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We develop county-level measures of structural and institutional barriers to care, and test associations between these barriers and birth outcomes for US-born Black and White mothers using national birth records for 2014-2017. Results indicate elevated odds of greater preterm birth severity for Black mothers in counties with higher uninsurance rates among Black adults, fewer Black physicians per Black residents, and fewer publicly-funded contraceptive services. Most structural barriers were not associated with small-for-gestational-age birth, and barriers defined for Black residents were not associated with birth outcomes for White mothers, with the exception of Black uninsurance rate. Structural determinants of care may influence preterm birth risk for Black Americans., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: Little is known regarding the effects of a prenatal diagnosis of congenital heart disease (CHD) on the cost of antenatal and delivery care. We sought to compare the maternal costs of care in pregnancies where the fetus or child was diagnosed prenatally vs. postnatally., Methods: Costs of maternal care were determined for pregnancies in which the fetus or child was diagnosed with CHD between 1997 and 2012 in the state of Utah. Cases of CHD were identified via a statewide birth defect surveillance program which included data on the timing of diagnosis, maternal demographic and clinical data, and linked to statewide inpatient maternal hospital discharge records. Antenatal testing costs were determined using Medicaid fee estimates and total facility costs were determined for all hospitalizations including delivery. The association of timing of diagnosis of CHD with costs was analyzed using univariable and multivariable models., Results: Of 2128 pregnancies included in the study, 36% had a fetus prenatally diagnosed with CHD. The prenatal diagnosis group was more likely to have a termination or stillbirth and were younger at delivery (gestational age 37.3 vs 38.0 weeks, p  < .001). Labor induction and cesarean delivery rates were similar between groups. Antenatal testing and delivery hospitalization costs were higher in the prenatal diagnosis group: $5819 vs $4041 ( p  < .001) and $10,509 vs $7802 ( p  < .001), respectively. Patients in the prenatal diagnosis group had longer lengths of hospital stays (3.5 vs 2.4 d, p  > .001). After controlling for significant differences between the groups, including lesion severity, the prenatal diagnosis remained directly associated with antenatal testing costs (+$1472), maternal hospitalization costs (+$2713), and maternal hospital length of stay (+1.0 d)., Conclusion: A prenatal diagnosis of fetal CHD was associated with increased prenatal costs, hospitalization costs, and hospital length of stay for affected pregnant patients.

Background: Significant and sustained weight loss resulting from bariatric surgery have demonstrated clinical reduction in severe obesity-related pain. Subsequentially, post-surgical pain reduction may reduce pain medication use. However, clear evidence regarding use of prescribed pain medications before and after bariatric surgery is absent., Methods: Linking two state-wide databases, patients who underwent bariatric surgery between July 1, 2013 and December 31, 2015 were identified. Proportion tests were used to compare percent of patients with pain medication prescriptions 1 year before and 1 year after bariatric surgery. Logistic regression was used to identify baseline factors that were associated with pain medication use 1-year following surgery., Results: A total of 3535 bariatric surgical patients aged 18-64 years at surgery were identified. Of these patients, 1339 patients met the following study criteria: covered by private insurance; known pre-surgical BMI; and continuous enrollment with health plan(s) from 12-month pre-surgery to 13-month post-surgery. While comparison of average number of overall pain medication prescriptions before and after surgery did not change, from 3.46 to 3.32 prescriptions (p value = 0.26), opioid prescription use increased from 1.62 vs. 2.05 (p value < 0.01). Patients prescribed more types of pain medications before surgery were more likely to have prescribed pain medications after surgery. Patients prescribed benzodiazepines at baseline had higher odds being prescribed post-surgery corticosteroids (OR = 1.89, p value < 0.01), muscle relaxants (OR = 2.18, p value < 0.01), and opioids (OR = 3.06, p value =  < 0.01) compared to patients without pre-surgery--prescribed benzodiazepine., Conclusion: While comparison of average number of overall pain medication prescriptions before and after bariatric surgery did not decrease, opioid prescription increased post-surgery. Further studies are needed to examine whether post-surgery opioids are prescribed in lieu of or in tandem with other pain medication prescriptions., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Risk of nutritional disorders (NDs) in bariatric surgical patients has led to guideline recommendations for pre- and post-operative nutrient deficiency screening. The aim of this study was to identify baseline factors associated with incident NDs and, in addition, to explore possible differences in health care spending and use between patients with and without incident NDs following bariatric surgery., Materials and Methods: Using data linked with a state-wide bariatric surgical registry and a state-wide claims database, subjects who underwent bariatric surgery between July 1, 2013, and December 31, 2015, were identified. Incident NDs and health care cost and use outcomes following 1 year from surgery were extracted from the claims data. Logistic regression was used to identify baseline factors associated with incident NDs. Zero-inflated negative binomial regression and generalized linear regression were used to estimate health care cost and use outcomes., Results: A total of 3535 patients who underwent bariatric surgery were identified. Of these patients, those without continuous health insurance enrollment (n=1880), having prevalent (pre-surgery) NDs (n=461), and missing baseline BMI (n=41) were excluded. Of patients analyzed (n=1153), about 30% had incident NDs, with a mean (SD) age and BMI at surgery of 46 (12) years and 48 (9.2) kg/m 2 , respectively. Patients with one incident ND had higher total health care spending (coefficient=$41118, p-value<0.01) and ED visits (IRR=1.86, p-value<0.01)., Conclusion: Those without pre-operative NDs may have a higher chance of having NDs post-operatively. Taking multivitamins and continues monitoring are necessary to prevent any negative outcomes related to post-operative NDs.

This study analyzes the direct medical costs of low physical activity by race/ethnicity and gender. Average health expenditures based on physical activity status for Black non-Hispanics (NH), Asian NHs, and Hispanics were compared to White NHs. Data from the National Health Interview Survey were merged with the Medical Expenditure Panel Survey for years 2000-2010 and 2001-2011, respectively, and weights were applied to ensure generalizability to the larger US population. The sample was restricted to non-pregnant adults between the ages of 25 and 64, with a final sample size of 44,953. The multivariate estimates reveal statistically significant lower annual health care expenditures among physically active men and women in five out of eight racial/ethnic groups relative to their inactive counterparts: on average, for men, $1041 less is spent among White NHs, $905 less is spent for Black NHs and $876 less is spent for Asian NHs. Among women, medical expenditures were $956 per year less among active White non-Hispanics relative to their inactive counterparts, and $815 per year among Hispanics. Essentially, the average reduction in health care expenditures is relatively consistent for five out of the eight groups. The absence of any reduction in average health care expenditures for three of the groups, however, suggests that there may be environmental factors at play for certain groups that mitigate the impact of physical activity on health expenditures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To assess longitudinal estimates of inpatient costs through early childhood in patients with critical congenital heart defects (CCHDs), for whom reliable estimates are scarce, using a population-based cohort of clinically validated CCHD cases., Study Design: Longitudinal retrospective cohort of infants with CCHDs live born from 1997 to 2012 in Utah. Cases identified from birth defect registry data were linked to inpatient discharge abstracts and vital records to track inpatient days and costs through age 10 years. Costs were adjusted for inflation and discounted by 3% per year to generate present value estimates. Multivariable models identified infant and maternal factors potentially associated with higher resource utilization and were used to calculate adjusted costs by defect type., Results: The final statewide cohort included 1439 CCHD cases among 803 509 livebirths (1.8/1000). The average cost per affected child through age 10 years was $136 682 with a median of $74 924 because of a small number of extremely high cost children; costs were highest for pulmonary atresia with ventricular septal defect and hypoplastic left heart syndrome. Inpatient costs increased by 1.6% per year during the study period. A single birth year cohort (~50 000 births/year) had estimated expenditures of $11 902 899 through age 10 years. Extrapolating to the US population, inpatient costs for a single birth year cohort through age 10 years were ~$1 billion., Conclusions: Inpatient costs for CCHDs throughout childhood are high and rising. These revised estimates will contribute to comparative effectiveness research aimed at improving the value of care on a patient and population level., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: This study gauged the cost-effectiveness of a community-based health coaching intervention aimed at improving diet and physical activity among women in culturally diverse communities., Methods: The Coalition for a Healthier Community for Utah Women and Girls recruited women from 5 cultural and ethnic groups and randomized them to receive quarterly versus monthly health coaching. Coaching was performed by trained community health workers from the targeted communities. Cost-effectiveness ratios were estimated to gauge the cost-effectiveness of the intervention., Results: Estimated quality-adjusted life years gained from both increased physical activity and improved diet were positive. Cost-effectiveness ratios varied by intervention arm, but all ratios fell within the favorable range described in the literature., Conclusions: This culturally adapted health coaching intervention was deemed to be cost-effective. Our findings suggest that to achieve the highest level of cost-effectiveness, programs should focus on enrolling at-risk women who do not meet recommended physical activity standards and/or dietary guidelines.

This paper explores the association between prenatal care and childhood obesity across racial/ethnic groups, with special focus on Asians, Native Hawaiian and other Pacific Islanders (NHOPI), and non-Hispanic Whites. Data were drawn from a statewide population-based data source that linked vital and administrative records for a large cohort of children (n=227,032). Multivariate logistic regression was used to estimate odds of overweight and obesity among children whose mothers received first trimester prenatal care versus those who did not. Compared with White and Asian women, NHOPI women had later initiation of prenatal care. However, NHOPI women who initiated early prenatal care had children with significantly lower risks of obesity and overweight than their counterparts who delayed such care. Timely prenatal care may be associated, with lower childhood obesity through focused monitoring and counseling on pregnancy-related weight gain as well as through reducing other potentially deleterious prenatal behaviors for this high-risk and underserved population.

No comprehensive benefit-to-cost analysis has been performed to date on a policy of routine ultrasound screening for fetal anomalies in the United States. We performed a preliminary benefit-to-cost analysis drawing upon our previous research on the cost or birth defects in the United States and upon the literature regarding (1) the sensitivity of ultrasound in detecting congenital anomalies, (2) the rate at which pregnancies are terminated upon detection of fetal anomalies, (3) the number of ultrasounds performed per pregnancy under a routine screening policy, and (4) the average cost of an ultrasound. We assumed a 100% subsequent replacement rate of terminated pregnancies with a normal child, an assumption most favorable to routine screening. The benefit-to-cost ratio ranged from .33 to 3, suggesting that a routine screening policy for fetal anomalies is of uncertain net societal benefit. Routine screening may be justified, however, based on standards that elude the methods for establishing societal benefits adopted in this analysis.

Decision analysis is a widely used tool to improve clinical decision making when randomized controlled trials are infeasible, underpowered, or lack generalizability. We performed an exploratory decision analysis of routine second trimester ultrasound to detect fetal anomalies, focusing on the assumptions that would have the greatest impact. Six outcome categories were considered: (1) abnormal ultrasound, anomalous child, (2) abnormal ultrasound, elective abortion of anomalous fetus, (3) abnormal ultrasound, healthy child, (4) abnormal ultrasound, elective abortion of healthy fetus, (5) normal ultrasound, healthy child, and (6) normal ultrasound, anomalous child. Live birth and fetal death rates for nine sonographically detectable anomalies were obtained from the California Birth Defects Monitoring Program. The sensitivity and specificity of ultrasound were estimated through meta-analysis of recent series. Plausible ranges for the probabilities of cesarean delivery and elective abortion, by anomaly, were determined through review of the literature. Standard gamble, willingness-to-pay, and human capital estimates of utility were rescaled for comparability. We found that routine ultrasound appears to be the preferred strategy for most women. This choice is sensitive primarily to the specificity of ultrasound and women's willingness-to-pay for the reassurance of a normal ultrasound.

The increase in income inequality in the United States over the past 20 years has been accompanied by a pronounced increase in economic segregation in urban areas. No research to date has analyzed the potential effects of such spatial segregation on mortality. To investigate these effects, the mortality experience of respondents aged 30 years and older on the 1986-94 National Health Interview Surveys residing in any one of 30 large metropolitan areas in the United States was analyzed. Concentrated poverty was associated with significantly elevated risk of mortality, even after controlling for individual household income. Concentrated affluence showed a consistent, protective effect only among the elderly. The effects were most pronounced among the poor, but were not confined to them. Urban planning should take into account the effects associated with economic residential segregation.

Managed care is spreading rapidly in the United States and creating incentives for physician practices to find the most efficient combination of health professionals to deliver care to an enrolled population. Given these trends, it is appropriate to reexamine the roles of physician assistants (PAs) and nurse practitioners (NPs) in the health care workforce. This paper briefly reviews the literature on PA and NP productivity, managed care plans' use of PAs and NPs, and the potential impact of PAs and NPs on the size and composition of the future physician workforce. In general, the literature supports the idea that PAs and NPs could have a major impact on the future health care workforce. Studies show significant opportunities for increased physician substitution and even conservative assumptions about physician task delegation imply a large increase in the number of PAs and NPs that can be effectively deployed. However, the current literature has certain limitations that make it difficult to quantify the future impact of PAs and NPs. Among these limitations is the fact that virtually all formal productivity studies were conducted in fee-for-service settings during the 1970s, rather than managed care settings. In addition, the vast majority of PA and NP productivity studies have viewed PAs and NPs as physician substitutes rather than as members of interdisciplinary health care teams, which may become the dominant health care delivery model over the next 10-20 years.

The purpose of this paper is to examine the hypothesis that marital and poverty status interact in their effects on mortality risks beyond their main effects. This study examines the epidemiological bases for applying an additive rather than a multiplicative specification when testing for interaction between two discrete risk factors. We specifically predict that risks associated with being nonmarried and with being poor interact to produce mortality risks that are greater than each risk acting independently. The analysis is based on men and women who were ages 25-74 during the 1971-1975 National Health and Nutrition Examination Survey I (NHANES I) and who were traced successfully in the NHANES I Epidemiologic Follow-Up Study in 1982-1984. Overall, being both poor and nonmarried places nonelderly (ages 25-64) men, but not women, at risk of mortality greater than that expected from the main effects. This study shows that for all-cause mortality, marital and poverty status interact for men but less so for women; these findings exist when interaction is assessed with either a multiplicative or an additive standard. This difference is most pronounced for poor, widowed men and (to a lesser degree) poor, divorced men. For violent/accidental deaths among men, the interaction effects are large on the basis of an additive model. Weak main and interaction effects were detected for the elderly (age 65+).

Birth defects now are the leading cause of infant mortality and a major contributor to heightened morbidity in the United States. Considerable medical and nonmedical resources are devoted to treating persons with birth defects. Yet, little is known about birth defects' economic burden to society and the profile of component direct and indirect costs over the lifespan of those born with specific birth defects. Using an incidence approach, we made the most comprehensive estimates to date of the cost of 18 of the most clinically significant birth defects in the United States. Our analysis provides the basis for assessing competing strategies for research and prevention.