Search

“Brain-predicted age” quantifies apparent brain age compared to normative neuroimaging trajectories. Advanced brain-predicted age has been well established in symptomatic Alzheimer disease (AD), but is underexplored in preclinical AD. Prior brain-predicted age studies have typically used structural MRI, but resting-state functional connectivity (FC) remains underexplored. Our model predicted age from FC in 391 cognitively normal, amyloid-negative controls (ages 18–89). We applied the trained model to 145 amyloid-negative, 151 preclinical AD, and 156 symptomatic AD participants to test group differences. The model accurately predicted age in the training set. FC-predicted brain age gaps (FC-BAG) were significantly older in symptomatic AD and significantly younger in preclinical AD compared to controls. There was minimal correspondence between networks predictive of age and AD. Elevated FC-BAG may reflect network disruption during symptomatic AD. Reduced FC-BAG in preclinical AD was opposite to the expected direction, and may reflect a biphasic response to preclinical AD pathology or may be driven by inconsistency between age-related vs. AD-related networks. Overall, FC-predicted brain age may be a sensitive AD biomarker.

Importance: More than 4 million Medicare beneficiaries have enrolled in dual-eligible Special Needs Plans (D-SNPs), and coordination-only D-SNPs are common. Little is known about the impact of coordination-only D-SNPs on Medicaid-covered services and spending, including long-term services and supports, which are financed primarily by Medicaid., Objective: To evaluate changes in Medicaid fee-for-service (FFS) spending before and after new enrollment in coordination-only D-SNPs vs new enrollment in non-D-SNP Medicare Advantage (MA) plans among community-living beneficiaries enrolled in both Medicare and North Carolina Medicaid., Design, Setting, and Participants: This cohort study applied a new user, active comparator design to control for selection into MA and inverse probability of treatment weighting to improve the comparability between groups. The cohort included community-living dual-eligible Medicare and Medicaid beneficiaries in North Carolina with 365 days of Medicare FFS enrollment prior to new enrollment in D-SNP (treatment) or other MA plan (active comparator). Linked 100% Medicare and North Carolina Medicaid claims data (2014-2017) provided payments across both payers prior to MA enrollment; after MA enrollment, payments for Medicaid-funded services and supplemental Medicaid payments for Medicare-funded services were observed. Data were analyzed from August 2023 to November 2024., Exposure: New D-SNP enrollment., Main Outcomes and Measures: Outcomes included annualized 1-year Medicaid FFS spending overall and by claim type, including inpatient, outpatient, carrier, home health, personal care services, and behavioral health services., Results: Among 8869 participants in the D-SNP cohort, 4762 (53.7%) were younger than 65 years, 5833 (65.8%), were female, and 975 (11.0%) resided in rural areas. After inverse probability of treatment weighting, characteristics were similar among the comparison MA cohort of 4389 participants (4706 [53.2%] aged <65 years; 5739 [64.9%] female; 971 [11.0%] rural). There were no significant differences in Medicaid FFS spending per person-year (PPY) at baseline or differential change in the year following new enrollment (mean marginal effect, -$387 [95% CI, -$1274 to $501) between groups. There were significant differences between groups in the change in spending on long-term services and supports, with maintained spending on community-based personal care services following new enrollment in D-SNPs compared with reductions for other MA, resulting in a relative increase of $343 (95% CI, $147 to $539)., Conclusions and Relevance: This cohort study found that coordination-only D-SNPs was associated with maintained North Carolina Medicaid FFS spending levels for long-term services and supports compared with other MA plans, despite limited integration requirements. However, to reduce or delay nursing home transitions, higher levels of integration may be necessary.

Lay Abstract: Black and non-White Latinx children tend to receive autism diagnoses later in life and with a higher degree of impairment than White children. The purpose of this study was to learn what is currently helping as well as preventing Black and non-White Latinx children from getting access to autism evaluation and services. We held virtual interviews with 26 experts who work with autistic children and their families, including clinical providers, researchers, advocates, and policymakers/government representatives. From these interviews, we identified four themes that have an impact on equity in autism services: (1) who makes up the workforce , (2) w orkforce capacity and accessibility , (3) workforce payment structure , and (4) changes due to the COVID-19 pandemic. These findings show the need for improved workforce diversity, autism-specific education, payment structures, and additional support for workforce members to avoid burnout. To make childhood autism services more equitable, diversity in recruitment across training levels, cultural awareness, increased autism education for all pediatric providers, and partnerships with caregivers as experts must be prioritized. These investments in the autism workforce will allow professionals in the field to better meet the needs of children and families from Black and non-White Latinx communities and achieve equity in early childhood autism services., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Missed infant well-child visits (WCV) result in lost opportunities for critical preventive care. Black infants consistently receive less WCV care than other racial groups. We sought to understand barriers and facilitators to timely infant WCV for Black families in the context of COVID-19., Methods: We conducted 21 semi-structured interviews with caregivers of Medicaid-insured Black children aged 15- to 24-months who attended six or fewer of eight recommended well-child visits within the first 15 months of life. Interviews focused on WCV value, barriers, and facilitators. After developing our initial coding structure through rapid qualitative analysis, we inductively derived the final codebook and themes through line-by-line content analysis., Results: Caregivers attended a mean of 3.53 of eight infant visits. Structural (e.g., transportation) and psychological (e.g., maternal depression) barriers delayed Black infant WCV. Families most frequently valued monitoring development and addressing concerns. Caregivers perceived visits as less urgent when infants seemed healthy or more recently avoided visits due to fears around COVID-19. Long waits and feeling rushed/dismissed were linked to WCV delays; positive provider relationships encouraged WCV attendance. Most caregivers reported reluctance to vaccinate. Vaccine hesitancy contributed to delayed infant WCV., Conclusions: Caregivers described several factors that impacted WCV attendance for Black infants. Persistent structural and psychological barriers are compounded by perceptions that caregiver time is not respected and by notable vaccine hesitancy. To address these barriers, well-care can meet Black families in their communities, better address caregiver wellbeing, more efficiently use caregiver and provider time, and cultivate partnerships with Black caregivers., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

A national emergency in child and adolescent mental health was declared in the United States in 2021 in the wake of the COVID-19 pandemic. This Open Forum discusses potential solutions to better support child and adolescent mental health by improving or expanding school-based mental health services, child psychiatry access programs, virtual mental health services, and new models of care (e.g., integrated youth services hubs and crisis stabilization units). The success of such programs is dependent on stable funding, strong leadership and accountability, robust and well-trained workforces, systems integration, and attention to health equity., Competing Interests: The authors report no financial relationships with commercial interests.

Background: Cognitive behavioural therapy (CBT) and medication are widely accepted and useful interventions for individuals with depression. However, a gap remains in our current understanding of how CBT directly benefits adolescents with depression., Aims: The purpose of this study was to examine the short- and long-term effectiveness of CBT only, CBT+Medication, or Medication alone in reducing the duration of major depressive episodes, lessening internalizing and externalizing symptoms and improving global functioning., Methods: Data were extracted from 14 unique studies with a total of 35 comparisons. Network meta-analysis was conducted and p -scores, a measure of the extent of certainty that one treatment is better than another, were used to rank treatments., Results: There was no significant difference between any two treatments for depression, nor internalizing or externalizing symptoms. For global functioning, CBT had significantly greater effect at the longest follow-up than CBT+Medication. CBT+Medication had the highest p -score for depression, short- and long-term effects, and internalizing and externalizing symptoms long-term effects. No indication of publication bias was found., Conclusions: Neither modality, CBT nor medication, is superior for treating adolescent depression. However, CBT was superior in improving global functioning, which is essential for meeting developmental goals.

Background: Childhood food insecurity increased considerably during the COVID-19 pandemic and is associated with compromised health. Health care systems are increasingly prioritizing food insecurity interventions to improve health, but it is unclear how health systems collaborate with other sectors that are addressing food insecurity. In this study, we aimed to evaluate existing collaborations and explore opportunities for further cross-sector engagement., Methods: From December 2020 to March 2021, we conducted semi-structured interviews (N = 34) with informants involved in increasing child food access in North Carolina. Our informants represented different sectors, including community (e.g., food pantry), education (e.g., school lunch program), and government (e.g., Supplemental Nutrition Assistance Program). Rapid qualitative analysis was used to interpret the results and identify themes., Results: Informants rarely mentioned the health care sector as a source of referrals or as a collaborator. Barriers limiting access to food insecurity programs were exacerbated by the COVID-19 pandemic, including lack of transportation, stigma deterring use, limited food choice, and burdensome enrollment processes. Stakeholders recommended mitigating barriers through the expansion of food delivery, colocalization of assistance programs in schools and health care settings, increased food choice, and supporting cross-program enrollment mechanisms., Limitations: The majority of the stakeholders represented programs from five counties in central North Carolina, with only a few representing statewide initiatives., Conclusions: The COVID-19 pandemic both highlighted the fragmented system of food insecurity organizations and accelerated development of cross-sector collaborations to reduce access barriers. Health care systems are siloed from school and community efforts but have the opportunity to leverage ongoing innovative policy initiatives to construct novel cross-sector models. Such models can better link food insecurity screening with community-based solutions to address family-level food access barriers., Competing Interests: Disclosure of interests. All authors report no relevant conflicts of interest.

Objective: The authors aimed to examine racial-ethnic differences in filled psychotropic prescriptions among a pediatric Medicaid population., Methods: This retrospective cohort study included patients ages 0-21 with at least one North Carolina Medicaid claim from October 1, 2017, through September 30, 2018 (N=983,886). The primary outcome was a filled psychotropic prescription. Separate multivariable modified Poisson regression models generated adjusted risk ratios (ARRs) and 95% confidence intervals (CIs), adjusted for patient demographic characteristics., Results: Black and Hispanic patients were significantly less likely to receive any filled psychotropic prescription (ARR=0.61, 95% CI=0.60-0.62; ARR=0.29, 95% CI=0.28-0.29, respectively) compared with White and non-Hispanic patients. Furthermore, Black and Hispanic patients were less likely to receive filled prescriptions in the four included drug classes compared with White and non-Hispanic patients., Conclusions: Future studies should focus on understanding the factors contributing to racial and ethnic differences among pediatric patients receiving filled psychotropic prescriptions.

Objective: We examined characteristics associated with receiving the North Carolina Home and Community-Based Services Waiver for intellectual and developmental disabilities (I/DDs) and its association with emergency department (ED) utilization., Method: Through analysis of the North Carolina 2017 to 2018 Medicaid claims and enrollment data, we examined characteristics (age, sex, race and ethnicity, geography, diagnosis (intellectual disability [ID] with or without autism spectrum disorders or autism spectrum disorder without ID) associated with receiving the NC I/DD Waiver and the association of this Wavier with ED utilization. We identified patients with at least 1 International Classification of Diseases-10-CM diagnosis code for an ID or autism spectrum disorder. We excluded patients with missing county information and whose enrollment in the NC I/DD Waiver program began after October 1, 2017., Results: Only 22% of 53,531 individuals with I/DD in North Carolina received the Waiver. Non-Hispanic Blacks and Hispanic individuals were less likely to receive the Waiver than non-Hispanic White individuals. Adults (>21 years old), men, and urban residents were more likely to receive the Waiver. Individuals who received the Waiver were 31% less likely to use the ED., Conclusion: Innovative strategies are needed to provide equitable access to the NC I/DD Waiver and provide services to the 14,000 people with I/DD currently waiting to receive the Waiver. Through the Waiver, those with I/DD can access preventative and therapeutic outpatient services and decrease their need for ED care. These findings highlight the need for policy reform to address inequities in access to the Waiver for individuals with I/DD., Competing Interests: Disclosure: J. Howard discloses personal fees from Roche. The remaining authors declare no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)