JAMA Network Open

BackgroundArtificial intelligence and machine learning (AI/ML) are among the fastest-growing domains in NIH research funding, but whether children have shared equitably in this expansion is unknown. We characterized pediatric representation in NIH AI/ML funding from fiscal years (FY) 2020 to 2024. MethodsNIH grant data were obtained from Research Portfolio Online Reporting Tools Expenditures and Results bulk files for FY2020 to FY2024. AI/ML grants were identified using the NIH Research, Condition, and Disease Categorization "Machine Learning and Artificial Intelligence" category, and pediatric grants using the "Pediatric" category. Subprojects were excluded. Grants were deduplicated within each fiscal year by core project number for trend analyses and across all years retaining the most recent fiscal year for cross-sectional totals. Disease areas were identified by keyword searches of titles and abstracts. ResultsAcross FY2020 to FY2024, 5,624 unique NIH AI/ML grants totaling $3,371 million were identified. Of these, 836 grants (14.9%) were classified as pediatric, representing $401 million (11.9%) of total NIH AI/ML funding. Although this share was consistent with the historically reported overall NIH pediatric funding baseline of approximately 10% to 12%, it remained substantially below the US pediatric population share of approximately 22%. The pediatric share of NIH AI/ML funding declined from 12.3% in FY2020 to 10.8% in FY2024, despite growth in absolute pediatric funding. Indexed to FY2020, pediatric AI/ML funding grew approximately 2.6-fold compared with 3.0-fold growth in the total portfolio. Across disease areas, unadjusted adult/general-to-pediatric funding ratios ranged from 2.0-fold in mental health to 9.8-fold in cancer. ConclusionsPediatric representation in NIH AI/ML funding remained low and declined over time as the overall portfolio expanded. These findings suggest that growth in NIH AI/ML investment has not been matched by proportional gains for pediatric research.

IntroductionMedicare Part B reimbursement data has been thoroughly evaluated in several surgical subspecialties to date, with significant ramifications for continued policy research and payment reform discussions. However, trends in maxillofacial surgery payment remain unstudied. MethodsIn this cross-sectional study of Part B reimbursement data, we analyzed regional trends in reimbursement for common maxillofacial repair and reconstruction procedures (N=17). All payment data converted to January 2019 United States dollars. ResultsFrom 2010 to 2019, fees for maxillofacial surgery evidenced strong region- and procedures-specific changes. After adjusting for inflation, the Southern United States reported an unweighted mean change in Medicare reimbursement of negative 12.59% (SD = 2.63%), while the Western United States reported an unweighted mean change in Medicare reimbursement of +0.08% (SD = 2.82%). In the Midwest, only Part B billing for reconstruction of the mandibular rami and/or body without internal rigid fixation (CPT code 21195) kept up with inflation. In the West, 8 CPT codes (47%) kept up with inflation: 21422, 21246, 21196, 21195, 21194, 21193, 21048, and 21046. In the Northeast and the South, all analyzed procedures reported decreased reimbursement rates after adjusting for inflation. ConclusionReimbursement for maxillofacial surgery has lagged behind inflation with pronounced regional bias.

ImportanceCigarette smoking during pregnancy increases the risks of miscarriage, ectopic pregnancy, placental complications, hypertensive disorders of pregnancy, and infant mortality. Reducing smoking in pregnancy remains a pressing public health priority. ObjectiveTo project the impact of a proposed nicotine product standard on maternal complications and infant mortality using the Smoking, E-cigarette use, and Pregnancy (SEP) microsimulation model. Design, Settings, and ParticipantsIndividual-level, annual-cycle microsimulation of U.S. females of reproductive age that tracks smoking, vaping, pregnancy, and pregnancy outcomes was constructed. Model inputs were drawn from national surveillance and vital statistics, including National Health Interview Survey (NHIS) for general population, Behavioral Risk Factor Surveillance System (BRFSS) (2016-2023) for smoking/vaping among pregnant women and NVSS Natality/Linked Birth-Infant Death files for late-pregnancy morbidities and infant mortality. Policy effects on tobacco and e-cig usage transitions are based on FDAs expert-elicitation and used to simulate outcomes under status quo vs. the new policy from 2027-2100. ExposureSmoking and vaping. Main Outcome(s)Maternal outcomes during pregnancy (ectopic pregnancy, miscarriage, placenta previa, placental abruption, hypertensive disorders of pregnancy/pre-eclampsia, eclampsia), infant mortality, pregnancy-related costs, and maternal Quality Adjusted Life Years (QALYs). ResultsUnder the nicotine product standard (policy start 2027), smoking in pregnancy falls sharply from 6.0% in 2027 to 1.2% by 2040. These behavioral shifts translate into large perinatal gains through 2100: approximately 167,000 ectopic pregnancies, 950,000 miscarriages, 15,000 placenta previa, 62,000 placental abruptions, 167,000 hypertensive disorders of pregnancy/pre-eclampsia, 9,000 eclampsia cases, and 64,000 infant deaths are averted cumulatively. Maternal health improves as well, with 103,000 pregnancy QALYs gained. Health system spending falls despite conservative costing, with $4.9 billion in pregnancy-related medical costs avoided. Across uncertainty bounds, direction and magnitude of benefit remain favorable for all maternal morbidities and infant deaths, indicating that new policy yields substantial and durable health gains alongside meaningful cost offsets. ConclusionsA proposed nicotine product standard is projected to improve maternal and infant outcomes and yield sizable pregnancy-related health gains and cost offsets. The SEP model complements prior tobacco policy evaluation frameworks while focusing on maternal and infant health.

IntroductionThe SARS-CoV-2 secondary attack rate (SAR) in schools is low when mitigation measures are adopted, Data on the relative impact of such strategies are limited. We evaluated the SARS-CoV-2 SAR in Massachusetts schools during 2020-21 and factors associated with transmission risk. MethodsIn a convenience sample of 25 Massachusetts public K-12 school districts, de-identified information about SARS-CoV-2 cases and their school-based contacts was reported using a standardized contact-tracing tool. Index cases were included if they were in school while infectious. SAR was defined as the proportion of in-school contacts acquiring SARS-CoV-2 infection and designated as possible or probable in-school transmission by school-based teams. We compared exposure-specific SAR using unadjusted risk ratios (RR) with 95% confidence intervals (CI); p-values were calculated using Fishers exact tests. ResultsEight districts (70 schools with >33,000 enrolled students) participated. There were 435 index cases and 1,771 school-based contacts (Table 1). Most contacts (1327/1771 [75%]) underwent SARS-CoV-2 testing and 39/1327 (2.9%) contacts tested positive. Of 39 positive contacts, 10 (25.6%) had clear out-of-school exposures and were deemed not in-school transmissions, so were excluded from further calculations. Twenty-nine (74.4%) contacts were deemed possible or probable in-school transmissions, resulting in an in-school SAR of 2.2%. Of the 29 in-school transmissions, 6 (20.7%) were staff-to-staff, 7 (24.1%) were staff-to-student, 3 (10.3%) were student-to-staff, and 13 (44.8%) were student-to-student; 6 (20.7%) occurred from index cases attending work/school while symptomatic. The unadjusted SAR (Table 2) was significantly higher if the index case was a staff member versus a student (RR 2.18, 95% CI 1.06-4.49; p=0.030), if the index case was identified via in-school contact tracing versus via school-based asymptomatic testing (RR 8.44, 95% CI 1.98-36.06; p=0.001), if the exposure occurred at lunch versus elsewhere (RR 5.74, 95% CI 2.11-15.63; p<0.001; all lunch transmissions were staff-to-staff), and if both parties were unmasked versus both masked (RR 6.98, 95% CI 3.09-15.77; p<0.001). For students, SAR did not differ by grade level. O_TBL View this table: org.highwire.dtl.DTLVardef@1b1f706org.highwire.dtl.DTLVardef@d0cea9org.highwire.dtl.DTLVardef@afcd27org.highwire.dtl.DTLVardef@1c5e7e7org.highwire.dtl.DTLVardef@1fc0731_HPS_FORMAT_FIGEXP M_TBL O_FLOATNOTable 1:C_FLOATNO O_TABLECAPTIONNumber of SARS-CoV-2 index cases, possible and probable in-school transmissions, secondary attack rates, and number of contacts per index case in 8 Massachusetts K-12 public school districts, 2020-21 C_TABLECAPTION C_TBL O_TBL View this table: org.highwire.dtl.DTLVardef@13c5853org.highwire.dtl.DTLVardef@cac231org.highwire.dtl.DTLVardef@1931f5eorg.highwire.dtl.DTLVardef@1f095c1org.highwire.dtl.DTLVardef@1f7bc21_HPS_FORMAT_FIGEXP M_TBL O_FLOATNOTable 2:C_FLOATNO O_TABLECAPTIONNumber of index cases and contacts and secondary attack rate by type of exposure: 8 public MA K-12 districts, 2020-21 C_TABLECAPTION C_TBL ConclusionsSecondary attack rates for SARS-CoV-2 were low in public school settings with comprehensive mitigation measures in place before the emergence of the delta variant; lack of masking and staff-to-staff dining were associated with increased risk.

BackgroundInvasive cervical cancer continues to disproportionately affect minoritized and rural populations. We analyzed racial/ethnic and geographic incidence trends in Wisconsin from 1998-2022. MethodsIncidence rates (per 100,000 individuals with a cervix) were compared by race/ethnicity and county using Wisconsin Cancer Reporting System data. ResultsOverall rates declined 28% (8.2 to 5.9/100,000), but unevenly across populations. Compared with Non-Hispanic White individuals, Non-Hispanic Black individuals had nearly double the incidence, and Hispanic individuals-despite a steeper decline (40.8%,15.7 to 9.3/100,000) -continued to have higher rates. Milwaukee County-Wisconsins most socially vulnerable county-had among the highest incidence rates and slowest decline over time (19.8%). DiscussionThe preventability of invasive cervical cancer makes the persistent disparities in Wisconsin a clear signal of structural inequities demanding urgent attention.

Objective: To examine whether Medicaid-enrolled preschoolers with untreated decayed teeth received dental treatment within one year of enrollment and identify the factors associated with a treatment gap. Methods: A retrospective cohort analysis of data from a cluster-randomized trial conducted in 18 community-based pediatric primary care practices in Northeastern Ohio (2017-2022). Treatment receipt was determined using Medicaid claims, with treatment gap defined as fewer teeth with treatment claims than teeth found on baseline exam with decay. Multivariable logistic regression assessed the association of treatment gap with child age, sex, race/ethnicity, caregiver education, and number and location of baseline decayed teeth. Results: Of 766 eligible children, 487 (63.6%) attended the dentist within one year. Among 155/487 (31.8%) with baseline untreated decay, 90/155 (58.1%) had a treatment gap. Odontograms visually showed that decay was concentrated on upper anterior and posterior teeth. A treatment gap was associated with a greater number of decayed posterior teeth (OR = 1.90, 95% CI: 1.60-2.30) and decayed anterior teeth (OR = 2.19, 95% CI: 1.51-3.39), both p < 0.001. Other socio-demographic variables were not significantly associated with a treatment gap. Conclusion: More than half of Medicaid-enrolled children attending well-child visits had a dental treatment gap after 1 year. This pattern may reflect dentists' hesitancy to restore primary teeth nearing exfoliation and needing multiple dental visits to complete needed restorative treatment. To address this gap, non-surgical interventions such as silver diamine fluoride can be applied by pediatric primary care providers to control the bacteria and prevent disease progression.

BackgroundSchool-based caries prevention using silver diamine fluoride (SDF) has been shown to effectively prevent and control dental caries. To better inform program design and implementation, this paper estimated transition probabilities for dental caries in a school SDF program. MethodsThe CariedAway project was a pragmatic, cluster-randomized trial of school-based caries prevention interventions conducted in predominately low-income minority children. For children in CariedAway receiving SDF, transition probabilities were computed between sound, carious, and arrested states for 6-year molars using multistate Markov models. Subject-level transition probabilities over one- and two-year periods were then calculated by aggregating states of all 6-year molars and first and second bicuspids. ResultsA total of 7418 children were enrolled in CariedAway, of which 1352 met inclusion criteria for this study. Of eligible participants, the baseline prevalence of untreated decay was 29% and the prevalence of dental sealants was 8%. The probability of transitioning between sound and carious states in 6-year molars ranged from 0.0022 to 0.0074. At the subject-level, the sound to carious transition probabilities were 0.07 and 0.12 after one and two years, respectively. Once in a fully arrested state, the probability of remaining arrested was 0.72 and 0.60 after one and two years. ConclusionsThe overall probabilities of teeth remaining in diseased-free or arrested states was high after receiving silver diamine fluoride, although multiple applications might be needed for consistent caries arrest.

Objectives To compare hospital claims and costs for major tobacco associated diseases with ICD 10 F17 tobacco dependence coding in Indonesian national health insurance claims and to assess whether the insurer records tobacco addiction or mainly pays for its complications. Design Retrospective claims based observational study using routinely collected administrative claims reported according to STROBE and the RECORD extension. Setting Indonesian national health insurance scheme Jaminan Kesehatan Nasional including referral hospital and primary care claims from 2015 to 2023. Participants A national mental health claims sample of 54820 members with at least one ICD 10 mental or behavioral F code diagnosis weighted to 1032022 members and 2074277 referral hospital visits. Primary and secondary outcome measures The primary outcome was verified claim costs in USD for hospital visits with a primary diagnosis of chronic obstructive pulmonary disease J44 or tracheal bronchial or lung cancer C33 to C34 or ischemic heart disease I20 to I25 or stroke I60 to I69. Secondary outcomes were counts of ICD 10 F17 tobacco dependence coding and the disease to F17 coding ratio. Results The four tobacco associated disease groups accounted for 13946 visits among 5223 patients and USD 4.20 million in verified costs representing 6.0 percent of hospital spending in the sample. Weighted costs were USD 74.7 million of which cardiovascular and cerebrovascular disease accounted for 95 percent. F17 appeared in only 51 referral hospital encounters and 26 primary care encounters. Only 2 of 5223 patients with these tobacco associated diseases or 0.04 percent were ever coded with F17. Conclusions The Indonesian national insurer paid substantially for tobacco associated morbidity while tobacco dependence was almost never coded. Smoking related diseases were reimbursed but tobacco dependence treatment was not captured as a financed care target. Embedding brief cessation care reimbursable pharmacotherapy and routine F17 coding into primary care could help shift tobacco related expenditure from downstream complications toward addiction care. Keywords tobacco dependence smoking cessation F17 coding health expenditure administrative claims Indonesia

BackgroundGlucagon-like peptide 1 receptor agonists (GLP-1 RAs) have shown promise for alcohol use disorder (AUD). ObjectiveTo evaluate the association between use of newer GLP-1 RAs (semaglutide, tirzepatide) and alcohol-related hospitalizations among adults with AUD and either type 2 diabetes (T2D) or obesity. MethodsThis retrospective target trial emulation study used electronic health record data from Truveta to identify adults with AUD and either T2D or obesity, who initiated a newer GLP-1 RA (semaglutide, tirzepatide) or relevant active comparator between 2018 and 2024. Four target trials were constructed to reflect clinically distinct populations and comparators: (1) ADM trial (patients with T2D and comparators of other anti-diabetic medications [ADM]), (2) AOM trial (patients with obesity but not T2D and comparators of other anti-obesity medications [AOM]), (3) MAUD-T2D trial (patients with T2D and markers of more severe AUD and comparators of medications for alcohol use disorder [MAUD]), (4) MAUD-obesity trial (patients with obesity, no T2D, and markers of more severe AUD and comparators of MAUD). The primary endpoint was time to alcohol-related hospitalization. Non-alcohol-related hospitalization served as a negative control outcome. Propensity score-based methods (weighting and matching) were used to control for confounding. Cox proportional hazards models were used to estimate the treatment effect of newer GLP-1 RA in four target trials. ResultsA total of 40,260 patients were identified, including 18,515 in the ADM trial, 9,256 in the AOM trial, 9,975 in the MAUD and T2D trial, and 11,039 in the MAUD and obesity trial. GLP-1 RAs were associated with a lower hazard of alcohol-related hospitalization in the ADM (HR [95% CI]: 0.70 [0.59 - 0.83] vs. sulfonylureas; 0.73 [0.62 - 0.86] vs. other ADMs), AOM (HR: 0.59 [0.48 - 0.74]), MAUD-T2D (HR: 0.36 [0.29 - 0.46]), and MAUD-obesity (HR: 0.32 [0.23 - 0.43]) trials. No significant differences were observed for non-alcohol-related hospitalizations for ADM and MAUD-T2D trials. ConclusionNewer GLP-1 RAs were associated with reduced risk of alcohol-related hospitalization across clinically distinct populations.

The dominance of the COVID-19 Delta variant has renewed questions about the impact of K12 school policies, including the role of masks, on disease burden.1 A recent study showed masks and testing could reduce infections in students, but failed to address the impact on the community,2 while another showed masking is critical to slow disease spread in communities, but did not consider school openings under Delta.3 We project the impact of school-masking on the community, which can inform policy decisions, and support healthcare system planning. Our findings indicate that the implementation of masking policies in school settings can reduce additional infections post-school opening by 23-36% for fully-open schools, with an additional 11-13% reduction for hybrid schooling, depending on mask quality and fit. Masking policies and hybrid schooling can also reduce peak hospitalization need by 71% and result in the fewest additional deaths post-school opening. We show that given the current vaccination rates within the community, the best option for children and the general population is to employ consistent high-quality masking, and use social distancing where possible.

Tuberculosis screening is not mandatory for prospective tissue donors. In 2021 and 2023, two different bone allograft products caused nationwide tuberculosis outbreaks. We assessed the morbidity and mortality of the second outbreak and reviewed donor and tissue screening to identify deficiencies. Thirty-six people residing in nine states received the product during spinal and dental procedures. Twenty-seven recipients had tuberculosis infection, 11 had microbiologic or imaging evidence of tuberculosis disease, and two died from tuberculosis within 12 months of outbreak detection. Another recipient died from tuberculosis nearly 3 years after product implantation. The bone donor died of pneumonia and septic shock. Polymerase chain reaction testing of the product before and after distribution did not detect Mycobacterium tuberculosis. Mycobacterial culture was not performed until after outbreak detection, when M. tuberculosis was isolated from 2 of 6 unused product units. This outbreak demonstrates persistent gaps in tissue transplant safety. Appropriate selection of donors and mycobacterial culture of donated tissues could reduce but not eliminate the risk of M. tuberculosis transmission. Therefore, it is important that clinicians monitor tissue recipients and promptly report adverse events to tissue establishments and health authorities.

IntroductionNew York City (NYC) has the largest public school system in the United States (US). During the SARS-CoV-2 pandemic, NYC was the first major US city to open schools for in-person learning in the 2020-2021 academic year. Several policies were implemented to reduce the risk of in-school transmission, including infection control measures (facemasks, physical distancing, enhanced indoor ventilation, cohorting of small groups, and hand hygiene), option of all-remote instruction, alternative options for how class schedules would rotate in-person and remote instruction, daily symptom screening, and testing 10-20% of students and staff weekly or monthly depending on local case rates. We sought to determine which of these policies had the greatest impact on reducing the risk of in-school transmission. MethodsWe evaluated the impact of each policy by referring to global benchmarks for the secondary attack rate (SAR) of SARS-CoV-2 in school settings and by simulating the potential for transmission in NYCs rotating cohort schedules, in which teachers could act as "bridges" across rotating cohorts. We estimated the impact of (1) infection control measures, (2) providing an option of all-remote instruction, (3) choice of class scheduling for in-person learners, (4) daily symptom screening, (5) testing to curtail transmission, and (6) testing to identify school outbreaks. Each policy was assessed independently of other policies, with the exception of symptom screening and random testing, which were assessed both independently and jointly. ResultsAmong the policies analyzed, the greatest transmission reduction was associated with the infection control measures, followed by small class cohorts with an option for all-remote instruction, symptom screening, and finally randomly testing 10-20% of school attendees. Assuming adult staff are the primary source of within-school SARS-CoV-2 transmission, weekly testing of staff could be at least as effective as symptom screening, and potentially more so if testing days occur in the beginning of the workweek with results available by the following day. A combination of daily symptom screening and testing on the first workday of each week could reduce transmission by 70%. ConclusionsAdherence to infection control is the highest priority for safe school re-opening. Further transmission reduction can be achieved through small rotating class cohorts with an option for remote learning, widespread testing at the beginning of the work week, and daily symptom screening and self-isolation. Randomly testing 10-20% of attendees weekly or monthly does not meaningfully curtail transmission and may not detect outbreaks before they have spread beyond a handful of individuals. School systems considering re-opening during the SARS-CoV-2 pandemic or similarly virulent respiratory disease outbreaks should consider these relative impacts when setting policy priorities.

WithdrawalThe authors have withdrawn this manuscript because there are increased rates of SARS- CoV-2 cases in the areas that we originally analyzed in this study. New analyses in the context of the third surge in the United States are therefore needed and will be undertaken directly in conjunction with the creators of the publicly-available databases on cases, hospitalizations, testing rates. Etc. We will be performing this in conjunction with machine learning experts at UCSF. Therefore, the authors do not wish this work to be cited as reference for the project. We hope to have an updated analysis using data from the 2nd and now 3rd wave of SARS-CoV-2 in this country soon. If you have any questions, please contact the corresponding author.

ImportanceDental caries is the worlds most prevalent noncommunicable disease and a source of severe health inequity. To prevent and reduce this burden, the Centers for Disease Control and Prevention recommends school dental sealant programs. ObjectiveTo determine whether silver diamine fluoride (SDF) is non-inferior to dental sealants and atraumatic restorative treatment (ART) for dental caries when used in a school-based program. DesignThe CariedAway study was a cluster-randomized, single-blind, pragmatic non-inferiority trial conducted from 2018-2023. Four years of follow-up were included. SettingPrimary schools in New York City with at least 55% of the student population reporting as Black or Hispanic/Latino and at least 80% receiving free or reduced lunch. ParticipantsAny child between the ages of 5 and 13 was eligible. There were 17741 eligible children across 48 schools. InterventionsParticipants were cluster-randomized at the school level to receive either a 38% concentration SDF solution or glass ionomer sealants and ART. Each participant also received fluoride varnish. Main OutcomesPrimary study outcomes were the prevalence and incidence of dental caries. Our a priori hypothesis was that SDF was non-inferior to sealants and ART in reducing caries prevalence. ResultsA total of 7418 children were enrolled and treated, of which 4100 completed at least one follow-up observation (55%). The overall baseline prevalence of dental caries was approximately 27% (95% CI = 25.7, 28.6). Following treatment, the odds of decay prevalence decreased longitudinally (OR = 0.79, 95% CI = 0.75, 0.83) and SDF was non-inferior compared to sealants and ART (OR = 0.94, 95% CI = 0.80, 1.11). The crude incidence of dental caries in children treated with SDF was 10.2 per 1,000 tooth-years, versus 9.8 per 1,000 tooth-years in children treated with sealants and ART, for a rate ratio of 1.046 (95% CI = 0.97, 1.12). Conclusions and RelevanceIn a pragmatic trial, application of silver diamine fluoride resulted in nearly identical caries incidence compared to dental sealants and ART and was non-inferior in the longitudinal prevalence of caries. SDF is an effective alternative for use in school caries prevention, increasing access and reducing costs for oral healthcare. Trial RegistrationClinicalTrials.gov, #NCT03442309

Organ procurement in the US has received attention from government officials and policymakers the last two years, culminating in CMS releasing an updated Final Rule related to organ donation this year. This regulatory change revises how organ procurement organizations (OPOs), the federal contractors tasked with managing deceased donation, are evaluated and certified/de-certified. We used 2019 data and the CMS methodology to calculate race-stratified donation data among racial/ethnic minorities across the 57 OPOs. We found that the variability in donation rates across the 57 OPOs are greater among minority populations than non-Hispanic white potential donors. Among Tier 3 OPOs, there are: a) some with low donation rates across all racial/ethnic groups; b) some with low donation rates among only certain groups, and c) some where donation rates are lowest among non-Hispanic white patients. Among low-performing OPOs, these race/ethnicity-stratified data show that under-performance in certain areas is not due to the population demographics, and identifies areas for targeted interventions to increase donation and avoid decertification

BackgroundA major concern in emergency departments is whether acute respiratory illness (ARI) is associated with increased risk of venous thromboembolism (VTE). MethodsThis prospective cohort study includes ARI patients from the 91-hospital, U.S. CDC- sponsored Respiratory Virus Laboratory Emergency Department Network Surveillance (RESP-LENS) program from January 2022 to June 2023. We calculated incidence rates and used multivariable regression models to test the null hypothesis that there is no association between the results or absence of laboratory viral testing and the risk of new onset VTE within 30-days. FindingsOut of 620,303 ARI encounters, 65% underwent laboratory viral testing; 13% tested positive for COVID and 3%-4% tested positive for influenza-A and/or RSV. The 30-day VTE incidence rate was 0.70% among unique first patient encounters and 0.82% overall. The highest VTE incidence rate occurred among viral test negative patient encounters (1.13% [95%CI 1.08%-1.19%]) and the lowest VTE rate occurred among patients who tested positive for COVID, influenza-A or RSV, or who did not undergo viral testing (95%CI 0.09%-0.86%). In adjusted models, only among patients receiving any ICU care was fluA associated with heightened VTE risk. New VTE was associated with increased 30-day mortality risk (RR 2.7, 95%CI 2.3-3.2), but there was no difference in 30-day mortality risk among VTE patients grouped by the results of viral testing (interaction p > 0.05). ConclusionIn the U.S. from January 2022 to June 2023, laboratory confirmed viral infection was not associated with increased risk of short-term VTE diagnosis or death among patients seeking emergency care.

ObjectiveTo evaluate the effect of Medicaid expansion under the Affordable Care Act (ACA) on total inpatient hospital charges among women with MDD, comparing Maryland, an expansion state with an All-Payer Model, and Florida, a non-expansion state. MethodsWe conducted a retrospective cohort study using the Maryland State Inpatient Database and the Florida State Inpatient Database. The study population included women aged 18-64 years admitted with a primary diagnosis of MDD. The study period was stratified into pre-ACA (2007-2009) and post-ACA (2018-2020) eras. Difference-in-differences models with robust standard errors, complemented by inverse probability-weighted regression adjustment (IPWRA), were employed to estimate policy effects on hospital charges. Models adjusted for age, race/ethnicity, insurance type, discharge quarter, comorbidities, and neighborhood income quartile. ResultsA total of 122,963 hospitalizations were analyzed. Pre-ACA, baseline charges in Maryland averaged $7,123 (95% CI, 6,878-7,369). Following the ACA, Maryland experienced a moderated increase of $3,108 (95% CI, 2,752-3,465; p<0.001). In contrast, Floridas charges remained significantly higher, exceeding Maryland by $5,136 pre-ACA and $11,413 post-ACA (p<0.001 for both). Difference-in-differences estimates confirmed that Medicaid expansion in Maryland mitigated cost escalation, producing a net relative reduction of $3,445 (95% CI, -3,886 to -3,004; p<0.001). Stratified analyses demonstrated the greatest financial protection among self-pay and Medicaid patients. ConclusionMedicaid expansion was associated with significantly lower inpatient charges among women with MDD in Maryland compared to non-expansion Florida, and may reduce financial burden, advance equity, and improve hospital resource sustainability.

ImportanceThe Centers for Disease Control and Prevention (CDC) announced in January 2023 that they were investigating a potential connection between administration of the Pfizer novel coronavirus disease-2019 (COVID-19) bivalent vaccine booster and ischemic stroke (IS). ObjectiveTo explore the relationship between Pfizer bivalent booster administration and IS in older patients in the United States and compare it to other COVID-19 vaccines. DesignA retrospective cohort study was conducted to compare hazard of IS among patients aged 65 years or over who received the Pfizer bivalent, Moderna bivalent, or Pfizer/Moderna monovalent COVID-19 booster vaccine 1-21 and 22-42 days after vaccination. SettingPatient data were collected from TriNetX, a cloud-based analytics platform that includes electronic health record data from over 90 million unique patients in the United States. ParticipantsPatients in the United States aged 65 years or over at the time of administration of a Pfizer bivalent (n = 43,216), Moderna bivalent (n = 4,267), or Pfizer/Moderna monovalent (n = 100,583) booster were included for analysis. Cohorts were propensity-score matched by demographic factors and risk factors for IS and severe COVID-19. ExposuresPfizer bivalent, Moderna bivalent, or Pfizer/Moderna monovalent COVID-19 booster administration. Main outcomesThe hazard ratio (HR) and 95% confidence interval (CI) for IS in the cohorts at 1-21 and 22-42 days after administration. ResultsAfter matching, the Pfizer bivalent cohort included 4,267 patients, with an average age of 73.7 years (44.43% male, 76.59% white). The Moderna bivalent cohort included 4,267 patients, with an average age of 74.0 years (44.08% male, 77.39% white). There was no significant difference in the hazard of IS encounters between the Pfizer bivalent versus Moderna bivalent cohorts at 1-21- or 22-42-days post-administration: HR = 0.59 (0.31, 1.11), 0.73 (0.33, 1.60). The hazard for IS was lower in the Pfizer bivalent cohort than in the Pfizer/Moderna monovalent cohort at both timepoints: HR = 0.24 (0.19, 0.29), 0.25 (0.20, 0.31). Conclusions and relevanceOlder adults administered the Pfizer bivalent booster had similar hazard for IS encounters compared to those administered the Moderna bivalent booster vaccine, but lower hazard than those administered the Pfizer/Moderna monovalent boosters. Key PointsO_ST_ABSQuestionC_ST_ABSWhat is the comparative hazard of ischemic stroke in American patients ages 65 years and over after administration of the Pfizer bivalent, Moderna bivalent, or Pfizer/Moderna monovalent COVID-19 booster vaccine? FindingsA retrospective cohort study was conducted. There was no significant difference in the hazard of ischemic stroke encounters between the Pfizer bivalent versus Moderna bivalent cohorts, but lower hazard for the Pfizer bivalent than the monovalent boosters at 1-21 or 22-42 days post-administration. MeaningThere is no evidence from these results that the Pfizer bivalent booster is associated with increased hazard for ischemic stroke.

This study assessed racial and ethnic disparities in severe maternal mortality during delivery through 6 weeks postpartum, before and during the COVID pandemic, in a statewide Medicaid population. This retrospective, population-based, cohort study used Medicaid claims data linked to birth certificates from the Michigan Department of Health and Human Services Health Services Data Warehouse that included all individuals giving birth between January 1, 2017, and October 31, 2021, in Michigan who had Medicaid insurance during the month of childbirth. The SMM rate increased more during the COVID pandemic for Black (1.36 [1.26-1.46]) compared to White individuals (1.17 [1.09-1.26], p-value<0.01 Black vs White). The Black-White and Hispanic-White disparities in severe maternal morbidity, already high in the Medicaid population, widened during the COVID pandemic. Multilevel interventions are needed to reduce disparities in maternal morbidity and mortality. Conflict of interest disclosureNo conflicts to disclose.

Importance: Parent/caregiver-infant early relational health (ERH) is known to play a critical role in the promotion of socio-emotional functioning and wellbeing across the life course. The negative impact of the COVID-19 pandemic on maternal mental health and secondarily on ERH and child socio-emotional functioning is clear. However, the direct impact of maternal viral exposure during pregnancy on ERH has not been investigated. Objective: The goal of this study was to determine the impact of prenatal SARS-CoV-2 exposure on ERH and infant socio-emotional functioning in the first 6 months of life. Design: Mothers with and without SARS-CoV-2 exposure during pregnancy who gave birth from 02/2020 to 09/2021 were enrolled from 05/2020 to 09/2021 in one of two parallel prospective studies (the COVID-19 Mother Baby Outcomes [COMBO] Initiative or the Respiratory Syndrome Coronavirus 2 in Pregnancy and Infancy [ESPI] COMBO sub-study). Mothers reported on their health and the socio-emotional functioning of their infant via online surveys (REDCap) at enrollment, 1, 2, 4, and 6 months. At 4 to 6 months, dyads were invited to participate in a video-based, remote assessment of ERH. Participants: 884 mother-infant dyads from three U.S. States (Alabama, New York, and Utah). Exposure: Prenatal SARS-CoV-2. Main Outcomes and Measures: Maternal-reported ERH (parental stress, parenting confidence and bonding) and observer-based ERH (video-coded quality of maternal caregiving behaviors and mother-infant emotional connection). Infant socio-emotional development assessed using the 6-month Ages and Stages Questionnaire: Socio-Emotional 2nd Edition (ASQ:SE-2). Results: 316 (36%) mothers had a positive prenatal SARS-CoV-2 exposure. Prenatal SARS-CoV-2 exposure was associated with an adjusted estimate of ~5% reduction (incidence rate ratio=0.95, 95% confidence interval [0.90, 1.00], p=0.03) in observed maternal caregiving quality, after accounting for postnatal maternal mental health and sociodemographic factors. We found no evidence of effect on other ERH constructs or infant socio-emotional functioning. Conclusions and Relevance: In this large prospective cohort study, prenatal SARS-CoV-2 was associated with a small decrement in caregiving quality, but not other ERH constructs or infant socio-emotional functioning. These findings should be interpreted as hypothesis generating and will require replication in independent studies.