Elizabeth A. Stuart's research while affiliated with Johns Hopkins Bloomberg School of Public Health and other places
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Publications (471)
Background:
Long-term treatment with medications for opioid use disorder (OUD), including methadone, is lifesaving. There has been little examination of how to measure methadone continuity in claims data.
Objectives:
To develop an approach for measuring methadone continuity in claims data, and compare estimates of methadone versus buprenorphine...
Importance:
Emergency department (ED)-based initiation of buprenorphine has been shown to increase engagement in outpatient treatment and reduce the risk of subsequent opioid overdose; however, rates of buprenorphine treatment in the ED and follow-up care for opioid use disorder (OUD) remain low in the US. The Opioid Hospital Quality Improvement P...
The COVID-19 pandemic has led to a worsening of mental health among U.S. adults. However, no review to date has synthesized the overall prevalence of population depressive symptoms in the U.S. over the COVID-19 pandemic. We aimed to document the population prevalence of depressive symptoms and psychological distress across time since the start of t...
Extending (i.e., generalizing or transporting) causal inferences from a randomized trial to a target population requires assumptions that randomized and nonrandomized individuals are exchangeable conditional on baseline covariates. These assumptions are made on the basis of background knowledge, which is often uncertain or controversial, and need t...
Estimating treatment effects conditional on observed covariates can improve the ability to tailor treatments to particular individuals. Doing so effectively requires dealing with potential confounding, and also enough data to adequately estimate effect moderation. A recent influx of work has looked into estimating treatment effect heterogeneity usi...
Comparisons between randomized trial analyses and observational analyses that attempt to address similar research questions have generated many controversies in epidemiology and the social sciences. There has been little consensus on when such comparisons are reasonable, what their implications are for the validity of observational analyses, or whe...
In epidemiology and social sciences, propensity score methods are popular for estimating treatment effects using observational data, and multiple imputation is popular for handling covariate missingness. However, how to appropriately use multiple imputation for propensity score analysis is not completely clear. This paper aims to bring clarity on t...
Importance:
Early observations suggested that COVID-19 pneumonia had a higher mortality rate than other causes of pneumonia.
Objective:
To compare outcomes between mechanically ventilated patients with pneumonia due to COVID-19 (March 2020 to June 2021) and other etiologies (July 2016 to December 2019).
Design, setting, and participants:
This...
Importance
Integrated care for children is rarely studied, especially in low- and middle-income countries, where generalists often provide mental health care.
Objectives
To explore the effect of adding a child and youth component to an existing adult collaborative care program on mental health outcomes and receipt of care.
Design, Setting, and Pa...
Objectives:
To estimate effects of potentially modifiable risk factors for self-harm among adolescents in the Child Protective Services (CPS) system.
Methods:
Data came from the National Survey of Child and Adolescent Well-being, a nationally representative longitudinal survey. Candidate risk factors included child's feelings of worthlessness, t...
With an emergence of research investigating the educational impacts of the COVID-19 pandemic, empirical studies assessing teachers’ mental health throughout the pandemic have been scarce. Using a large national data set, the current study compares mental health outcomes during the pandemic between pre-K–12 teachers and professionals in other occupa...
Background
The United States faces an ongoing drug crisis, worsened by the undertreatment of substance use disorders (SUDs). Family enrollment in highdeductible health plans (HDHPs) and the resulting increased cost exposure could exacerbate the undertreatment of SUD. This study characterized the distribution of health care spending within families...
Background:
Transseptal puncture (TSP) is routinely performed for left atrial ablation procedures. The use of a three-dimensional (3D) mapping system or intracardiac echocardiography (ICE) is useful in localizing the fossa ovalis and reducing fluoroscopy use. We aimed to compare the safety and efficacy between 3D mapping system-guided TSP and ICE-...
The academic, socioemotional, and health impacts of school policies throughout the COVID-19 pandemic have been a source of many questions that require accurate information about the extent of onsite schooling occurring. This article investigates school operational status datasets during the pandemic, comparing (1) self-report data collected nationa...
Objectives:
Although high-deductible health plans (HDHPs) reduce health care spending, higher deductibles may lead to forgone care. Our goal was to determine the effects of HDHPs on the use of and spending on substance use disorder (SUD) services.
Study design:
We used difference-in-differences models to compare service use and spending for trea...
Study objective:
To evaluate the efficacy and safety of utilizing emergency medical services units to administer high dose buprenorphine after an overdose to treat withdrawal symptoms, reduce repeat overdose, and provide a next-day substances use disorder clinic appointment to initiate long-term treatment.
Methods:
This was a retrospective match...
![A simple DAG with variables relevant to E [ Y a ] {\rm{E}}\left[{Y}_{a}] .](publication/363776245/figure/fig1/AS:11431281120807489@1676645561237/A-simple-DAG-with-variables-relevant-to-E-Y-a-rmEleftY-a_Q320.jpg)
Causal mediation analysis is complicated with multiple effect definitions that require different sets of assumptions for identification. This article provides a systematic explanation of such assumptions. We define five potential outcome types whose means are involved in various effect definitions. We tackle their mean/distribution’s identification...
Background:
Many states have adopted laws that limit the amount or duration of opioid prescriptions. These limits often focus on prescriptions for acute pain, but there may be unintended consequences for those diagnosed with chronic pain, including reduced opioid prescribing without substitution of appropriate non-opioid treatments.
Objective:
T...
Policy implementation is a key component of scaling effective chronic disease prevention and management interventions. Policy can support scale-up by mandating or incentivizing intervention adoption, but enacting a policy is only the first step. Fully implementing a policy designed to facilitate implementation of health interventions often requires...
Introduction
In response to the role of opioid prescribing in the U.S. opioid crisis, states have enacted laws intended to curb high risk opioid prescribing practices. This study assessed the effects of state prescribing cap laws that limit the dose and/or duration of dispensed opioid prescriptions on opioid prescribing patterns and opioid overdose...
While prior studies have addressed bullying experienced during school, limited research exists on the associations between participation in school-sponsored extracurricular activities and bullying victimization risk. The current study utilized data from the 2013, 2015, and 2017 National Crime and Victimization Survey’s School Crime Supplement (n =...
Existing studies have suggested superior performance of nonparametric machine learning over logistic regression for propensity score estimation. However, it is unclear whether the advantages of nonparametric propensity score modeling are carried to settings where there is clustering of individuals, especially when there is unmeasured cluster‐level...
Importance:
High-dose and long-duration opioid prescriptions remain relatively common among children and adolescents, but there is insufficient research on the association of state laws limiting the dose and/or duration of opioid prescriptions (referred to as opioid prescribing cap laws) with opioid prescribing for this group.
Objective:
To exam...
We estimated the degree to which language used in the high profile medical/public health/epidemiology literature implied causality using language linking exposures to outcomes and action recommendations; examined disconnects between language and recommendations; identified the most common linking phrases; and estimated how strongly linking phrases...
The primary goal of depression screening is to reduce adverse psychiatric outcomes, which may have downstream implications for reducing avoidable health services use. The objective of this study was to examine the association of depression screening with emergency health services use and medically-treated suicidal behaviors among adolescents in the...
Understanding how best to estimate state-level policy effects is important, and several unanswered questions remain, particularly about the ability of statistical models to disentangle the effects of concurrently enacted policies. In practice, many policy evaluation studies do not attempt to control for effects of co-occurring policies, and this is...
Objective:
To evaluate the effects of state opioid prescribing cap laws on opioid prescribing after surgery.
Data sources:
OptumLabs Data Warehouse administrative claims data covering all 50 states from July 2012 through June 2019.
Study design:
We included individuals from 20 states that had implemented prescribing cap laws without exemptions...
Family violence, including child maltreatment (CM) and intimate partner violence (IPV), plagues far too many American families, particularly those in low-income communities. CM and IPV are intertwined and impose a significant emotional, health and financial burden on children and families and an economic burden on our country. Although these and ot...
Background
Knee osteoarthritis (OA) is the most prevalent arthritic disorder, characterized by joint paint, which is exacerbated by chronic depressive episodes. Depression in knee OA is also associated with declines in physical activity level and greater disability; however, the impact of persistent depressive symptoms on physical performance remai...
The aim of this study was to identify independent risk and protective factors associated with self-reported suicidal thoughts and behaviors (STB) among young adolescents by examining self-report data on mental health, substance abuse, violence involvement, social and economic challenges and supports, physical health and demographics in relation to...
Propensity score methods are a popular approach to mitigating confounding bias when estimating causal effects in observational studies. When study units are clustered (eg, patients nested within health systems), additional challenges arise such as accounting for unmeasured confounding at multiple levels and dependence between units within the same...
Because of the importance of schools to childhood development, the relationship between in-person schooling and COVID-19 risk has been one of the most important questions of this pandemic. Previous work in the United States during winter 2020-2021 showed that in-person schooling carried some risk for household members and that mitigation measures r...
Background
Opioid treatment programs (OTPs) serve as daily essential services for people with opioid use disorder. This study seeks to identify modifications to operations and adoption of safety measures at Pennsylvania OTPs during the COVID-19 pandemic.
Methods
A 25-min online survey to clinical and administrative directors at all 103 state-licen...
Background:
There is concern that state laws to curb opioid prescribing may adversely affect patients with chronic noncancer pain, but the laws' effects are unclear because of challenges in disentangling multiple laws implemented around the same time.
Objective:
To study the association between state opioid prescribing cap laws, pill mill laws,...
![FIGURE 1 | Temporal Trends in Policies [Panel (A)] and Prevalence of...](publication/358985843/figure/fig1/AS:1136646913298433@1648009150456/Temporal-Trends-in-Policies-Panel-A-and-Prevalence-of-Anxiety-and-Depressive_Q320.jpg)
Objectives: To examine the association of non-pharmaceutical interventions (NPIs) with anxiety and depressive symptoms among adults and determine if these associations varied by gender and age.
Methods: We combined survey data from 16,177,184 adults from 43 countries who participated in the daily COVID-19 Trends and Impact Survey via Facebook with...
Methods for extending – generalizing or transporting – inferences from a randomized trial to a target population involve conditioning on a large set of covariates that is sufficient for rendering the randomized and non-randomized groups exchangeable. Yet, decision-makers are often interested in examining treatment effects in subgroups of the target...
There is substantial evidence that adequate access to healthcare among low-income adults through the Affordable Care Act Medicaid expansion mitigates risk factors associated with childhood maltreatment, including parental financial insecurity, substance use, and poor mental health. Indeed, studies identified reduced reports of child neglect in stat...
Objectives:
We sought to understand how opioid treatment programs (OTPs) adapted OTP operations to the COVID-19 pandemic and new federal regulations around methadone and buprenorphine.
Methods:
In fall 2020, we conducted an online survey of all 103 OTPs licensed by the Pennsylvania Department of Drug and Alcohol Programs, including clinical dire...
Objective
This study investigates predictors of weight loss among individuals with serious mental illness participating in an 18-month behavioral weight loss intervention, using Lasso regression to select the most powerful predictors.
Methods
Data were analyzed from the intervention group of the ACHIEVE trial, an 18-month behavioral weight loss in...
Background
The COVID-19 pandemic has had an impact on mental health and alcohol use in the US, however there is little research on its impacts on cannabis use. Considering the role of cannabis as a coping strategy or self-medicating behavior, there is a need to understand how individuals who use cannabis have adapted their use amid the pandemic. Th...
Introduction
Assessing the impact of COVID-19 policy is critical for informing future policies. However, there are concerns about the overall strength of COVID-19 impact evaluation studies given the circumstances for evaluation and concerns about the publication environment.
Methods
We included studies that were primarily designed to estimate the...
Randomized controlled trials (RCTs) are the gold standard for evaluation of new medical products. However, RCTs may not always be ethical or feasible. In cases where the investigational product is available outside the trial (e.g., through accelerated approval), patients may fail to enroll in clinical trials or drop out early to take the investigat...
Introduction
Access to medication for opioid use disorder (MOUD) is a recognized public health challenge to improving the health of people with opioid use disorder (OUD) in many communities. Prior studies have shown that although MOUD availability has increased over time, particularly in some states, many substance use treatment facilities still do...
Background: The COVID-19 pandemic has had an impact on mental health and alcohol use in the US, however there is little research on its impacts on cannabis use. Considering the role of cannabis as a coping strategy or self-medicating behavior, there is a need to understand how individuals who use cannabis have adapted their use amid the pandemic. T...
The objective of this study is to determine county-level factors associated with anxiety, depression, and isolation during the coronavirus disease 2019 (COVID-19) pandemic. This study used daily data from 23,592,355 respondents of a nationwide Facebook-based survey from April 2020 to July 2021, aggregated to the week-county level to yield 212,581 o...
When effect modifiers influence the decision to participate in randomized trials, generalizing causal effect estimates to an external target population requires the knowledge of two scores – the propensity score for receiving treatment and the sampling score for trial participation. While the former score is known due to randomization, the latter s...
Purpose:
The objectives of the current study were to (1) assess associations between household structure (i.e., living with spouse compared to living alone, with children, or with a spouse and children), presence of children, and mental distress in April 2020 and change in mental distress (between April and August 2020); and (2) determine whether...
Background
The United States is experiencing a drug addiction and overdose crisis, made worse by the COVID-19 pandemic. Relative to other types of health services, addiction treatment and overdose prevention services are particularly vulnerable to disaster-related disruptions for multiple reasons including fragmentation from the general medical sys...
Background:
Reliable evaluations of state-level policies are essential for identifying effective policies and informing policymakers' decisions. State-level policy evaluations commonly use a difference-in-differences (DID) study design; yet within this framework, statistical model specification varies notably across studies. More guidance is neede...
Background
Guidelines and recommendations from public health authorities related to face masks have been essential in containing the COVID-19 pandemic. We assessed the prevalence and correlates of mask usage during the pandemic.
Methods
We examined a total of 13,723,810 responses to a daily cross-sectional online survey in 38 countries of people w...
New research can help policymakers make evidence-based decisions about the risks and benefits of in-person schooling; strategic use of the available data will be key to getting this right.
Purpose/Objective(s)
Despite evidence for the superiority of twice daily (BID) radiotherapy schedules, their utilization in practice remains logistically challenging. Hypofractionation (HFRT) is a commonly implemented alternative. We aim to compare the outcomes and toxicities in limited stage small cell lung cancer (LS-SCLC) patients treated with h...
Introduction
Depression screening is universally recommended for adolescents presenting in primary care settings in the U.S. However, little is known about how depression screening affects the likelihood of being diagnosed with a mental disorder or accessing mental health care over time.
Methods
This longitudinal cohort study used insurance claims...
Because of the importance of schools to childhood development, the relationship between in-person schooling and COVID-19 risk has been one of the most important questions of the COVID-19 pandemic. Previous work using data from the United States in winter 2020-21 showed that in-person schooling carried some risk for household members, and that mitig...
We examined the prevalence and correlates of self-harm among adolescents in the three years following an investigation by U.S. Child Protective Services (CPS) into alleged child maltreatment. Participants (N = 1573, 47% Male, 45% White) were drawn from the National Survey of Child and Adolescent Well-Being, cohort II. Self-harm was assessed at the...
Objective:
High-deductible health plans (HDHPs) are increasingly common in the U.S. health insurance market and are intended to reduce the use of low-value services, but evidence suggests that HDHP enrollees also reduce the use of high-value services. This study examined the effects of HDHPs on enrollees with mental health conditions, a population...
Purpose of Review
This review summarizes studies examining impacts of medical and recreational cannabis laws on opioid prescribing, opioid use, opioid use disorder, opioid-related service utilization, and opioid-involved mortality. We also discuss research challenges and recommendations for future work.
Recent Findings
Twenty-one US-based studies...
Objective
Among persons with opioid use disorder (OUD), co-occurring depression is linked to a greater risk of opioid misuse, overdose and suicide. Less is known about characteristics and other comorbid health conditions of persons with co-occurring opioid use and depressive disorders. Methods: This study used electronic health record (EHR) encount...
Methods for extending -- generalizing or transporting -- inferences from a randomized trial to a target population involve conditioning on a large set of covariates that is sufficient for rendering the randomized and non-randomized groups exchangeable. Yet, decision-makers are often interested in examining treatment effects in subgroups of the targ...
Mediation analysis aims to investigate the “mechanisms of action” behind the effects of interventions or treatments. Originally developed in psychology, a robust set of mediation methods are now used across a range of fields. Given the history and common use of mediation in mental health research, this review aimed to understand how mediation analy...
While there is an emergence of research investigating the educational impacts of the COVID-19 pandemic, empirical studies assessing teacher mental health throughout the pandemic have been scarce. Using a large national dataset, the current study first compared mental health outcomes during the pandemic between pK-12 teachers and professionals in ot...
Causal inference analyses often use existing observational data, which in many cases has some clustering of individuals. In this paper, we discuss propensity score weighting methods in a multilevel setting where within clusters individuals share unmeasured confounders that are related to treatment assignment and the potential outcomes. We focus in...
Introduction:
The U.S. Affordable Care Act Medicaid expansion, which allowed states to expand Medicaid coverage to low-income adults beginning in 2014, has reduced the risk factors for child neglect and physical abuse, including parental financial insecurity, substance use, and untreated mental illness. This study examines the associations between...
We estimated the degree to which language used in the high profile medical/public health/epidemiology literature implied causality using language linking exposures to outcomes and action recommendations; examined disconnects between language and recommendations; identified the most common linking phrases; and estimated how strongly linking phrases...
Background
Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD.Objective
To estimate the impact of HDHPs on continuity of buprenorphi...
The COVID-19 pandemic may disproportionately impact parents of children with autism spectrum disorder (ASD). Loss of services and supports, heightened fears about increased infection rates, and disruption of daily routines likely adversely affect the well-being of children with ASD and their families. The goal of this study was to examine differenc...
Background
The Community Eligibility Provision (CEP) allows high-poverty schools participating in US Department of Agriculture meal programs to offer universal free school meals. Emerging evidence suggests benefits of CEP for student meal participation, behavior, and academic performance. Although CEP became available nationwide in 2014, in school...
Panel data methods, which include difference-in-differences and comparative interrupted time series, have become increasingly common in education policy research. The key idea is to use variation across time and space (e.g., school districts) to estimate the effects of policy or programmatic changes that happen in some localities but not others. In...
Since the beginning of the COVID-19 pandemic, pharmaceutical treatment hypotheses have abounded, each requiring careful evaluation. A randomized controlled trial generally provides the most credible evaluation of a treatment, but the efficiency and effectiveness of the trial depend on the existing evidence supporting the treatment. The researcher m...
Policy responses to COVID-19, particularly those related to non-pharmaceutical interventions, are unprecedented in scale and scope. However, policy impact evaluations require a complex combination of circumstance, study design, data, statistics, and analysis. Beyond the issues that are faced for any policy, evaluation of COVID-19 policies is compli...
Aims
To examine changes in drinking behavior among US adults between March 10 and July 21, 2020, a critical period during the COVID-19 pandemic.
Design
Longitudinal, internet-based panel survey.
Setting
The Understanding America Study (UAS), a nationally-representative panel of US adults aged 18 or older.
Participants
4,298 US adults who reporte...
Matching and weighting methods for observational studies require the choice of an estimand, the causal effect with reference to a specific target population. Commonly used estimands include the average treatment effect in the treated (ATT), the average treatment effect in the untreated (ATU), the average treatment effect in the population (ATE), an...
In severe viral pneumonia, including Coronavirus disease 2019 (COVID-19), the viral replication phase is often followed by hyperinflammation, which can lead to acute respiratory distress syndrome, multi-organ failure, and death. We previously demonstrated that alpha-1 adrenergic receptor (⍺ 1 -AR) antagonists can prevent hyperinflammation and death...
Propensity score weighting and outcome regression are popular ways to adjust for observed confounders in epidemiological research. Here, we provide an introduction to matching methods, which serve the same purpose but can offer advantages in robustness and performance. A key difference between matching and weighting methods is that matching methods...
Despite evidence for the superiority of twice-daily (BID) radiotherapy schedules, their utilization in practice remains logistically challenging. Hypofractionation (HFRT) is a commonly implemented alternative. We aim to compare the outcomes and toxicities in limited-stage small-cell lung cancer (LS-SCLC) patients treated with hypofractionated versu...
Objective. Understanding how best to estimate state-level policy effects is important, and several unanswered questions remain, particularly about optimal methods for disentangling the effects of concurrently implemented policies. In this paper, we examined the impact of co-occurring policies on the performance of commonly used models in state poli...
Background: The American College of Obstetricians and Gynecologists recommends universal screening for tobacco, alcohol, and drug use as a part of routine prenatal care. However, little is known about the prevalence of prenatal substance use screening or factors that may contribute to differential rates of screening during prenatal care.
Objectives...
The Adolescent Brain Cognitive Development (ABCD) Study is the largest single-cohort prospective longitudinal study of neurodevelopment and children's health in the United States. A cohort of n= 11,880 children aged 9-10 years (and their parents/guardians) were recruited across 22 sites and are being followed with in-person visits on an annual basi...
To limit the spread of the novel coronavirus, governments across the world implemented extraordinary physical distancing policies, such as stay-at-home orders. Numerous studies aim to estimate the effects of these policies. Many statistical and econometric methods, such as difference-in-differences, leverage repeated measurements, and variation in...