Faculty Bibliography

This ecologic cohort study explores the relationship between state minimum wage laws and rates of HIV diagnoses among heterosexual black residents of U.S metropolitan areas over an 8-year span. Specifically, we applied hierarchical linear modeling to investigate whether state-level variations in minimum wage laws, adjusted for cost-of-living and inflation, were associated with rates of new HIV diagnoses among heterosexual black residents of metropolitan statistical areas (MSAs; n=73), between 2008 and 2015. Findings suggest that an inverse relationship exists between baseline state minimum wages and initial rates of newly diagnosed HIV cases among heterosexual black individuals, after adjusting for potential confounders. MSAs with a minimum wage that was $1 higher at baseline had a 27.12% lower rate of newly diagnosed HIV cases. Exploratory analyses suggest that income inequality may mediate this relationship. If subsequent research establishes a causal relationship between minimum wage and this outcome, efforts to increase minimum wages should be incorporated into HIV prevention strategies for this vulnerable population.

Systems science models use computer-based algorithms to model dynamic interactions between study units within and across levels and are characterized by nonlinear and feedback processes. They are particularly valuable approaches that complement the traditional epidemiologic toolbox in cases in which real data are not available and in cases in which traditional epidemiologic methods are limited by issues such as interference, spatial dependence, and dynamic feedback processes. In this commentary, we propose 2 key contributions that systems models can make to epidemiology: 1) the ability to test assumptions about underlying mechanisms that give rise to population distributions of disease; and 2) help in identifying the types of interventions that have the greatest potential to reduce population rates of disease in the future or in new sites where they have not yet been implemented. We discuss central challenges in the application of systems science approaches in epidemiology, propose potential solutions, and predict future developments in the role that systems science can play in epidemiology.

OBJECTIVE:This study investigated patient- and area-level characteristics associated with adolescent emergency department (ED) patients' risk of subsequent ED visits for self-harm. METHOD:Retrospective analysis of adolescent patients presenting to a California ED in 2010 (n = 480,706) was conducted using statewide, all-payer, individually linkable administrative data. We examined associations between multiple predictors of interest (patient sociodemographic factors, prior ED utilization, and residential mobility; and area-level characteristics) and odds of a self-harm ED visit in 2010. Patients with any self-harm in 2010 were followed up over several years to assess predictors of recurrent self-harm. RESULTS:Self-harm patients (n = 5539) were significantly more likely than control patients (n = 16,617) to have prior histories of ED utilization, particularly for mental health problems, substance abuse, and injuries. Residential mobility also increased risk of self-harm, but racial/ethnic minority status and residence in a disadvantaged zipcode decreased risk. Five-year cumulative incidence of recurrent self-harm was 19.3%. Admission as an inpatient at index visit, Medicaid insurance, and prior ED utilization for psychiatric problems or injury all increased recurrent self-harm risk. CONCLUSIONS:A range of patient- and area-level characteristics observable in ED settings are associated with risk for subsequent self-harm among adolescents, suggesting new targets for intervention in this clinical context.

OBJECTIVES/OBJECTIVE:To estimate associations between psychiatric disorders and gun carrying among adolescents and to estimate the total number of adolescents in the US who have psychiatric disorders and report carrying guns. STUDY DESIGN/METHODS:We used cross-sectional data from the National Comorbidity Survey - Adolescent Supplement, a nationally representative sample of adolescents age 13-18 years (N = 10 123; response rate = 75.6%). Psychiatric disorders were assessed using the Composite International Diagnostic Interview. Gun carrying in the 30 days prior to the interview was assessed by self-report. We used multivariable Poisson regression to test for associations. RESULTS:The analytic sample included 10 112 adolescents, 2.4% of whom reported carrying a gun in the prior 30 days. The prevalence of gun carrying was greater among adolescents with conduct disorder (adjusted prevalence ratio [APR] = 1.88, 95% CI 1.38, 2.57), drug use disorders (APR = 1.91, 95% CI 1.05, 3.45), and specific phobias (APR = 1.54, 95% CI 1.07, 2.22) compared with adolescents without these disorders. We estimated that 1.1% (95% CI 0.77, 1.48) of adolescents with a disorder associated with self- or other-directed violence also carry guns. Nationally, that is approximately 272 000 adolescents with both risk factors. CONCLUSIONS:Specific psychiatric disorders are associated with an increased risk of gun carrying among adolescents, but the vast majority of adolescents with psychiatric disorders did not report gun carrying. Targeted efforts to assess access to and use of firearms in mental healthcare and other clinical settings are important, as are efforts to identify population approaches to prevention.

OBJECTIVE:To determine whether restrictiveness-permissiveness of state gun laws or gun ownership are associated with mass shootings in the US. DESIGN/METHODS:Cross sectional time series. SETTING AND POPULATION/METHODS:US gun owners from 1998-2015. EXPOSURE/METHODS:An annual rating between 0 (completely restrictive) and 100 (completely permissive) for the gun laws of all 50 states taken from a reference guide for gun owners traveling between states from 1998 to 2015. Gun ownership was estimated annually as the percentage of suicides committed with firearms in each state. MAIN OUTCOME MEASURE/METHODS:Mass shootings were defined as independent events in which four or more people were killed by a firearm. Data from the Federal Bureau of Investigation's Uniform Crime Reporting System from 1998-2015 were used to calculate annual rates of mass shootings in each state. Mass shooting events and rates were further separated into those where the victims were immediate family members or partners (domestic) and those where the victims had other relationships with the perpetrator (non-domestic). RESULTS:Fully adjusted regression analyses showed that a 10 unit increase in state gun law permissiveness was associated with a significant 11.5% (95% confidence interval 4.2% to 19.3%, P=0.002) higher rate of mass shootings. A 10% increase in state gun ownership was associated with a significant 35.1% (12.7% to 62.7%, P=0.001) higher rate of mass shootings. Partially adjusted regression analyses produced similar results, as did analyses restricted to domestic and non-domestic mass shootings. CONCLUSIONS:States with more permissive gun laws and greater gun ownership had higher rates of mass shootings, and a growing divide appears to be emerging between restrictive and permissive states.

BACKGROUND:Medical cannabis laws (MCL) have received increased attention as potential drivers of cannabis use (CU), but little work has explored how the broader policy climate, independent of MCL, may impact CU outcomes. We explored the association between state-level policy liberalism and past-year cannabis use (CU) and cannabis use disorder (CUD). METHODS:We obtained state-level prevalence of past-year CU and CUD among past year cannabis users for ages 12-17, 18-25, and 26+ from the 2004-2006 and 2010-2012 National Surveys on Drug Use and Health. States were categorized as liberal, moderate, or conservative based on state-level policy liberalism rankings in 2005 and 2011. Linear models with random state effects examined the association between policy liberalism and past-year CU and CUD, adjusting for state-level social and economic covariates and medical cannabis laws. RESULTS:In adjusted models, liberal states had higher average past-year CU than conservative states for ages 12-17 (+1.58 percentage points; p = 0.03) and 18-25 (+2.96 percentage points; p = 0.01) but not for 26+ (p = 0.19). CUD prevalence among past year users was significantly lower in liberal compared to conservative states for ages 12-17 (-2.87 percentage points; p = 0.045) and marginally lower for ages 26+ (-2.45 percentage points; p = 0.05). CONCLUSION/CONCLUSIONS:Liberal states had higher past-year CU, but lower CUD prevalence among users, compared to conservative states. Researchers and policy makers should consider how the broader policy environment, independent of MCL, may contribute to CU outcomes.

Importance/UNASSIGNED:Prescription opioids are involved in 40% of all deaths from opioid overdose in the United States and are commonly the first opioids encountered by individuals with opioid use disorder. It is unclear whether the pharmaceutical industry marketing of opioids to physicians is associated with mortality from overdoses. Objective/UNASSIGNED:To identify the association between direct-to-physician marketing of opioid products by pharmaceutical companies and mortality from prescription opioid overdoses across US counties. Design, Setting, and Participants/UNASSIGNED:This population-based, county-level analysis of industry marketing information used data from the Centers for Medicare & Medicaid Services Open Payments database linked with data from the Centers for Disease Control and Prevention on opioid prescribing and mortality from overdoses. All US counties were included, with data on overdoses from August 1, 2014, to December 31, 2016, linked to marketing data from August 1, 2013, to December 31, 2015, using a 1-year lag. Statistical analyses were conducted between February 1 and June 1, 2018. Main Outcomes and Measures/UNASSIGNED:County-level mortality from prescription opioid overdoses, total cost of marketing of opioid products to physicians, number of marketing interactions, opioid prescribing rates, and sociodemographic factors. Results/UNASSIGNED:Between August 1, 2013, and December 31, 2015, there were 434 754 payments totaling $39.7 million in nonresearch-based opioid marketing distributed to 67 507 physicians across 2208 US counties. After adjustment for county-level sociodemographic factors, mortality from opioid overdoses increased with each 1-SD increase in marketing value in dollars per capita (adjusted relative risk, 1.09; 95% CI, 1.05-1.12), number of payments to physicians per capita (adjusted relative risk, 1.18; 95% CI, 1.14-1.21, and number of physicians receiving marketing per capita (adjusted relative risk, 1.12; 95% CI, 1.08-1.16). Opioid prescribing rates also increased with marketing and partially mediated the association between marketing and mortality. Conclusions and Relevance/UNASSIGNED:In this study, across US counties, marketing of opioid products to physicians was associated with increased opioid prescribing and, subsequently, with elevated mortality from overdoses. Amid a national opioid overdose crisis, reexamining the influence of the pharmaceutical industry may be warranted.

BACKGROUND:Prescription opioid overdose (POD) and heroin overdose (HOD) rates have quadrupled since 1999. Community-level socioeconomic characteristics are associated with opioid overdoses, but whether this varies by urbanicity is unknown. METHODS:In this serial cross-sectional study of zip codes in 17 states, 2002-2014 (n = 145,241 space-time units), we used hierarchical Bayesian Poisson space-time models to analyze the association between zip code-level socioeconomic features (poverty, unemployment, educational attainment, and income) and counts of POD or HOD hospital discharges. We tested multiplicative interactions between each socioeconomic feature and zip code urbanicity measured with Rural-Urban Commuting Area codes. RESULTS:Percent in poverty and of adults with ≤ high school education were associated with higher POD rates (Rate Ratio [RR], 5% poverty: 1.07 [95% credible interval: 1.06-1.07]; 5% low education: 1.02 [1.02-1.03]), while median household income was associated with lower rates (RR, $10,000: 0.88 [0.87-0.89]). Urbanicity modified the association between socioeconomic features and HOD. Poverty and unemployment were associated with increased HOD in metropolitan areas (RR, 5% poverty: 1.12 [1.11-1.13]; 5% unemployment: 1.04 [1.02-1.05]), and median household income was associated with decreased HOD (RR, $10,000: 0.88 [0.87-0.90]). In rural areas, low educational attainment alone was associated with HOD (RR, 5%: 1.09 [1.02-1.16]). CONCLUSIONS:Regardless of urbanicity, elevated rates of POD were found in more economically disadvantaged zip codes. Economic disadvantage played a larger role in HOD in urban than rural areas, suggesting rural HOD rates may have alternative drivers. Identifying social determinants of opioid overdoses is particularly important for creating effective population-level interventions.

INTRODUCTION/BACKGROUND:We sought to understand the association between youthful self-harm and subsequent chronic disease-related healthcare utilization and whether self-harm reflects unique vulnerability in comparison with severe psychiatric disorders. METHODS:We used a retrospective matched cohort design with statewide, all-payer, individually linked emergency department (ED) data from California, USA. Risk of future ED visits for common chronic conditions in adolescence (headaches, asthma, epilepsy, diabetes, and gastrointestinal disorders, assessed using ICD-9 diagnoses) were compared between three adolescent study groups presenting to an ED in 2010: self-harm patients (n = 5,484), patients with psychiatric complaints but no self-harm (n = 14,235), and patients with other complaints (n = 16,452). Cohort follow-up ended on Sept. 30, 2015. Analyses were adjusted for patients' prior histories of ED utilization for chronic conditions as well as patient- and area-level sociodemographic characteristics. RESULTS:Risk of subsequent ED visits was higher among self-harm patients compared to non-psychiatric control patients for subsequent epilepsy- (aRR = 1.77, 95% CI [1.42, 2.21]). Risk of subsequent ED visits was higher among psychiatric patients compared to non-psychiatric control patients for subsequent headache- (aRR = 1.31, 95% CI [1.21, 1.42]), and epilepsy-related problems (aRR = 1.85, 95% CI [1.55, 2.21]). Self-harm patients were at higher risk than psychiatric patients for subsequent gastrointestinal disorder (aRR = 1.76, 95% CI [1.03, 3.01]). CONCLUSIONS:Findings suggest that self-harm behavior and psychiatric disorders are associated with increased ED utilization for subsequent chronic disease-related ED utilization. Chronic disease among adolescent psychiatric patients should be attended to, potentially involving new models of clinical follow-up care.