The Association Between Preconception Care Receipt and the Timeliness and Adequacy of Prenatal Care: An Examination of Multistate Data from Pregnancy Risk Assessment Monitoring System (PRAMS) 2009–2011

Objectives Prenatal care (PNC) is a critical preventive health service for pregnant women and infants. While timely PNC has been associated with improved birth outcomes, improvements have slowed since the late 1990s. Therefore, focus has shifted to interventions prior to pregnancy. Preconception care is recommended for all women of reproductive age. This study aimed to examine preconception care and its association with timeliness and adequacy of PNC. Methods This retrospective cohort study used data from a large sample of United States first-time mothers (n?=?13,509) who participated in the 2009–2011 Pregnancy Risk Assessment Monitoring System in ten states. Timeliness and adequacy of PNC data came from birth certificates, while preconception care receipt was self-reported. Logistic regression provided odds ratios (ORs) and 95% confidence intervals (CIs) to model the association between preconception care receipt and the two PNC outcomes. Results After adjustment, women who received preconception care had statistically significant increased odds of timely (OR 1.30, 95% CI 1.08, 1.57), but not adequate PNC (OR 1.08, 95% CI 0.94, 1.24) as compared to women who did not receive preconception care. Pregnancy intention modified these associations. Associations were strongest among women with intended pregnancies (timely PNC: OR 1.63 and adequate PNC: OR 1.22). Conclusions for Practice Given that untimely PNC is associated with adverse birth outcomes, the observed association warrants increased focus on implementing preconception care. Future studies should investigate how specific components of preconception care are associated with PNC timeliness/adequacy, health behaviors during pregnancy, and birth outcomes.     

The management of embedded metal fragment patients and the role of chelation Therapy: A workshop of the Department of Veterans Affairs—Walter Reed National Medical Center

Exposure to retained metal fragments from war-related injuries can result in increased systemic metal concentrations, thereby posing potential health risks to target organs far from the site of injury. Given the large number of veterans who have retained fragments and the lack of clear guidance on how to medically manage these individuals, the Department of Veterans Affairs (VA) convened a meeting of chelation experts and clinicians who care for embedded fragment patients to discuss current practices and provide medical management guidance. Based on this group's clinical expertise and review of published literature, the evidence presented suggests that, at least in the case of lead fragments, short-term chelation therapy may be beneficial for embedded fragment patients experiencing acute symptoms associated with metal toxicity; however, in the absence of clinical symptoms or significantly elevated blood lead concentrations (greater than 80 µg/dL), chelation therapy may offer little to no benefit for individuals with retained fragments and pose greater risks due to remobilization of metals stored in bone and other soft tissues. The combination of periodic biomonitoring to assess metal body burden, longitudinal fragment imaging, and selective fragment removal when metal concentrations approach critical injury thresholds offers a more conservative management approach to caring for patients with embedded fragments.     

The "Adequacy of Prenatal Care Utilization" (APNCU) index to study low birth weight: is the index biased?

A recent, nationwide study of 54 million births reported increasing trends toward more prenatal resource utilization from 1981 to 1995, when other indicators have shown worsening trends in birth outcomes. The Adequacy of Prenatal Care Utilization (APNCU) Index was used to measure resource utilization, but the Index appears to be biased because women grouped in the intensive category have the highest rates of low birth weight (LBW). The objective of this paper is to provide a systematic examination of the Index and to uncover biases that may preclude its use in analyzing the association between resource utilization and birth outcomes. This is a cross-sectional study including all singleton live births in 1993 through 1996 (n = 591,403) in Ohio. Birth certificate data are used to derive the Index, which categorizes women as follows: Adequate Plus (A+), Adequate, Intermediate, and Inadequate. The Index is based on the ratio of observed to expected (O/E) number of prenatal visits. The expected number of visits is based on the American College of Obstetricians and Gynecologists (ACOG) recommendations. The Index also considers the month of initiation of prenatal care. The outcome measures are low birth weight (LBW) and small-for-gestational age (SGA). The LBW rate is 11.8% in the (A+) category, compared to 9.4% in the Inadequate category, and 3.3% and 3.5% in each of the Intermediate and Adequate categories, respectively. Preterm births are disproportionately represented in the (A+) category: 61.2% of births prior to 37 weeks are (A+), whereas only 18.9% of term births are (A+). This apparent bias results from the fact that the ACOG schedule of prenatal visits allocates nearly one third of the total visits to the last 4-5 weeks of gestation. A shorter gestational age implies fewer number of expected visits, a smaller denominator in the O/E ratio, and O/E ratios exceeding 100% by large margins. In fact, the observed number of visits exceeds the expected number of visits by only one or two in 40.1% of all births grouped in the (A+) category. Consequently, the Index yields misleading results indicating that women grouped in the (A+) category (or O/E ratios > 110%) are most likely to deliver LBW infants. Contrary to the results obtained through the APNCU Index, our gestational age-specific analysis showed that increasing number of prenatal visits is associated with improved birth outcomes. We recommend that the use of the APNCU Index to study the association between prenatal resource utilization and LBW be discontinued.     

The Association Between Unhealthy Alcohol Use and Acute Care Expenditures in the 30 Days Following Hospital Discharge Among Older Veterans Affairs Patients with a Medical Condition

Hospital readmissions and emergency department (ED) visits within 30 days of discharge are costly. Heavy alcohol use could predict increased risk for post-discharge acute care. This study assessed 30-day acute care utilization and expenditures for different categories of alcohol use. Veterans Affairs (VA) patients age ≥65 years with past-year alcohol screening, hospitalized for a medical condition, were included. VA and Medicare health care utilization data were used. Two-part models adjusted for patient demographics. Among 416,050 hospitalized patients, 25% had 30-day acute care use. Nondrinking patients (n?=?267,746) had increased probability of acute care use, mean utilization days, and expenditures (difference of $345; 95% CI $268–$423), relative to low-risk drinkers (n?=?105,023). High-risk drinking patients (n?=?5,300) had increased probability of acute care use and mean utilization days, but not expenditures. Although these patients did not have greater acute care expenditures than low-risk drinking patients, they may nevertheless be vulnerable to poor post-discharge outcomes.     

Anticipating the Traumatic Brain Injury–Related Health Care Needs of Women Veterans After the Department of Defense Change in Combat Assignment Policy

BackgroundFemale service members' presence in combat zones during Operation Enduring Freedom and Operation Iraqi Freedom is unprecedented both in terms of the number of women deployed and the nature of their involvement. In light of changing Department of Defense policy governing the deployment of women in combat zones, this article intends to set the groundwork for estimating future combat-related injuries and subsequent Veterans Health Administration (VHA) utilization while focusing on traumatic brain injury (TBI).MethodsThe article summarizes and presents the results of a study that examines veterans who present to VHA for TBI evaluation. For a national sample of veterans, a dataset including information on post-screening utilization, diagnoses, and location of care was constructed. The dataset included self-reported health symptoms and other information obtained from a standardized national VHA post-screening clinical evaluation, the comprehensive TBI evaluation (CTBIE).FindingsBoth women and men utilize high levels of VHA health care after a CTBIE. However, there are gender differences in the volume and types of services used, with women utilizing different services than their male counterparts and incurring higher costs, including higher overall and outpatient costs.ConclusionAs women veterans seek more of their health care from the VHA, there will be a need for more coordinated care to identify and manage deployment-related TBI and common comorbidities such as posttraumatic stress disorder, depression, and chronic pain. Deployment-connected injuries are likely to rise because of the rescinding of the ban on women in combat. This in turn has critical implications for VHA strategic planning and budgeting.     

Special Services for Women in Substance Use Disorders Treatment: How Does the Department of Veterans Affairs Compare with Other Providers?

BackgroundGender is an important consideration in the treatment of substance use disorders (SUD). Although the number of women seeking care through the Department of Veterans Affairs (VA) has increased dramatically, little is known about the capacity of the VA to meet the needs of women with SUD. We examined the prevalence of programs and key services for women in VA facilities in a survey of 14,311 SUD treatment facilities.MethodsUsing data from the 2012 National Survey of Substance Abuse Treatment Services, we calculated the percent of VA facilities offering special programs or groups exclusively for women, compared with facilities under other types of ownership. For each ownership type, we also calculated the mean number of ancillary services offered that are critical for many women in SUD treatment, including child care, domestic violence counseling, and transportation assistance. Multivariable models were used to adjust for differences in other facility characteristics.FindingsApproximately 31% of facilities had special programs exclusively for women. The VA had the lowest prevalence of programs for women, at 19.1%; however, the VA offered an average of 5 key services for women, which was significantly higher than the averages for other federal (n = 2), local (n = 4), and private for-profit (n = 2) facilities. Results were generally robust to multivariable adjustments.ConclusionsThe VA should consider developing more SUD programs and groups exclusively for women, while maintaining ancillary services at their relatively abundant level. Gender-specific programs and groups could serve as points of referral to ancillary services for women veterans.     

Estimates of Prenatal HIV,Hepatitis B Virus,and Hepatitis C Virus Testing Among Pregnant People Enrolled in Wisconsin Medicaid, 2011–2015

Maternal and Child Health Journal - The opioid epidemic and rising rates of injection drug use are increasing the risk of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis...     

Adolescent Use of the Emergency Department Instead of the Primary Care Provider: Who,Why, and How Urgent?

PurposeAdolescents frequently rely on emergency medical care, rather than using primary care providers (PCPs). Our objectives were to characterize a population of adolescents presenting to a large, urban emergency department (ED) and to examine the reasons why they present to the ED, rather than to their PCP's office.MethodsAdolescents ages 12 to 21 years and their parents/guardians were invited to participate and asked to complete a brief online survey. Demographic data and triage information were collected from electronic medical records.ResultsOf 203 participants, 66% (n = 134) had public insurance, and 40% (n = 82) were triaged as nonurgent. Nearly all (93%, n = 189) reported having a PCP or primary clinic. The most common reasons given for presenting to the ED were participant perception of illness requiring immediate care (34%), followed by PCP referral to the ED (21%). Those with public insurance (odds ratio = 4.44; 95% CI 2.01 to 9.81) or no insurance/unknown insurance status (odds ratio = 4.77; 95% CI 1.34 to 17.01) were more likely to be triaged as nonurgent than those with private insurance.ConclusionsMany adolescents in this study were triaged as nonurgent, with several participants perceiving they were acutely ill requiring immediate physician care. Further analyses revealed that private insurance was significantly associated with urgent triage status. Future studies could educate adolescents and families about appropriate use of the ED or examine PCP offices directly to determine practices for phone triage and ED referrals of adolescents.     

Regulating Alcohol Advertising: Content Analysis of the Adequacy of Federal and Self-Regulation of Magazine Advertisements, 2008–2010

Objectives. We analyzed beer, spirits, and alcopop magazine advertisements to determine adherence to federal and voluntary advertising standards. We assessed the efficacy of these standards in curtailing potentially damaging content and protecting public health.Methods. We obtained data from a content analysis of a census of 1795 unique advertising creatives for beer, spirits, and alcopops placed in nationally available magazines between 2008 and 2010. We coded creatives for manifest content and adherence to federal regulations and industry codes.Results. Advertisements largely adhered to existing regulations and codes. We assessed only 23 ads as noncompliant with federal regulations and 38 with industry codes. Content consistent with the codes was, however, often culturally positive in terms of aspirational depictions. In addition, creatives included degrading and sexualized images, promoted risky behavior, and made health claims associated with low-calorie content.Conclusions. Existing codes and regulations are largely followed regarding content but do not adequately protect against content that promotes unhealthy and irresponsible consumption and degrades potentially vulnerable populations in its depictions. Our findings suggest further limitations and enhanced federal oversight may be necessary to protect public health.Alcohol is heavily marketed in the United States; alcohol companies spend at least $4 billion a year on marketing and promotion.1,2 Alcohol is the drug young people are most likely to have used in the past 30 days3 and is responsible for approximately 4700 deaths per year among persons younger than 21 years.4 Young people are developmentally susceptible to the content of advertising5,6 and alcohol advertising specifically,5,7 and growing evidence indicates that alcohol advertising influences youth alcohol consumption, including encouraging earlier and heavier consumption.8,9 For those who have not yet initiated use, advertising is 1 way that positive expectations about the product and its potential benefits are developed10,11; in minority communities, alcohol ads have been found to portray alcohol consumption as routine and normative, an entry point into “the good life,” and a marker of individual success.12,13 As of 2008, youths aged 12 to 20 years were exposed to 10% more national magazine advertising for beer than were adults aged 21 years and older and to 16% more advertising for alcopops (also known as “flavored malt beverages” or “ready-to-drink flavored alcoholic beverages,” these are sweet beverages such as Smirnoff Ice or Mike’s Hard Lemonade that are served in a ready to drink, single-serving bottle or can).14 Youths’ exposure to distilled spirits advertising was approximately equal to that of adults. African American youths were exposed to 32% more alcohol advertising in magazines than were youths in general, although they had slightly less exposure than did African American adults.14Considering the resources expended, levels of youths’ exposure, and advertising’s demonstrated power to shape potentially damaging behaviors, it is important that the public health community be consistently knowledgeable about alcohol advertising content. Alcohol advertising appears in multiple media and forms. For example, between 2008 and 2010, alcohol companies developed 1795 unique advertising images (“creatives”) and placed them 7634 times in national magazines in the United States at a cost estimated by Nielsen of $847 712 100 (Nielsen Monitor-Plus, 2008–2010, The Nielsen Company, New York, NY). The growth of digital media offers greater access to younger audiences, the opportunity for marketing to be interactive, and a relative lack of regulation.15 Public health is best served when the context for advertising prioritizes health protection alongside a recognition of the principles of commercial free speech.

Federal Regulations

Despite growing evidence of the damaging impact of alcohol marketing and advertising on youths, federal regulation is minimal. The Treasury Department’s Alcohol and Tobacco Tax and Trade Bureau is the federal agency charged with collecting taxes and ensuring compliance with labeling and marketing regulations pertaining to all spirits, wine, and malt beverages (including beer) sold in the United States. According to Alcohol and Tobacco Tax and Trade Bureau regulations, marketing is prohibited from making false claims intended to deceive and cannot include statements and representations judged obscene or indecent.Health claims and curative statements are also prohibited. Spirits marketing may not include claims of product purity, and beer ads cannot make any representation of product strength (

Exploring Weathering: the Relation of Age to Low Birth Weight Among First Generation and Established United States-Born Mexican–American Women

To determine the age-related patterns of low birth weight, preterm birth, and intrauterine growth retardation among first generation and established US-born Mexican?CAmerican mothers. We performed stratified analyses on an Illinois transgenerational dataset of Mexican?CAmerican infants (1989?C1991) and their mothers (1956?C1976) with appended U.S. census income information. In Cook County, Illinois established (second or higher generation) US-born Mexican?CAmerican women (N?=?2,006) had a low birth weight (<2,500?g) rate of 6.2% compared to 4.8% for first generation US-born Mexican?CAmerican women (N?=?1,450), RR?=?1.3 (1.0?C1.6). In both subgroups, low birth weight, preterm, and intrauterine growth retarded components rates did not increase with advancing maternal age. First generation 30?C35?year old US-born Mexican?CAmerican women (N?=?159) had a low birth weight rate of 3.1% compared to 4.2% for their teen counterparts (N?=?386), RR?=?0.8 (0.3?C2.0). Established 30?C35?year old US-born Mexican?CAmerican women (N?=?330) had a low birth weight rate of 4.9% compared to 7.4% for their teen counterparts (N?=?459), RR?=?0.7 (0.4?C1.2). There was no evidence of weathering among US-born Mexican?CAmerican mothers with a lifelong residence in lower income neighborhoods, with a general downward trend in low birth weight rates with increasing age until age 30?C35. Rates of low birth weight, preterm birth, and intrauterine growth retardation do not increase with advancing age among first generation and established US-born 15?C35?year old Mexican?CAmerican women. This trend persists among both generations of women with a lifelong residence in lower income neighborhoods.     

Prescription Opioid Misuse and Suicidal Behaviors Among US Veterans: A Cross-Sectional Study from the 2015–2019 National Survey on Drug Use and Health

The Journal of Behavioral Health Services & Research - Suicide continues to be a serious public health issue for the US veteran population as its prevalence has skyrocketed over the last...     

Women’s Use of Health Care in the First 2 Years Postpartum: Occurrence and Correlates

Objectives We sought to determine rates and correlates of accessing health care in the 2 years following delivery among women at an urban academic medical center. Methods We used electronic medical records, discharge, and billing data to determine the occurrence of primary care, other non-primary outpatient care, emergency department visits, and inpatient admissions among women delivering at a single medical center who had a known primary care affiliation to that medical center over a 5 year period. We explored sociodemographic, clinical, and health care-related factors as correlates of care, using bivariate and multivariable modeling. Results Of 6216 women studied, most (91 %) had had at least one health care visit in the window between 2 months and 2 years postpartum (the “late postpartum period”). The majority (81 %) had had a primary care visit. Factors associated with use of health care in this period included a chronic medical condition diagnosed prior to pregnancy (adjusted odds ratio (AOR) 1.42, 95 % CI [1.19, 1.71]), prenatal care received in an urban community health center (AOR 1.35 [1.06, 1.73]), having received obstetric (AOR 1.90 [1.51, 2.37]), primary (AOR 2.30 [1.68, 3.23]), or other non-primary outpatient care (AOR 2.35 [1.72, 3.39]) in the first 2 months postpartum, and living closer to the hospital [AOR for residence >17.8 miles from the medical center (AOR 0.74 [0.61, 0.90])]. Having had an obstetrical complication did not increase the likelihood of receipt of care during this window. Conclusions for Practice Among women already enrolled in a primary care practice at our medical center, health care utilization in the late postpartum period is high, but not universal. Understanding the characteristics of women who return for health care during this window, and where they are seen, can improve transitions of care across the life course and can provide opportunities for important and consistent interconception and well-woman messaging.     

Enhancing Health Communication Outcomes Among Ethnic Minority Patients: The Effects of the Match Between Participation Preferences and Perceptions and Doctor–Patient Concordance

Ethnic minority patients are less participative in medical consultations compared to ethnic majority patients. It is thus important to find effective strategies to enhance ethnic minority patients’ participation and improve subsequent health outcomes. This study therefore aimed to investigate the relation between the match between patients’ preferred and perceived participation and doctor–patient concordance in preferred doctor–patient relationship on patient satisfaction, fulfillment of information needs, and understanding of information among Turkish-Dutch and Dutch patients. Pre- and postconsultation questionnaires were filled out by 136 Dutch and 100 Turkish-Dutch patients in the waiting rooms of 32 general practitioners (GPs). GPs completed a questionnaire too. Results showed that a match between patients’ preferred and perceived participation was related to higher patient satisfaction, more fulfillment of information needs, and more understanding of information than a mismatch for both patient groups. For doctor–patient concordance a conditional main effect on all outcome measures emerged only among Turkish-Dutch patients. That is, for patients who were discordant with their GP, higher perceived participation was related to lower satisfaction, worse fulfillment of information needs, and worse understanding of the information. In order to improve medical communication GPs should thus primarily be trained to tailor their communication styles to match patients’ preferences for participation.     

The Effects of Smoking-Related Television Advertising on Smoking and Intentions to Quit Among Adults in the United States: 1999–2007

Objectives. We investigated whether state-sponsored antitobacco advertisements are associated with reduced adult smoking, and interactions between smoking-related advertising types.Methods. We measured mean exposure to smoking-related advertisements with television ratings for the top-75 US media markets from 1999 to 2007. We combined these data with individual-level Current Population Surveys Tobacco Use Supplement data and state tobacco control policy data.Results. Higher exposure to state-sponsored, Legacy, and pharmaceutical advertisements was associated with less smoking; higher exposure to tobacco industry advertisements was associated with more smoking. Higher exposure to state- and Legacy-sponsored advertisements was positively associated with intentions to quit and having made a past-year quit attempt; higher exposure to ads for pharmaceutical cessation aids was negatively associated with having made a quit attempt. There was a significant negative interaction between state- and Legacy-sponsored advertisements.Conclusions. Exposure to state-sponsored advertisements was far below Centers for Disease Control and Prevention–recommended best practices. The significant negative relationships between antismoking advertising and adult smoking provide strong evidence that tobacco-control media campaigns help reduce adult smoking. The significant negative interaction between state- and Legacy-sponsored advertising suggests that the campaigns reinforce one another.Cigarette smoking remains the leading cause of preventable death in the United States. State tobacco control programs rely heavily on paid television advertising to promote tobacco control messages, with the goals of influencing attitudes and beliefs about tobacco use, and reducing population smoking. The California Tobacco Control Program, launched in 1990, is the largest and longest-running state-sponsored antismoking media campaign in the United States.1 Massachusetts introduced a campaign in 1994, Arizona in 1997, and Oregon and Florida in 1998.2,3 Between 1998 and 2002, at least 30 other states started antismoking media campaigns. Cigarette excise taxes and earmarked funds from the 1998 Master Settlement Agreement (MSA) have financed the majority of such campaigns4; in recent years, however, many of these state campaigns have been significantly cut, or even eliminated. The American Recovery and Reinvestment Act of 2009 allocated $650 million toward the Communities Putting Prevention to Work initiatives, many of which included significant tobacco control media campaigns.5 This recent infusion of funding represents the largest expansion of state and regional tobacco control media campaigns since 1998. In addition, the US Food and Drug Administration has announced its own sizable tobacco control media campaign scheduled in 2012.6State-sponsored antitobacco advertisements are not the only smoking-related messages seen on television in the United States in recent years. Since 1996, when nicotine replacement therapies were approved for over-the-counter distribution, pharmaceutical companies have used television advertising extensively to promote smoking cessation aids.7 Also as a result of the MSA, the American Legacy Foundation (Legacy) was formed in 1999, and in 2000 introduced “truth,” its national antismoking advertising campaign. In addition, Philip Morris and Lorillard each launched media campaigns in 1998, which included television advertising with putatively antismoking messages.8Early evidence has suggested that public investments in antismoking media campaigns contributed to reductions in smoking among youths.9 Research on the relationship between antismoking advertisements and adult smoking behavior is encouraging but less conclusive.4,10 Most studies have focused on individual media campaigns within a single state or country, and have not controlled for other smoking-related advertising or other tobacco control policies, such as cigarette excise taxes or clean indoor air regulations, which also influence smoking.11 For example, a recent Australian study showed that higher levels of televised antismoking advertising was associated with reduced adult smoking, with control for important concurrent tobacco control policies.12 One multistate study of the relationship between antismoking advertisements and adult smoking in the United States showed that smokers with higher levels of awareness of antismoking media campaigns were more likely to quit, even after control for other tobacco control policies in the 9 states studied.13 However, that study did not explore the impact of other antitobacco or cessation-related advertising, such as Legacy’s truth campaign or advertisements for pharmaceutical cessation aids. Adults in the United States received substantial levels of exposure to ads for pharmaceutical cessation aids, as well as to Legacy’s predominantly youth-targeted antitobacco media campaign.7 Exposure to either or both of these smoking-related messages may therefore have had important effects on adult smoking. To date, there has been no research on the relationship between smoking among US adults and concurrent exposure to smoking-related advertisements produced by various sponsors, or potential interactions among advertising produced by various sponsors.We examined the relationships between US adults’ smoking behaviors and their exposure to smoking-related television advertisements sponsored by state health departments, the American Legacy Foundation, tobacco companies, and pharmaceutical companies promoting their cessation products. We hypothesized that higher levels of exposure to state-sponsored antitobacco advertisements would be associated with reduced smoking. Our models controlled for individual characteristics, as well as state tobacco control policies and, therefore, overcame the limitations of previous research on the effects of antismoking advertising on smoking among adults.