV, HBV, and HCV among Medicaid enrollees initiating MOUD and examine enrollee characteristics associated with testing. Methods We conducted a serial cross-sectional study of 505 440 initiations of MOUD from 2016 to 2019 among 361 537 Medicaid enrollees in 11 states. Measures of MOUD initiation; HIV, HBV, and HCV testing; comorbidities; and demographics were based on enrollment and claims data. Each state used Poisson regression to estimate associations between enrollee characteristics and testing prevalence within 90 days of MOUD initiation. We pooled state-level estimates to generate global estimates using random effects meta-analyses. Results From 2016 to 2019, testing increased from 20% to 25% for HIV, from 22% to 25% for HBV, from 24% to 27% for HCV, and from 15% to 19% for all 3 conditions. Adjusted rates of testing for all 3 conditions were lower among enrollees who were male (vs nonpregnant females), living in a rural area (vs urban area), and initiating methadone or naltrexone (vs buprenorphine). Associations between enrollee characteristics and testing varied across states. Conclusions Among Medicaid enrollees in 11 US states who initiated medications for opioid use disorder, testing for human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and all 3 conditions increased between 2016 and 2019 but the majority were not tested.
