Literature Collection

Grief is a universal experience, but for approximately 1 in 10 individuals, grief can become impairing. Despite servicemembers' frequent exposure to death, research on grief in the military remains limited. The purpose of the study was to explore the prevalence and correlates of complicated grief (CG) in military primary care. A quantitative survey was conducted with 161 non-treatment-seeking service members, veterans, and their dependents, of whom 138 reported a significant loss. Results revealed that 35% of the respondents who were bereaved met the cut-off score of 25 on the Inventory of Complicated Grief (ICG). Furthermore, 10% met the cut-off score of 30 on the Prolonged Grief Disorder-13-Revised Scale (PG-13-R). Importantly, death by suicide and pre-existing mental health conditions were associated with greater symptom severity. These findings have important implications for primary care providers and other clinicians working with military populations.

Firearm-related injuries remain the leading cause of mortality in children in the United States. It is not well-characterized how often clinicians perform firearms access screening and safety counseling. We examined documentation of these services in a cross-sectional study of well child exams (WCEs) at a tertiary academic center in Southeast Michigan. Overall, we found that clinicians documented screening in 25,469 of 32,582 WCE encounters due to categorical Pediatrics clinicians doing so in 73.8% of encounters; Family Medicine and Internal Medicine-Pediatrics clinicians documented some form of screening in nearly all (> 99%) encounters. Clinicians documented counseling in 21.8% of encounters with Family Medicine clinicians lagging the other two specialties (8.2% versus 23.9% and 18.4% for Pediatrics and Internal Medicine-Pediatrics, respectively). Multinomial logistic regression for screening (conducted only for Pediatrics given the near universal screening by Family Medicine and Internal Medicine-Pediatrics) and counseling (conducted for all specialties) showed decreased likelihood of both screening and counseling for certain age and sociodemographic groups; however, while there was decreased likelihood for non-attending physician clinicians (i.e. advanced practice providers and resident/fellow physicians) and high inter-clinic variability (77.1%) for screening, the opposite was true for counseling with decreased likelihood for attending physicians and inter-clinic variability of 16.7%. Findings suggest that quality improvement efforts and clinician training are needed to eliminate gaps in risk-stratified screening and counseling regarding firearm safety.

IMPORTANCE: The incidence of opioid use during pregnancy is increasing, and drug overdoses are a leading cause of postpartum mortality. Most women who are pregnant do not receive medications for treatment of opioid use disorder, despite the mortality benefit that these agents confer. Furthermore, buprenorphine is associated with milder symptoms of neonatal abstinence syndrome (NAS) compared with methadone. OBJECTIVE: To describe the prevalence and geographic distribution across the US of obstetrician-gynecologists who can prescribe buprenorphine (henceforth described as X-waivered) in 2019. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional, nationwide study linking physician-specific data to county- and state-level data was conducted from September 1, 2019, to March 31, 2020. Data were obtained on 31 211 obstetrician-gynecologists who accept Medicaid insurance through the Centers for Medicare & Medicaid Services Physician Compare data set and linked to the Drug Addiction Treatment Act buprenorphine-waived clinician list. EXPOSURES: State-level NAS incidence and county-level uninsured rates and rurality. MAIN OUTCOMES AND MEASURES: Prevalence and geographic distribution of obstetrician-gynecologists who are trained to prescribe buprenorphine. RESULTS: Among the 31 211 identified obstetrician-gynecologists, 18 710 (59.9%) were women. Most had hospital privileges (23 236 [74.4%]) and worked in metropolitan counties (28 613 [91.7%]). Only 560 of the identified obstetrician-gynecologists (1.8%) were X-waivered. Obstetrician-gynecologists in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered (adjusted odds ratio [aOR], 1.59; 95% CI, 1.04-2.44; P = .04) compared with those in counties with greater than 15% uninsured residents. Compared with those located in metropolitan counties, obstetrician-gynecologists in suburban counties (eg, urban population of ≥20 000 and adjacent to a metropolitan area) were more likely to be X-waivered (aOR, 1.85; 95% CI, 1.26-2.71; P = .002). Compared with states with an NAS rate of 5 per 1000 births or less, obstetrician-gynecologists in states with an NAS rate of 15 per 1000 births or greater had nearly 5 times the odds of being X-waivered (aOR, 4.94; 95% CI, 3.60-6.77; P < .001). Obstetrician-gynecologists without hospital privileges were more likely to be X-waivered (aOR, 1.32; 95% CI, 1.08-1.61; P = .007). CONCLUSIONS AND RELEVANCE: Fewer than 2% of obstetrician-gynecologists who accept Medicaid are able to prescribe buprenorphine, and their geographic distribution appears to be skewed in favor of suburban counties. This finding suggests that there is an opportunity for health systems and professional societies to incentivize X-waiver trainings among obstetrician-gynecologists to increase patients' access to buprenorphine, especially during pregnancy.

BACKGROUND: Posttraumatic stress disorder (PTSD) is often underdiagnosed based on medical records. This study aimed to estimate the prevalence and health care utilization of individuals with PTSD and other trauma-related disorders in a large, integrated health care system. METHODS: Adults (between the ages of 18 and 65) with Kaiser Permanente Northern California membership and ≥ 1 outpatient visit in 2022 were eligible. Unspecified/other specified trauma and stressor-related disorder, acute stress disorder, and PTSD were based on diagnosis codes from the International Classification of Diseases, 10th Revision, Clinical Modification. The Primary Care PTSD (PC-PTSD) Scale was used as a screening tool. Prevalence was assessed overall and among the subset of patients seen in primary care, psychiatry, and addiction medicine. To contextualize health care utilization, the authors compared patients with trauma-related disorders to those with major depressive disorder. RESULTS: Of the 2,128,670 eligible adults, the overall prevalence of trauma-related diagnoses and positive screening on PC-PTSD was 4.9% (103,947); 1.3% (n = 27,670) had PTSD, 1.9% (n = 41,205) had unspecified/other specified trauma and stressor-related disorder, 0.1% (n = 1818) had acute stress disorder, and 1.6% (n = 33,254) screened positive on PC-PTSD without a trauma-related International Classification of Diseases code. Prevalence of trauma-related diagnoses by department was 18.3% (n = 47,516) in psychiatry, 16.5% (n = 3816) in addiction medicine, and 3.4% (n = 67,469) in primary care. There were no clinically meaningful differences in health care utilization between those with trauma-related diagnoses compared with major depressive disorder. CONCLUSION: Broadly defining trauma-related disorders and substantial symptoms may provide a more accurate representation of the actual prevalence of PTSD in a health care system. These data may help health care leaders plan treatment options for this diverse group of individuals.

BACKGROUND: Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. OBJECTIVE: To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. DESIGN: Retrospective observational cohort study using electronic health record and insurance data. PARTICIPANTS: Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). MAIN MEASURES: The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. KEY RESULTS: The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). CONCLUSIONS: Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.

Electronic cigarettes (e-cigarettes) are the most used tobacco product among US adolescents. Information about the prevalence of use in a pediatric primary care population has been limited. Youth aged 12 to 17 attending a well-child visit completed screening for past year e-cigarette, cigarette, cannabis, and alcohol use, as well as depression and anxiety symptoms. We examined e-cigarette-use prevalence, frequency, and relationship to demographics, mental health symptoms, and other substance use. Among 9740 patients, 8.2% reported past-year e-cigarette use. Males (7.2%) were less likely than females (9.2%) to use e-cigarettes, while more frequent use was associated with more frequent cannabis, alcohol, and cigarette use, as well as elevated depression and anxiety symptoms. Sex differences support a recent trend toward young females using e-cigarettes at higher rates than males. Polysubstance use was common, highlighting the importance of regular screening for all substances and feasible interventions for this setting.