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Objective: To assess the impact of geographic access to surgical center on readmission risk and burden in children after congenital heart surgery., Study Design: Children <6 years old at discharge after congenital heart surgery (Risk Adjustment for Congenital Heart Surgery-1 score 2-6) were identified using Pediatric Health Information System data (46 hospitals, 2004-2015). Residential distance from the surgery center, calculated using ZIP code centroids, was categorized as <15, 15-29, 30-59, 60-119, and ≥120 miles. Rurality was defined using rural-urban commuting area codes. Geographic risk factors for unplanned readmissions to the surgical center and associated burden (total hospital length of stay [LOS], costs, and complications) were analyzed using multivariable regression., Results: Among 59 696 eligible children, 19 355 (32%) had ≥1 unplanned readmission. The median LOS was 9 days (IQR 22) across the entire cohort. In those readmitted, median total costs were $31 559 (IQR $90 176). Distance from the center was inversely related but rurality was positively related to readmission risk. Among those readmitted, increased distance was associated with longer LOS, more complications, and greater costs. Compared with urban patients, highly rural patients were more likely to have an unplanned readmission but had fewer average readmission days., Conclusions: Geographic measures of access differentially affect readmission to the surgery center. Increased distance from the center was associated with fewer unplanned readmissions but more complications. Among those readmitted, the most isolated patients had the greatest readmission costs. Understanding the contribution of geographic access will aid in developing strategies to improve care delivery to this population., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Since 2014, when the Health Insurance Marketplaces (HIMs) authorized by the Patient Protection and Affordable Care Act (ACA) were implemented, considerable premium changes have been observed in the marketplaces across the 50 states and the District of Columbia. This policy brief assesses the changes in average HIM plan premiums from 2014 to 2016, before accounting for subsidies, with an emphasis on the widening variation across rural and urban places. Since this brief focuses on premiums without accounting for subsidies, this is not intended to be an analysis of the "affordability" of ACA premiums, as that would require assessment of premiums, cost-sharing adjustments, and other factors.

Purpose: This study uses data collected as part of the Well-Being of Adolescents in Vulnerable Environments study to (1) compare the perceptions of neighborhood-level factors among adolescents across five different urban sites; (2) examine the associations between factors within the physical and social environments; and (3) examine the influence of neighborhood-level factors on two different health outcomes-violence victimization in the past 12 months and ever smoked., Methods: Across five urban sites (Baltimore, New Delhi, Johannesburg, Ibadan, and Shanghai), 2,320 adolescents aged 15-19 years completed a survey using audio computer-assisted self-interview technology. To recruit adolescents, each site used a respondent-driven sampling method, which consisted of selecting adolescents as "seeds" to serve as the initial contacts for recruiting the entire adolescent sample. All analyses were conducted with Stata 13.1 statistical software, using complex survey design procedures. To examine associations between neighborhood-level factors and among our two outcomes, violence victimization and ever smoked, bivariate and multivariate analyses were conducted., Results: Across sites, there was great variability in how adolescents perceived their neighborhoods. Overall, adolescents from Ibadan and Shanghai held the most positive perceptions about their neighborhoods, whereas adolescents from Baltimore and Johannesburg held the poorest. In New Delhi, despite females having positive perceptions about their safety and sense of social cohesion, they had the highest sense of fear and the poorest perceptions about their physical environment. The study also found that one of the most consistent neighborhood-level factors across sites and outcomes was witnessing community violence, which was significantly associated with smoking among adolescents in New Delhi and Johannesburg and with violence victimization across nearly every site except Baltimore. No other neighborhood-level factor exerted greater influence., Conclusions: This study confirms the important associations between perceptions of a neighborhood and adolescent health. At the same time, it demonstrates that not all neighborhood-level factors are associated with adolescent health outcomes in the same way across different urban contexts. Further longitudinal research is needed to examine the direction of causation between adolescent health neighborhood contexts and health outcomes and the reasons for why different urban contexts may exert varying levels of influence on the health of adolescents., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Social capital is essential for the successful development of young people. The current study examines direct measures of social capital in young people in five urban global contexts., Methods: The Well-Being of Adolescents in Vulnerable Environments is a global study of young people aged 15-19 years living in disadvantaged, urban settings. Respondent-driven sampling was used to recruit approximately 500 participants from each site. The sample included 2,339 young people (mean age 16.7 years; 47.5% female). We examined the associations between social capital in four domains-family, school, peers, and neighborhood and demographic characteristics-using gender-stratified ordinary least-squares regression. We also examined associations between self-reported health and the four social capital domains, which was minimal., Results: School enrollment was positively associated with social capital for young women in Baltimore, Delhi, and Shanghai; the association was less consistent for young men. The same pattern is true for perceived wealth. Unstable housing was associated with low familial social capital in all groups except young women in Shanghai and young men in Ibadan and Johannesburg. Being raised outside a two-parent family has a widespread, negative association with social capital. Self-reported health had a mainly positive association with social capital with the most consistent association being neighborhood social capital., Conclusions: Different types of social capital interact with social contexts and gender differently. Strategies that aim to build social capital as part of risk reduction and positive youth development programming need to recognize that social capital enhancement may work differently for different groups and in different settings., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Globally, adolescent women are at risk for gender-based violence (GBV) including sexual violence and intimate partner violence (IPV). Those in economically distressed settings are considered uniquely vulnerable., Methods: Female adolescents aged 15-19 from Baltimore, Maryland, USA; New Delhi, India; Ibadan, Nigeria; Johannesburg, South Africa; and Shanghai, China (n = 1,112) were recruited via respondent-driven sampling to participate in a cross-sectional survey. We describe the prevalence of past-year physical and sexual IPV, and lifetime and past-year non-partner sexual violence. Logistic regression models evaluated associations of GBV with substance use, sexual and reproductive health, mental health, and self-rated health., Results: Among ever-partnered women, past-year IPV prevalence ranged from 10.2% in Shanghai to 36.6% in Johannesburg. Lifetime non-partner sexual violence ranged from 1.2% in Shanghai to 12.6% in Johannesburg. Where sufficient cases allowed additional analyses (Baltimore and Johannesburg), both IPV and non-partner sexual violence were associated with poor health across domains of substance use, sexual and reproductive health, mental health, and self-rated health; associations varied across study sites., Conclusions: Significant heterogeneity was observed in the prevalence of IPV and non-partner sexual violence among adolescent women in economically distressed urban settings, with upwards of 25% of ever-partnered women experiencing past-year IPV in Baltimore, Ibadan, and Johannesburg, and more than 10% of adolescent women in Baltimore and Johannesburg reporting non-partner sexual violence. Findings affirm the negative health influence of GBV even in disadvantaged urban settings that present a range of competing health threats. A multisectoral response is needed to prevent GBV against young women, mitigate its health impact, and hold perpetrators accountable., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

The global adolescent population is larger than ever before and is rapidly urbanizing. Global surveillance systems to monitor youth health typically use household- and school-based recruitment methods. These systems risk not reaching the most marginalized youth made vulnerable by conditions of migration, civil conflict, and other forms of individual and structural vulnerability. We describe the methodology of the Well-Being of Adolescents in Vulnerable Environments survey, which used respondent-driven sampling (RDS) to recruit male and female youth aged 15-19 years and living in economically distressed urban settings in Baltimore, MD; Johannesburg, South Africa; Ibadan, Nigeria; New Delhi, India; and Shanghai, China (migrant youth only) for a cross-sectional study. We describe a shared recruitment and survey administration protocol across the five sites, present recruitment parameters, and illustrate challenges and necessary adaptations for use of RDS with youth in disadvantaged urban settings. We describe the reach of RDS into populations of youth who may be missed by traditional household- and school-based sampling. Across all sites, an estimated 9.6% were unstably housed; among those enrolled in school, absenteeism was pervasive with 29% having missed over 6 days of school in the past month. Overall findings confirm the feasibility, efficiency, and utility of RDS in quickly reaching diverse samples of youth, including those both in and out of school and those unstably housed, and provide direction for optimizing RDS methods with this population. In our rapidly urbanizing global landscape with an unprecedented youth population, RDS may serve as a valuable tool in complementing existing household- and school-based methods for health-related surveillance that can guide policy., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Recent research has driven home the close relationship between place and health. Geography is often a greater driver of adolescent morbidity and mortality than behavior. To elucidate these relationships, the Well-Being of Adolescents in Vulnerable Environments study has collected and analyzed data on the health and well-being of adolescents' lowest income communities of five cities: Baltimore, United States; Ibadan, Nigeria; Johannesburg, South Africa; New Delhi, India; and Shanghai, China., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Globally, adolescents are at risk of depression, traumatic stress, and suicide, especially those living in vulnerable environments. This article examines the mental health of 15- to 19-year-old youth in five cities and identifies the social support correlates of mental health., Methods: A total of 2,393 adolescents aged 15-19 years in economically distressed neighborhoods in Baltimore, MD; New Delhi, India; Ibadan, Nigeria; Johannesburg, South Africa; and Shanghai, China were recruited in 2013 via respondent-driven sampling to participate in a survey using an audio computer-assisted self-interview. Weighted logistic regression and general linear models were used to explore the associations between mental health and social supports., Results: The highest levels of depression and posttraumatic stress symptoms were displayed in Johannesburg among females (44.6% and 67.0%, respectively), whereas the lowest were among New Delhi females and males (13.0% and 16.3%, respectively). The prevalence of suicidal ideation ranged from 7.9% (New Delhi female adolescents) to 39.6% (Johannesburg female adolescents); the 12-month prevalence of suicide attempts ranged from 1.8% (New Delhi females) to 18.3% (Ibadan males). Elevated perceptions of having a caring female adult in the home and feeling connected to their neighborhoods were positively associated with adolescents' levels of hope across the sites while negatively associated with depression and posttraumatic stress symptoms with some variation across sites and gender., Conclusions: Adolescents living in the very economically distressed areas studied register high levels of depression and posttraumatic stress. Improving social supports in families and neighborhoods may alleviate distress and foster hope. In particular, strengthening supports from female caretakers to their adolescents at home may improve the outlooks of their daughters., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The impact of pregnancy on the health and livelihood of adolescents aged 15-19 years is substantial. This study explored sociodemographic, behavioral, and environmental-level factors associated with adolescent pregnancy across five urban disadvantaged settings., Methods: The Well-Being of Adolescents in Vulnerable Environments study used respondent-driven sampling (RDS) to recruit males and females from Baltimore (456), Johannesburg (496), Ibadan (449), New Delhi (500), and Shanghai (438). RDS-II and poststratification age weights were used to explore the odds associated with "ever had sex" and "ever pregnant"; adjusted odds of pregnancy and 95% confidence interval were developed by site and gender., Results: Among the sexually experienced, pregnancy was most common in Baltimore (females, 53% and males, 25%) and Johannesburg (females, 29% and males 22%). Heterosexual experience and therefore pregnancy were rare in Ibadan, New Delhi, and Shanghai. Current schooling and condom use at the first sex decreased the odds of pregnancy among females in Baltimore and Johannesburg participants. Factors associated with higher odds of pregnancy were early sexual debut (Johannesburg participants and Baltimore females) being raised by someone other than the two parents (Johannesburg females); alcohol use and binge drinking in the past month (Baltimore participants); greater community violence and poor physical environment (Baltimore males and Johannesburg participants)., Conclusions: The reported prevalence of adolescent pregnancy varies substantially across similarly economically disadvantaged urban settings. These differences are related to large differences in sexual experience, which may be underreported, and differences in environmental contexts. Pregnancy risk needs to be understood within the specific context that adolescents reside with particular attention to neighborhood-level factors., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Adolescent substance use has numerous consequences. Our goals in this article are to compare the prevalence and correlates of substance use among ethnically diverse adolescents., Methods: Data were from 2,332 adolescents aged 15-19 years recruited via respondent-driven sampling from disadvantaged settings in five cities. Multivariate logistic regression was used to identify correlates of current substance use., Results: About half of the respondents were male. Most adolescents (73.4%) were currently enrolled in school and identified a father (86.2%) and mother (98.6%) figure and strong peer support. Sixty-two percent reported lifetime use of at least one substance. Overall, the most common substances ever used were alcohol (44.6%), cigarettes (26.2%), and marijuana (17.9%). Mean age at first use of alcohol was 14.2 ± 3.1 years. Current alcohol use was highest in Johannesburg (47.4%) and lowest in Delhi (2.1%). The mean age at first use of cigarettes was 14.4 ± 2.8 years. Current cigarette smoking was highest in Johannesburg (32.5%) and lowest in Delhi (3.7%). Male gender predicted current alcohol use in all sites, older age (17-19 years) was also a predictor in Baltimore. Male gender (Johannesburg and Shanghai), older age (Baltimore and Shanghai), and being out of school (Baltimore, Johannesburg, and Shanghai) predicted current cigarette smoking. Absence of a caring father figure was predictive for current alcohol use in Baltimore and Shanghai. Stronger peer support predicted alcohol (Johannesburg and Shanghai) and cigarette use (Johannesburg)., Conclusions: Substance use is still a major issue among adolescents around the world, underscoring the need for continued research and interventions., (Copyright © 2014 Society for Adolescent Health and Medicine. All rights reserved.)

With the recent emphasis on evidence-based practice and healthcare reform, understanding the cost of dysphagia management has never been more important. It is helpful for clinicians to understand and objectively report the costs associated with dysphagia when they advocate for their services in this economy. Having carefully estimated cost of illness, inputs are needed for cost-effectiveness analyses that help support the value of treatments. This study sought to address this issue by examining the 1-year cost associated with a diagnosis of dysphagia post-stroke in South Carolina. Furthermore, this study investigated whether ethnicity and residence differences exist in the cost of dysphagia post-stroke. Data on 3,200 patients in the South Carolina Medicare database from 2004 who had ICD-9 codes for ischemic stroke, 434 and 436, were retrospectively included in this study. Differences between persons with and without dysphagia post-stroke were compared with respect to age, gender, ethnicity, mortality, length of stay, comorbidity, rurality, discharge disposition, and cost to Medicare. Univariate analyses and a gamma-distributed generalized linear multivariable model with a log link function were completed. We found that the 1-year cost to Medicare for persons with dysphagia post ischemic stroke was $4,510 higher than that for persons without dysphagia post ischemic stroke when controlling for age, comorbidities, ethnicity, and proportion of time alive. Univariate analysis revealed that rurality, ethnicity, and gender were not statistically significantly different in comparisons of individuals with or without dysphagia post-stroke. Post-stroke dysphagia significantly increases post-stroke medical expenses. Understanding the expenditures associated with post-stroke dysphagia is helpful for optimal allocation and use of resources. Such information is needed to conduct cost-effectiveness studies.

Background: Cost savings from the use of generic drugs versus brand-name drugs are well known. Both private and public prescription drug plans encourage the use of generic drugs through a variety of mechanisms. The magnitude of cost savings for a given generic drug is dependent on the degree to which the generic market is competitive. Should the competitive structure become compromised, higher prices and reduced cost savings may result. An alleged conspiracy between Mylan Laboratories and its active-ingredient suppliers in 1997 was associated with an increase in seller concentration in the generic lorazepam market. The Federal Trade Commission (FTC) alleged that Mylan raised costs to consumers by $120 million because of price increases for generic lorazepam from March through December 1998 and for generic clorazepate from January through December 1998. In November 2002, a settlement with Mylan was approved by the FTC, and a federal district court required Mylan to pay $147 million, including $28.2 million to state agencies including Medicaid., Objectives: To (a) describe the seller concentration in the national Medicaid generic lorazepam market over a 19-year period from January 1991 through December 2009, (b) estimate the excess payments for generic lorazepam by Medicaid between 1998 and 2009, and (c) investigate potentially increased utilization and prices of 2 substitute pharmaceuticals: branded lorazepam (Ativan) and generic alprazolam (another widely used intermediate-acting benzodiazepine)., Methods: Using Medicaid State Drug Utilization Data from the Centers for Medicare Medicaid Services, we calculated the 4-firm concentration ratio (CR₄) and the Herfindahl-Hirschman Index (HHI) for the Medicaid generic lorazepam market, along with pre-rebate reimbursement for pharmacy claims, number of claims (utilization), and average pre-rebate reimbursement per claim (average "price") for generic lorazepam, from 1991 through 2009. Medicaid's excess payments were estimated under 2 different assumptions regarding what the average generic lorazepam price would have been in the absence of the alleged conspiracy. To find counterfactual prices, the average per-claim reimbursement for lorazepam for the 4 quarters prior to the alleged conspiracy, $6.80, was inflated using (a) the quarterly change in the average per-claim reimbursement for generic alprazolam and (b) the Consumer Price Index (CPI) for all urban consumers, all goods. Potential impact of the alleged conspiracy on the branded lorazepam and generic alprazolam markets was investigated., Results: The average pre-rebate reimbursements per claim for generic lorazepam were $10.25, $23.12, and $8.48 in 1991, 1998, and 2009, respectively. For the same 3 years, CR₄ = 52.80, 76.02, and 86.74, while HHI = 905.71, 2,166.25, and 2,233.36. Medicaid's excess payments from 1998-2009 were estimated at approximately $625-$657 million. The data also suggest the possibility of small impacts on the utilization of branded lorazepam and the price of generic alprazolam., Conclusions: Prior to the alleged conspiracy in 1997, average pre-rebate reimbursement per claim for generic lorazepam was declining, while seller concentration was rising. After a jump in average payment per claim in the years immediately following the alleged conspiracy, prices have gradually returned to their pre-1998 levels. However, the generic lorazepam market was more concentrated in 2009 than prior to the alleged conspiracy., (Copyright © 2012, Academy of Managed Care Pharmacy. All rights reserved.)