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OBJECTIVE Lead is a neurotoxicant that negatively affects health. Reducing lead exposure and early detection among children are important public health goals. Our objective with this study was to determine if the September 2015 lead advisory in Flint, Michigan affected lead testing among children when possible exposure was widely publicized. METHOD This study included 206 001 children born in Michigan from 2013 to 2015 and enrolled in Medicaid, using 2013 to 2017 claims data to determine if and at what age an individual received a lead test. Difference-in-differences regression models were used to compare the receipt of lead tests among children in Flint with other cities in Michigan before and after September 2015, when a lead advisory was issued for the city warning about potential exposure to lead in publicly supplied water. RESULTS Before the lead advisory, approximately 50% of children in Flint received a lead test by 12 months of age and nearly 75% received a lead test by 24 months of age. After the September 2015 advisory, the receipt of lead tests among children in Flint increased 10 percentage points by 12 months compared with other cities. Effects by 10-month cohorts, as of 2016, revealed a 20-percentage-point increase for children in Flint compared with other cities. CONCLUSIONS Despite a highly publicized lead advisory, children in Flint enrolled in Medicaid received lead tests earlier, but the proportion of Medicaid-eligible children who were tested did not change. This suggests that increasing lead testing is a difficult policy goal to achieve and, therefore, supports recent efforts focusing on primary prevention to reduce lead exposure.

Emergencies, such as natural and manmade disasters, can present an opportunity or be a detriment to preventive healthcare. While stay-at-home orders which some states implemented to mitigate the impact of COVID-19 are known to reduce acute and routine care, little is known about missed preventive care. Dental care, unlike other forms of preventive care - such as pediatric vaccines and well-visits, is simpler to analyze as it is not practicable with telehealth. Using weekly foot traffic data by SafeGraph from January 2018 to June 2020, we examine the effect of stay-at-home orders on visits to dental offices, finding a 15.4% decline after March 2020 for states with stay-at-home orders. Surprisingly, we find that states which allowed dental care during the stay-at-home period experienced a further 7.4% decline in visits. Using Michigan Medicaid dental claims for children we find that the decline of 0.25 claims per month is driven primarily by fewer diagnostic and preventive care visits. Though some preventive visits were rescheduled, we estimate only 58% of visits missed in March and April 2020 were made up by the end of the year. These estimates quantify the short-term declines in preventive dental care, suggesting similar declines in other preventive care.

Environmental disasters impact disadvantaged communities disproportionately both through the epidemiological challenge of exposure, but also by undermining the progress of public health efforts. This paper studies changes to smoking cessation, breastfeeding, and weight gain during pregnancy in the period following the switch in water supply in Flint, Michigan, in April 2014. As the switch resulted in immediate and significant deterioration in water quality, eventually leading to its contamination with lead, we estimate a 10.5 percentage point increase in smoking and a 2.1 percentage point decrease in breastfeeding. We show evidence that these changes in maternal behavior are linked to increased stress due to changing water quality. We estimate that the increase in smoking alone is responsible for most of the increase in incidence of low birthweight among infants in Flint, resulting in $700 additional costs per birth. Increased smoking during pregnancy and lower breastfeeding rates in Flint roll back years of public health efforts, resulting in lifetime higher rates of cardiovascular disease, diabetes, and cancer for mothers in the community.

Objectives To characterize the effects of Michigan’s controlled substance legislation on acute care prescriber behavior by specialty, in a single hospital system. Design A retrospective study of opioid and benzodiazepine prescription records from a hospital electronic medical record system between August 1, 2016, and March 31, 2019, in Detroit, Michigan. Setting Discharges from inpatient and emergency department visits. Intervention Evaluating the impact of implementation of state controlled substance legislation, comparing prescriptions by physicians before, upon, and after June 1, 2018, using regression discontinuity analysis. Methods Total daily prescriptions of opioids and total daily prescriptions of benzodiazepine by physicians in the hospital system. Prescriptions were converted to morphine and lorazepam equivalents for comparability. Results We find 38.5% (95% confidence interval [CI] : 74.1% – 2.9%) decrease of prescription in milligrams of opioid equivalents attributable to implementation of legislation. The main catalyst of the decrease was emergency medicine which experienced 63.9% (95% CI: 109.7%–18.0%) decrease in milligrams of opioid equivalent prescriptions, while surgery increased prescriptions. Though we do not find any statistically significant changes in prescriptions of milligram equivalent of benzodiazepines, we estimate 43.1% (95% CI: 82.6%–3.7%) decrease in count of these prescriptions, implying a significant increase in average dosage of prescriptions. Conclusions The introduction of new regulatory requirements for the prescription of controlled substances led to a general decrease in morphine equivalent milligrams prescribed in most specialties, though it may have increased the dosage of benzodiazepine prescriptions. The change in prescription behavior could be motivated by regulatory hassle or by change in attitude towards opioid prescriptions and increased recognition of opioid use disorder.

INTRODUCTION: Morbidity and mortality from poison- and drug-related illness continue to rise in the USA. Medical toxicologists are specifically trained to diagnose and manage these patients. Inpatient medical toxicology services exist but their value-based economic benefits are not well established. METHODS: This was a retrospective study where length of stay (LOS) and payments received between a hospital with an inpatient medical toxicology service (TOX) and a similar hospital in close geographic proximity that does not have an inpatient toxicology service (NONTOX) were compared. Controlling for zip code, demographics and distance patients lived from each hospital, we used a fitted multivariate linear regression model to identify factors associated with changes in LOS and payment. RESULTS: Patients admitted to the TOX center had 0.87 days shorter LOS per encounter and the hospital received an average of $1800 more per patient encounter. CONCLUSION: In this study, the presence of an inpatient medical toxicology service was associated with decreased patient LOS and increased reimbursement for admitted patients. Differences may be attributable to improved direct patient care provided by medical toxicologists, but future prospective studies are needed.

A large body of evidence documents a link between alcohol consumption and violence involving intimate partners and close family members. Recent scholarship suggests that since the onset of the COVID-19 pandemic and subsequent stay-at-home orders, there has been a marked increase in domestic violence. This research considers an important mechanism behind the increase in domestic violence during the COVID-19 pandemic: an increase in the riskiness of alcohol consumption. We combine 911 call data with newly-available high-resolution microdata on visits to bars and liquor stores in Detroit, MI and find that the strength of the relationship between visits to alcohol outlets and domestic violence more than doubles starting in March 2020. We find more limited evidence with respect to non-domestic assaults, supporting our conclusion that it is not alcohol consumption per se but alcohol consumption at home that is a principal driver of domestic violence

Background Protocols utilizing high-sensitivity cardiac troponin (hs-cTn) assays for the evaluation of suspected acute coronary syndrome (ACS) in the emergency department (ED) have been gaining popularity across the US and the world. These protocols more rapidly rule-out ACS and more accurately identify the presence of acute myocardial injury. At this time, few randomized trials have evaluated the safety and operational impact of these assays, resulting in limited evidence to guide the use and implementation of hs-cTn in the ED. Objective The main study objective is to test the effectiveness of a rapid ACS rule-out pathway using hs-cTnI in safely discharging patients from the ED for whom clinical suspicion for ACS exists. Design This prospective, implementation trial (n = 11,070) will utilize a stepped wedge cluster randomized trial design. The design will allow for all participating sites to capture benefit from the implementation of the hs-cTnI pathway while providing data evaluating the effectiveness in providing safe and rapid evaluation of patients with clinical suspicion for ACS. Summary Demonstrating that clinical pathways using hs-cTnI can be effectively implemented to rapidly rule-out ACS while conserving costly hospital resources has significant implications for the care of patients with possible acute cardiac conditions in EDs across the US. Clinicaltrials.gov identifier NCT04488913.

Emergency department visits are costly to providers and to patients. We use the Flint water crisis to test if an increase in office visits reduced avoidable emergency room visits. In September 2015, the city of Flint issued a lead advisory to its residents, alerting them of increased lead levels in their drinking water, resulting from the switch in water source from Lake Huron to the Flint River. Using Medicaid claims for 2013-2016, we find that this information shock increased the share of enrollees who had lead tests performed by 1.7 percentage points. Additionally, it increased office visits immediately following the information shock and led to a reduction of 4.9 preventable, non-emergent, and primary-care-treatable emergency room visits per 1000 eligible children (8.2%). This decrease is present in shifts from emergency room visits to office visits across several common conditions. Our analysis suggest that children were more likely to receive care from the same clinic following lead tests and that establishing care reduced the likelihood parents would take their children to emergency rooms for conditions treatable in an office setting. Our results are potentially applicable to any situation in which individuals are induced to seek more care in an office visit setting.

This concept article introduces a transformative vision to reduce the population burden of chronic disease by focusing on data integration, analytics, implementation and community engagement. Known as PHOENIX (The Population Health OutcomEs aNd Information EXchange), the approach leverages a state level health information exchange and multiple other resources to facilitate the integration of clinical and social determinants of health data with a goal of achieving true population health monitoring and management. After reviewing historical context, we describe how multilevel and multimodal data can be used to facilitate core public health services, before discussing the controversies and challenges that lie ahead.

Wellness programs constitute central components of disease prevention efforts under the Affordable Care Act and are likely to remain a component of employer provided health insurance. This paper evaluates the impact of such programs on medical utilization 4 to 7 years after enrollment in the plan. Using a unique suited data provided by a large private employer, I analyze medical expenditure and utilization for individuals enrolled in a wellness plan. The analysis compares expenditures and visits between wellness members and nonmembers who are matched through propensity score methods. The results show that although the wellness program increases utilization of preventive and outpatient care, by as much as 1.57 visits per year, there is no comparable decline in emergency or inpatient care, resulting in an overall increase in medical expenditure of around $507 per person per year. The increase in medical expenditure persists even 6 to 7 years of continued enrollment in wellness. I find some evidence of improved health, as diagnoses of diabetes decline 0.8 percentage points among wellness members. The results suggest that employer savings stemming from improved health and more judicious use of medical services are not likely to materialize in this wellness program.

Background The Affordable Care Act (ACA) has impacted the insurance mix of emergency department (ED) visits, yet the degree to which this has influenced provider behavior is not clear. Methods This was a difference-in-differences (DID) analysis of ED-visit data from five states in 2013 and 2014. Sample states included 3 expanding Medicaid under the ACA, 1 rejecting ACA funding and delaying an eligibility expansion, and 1 with no eligibility change. We included self-pay and Medicaid patients aged 27 to 64 years. A subsample analysis was done for chest pain visits. DID logistic models were estimated for likelihood of admission for given Medicaid-paid ED visits in expansion states as compared to non-expansion states. Among chest pain visits we assessed likelihood given visits resulted in admission or advanced cardiac imaging, where clinician discretion may be more significant. Results A total of 8,157,748 ED visits with primary payer Medicaid and self-pay were included, of which 331,422 were for chest pain. The proportion of visits paid for by Medicaid rose in expansion states by between 15.8% and 38.9%. Medicaid eligibility expansion was associated with increased odds of admission (OR 1.070 [95% CI 1.051–1.089]). Among chest pain visits, expansion was associated with increased odds of admission (OR 1.294 [95% CI 1.144–1.464]), but not advanced cardiac imaging (OR 1.099 [95% CI 0.983–1.229]). Conclusion Medicaid expansion was associated with small increases in ED visit admissions across the board and among the subgroup of patients presenting with chest pain.

A large literature points out that exposure to criminal victimization has far-reaching effects on public health. What remains surprisingly unexplored is that role that health shocks play in explaining aggregate fluctuations in offending. This research finds novel evidence that crime is sensitive to health shocks. We consider the responsiveness of crime to a pervasive and common health shock which we argue shifts costs and benefits for offenders and victims: seasonal allergies. Leveraging daily variation in city-specific pollen counts, we present evidence that violent crime declines in U.S. cities on days in which the local pollen count is unusually high and that these effects are driven by residential violence. While past literature suggests that property crimes have more instrumental motives, require planning, and hence are particularly sensitive to permanent changes in the cost and benefits of crime, we find that violence may be especially sensitive to health shocks.

Nearly 85% of acute heart failure (AHF) patients who present to the emergency department (ED) with acute heart failure are hospitalized. Once hospitalized, within 30 days post-discharge, 27% of patients are re-hospitalized or die. Attempts to improve outcomes with novel therapies have all failed. The evidence for existing AHF therapies are poor: No currently used AHF treatment is known to improve long-term outcomes. ED treatment is largely the same today as 40 years ago. Admitting patients who could have avoided hospitalization may contribute to adverse outcomes. Hospitalization is not benign; patients enter a vulnerable phase post-discharge, at increased risk for morbidity and mortality. When hospitalization is able to be shortened or avoid completely, certain risks can be mitigated, including risk of medication errors, in-hospital falls, delirium, nosocomial infections, and other iatrogenic complications. Additionally, patients would prefer to be home, not hospitalized. Furthermore, hospitalization and re-hospitalization for AHF predominantly affects patients of lower socioeconomic status (SES). Avoiding hospitalization in patients who do not require admission may improve outcomes and quality of life, while reducing costs. Short stay unit (SSU:24 h, also referred to as an 'observation unit') management of AHF may be effective for lower risk patients. However, to date there have only been small studies or retrospective analyses on the SSU management for AHF patients. In addition, SSU management has been considered 'cheating' for hospitals trying to avoid 30-day readmission penalties, as SSUs or observation units do not count as an admission. However, more recent analyses demonstrate differential use of observation status has not led to decreases in re-admission, suggesting this concern may be misplaced. Thus, we propose a robust clinical effectiveness trial to demonstrate the effectiveness of this patient-centered strategy.

We estimate the impact of the ACA Medicaid expansion on the intensity of treatment in the emergency department. We conduct a visit level analysis with a difference-in-differences specification for the number of procedures, number of diagnoses, and visit characterization according to the NYU Algorithm using the State Emergency Department Databases (SEDD) for six states in 2013-2014. Our results show that in expanding states the number of procedures increased by up to 0.27 per visits (3.9%), and the number of diagnoses declined by up to 0.10 diagnoses per visit. While we remain agnostic about the mechanism for the increase in procedures, we believe increasing reimbursements motivates providers to perform more procedures, or bill more carefully, or both. We also find evidence of changing composition of visit type, with an increase in non-preventable emergency visits and primary care treatable visits. This increase is particularly strong among patients who were uninsured in 2013. We estimate that the additional procedures cost $248 million, constituting at least 3.1% of the total medical expenditure associated with the expansion in the four expanding states in our study. We conclude that the provider side response in treatment presents a substantial additional cost to expanding insurance coverage with fee-for-service payment structure, and should be accordingly included in projected costs of future insurance expansions.

Importance: Expanding health insurance coverage, in addition to increasing access to healthcare, affects medical provider revenue. While projections of medical expenditure include increased utilization attributable to improved access, they do not include changes in provider practice and billing misestimating the cost of insurance expansion. Objective: To evaluate changes to provider practice and billing following the Affordable Care Act (ACA) mandated Medicaid expansion in the emergency department (ED). We analyze total number of procedures and diagnoses on discharge records, then we focus on two diagnostic categories to examine use of specific tests. Design: We analyze 18,872,744 discharges in six states, four of which chose to expand Medicaid, and two which did not, using State Emergency Department Databases (SEDD) for 2013-2014. Using difference-in-differences analysis, we compared outcomes of interest adjusting for patient, visit, and zip code characteristics. Results: The number of procedures in expanding states increased by 0.27 per visit (95% CI, 0.09-0.45), while the number of diagnoses declined by 0.098 per visit (95% CI, -0.22 – 0.03) in 2014 compared to non-expanding states. Focusing on diagnoses of abdominal and pelvic symptoms, we find consistent evidence of decreased use of ultrasounds of abdomen and pelvis (-0.0076, 95% CI, -0.01- -0.002), and some evidence of decreased use of CTs of abdomen and pelvis (-0.0112, 95% CI, -0.01 - -0.001). For diagnoses of upper respiratory symptoms, we find evidence of substitution between tests: 3.2 percentage point decrease in use of ECGs (95% CI, -0.04 - -0.02), and a parallel 1.8 percentage point increase in use of chest x-rays (95% CI, 0.01-0.03). While these magnitudes appear small, the average CMS reimbursement for ECGs is $11.76 and for x-rays is $43.32, an almost four-fold increase in cost. Conclusion: We find that the Medicaid expansion led to between 2.7% to 4.0% increase in number of procedures per visit in the ED. This increase translates into 1,057,169 extra procedures performed in the four expanding states studied here in 2014, adding an estimated cost of $248 million to health expenditures in these states, of which $95.8 million was paid by Medicaid, a cost not captured by current policy projections.

We sought to assess the association between parental depressive symptoms and school attendance and emergency department (ED) use among children with and without chronic health conditions. Secondary analysis of the 1997-2004 National Health Interview Survey, a nationally representative survey. Parental depressive symptoms were measured by three questions assessing sadness, hopelessness, or worthlessness in the past month. Children with and without asthma or attention-deficit/hyperactivity disorder (ADHD) were identified, and their school attendance and ED visits were reported by adult household respondents. Children with information on parental depressive symptoms, health conditions, and services use were eligible. We incorporated weights available in the survey for each eligible child to reflect the complex sampling design. 104,930 eligible children were identified. The point prevalence of parental depressive symptoms was low (1.8 %, 95 % CI 1.7-2.0), but greater among children with asthma (2.7 %, 95 % CI 2.4-3.0) and ADHD (3.8 %, 95 % CI 3.2-4.4) than among other children (1.6 %, 95 % CI 1.5-1.7). After adjustment for potential confounders, children whose parents reported depressive symptoms most or all of the time were more likely to report an ED visit (adjusted incident rate ratio [IRR] 1.18, 95 % CI 1.06-1.32) or school absence (adjusted IRR 1.36, 95 % CI 1.14-1.63) than children whose parents did not. The effect of parental depressive symptoms was not modified by child health conditions. Parental depressive symptoms were adversely associated with school attendance and ED use in children. These results suggest the importance of measuring depressive symptoms among adult caregivers of children.

Objectives. We sought to determine whether the reversal of the public charge rule of the Illegal Immigration Reform and Immigrant Responsibility Act, which may have required families to pay for benefits previously received at no cost, led to immigrant children becoming increasingly reliant on public health insurance programs. Methods. We conducted a secondary data analysis focusing on low-income children sampled in the 1997 through 2004 versions of the National Health Interview Survey. Results. Between 1997 and 2004, public health insurance enrollments and the numbers of uninsured foreign-born children in the United States increased by 3.1% and 2.7%, respectively. Using multinomial logistic regression models to account for the substantial differences in socioeconomic status between foreign-born and US-born children, we found that low-income US-born children were just as likely as foreign-born children to have public health insurance coverage (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.89, 1.52) and that, after 2000, foreign-born children were 1.59 times (95% CI = 1.24, 2.05) more likely than were US-born children to be uninsured (vs publicly insured). Conclusions. In the wake of the reversal of the public charge rule, immigrant children are increasingly likely to be uninsured as opposed to relying on public health insurance.