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Importance: Retention in care for individuals with opioid use disorder (OUD) is one of the single greatest predictors of reduced mortality. Although clinical trials support use of OUD medications among adolescents and young adults (“youth”), data on timely receipt of buprenorphine, naltrexone, and methadone and its association with retention in care in real-world treatment settings are lacking. Objective: To identify the proportion of youth who receive timely addiction treatment, and to determine whether timely receipt of OUD medications is associated with retention in care. Design: Retrospective cohort. Setting: Enrollment and complete health insurance claims of 2.4 million Medicaid-enrolled youth from 11 states, January 1, 2014 to December 31, 2015. Participants: Youth of age 13–22 years diagnosed with OUD. Exposures: Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within three months of diagnosis, compared to receipt of behavioral health services alone. Main Outcome and Measures: Retention in care, with attrition defined as ≥60 days without any treatment-related claims. Results: Among 4,837 youth diagnosed with OUD, 56.9% were female and 76.0% were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19–22). Overall, 3,654 (75.5%) youth received any treatment within three months. Most received only behavioral health services (n=2,515; 52.0%), with fewer receiving OUD medications (n=1,139; 23.5%). Only 4.7% (95% confidence interval [CI], 3.1–6.2%) of adolescents <18 years and 24.7% (95% CI, 23.4–26.0%) of young adults ≥18 years received timely OUD medications. Median retention in care among youth who received timely buprenorphine, naltrexone, or methadone was 123 days (IQR, 33–434), 150 days (IQR, 50–670), and 324 days (IQR, 115–670), respectively, compared to 67 days (IQR, 14–206) among youth who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio [aHR], 0.58; 95% CI, 0.52–0.64), naltrexone (aHR, 0.54; 95% CI, 0.43–0.69), and methadone (aHR, 0.32; 95% CI, 0.22–0.47) were each independently associated with lower attrition from treatment compared to receiving behavioral health services alone. Conclusions and Relevance: Timely receipt of buprenorphine, naltrexone, or methadone is associated with greater retention in care among youth with OUD. Strategies to address the underutilization of evidence-based medications for youth are urgently needed.

OBJECTIVE: To describe recent, 10-year trends in pediatric hospital resource use with and without a psychiatric diagnosis and examine how these trends vary by type of psychiatric and medical diagnosis cooccurrence. METHODS:A retrospective, longitudinal cohort analysis using hospital discharge data from 33 tertiary care US children's hospitals of patients ages 3 to 17 years from January 1, 2005 through December 31, 2014. The trends in hospital discharges, hospital days, and total aggregate costs for each psychiatric comorbid group were assessed by using multivariate generalized estimating equations. RESULTS:From 2005 to 2014, the cumulative percent growth in resource use was significantly (all P < .001) greater for children hospitalized with versus without a psychiatric diagnosis (hospitalizations: +137.7% vs +26.0%; hospital days: +92.9% vs 5.9%; and costs: +142.7% vs + 18.9%). During this time period, the most substantial growth was observed in children admitted with a medical condition who also had a cooccurring psychiatric diagnosis (hospitalizations: +160.5%; hospital days: +112.4%; costs: +156.2%). In 2014, these children accounted for 77.8% of all hospitalizations for children with a psychiatric diagnosis; their most common psychiatric diagnoses were developmental disorders (22.3%), attentiondeficit/hyperactivity disorder (18.1%), and anxiety disorders (14.2%). CONCLUSIONS:The 10-year rise in pediatric hospitalizations in US children's hospitals is 5 times greater for children with versus without a psychiatric diagnosis. Strategic planning to meet the rising demand for psychiatric care in tertiary care children's hospitals should place high priority on the needs of children with a primary medical condition and cooccurring psychiatric disorders.

Children with medical complexity disproportionately use the majority of ICU resources in children's hospitals. Efforts to improve quality and provide cost-effective care should focus on this population.

IMPORTANCENonfatal opioid overdose may be a critical touch point when youths who have never received a diagnosis of opioid use disorder can be engaged in treatment. However, the extent to which youths (adolescents and young adults) receive timely evidence-based treatment following opioid overdose is unknown.OBJECTIVE To identify characteristics of youths who experience nonfatal overdose with heroin or other opioids and to assess the percentage of youths receiving timely evidence-based treatment. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the 2009-2015 Truven-IBM Watson Health MarketScan Medicaid claims database from 16 deidentified states representing all US census regions. Data from 4 039 216 Medicaid-enrolled youths aged 13 to 22 years were included and were analyzed from April 20, 2018, to March 21, 2019. EXPOSURES Nonfatal incident and recurrent opioid overdoses involving heroin or other opioids. MAIN OUTCOMES AND MEASURESReceipt of timely addiction treatment (defined as a claim for behavioral health services, for buprenorphine, methadone, or naltrexone prescription or administration, or for both behavioral health services and pharmacotherapy within 30 days of incident overdose). Sociodemographic and clinical characteristics associated with receipt of timely treatment as well as with incident and recurrent overdoses were also identified. RESULTS Among 3791 youths with nonfatal opioid overdose, 2234 (58.9%) were female, and 2491 (65.7%) were non-Hispanic white. The median age was 18 years (interquartile range, 16-20 years). The crude incident opioid overdose rate was 44.1 per 100 000 person-years. Of these 3791 youths, 1001 (26.4%) experienced a heroin overdose; the 2790 (73.6%) remaining youths experienced an overdose involving other opioids. The risk of recurrent overdose among youths with incident heroin involvement was significantly higher than that among youths with other opioid overdose (adjusted hazard ratio, 2.62; 95% CI, 2.14-3.22), and youths with incident heroin overdose experienced recurrent overdose at a crude rate of 20 700 per 100 000 person-years. Of 3606 youths with opioid-related overdose and continuous enrollment for at least 30 days after overdose, 2483 (68.9%) received no addiction treatment within 30 days after incident opioid overdose, whereas only 1056 youths (29.3%) received behavioral health services alone, and 67 youths (1.9%) received pharmacotherapy. Youths with heroin overdose were significantly less likely than youths with other opioid overdose to receive any treatment after their overdose (adjusted odds ratio, 0.64; 95% CI, 0.49-0.83).CONCLUSIONS AND RELEVANCE After opioid overdose, less than one-third of youths received timely addiction treatment, and only 1 in 54 youths received recommended evidence-based pharmacotherapy. Interventions are urgently needed to link youths to treatment after overdose, with priority placed on improving access to pharmacotherapy.

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BACKGROUND: Urgent care (UC) is one of the fastest growing venues of health care delivery. We compared clinical and cost attributes of pediatric UC and emergency department (ED) visits that did not result in admission.

Key Points Question Does the use of diagnostic imaging for children receiving care in US pediatric emergency departments (EDs) differ by race and ethnicity? Findings This multicenter cross-sectional study of more than 13 million pediatric ED visits to 44 children’s hospitals demonstrated that non-Hispanic Black and Hispanic patients were less likely to undergo diagnostic imaging compared with non-Hispanic White patients. Meaning In these findings, race and ethnicity appear to be independently associated with imaging decisions in the pediatric ED, highlighting the need to better understand and mitigate these disparities.