SwRI, UTSA collaborate on a novel process to produce low carbon fuels

Project will develop catalyst formulations to create cleaner, more cost-effective fuels

Grant and Award Announcement

SOUTHWEST RESEARCH INSTITUT

SAN ANTONIO — Aug. 3, 2021 — Southwest Research Institute and The University of Texas at San Antonio are collaborating to combine two catalytic processes into a single reactor, with the overall goal of recycling carbon from CO2 to produce low-cost hydrocarbon fuels. The work, led by Dr. Grant Seuser of SwRI’s Powertrain Engineering Division and Dr. Gary Jacobs of UTSA’s College of Engineering, is supported by a $125,000 grant from the Connecting through Research Partnerships (Connect) Program.

Greenhouse gas emissions are expected to increase by about 17% by 2040 as a result of increasing energy and transportation needs in the developing world.

“We’re facing a lack of renewable fuels and the technology to deliver cleaner power generation,” Seuser said. “We’re seeing a rise in battery-powered passenger vehicles, but the high power demands of the aviation, locomotive, shipping, and long-haul trucking industries will continue to require energy-dense hydrocarbons for the foreseeable future.”

Seuser and Jacobs propose using a process called carbon dioxide (CO2) hydrogenation to produce cleaner renewable liquid hydrocarbon fuels for transportation. To accomplish this, they plan to build a single reactor capable of performing two chemical processes in one step. The first will react hydrogen with CO2 to make carbon monoxide (CO) and the second will convert the CO and hydrogen, a blend known as synthesis gas or syngas, into liquid hydrocarbon fuel by a catalytic process known as Fischer-Tropsch synthesis.

“Fischer-Tropsch synthesis was discovered in Germany about a century ago and is still used in places like South Africa and Quatar to convert coal and natural gas into liquid hydrocarbon fuels. Plant capacities ranging from tens of thousands to hundreds of thousands of barrels of fuel per day. It will be an interesting challenge to integrate this catalytic technology into a process that uses CO2 in the feed,” Jacobs said.

Additionally, the process the SwRI-UTSA team is developing will be able to utilize CO2 captured at fossil fuel-fired power plants that would otherwise be sequestered underground or emitted into the atmosphere.

“Combining the functionality of these two catalytic processes, reverse water-gas shift and Fischer-Tropsch synthesis, into a single reactor would simplify the process and increase its economic viability,” Jacobs said.

The effort will also explore novel catalyst formations aimed at combining reverse water-gas shift and Fischer Tropsch synthesis functions, which Jacobs will create and characterize at UTSA. Seuser will use the catalysts in a SwRI reactor to assess their industrial viability.

“Reducing the complexity of converting CO2 into hydrocarbon fuels would have a big impact,” Seuser said. “Finding a way to produce low-carbon fuels and maintain our current energy infrastructure is critical to avoid further increases in Earth’s temperature.”

SwRI’s Executive Office and UTSA’s Office of the Vice President for Research, Economic Development, and Knowledge Enterprise sponsor the Connect program, which offers grant opportunities to enhance greater scientific collaboration between the two institutions.

For more information, visit https://www.swri.org/emissions/catalyst-formulation.

 

The graveyard never lies

New Study Shows which Countries have Underreported their COVID-19 Deaths and the Extent of their Deception

Peer-Reviewed Publication

THE HEBREW UNIVERSITY OF JERUSALEM

For the past year and a half, many of our decisions regarding whether it is safe to fly to country X or to vacation in country Y have been based a given country’s reported COVID-19 deaths.  These stats give the public a sense of how successful—or unsuccessful—that country has been at containing the spread of the coronavirus and its variant offspring.  However, not all countries have been playing fair.  Several have underreported their numbers, either deliberately or due to faulty testing capacities.

Now, two young researchers, one from Israel and one from Germany, have teamed up to set the record straight.  Instead of relying on countries’ published COVID-19 death rates, they created the World Mortality Dataset, the largest existing collection of overall mortality data, to uncover the true rate of COVID-19 deaths in more than 100 countries.  They published their findings in eLife journal.

In any given period of time, a certain number of people die due to a variety of reasons: old age, illness, violence, traffic accidents and more.  These deaths are commonly known as “expected deaths”.  Researchers use this data to predict the number of expected deaths in coming months and years.  However, pandemics, wars, natural and manmade disasters cause additional deaths, above and beyond the expected.  These are known as “excess deaths”. 

To calculate a given country’s true COVID-19 death toll, Ariel Karlinsky, a graduate student at Hebrew University of Jerusalem (HU)’s economics Department and Dmitry Kobak from Germany’s Tübingen University collected mortality data from 103 countries.  “We gathered mortality data to answer a number of questions,” Karlinsky shared. “We wanted to find out whether the pandemic caused excess deaths in the countries we covered and, if so, to what extent.”

To do so, the team compared the number of overall “known deaths” during the COVID pandemic with the number of overall deaths from previous years.  In this way, they were able to determine the likely number of excess deaths caused by the coronavirus pandemic.  “Even though the number of excess deaths does not exactly equal the mortality rate from COVID-19 infections, for many countries it is the most objective indicator of their pandemic death toll,” Karlinsky explained. 

For example, several Latin American countries, namely Bolivia, Ecuador, Mexico and Peru underreported their COVID-19 deaths, even though the number of excess deaths sustained during the pandemic period was over 50% higher than the number of expected deaths. According to Karlinsky and Kobak’s World Mortality Dataset, Bolivia’s true number of COVID deaths is likely 2.5 times higher than they reported—36,000 deaths instead of 15,000. In Ecuador, it’s 2.9 times higher—64,000 deaths instead of the 22,000 reported, while in Mexico, the figure is 2.1 times higher—471,000 instead of the 221,000 pandemic deaths that were reported. 

However, Peru stood out from the bunch.  They originally underreported their COVID-19 deaths—claiming only 69,000 deaths when in reality that figure was closer to 185,000.  After an outcry by public health officials, Peru’s health ministry made amends.  They audited all deaths during the pandemic period and resubmitted COVID-19 death stats to the World Health Organization that more accurately reflect the true number of excess deaths caused by the pandemic.

Meanwhile, other countries have obstinately continued to underreport their COVID-19 deaths.  The true number of pandemic deaths sustained by Russia is likely 4 times higher than reported—551,000 deaths instead of 135,000.  In Belarus that number is 14.5 times higher—5,700 deaths, instead of 392, and in Uzbekistan 29 times higher—21,500 deaths, instead of the 740 reported.  Tajikistan wins the underreporting prize with a COVID-19 death rate that is whopping 100-times higher than reported—9,000 deaths, instead of 90. 

The former Soviet Union is not alone in vastly underreporting its COVID-19 deaths.  According to the Karlinsky-Kobak study, Nicaragua’s true number of pandemic deaths is 50 times higher than reported—7,000 coronavirus deaths instead of the 137 reported.  However, it’s not all doom and gloom. Australia and New Zealand’s death rate during the pandemic was actually lower than previous periods.  This is likely due to their virus-containment efforts, which included border closures, social distancing and mask-wearing which decreased their overall number of deaths during the pandemic period. 

Among European nations, the team found that many countries faithfully reported their pandemic deaths.  Per 100,000 people, the United Kingdom suffered 159 deaths, France 110, Switzerland 100.  The Czech Republic suffered 320 pandemic deaths and Poland 310.  Denmark and Norway were unique in that they experienced no excess mortality during the pandemic.  The United States had 194 excess deaths per 100,000 persons.

“Our results present a comprehensive picture of the impact of COVID-19,” Kobak shared.  “We hope these findings—and their methodology –will lead to a better understanding of the pandemic and highlight the importance of open-source and fast mortality reporting.”

In the Middle East, Israel’s excess deaths during the coronavirus pandemic were actually smaller than their reported figures—5,000 instead of 6,400, as reported.  This is likely due to a decrease in the overall number of deaths from non-COVID 19 respiratory infections during the winter months.  At 58 excess deaths per 100,000 persons, Israel fared better than its neighboring countries (which provided overall mortality data).  Egypt’s excess deaths were 13 times higher than reported—196,000 instead of 15,000, Iran’s were 2.15 times higher—115,000 COVID-19 deaths instead of 54,000, and Lebanon’s figures were 1.23 times higher than reported—9,000 deaths instead of 7,300. 

When analyzing the overall figures, Karlinsky shared his hope, “that our dataset will be a valuable asset for public health officials looking to assess the risks and benefits of a given pandemic-containment measure.  Kobak and I are constantly expanding our dataset and will continue to track excess mortality around the world for the remainder of the COVID-19 pandemic”.

---

DOI

10.7554/eLife.69336

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

Not applicable

ARTICLE TITLE

Tracking excess mortality across countries during the COVID-19 pandemic with the World Mortality Dataset

ARTICLE PUBLICATION DATE

2-Aug-2021

 

Study tracks global death toll of COVID-19 pandemic

Using the World Mortality Dataset, the largest existing collection of mortality data, researchers have tracked the impact of COVID-19 across more than 100 countries.

Peer-Reviewed Publication

ELIFE

New insight on the death toll of the COVID-19 pandemic worldwide has been published in the open-access eLife journal.

Comparing the impact of COVID-19 between countries or during a given period of time is challenging because reported numbers of cases and deaths can be affected by testing capacity and reporting policy. The current study provides a more accurate picture of the effects of COVID-19 than using these numbers, and may improve our understanding of this and future pandemics.

In any given period of time, a certain number of people die due to many particular reasons, such as old age, illness, violence, traffic accidents and more. Researchers are able to predict the number of deaths from these causes over coming months or years, known as expected deaths, using the same information gathered from previous months and years. However, pandemics, conflicts, and natural and man-made disasters cause additional deaths above and beyond those expected, which are known as ‘excess deaths’.

“Measuring excess deaths allows us to quantify, monitor and track pandemics such as COVID-19 in a way that goes above testing and reporting capacity and policy,” says Ariel Karlinsky, a graduate  student at the Hebrew University of Jerusalem in Israel, and co-author alongside research scientist Dmitry Kobak, from Tübingen University, Germany. “However, until now, there has been no global, frequently updated repository of mortality data across countries.”

To fill this gap, Karlinsky and Kobak collected weekly, monthly or quarterly mortality data from 103 countries and territories, which they have made openly available as the World Mortality Dataset. They then used the data to work out the number of excess deaths in each country during the COVID-19 pandemic.

“We used our data to answer a number of questions,” Karlinsky explains. “Specifically, we wanted to find out whether the pandemic caused excess deaths in the countries we covered and, if so, to what extent. We were also curious to see whether the numbers of excess deaths were matched across countries.”

Their analyses showed that, in several of the countries worst affected by COVID-19 – namely Peru, Ecuador, Bolivia and Mexico – excess deaths were more than 50% above the expected annual mortality rate, or above 400 excess deaths per 100,000 people as in Peru, Bulgaria, North Macedonia and Serbia. At the same time, in countries such as Australia and New Zealand, mortality during the pandemic was below the usual level, which the authors suggest is likely due to social distancing measures reducing the number of deaths caused by other infections besides COVID-19.

Furthermore, the researchers found that while many countries have been reporting their COVID-19 death rates accurately, some including Nicaragua, Belarus, Egypt and Uzbekistan have underreported these numbers by more than 10 times.

“Together, our results present a comprehensive picture of the impact of COVID-19, which we hope will contribute to better understanding of the pandemic and assessing the success of different mitigation strategies,” Kobak concludes. “The work also highlights the importance of open and rapid mortality reporting for monitoring the effects of COVID-19. We hope that our dataset will provide a valuable resource to help other investigators answer their own questions about the pandemic. We are constantly expanding our dataset and will continue to track excess mortality around the world.”

##

Media contacts

Emily Packer, Media Relations Manager

eLife

e.packer@elifesciences.org

+44 (0)1223 855373

Tali Aronsky, International Media Director

The Hebrew University of Jerusalem 

taliaron@savion.huji.ac.il

+972-55-666-4371

About eLife

eLife is a non-profit organisation created by funders and led by researchers. Our mission is to accelerate discovery by operating a platform for research communication that encourages and recognises the most responsible behaviours. We aim to publish work of the highest standards and importance in all areas of biology and medicine, including Epidemiology and Global Health, while exploring creative new ways to improve how research is assessed and published. eLife receives financial support and strategic guidance from the Howard Hughes Medical Institute, the Knut and Alice Wallenberg Foundation, the Max Planck Society and Wellcome. Learn more at https://elifesciences.org/about.

To read the latest Epidemiology and Global Health research published in eLife, visit https://elifesciences.org/subjects/epidemiology-global-health.

About Hebrew University

The Hebrew University of Jerusalem (HU) is Israel's leading academic and research institution, serving 24,000 students from 80 countries. Founded in 1918 by visionaries including Albert Einstein and Sigmund Freud, HU is ranked among the world's 100 leading universities. To date, HU faculty and alumni have won eight Nobel Prizes, one Fields Medal and one Abel Prize. For more information, visit http://new.huji.ac.il/en. 

About the University of Tübingen

Innovative. Interdisciplinary. International. These have been our guiding principles in research and teaching since our founding in 1477. Tübingen’s success in the German government’s Excellence programs since 2012 have placed it among the most outstanding universities in Germany. The University is also well-placed in international higher education rankings.

More than 4,500 scientists and academics work at the University of Tübingen. We invest more than 200 million euros annually in a wide variety of research projects. As a comprehensive research university, Tübingen has solid foundations in the Sciences and Life Sciences as well as in the Humanities and Social Sciences. We have special strength due to our close collaboration with many non-university research institutions in our region and with notable universities around the world.

With more than 200 subjects on offer, the University of Tübingen gives prospective students a wide range of choices. A sharp focus on research is a major drawcard for Master’s students and doctoral candidates. The University not only trains our future experts and leaders; it is living up to its responsibility for the world of tomorrow.

---

DOI

10.7554/eLife.69336

METHOD OF RESEARCH

Data/statistical analysis

ARTICLE TITLE

Tracking excess mortality across countries during the COVID-19 pandemic with the World Mortality Dataset

 

Digital marketing improves product recall compliance, providing a new tool to enhance consumer safety

News from the Journal of Marketing

Peer-Reviewed Publication

AMERICAN MARKETING ASSOCIATION

Researchers from The Pennsylvania State University and the University of South Carolina published a new paper in the Journal of Marketing that examines a digital marketing campaign’s impact on improving low consumer recall completion rates.

The study, forthcoming in the Journal of Marketing, is titled “Regulating Product Recall Compliance in the Digital Age: Evidence from the ‘Safe Cars Save Lives’ Campaign” and is authored by Sotires Pagiavlas, Kartik Kalaignanam, Manpreet Gill, and Paul D. Bliese.

There were 786 automotive recalls in the United States in 2020 alone, affecting close to 32 million vehicles. The National Highway Traffic Safety Administration (NHTSA), the U.S. automobile industry’s regulator, estimates that 40 percent of recalled vehicles on the road are unrepaired, creating a critical public safety issue. In 2014, concerns regarding automotive product recalls peaked, as defective Takata airbag inflators led to fatalities and hundreds of drivers being injured. The debacle’s scope led to a record-breaking 63 million vehicles recalled in 2014 and 51 million in 2015 in the U.S.

Against this backdrop, this study focuses on a digital marketing campaign the NHTSA launched in January of 2016 to improve low consumer recall completion rates in the wake of mounting challenges. The “Safe Cars Save Lives” campaign was a nationwide digital marketing campaign that sought to push consumers to use the NHTSA’s recall lookup webpage. It used both paid search and online display advertisements to encourage consumers to check for open recalls using the webpage and then fix defective vehicles quickly.
 
The research team finds that the “Safe Cars Save Lives” campaign increased the number of vehicles fixed, on average, by 20,712 per non-airbag-related recall above what was to be expected without the digital marketing campaign in the first four calendar quarters it was active. The positive impact of the campaign was even greater for airbag inflator-related recalls. This finding is economically meaningful because improving recall compliance in the automobile industry has been shown to reduce the number of accidents on the road and thereby lower the economic costs of vehicle accidents. Even though the automobile industry receives considerable media attention, getting consumers to pay attention to recall notifications is challenging. The study provides evidence that a lack of available relevant information is a significant contributing factor to low consumer recall compliance, an issue that the “Safe Cars Save Lives” campaign addressed directly.
 
Second, the study finds that media coverage of a recall by the popular press improved the effectiveness of the digital marketing campaign. Although recent work notes that manufacturers view greater media coverage of a recall as damaging to their brands’ financial health, Pagiavlas says that “We found that media coverage contributed to improving safety outcomes by increasing the effectiveness of the digital marketing. In other words, the digital marketing campaign was more impactful for recall campaigns that received greater media coverage, suggesting that these two media formats can work synergistically to improve consumer recall compliance.”
 
Third, the digital marketing campaign’s positive impact on consumer recall compliance was even stronger when recalled vehicles were older. According to J.D. Power, just 44% of vehicles manufactured between 2003 and 2007 had their defects remedied, drastically below the recall completion percentage of 73% for vehicles of model years between 2013 and 2017. Federal and industry leaders have cited improving compliance among owners of older vehicles as one of four key topic areas to address moving forward. As Kalaignanam says, “The digital marketing campaign’s effectiveness on owners of older vehicles further suggests that regulators’ use of digital tools to facilitate consumer access to relevant information could improve compliance.” 
 
Finally, our findings caution regulators to be mindful of the time inconvenience consumers face in repairing their defective vehicles as a serious impediment to their recall compliance. While the campaign was effective at improving compliance, its impact was lower for recall campaigns with defective components that required more time to repair. Although consumers often do not cite the time needed to complete a repair as the most important factor in deciding whether to remedy safety defects, as Gill explains, “Our findings suggest that time-related inconvenience is a serious obstacle to achieving consumer compliance.”
 
These findings should enable regulatory agencies to make more compelling cases for financial resources devoted to digital marketing initiatives seeking to improve consumer recall compliance. Providing consumers with relevant information in an easy-to-access way can increase their awareness of important recall-related issues and ultimately contribute to improved compliance. Bliese states that “Improved recall compliance can thereby reduce the number of accidents and deaths stemming from unaddressed product recalls.”

Full article and author contact information available at: https://doi.org/10.1177/0022242921102301

About the Journal of Marketing 

The Journal of Marketing develops and disseminates knowledge about real-world marketing questions useful to scholars, educators, managers, policy makers, consumers, and other societal stakeholders around the world. Published by the American Marketing Association since its founding in 1936, JM has played a significant role in shaping the content and boundaries of the marketing discipline. Christine Moorman (T. Austin Finch, Sr. Professor of Business Administration at the Fuqua School of Business, Duke University) serves as the current Editor in Chief.
https://www.ama.org/jm

About the American Marketing Association (AMA) 

As the largest chapter-based marketing association in the world, the AMA is trusted by marketing and sales professionals to help them discover what is coming next in the industry. The AMA has a community of local chapters in more than 70 cities and 350 college campuses throughout North America. The AMA is home to award-winning content, PCM® professional certification, premiere academic journals, and industry-leading training events and conferences.
https://www.ama.org

---

JOURNAL

Journal of Marketing

DOI

10.1177/0022242921102301

ARTICLE TITLE

Regulating Product Recall Compliance in the Digital Age: Evidence from the “Safe Cars Save Lives” Campaign

ARTICLE PUBLICATION DATE

20-May-2021

 

Disadvantaged people may support social hierarchies and inequality to benefit their group

Peer-Reviewed Publication

THE POLISH ASSOCIATION OF SOCIAL PSYCHOLOGY

 

IMAGE: AS LONG AS STATUS POSITIONS BETWEEN SOCIAL GROUPS APPEAR UNSTABLE AND THUS, REVERSIBLE, PEOPLE IDENTIFIED WITH A LOWER SOCIAL-STATUS GROUP MAY FEEL INCLINED TO REINFORCE THEIR SUPPORT FOR HIERARCHICAL RELATIONS AND INEQUALITY. view more 

CREDIT: JEREMY BISHOP ON UNSPLASH

As long as status positions between social groups are perceived as unstable and thus, reversible, people who identified with a lower social-status group may feel inclined to reinforce their support for hierarchical relations and inequality between groups. By doing so, the group is indeed turning to a long-term strategy where they may engage in collective actions to eventually take over the position, power and resources of the current domineering party.   

With their findings, published in the peer-reviewed scholarly journal Social Psychological Bulletin, the research team, led by Dr Catarina L. Carvalho (University of Porto, Portugal), provides the first evidence that the endorsement of ideologies that promote hierarchically structured relationships between groups may actually serve as the stepping stone for lower-status groups up the social ladder. Their work presents a new perspective on what motivates disadvantaged groups to support such ideologies and highlight the importance of including ideological processes in collective action research.

All in all, people in lower status groups may engage in actions to achieve a more advantageous position in the status hierarchy motivated by different concerns. On one hand, such efforts could be aimed at promoting equality between all social groups, for example the civil rights movements. On the other hand, they may feel motivated to compete with another relevant group with higher status in an attempt to claim more power and resources for their group, to the detriment of the opposition. This is the case in sports, university rankings and political elections. Yet, while the former strategy seeks to close the gaps between the parties, the latter effectively legitimates the existing hierarchical social system and status differentials between groups.

In order to test whether members of low-status groups would indeed increase their support for group-based hierarchies and inequality as a strategy to guarantee the legitimacy of their future advantage over the current dominating party, the researchers conducted a survey with 113 first-year university psychology students attending a Portuguese University. The participants were told that they were taking part in a study on different styles of cognitive processing: Inductive and Deductive thinking. 

Firstly, the students filled in (bogus) cognitive inventory, supposedly to determine their cognitive processing style. At the end of the task, they received (false) feedback about their thinking style, where all participants were categorised as Deductive thinkers. Then, they learned that, allegedly based on previous studies, Deductive Thinkers (their group) occupied a lower (vs. higher, depending on the experimental condition) occupational status in everyday life. However, additional information was provided pointing out the lack of certainty and replicability of those results. 

Then, the participants answered to some control measures, followed by the main measurements meant to assess their social dominance orientation - that is, their support for group-based hierarchies and inequality - and their motivation to get involved in collective actions, including signing petitions and engaging in protests, aimed at promoting the success of Deductive thinkers or against any injustice towards Deductive thinkers.

“In sum, when social competition is favoured, low-status group members may intend to establish and maintain hierarchically structured intergroup relations not only because it serves a palliative function for them, but also because they believe it is possible for their group to achieve a higher status in the existing status hierarchy,” explain the authors of the study. 

“However, advances in the status hierarchy and improvement in group status will only be possible if the hierarchical system remains (i.e., maintenance of groups status differentials where one group has more power and prestige than the others) but with an unstable character.”

Lead author Dr Catarina L. Carvalho provides further context:

“This study was developed as part of my PhD project that aimed to explore the idea that, the hope for future ingroup high-status motivation can lead members of low-status group to endorse hierarchy-enhancing ideologies (i.e., SDO) on behalf of ingroup's interests. This idea challenges previous research and theoretical assumptions stating that members of low-status groups support hierarchical social systems because they feel negatively about their group membership or because it may help them to deal and cope with their disadvantaged position. Thus, from this perspective, SDO endorsement is expected to go against these groups’ interests.”

“Indeed, our results seem to confirm our predictions and expectations that SDO endorsement, among low-status group members, can represent an ideological strategy to maintain the existing hierarchical social system to guarantee a legitimate future advancement of the ingroup within the prevailing status hierarchy, offering a new perspective on why members of low-status group endorse hierarchy-enhancing ideologies.”

Research article:

Carvalho, C. L., Pinto, I. R., Costa-Lopes, R., Paéz, D., & Marques, J. M. (2021). Support for Group-Based Inequality Among Members of Low-Status Groups as an Ingroup Status-Enhancement Strategy. Social Psychological Bulletin, 16(2), 1-27. https://doi.org/10.32872/spb.5451

---

JOURNAL

Social Psychological Bulletin

DOI

10.32872/spb.5451

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Support for Group-Based Inequality Among Members of Low-Status Groups as an Ingroup Status-Enhancement Strategy

ARTICLE PUBLICATION DATE

29-Jul-2021

 

In rural America, religious attendance and norms reduce compassion for people who use opioids

A new study found that religious individuals in Appalachian and Midwestern states were more likely to support punitive drug policies.

Peer-Reviewed Publication

UNIVERSITY OF PENNSYLVANIA

Estimates suggest that 1.7 million people in the United States suffer from opioid-related substance abuse disorders and approximately 50,000 people die each year from an opioid-related overdose.

The opioid epidemic is a widespread crisis, but rural areas—particularly those in Appalachian and Midwestern states—have been the hardest hit. However, many individuals in those same states do not support policies scientifically proven to help, like medically aided treatment and syringe exchanges.

A new study from the Social Action Lab at the University of Pennsylvania’s Annenberg School for Communication found that individuals in rural areas of Appalachia and the Midwest who regularly attend religious services were more likely to support punitive drug policies and less likely to support policies that aid people who use drugs. They were also more likely to support the same policies as those they perceived their religious leaders supported, whether punitive or supportive. The findings suggest that religious leaders, if persuaded of the benefits of policies that aid people with a substance use disorder, could influence the general population’s opinion toward those measures.

“Many religious communities have either disapproved of or overtly repudiated protective drug policies, like medication-assisted treatment, retail access to syringes, or syringe exchange programs,” says Dolores Albarracín, Alexandra Heyman Nash University Professor and Director of the Social Action Lab. “This is largely because they interpret substance use as a moral failure rather than a disease and see these kinds of programs as enabling drug use. Our study supports this hypothesis, but it also indicates that religious leaders could be mobilized to support protective and efficacious drug policy to curb the opioid epidemic.”

Albarracín and her co-authors surveyed more than 3,000 people from 14 states, including Alabama, Georgia, Illinois, Indiana, Kansas, Kentucky, Michigan, Missouri, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia. Participants were asked questions about their own alcohol and drug use; their attitudes toward alcohol and drug use, social support, public policy, and mental health; and attitudes and resources within their communities. They were also asked about their religious affiliation, their religious-service attendance, and their religious leaders’ attitudes about drug use and public policy.

The researchers found that while religious affiliation had no impact on either protective or punitive policy attitudes, a respondent’s likelihood to support punishment and incarceration for people who use drugs increased with the frequency with which they attended religious services. However, if an individual’s religious leaders supported protective policies, they were more likely to also support protective policies.

“Ending the opioid epidemic requires finding ways to help religious communities become more open to protective policies that are scientifically shown to be more effective at supporting people using drugs,” says Albarracín. “Our study suggests that incorporating religious leaders into those efforts and developing an agenda that incorporates religious values in a way that increases compassion may go a long way in reducing the harm of drug use in rural areas in the United States.”

The study, entitled “The Associations of Religious Affiliation, Religious Service Attendance, and Religious Leader Norm with Support for Protective versus Punitive Drug Policies: A Look at the States Affected by the Rural Opioid Epidemic in the United States,” was published today in the Journal of Rural Mental Health. In addition to Albarracín, authors include Marta Durantini, a senior investigator at the Annenberg Public Policy Center; and the Grid for the Reduction of Vulnerability, a consortium of agencies from counties in the affected areas.

---

DOI

10.1037/rmh0000188

ARTICLE TITLE

The Associations of Religious Affiliation, Religious Service Attendance, and Religious Leader Norm with Support for Protective versus Punitive Drug Policies: A Look at the States Affected by the Rural Opioid Epidemic in the United States

 

Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids

Alicia Agnoli, MD, MPH, MHS^1,2; Guibo Xing, PhD²; Daniel J. Tancredi, PhD^2,3; et alElizabeth Magnan, MD, PhD^1,2; Anthony Jerant, MD^1,2; Joshua J. Fenton, MD, MPH^1,2,4

Author Affiliations Article Information

JAMA. 2021;326(5):411-419. doi:10.1001/jama.2021.11013

editorial comment ico

Key Points

Question  In patients prescribed stable, long-term, high-dose opioid therapy, is dose tapering associated with an increased risk of overdose or mental health crisis?

Findings  In this retrospective cohort study that included 113 618 patients prescribed stable, high-dose opioid therapy, patients in periods following dose tapering, compared with patients before or without tapering, had an adjusted incidence rate ratio of 1.68 for overdose and 2.28 for mental health crisis; both risks were statistically significant.

Meaning  Opioid dose tapering was associated with increased risk for overdose and mental health crisis, but interpretation of these findings is limited by the study design.

Abstract

Importance  Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis.

Objective  To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids.

Design, Setting, and Participants  Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion.

Exposures  Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period.

Main Outcomes and Measures  Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity.

Results  The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21).

Conclusions and Relevance  Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

Introduction

Amidst the ongoing US national crisis of opioid-related mortality and morbidity, heightened scrutiny and shifts in opioid prescribing trends have occurred in the US.^1-3 Key guidelines released in 2016 by the Centers for Disease Control and Prevention (CDC)⁴ recommended against higher doses of opioids in managing chronic pain and recommended dose tapering when harms of continued therapy outweigh perceived benefits for individual patients. These and other widely disseminated recommendations have led to increased opioid tapering among patients prescribed long-term opioid therapy.^5,6 However, opioid-related mortality has continued to rise.⁷

Subsequent US recommendations have advised caution in opioid de-prescribing.^8,9 Studies suggest risks of suicidal ideation, transition to illicit opioids, and overdose after opioid tapering and discontinuation. The US Food and Drug Administration issued a prescriber warning about potential hazards of rapid dose reduction in patients prescribed long-term opioids.⁹ However, studies assessing harms of opioid dose reduction have been limited to smaller samples,¹⁰ veteran populations,¹¹ or specific regions¹² or have focused on discontinuation and not included sensitive indicators for tapering initiation.^11,13,14 As clinicians and patients face difficult decisions about whether and how to de-prescribe opioids,¹⁵ there is a need to elucidate the potential harms of stopping or decreasing these medications.

It was hypothesized that tapering the dose of patients receiving stable, long-term, high-dose opioid therapy would be associated with increased risk for specific adverse events. Dose disruption among this population might trigger unhealthy substance use, withdrawal, depression, or anxiety, leading to increased acute care events related to drug toxicity and mental health. The objective of this study was to assess whether there are associations between opioid dose tapering among patients prescribed stable, long-term, higher-dose opioids and subsequent rates of overdose and mental health crisis. The potential risks associated with faster rate of opioid dose reduction were also assessed.

Methods

Study Data, Setting, and Participants

This retrospective cohort study used administrative claims data from the OptumLabs Data Warehouse from 2007 to 2019. The database contains deidentified retrospective administrative data, including medical and pharmacy claims (with associated diagnosis codes) and eligibility information as well as electronic health data for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients representing a diverse mix of ages, ethnicities, and US geographical regions (OptumLabs and OptumLabs Data Warehouse Descriptions and Citation. OptumLabs; 2020). The Institutional Review Board of the University of California determined this study to not be human subjects research because it involved analysis of preexisting, deidentified data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines.

We identified a cohort of patients prescribed stable, high doses of opioids for at least 12 months. Patients 18 years or older at the time of receiving an opioid prescription between January 1, 2008, and December 31, 2019, were eligible for inclusion if they had at least 14 months of continuous enrollment in medical, pharmacy, and mental health coverage and 12 months of continuous opioid prescriptions (operationalized as ≥90% of days filled), with mean daily dose of at least 50 morphine milligram equivalents (MME) that varied by no more than 10% above or below the mean monthly dose across the baseline year. We required at least 14 months of enrollment to allow for establishment of the stable baseline period and at least 2 months of follow-up to observe for tapering. We excluded patients with cancer, those receiving hospice or palliative care, and those prescribed buprenorphine (Figure 1).

Beginning the first day after the end of the baseline year of stable dosing, patients were followed up for up to 1 year for outcome events. Patients were censored if they died; their enrollment was disrupted; they developed a new diagnosis of cancer; or they entered hospice, palliative, or skilled nursing care for at least 90 days. We also censored patients during the first 7 months of follow-up if their mean daily dose increased by greater than or equal to 15% above their baseline dose and they had not previously initiated a taper; this censoring rule was adopted to allow comparison of outcomes among patients with continued opioid dose stability and those who underwent dose tapering. The study design allowed individual patients to contribute multiple baseline and follow-up periods during the study period, and the analysis plan accounted for time-varying covariates and variable follow-up duration.

Identifying Opioid Tapering

Following the 12-month baseline period, we computed 60-day moving mean daily doses during 6 overlapping windows spanning the 7 months following the baseline period. A taper was identified if the mean daily dose during one of these periods was greater than or equal to 15% below the mean daily dose in the baseline period. Tapering status was defined as a binary time-varying event history variable, specified as nontapered during all months prior to and during the 60-day period in which tapering was identified and tapered during all subsequent study months (eFigure 1 in the Supplement).⁵ The sensitivity and specificity of this measure has not been determined. However, the predictive validity of the measure was suggested by a longitudinal study in which 69.8% of patients identified as undergoing dose tapering showed sustained relative dose reduction of greater than or equal to 15% at least 9 months after tapering was identified.¹⁶

Dose Reduction Velocity

For all patients in the cohort, we used dosing data from the initial 6 overlapping 60-day periods of follow-up to identify the fastest monthly rate of dose reduction (velocity) occurring prior to the observation month. Detailed methods for specifying dose reduction velocities are included in the eMethods in the Supplement. For each follow-up month, we identified the maximum velocity of dose reduction that occurred in previous dosing intervals, and maximum velocity of dose reduction was a time-varying variable. Based on descriptive and graphical analyses of the distribution of tapering velocities, maximum velocity of dose reduction was then categorized as less than 10%, 10% to 19.9%, 20% to 49.9%, or at least 50%.

Outcome Variables

After each stable baseline period, we examined medical claims during the following 12 months to identify monthly (30-day) counts of 2 coprimary end points.

Overdose or withdrawal events were defined as emergency department visits or inpatient hospital admissions for any drug overdose, alcohol intoxication, or drug withdrawal. We identified International Classification of Diseases, Clinical Modification, Ninth Revision and International Classification of Diseases, Clinical Modification, Tenth Revision codes for this outcome by augmenting the definition for “all-drug overdose” specified in CDC drug overdose surveillance guidelines,¹⁷ with additional codes for alcohol intoxication and alcohol or drug withdrawal. In sensitivity analyses, we also assessed the “all-drug overdose,” as specified in the CDC guidance (without additional alcohol or withdrawal codes), and “opioid overdose.” In validation studies based on medical record reviews, diagnostic codes for opioid overdoses identified emergency or hospital events for opioid overdose with positive predictive values ranging from 67% to 84%.^18,19

Mental health crisis events were defined as emergency department or inpatient hospital admissions with depression or anxiety diagnosis codes in the primary diagnosis position (to make the outcome more specific to acute episodes of depression or anxiety rather than prevalent depressive/anxiety disorders coded during an episode for a different medical issue) or suicide attempt or intentional self-harm in any diagnosis position. In addition to the main analysis using the composite outcome, we also examined each mental health crisis outcome separately (depression, anxiety, and suicide attempt). In a systematic review and validation study, diagnostic codes for depression had sensitivities of 29% to 36%, specificities of approximately 99%, and positive predictive values of approximately 90%.²⁰ In a systematic review, diagnostic codes for suicide attempts or intention had positive predictive values between 55% and 100%.²¹ The list of diagnostic codes used to identify study outcomes is included in eTable 1 in the Supplement.

Covariates

We included covariates that might contribute to differences in rates of the outcomes of interest in populations prescribed opioids. Sociodemographic information included age, sex, education status, rurality of home address (dichotomized as metropolitan/micropolitan vs small town/rural using rural-urban commuting area codes 1-6 vs 7-10),²² and insurance status (commercial vs Medicare Advantage). Age was categorized as 18 to 34, 35 to 49, 50 to 64, and 65 years or older. Education was categorized based on median household education level for the patient’s zip code derived from US census data. A valid race variable was not available in the data set.

We included key clinical factors as covariates. Baseline opioid dose was calculated using pharmacy claims for all opioids during the baseline period and categorized as 50 to 89, 90 to 149, 150 to 299, and greater than or equal to 300 MME per day. To account for the increased risk of adverse outcomes conferred by co-prescribing benzodiazepines and opioids, we included a variable for whether the patient was concurrently prescribed a benzodiazepine (identified by National Drug Codes) on the final day of the baseline period. We included a count variable for the number of overdose events in the baseline year, specified by the same criteria as the overdose outcome variable. Baseline depression or anxiety was identified by either claims diagnoses²³ or 1 or more pharmacy claim for a selective serotonin reuptake inhibitor prescription during the baseline year. Comorbidities were accounted for using 27 discrete indicator variables for noncancer conditions in the Elixhauser comorbidity index, which includes variables labeled drug abuse and alcohol abuse (hereafter referred to as drug use disorder and alcohol use disorder), as well as psychosis.²⁴ Year of cohort entry was also included.

Statistical Analysis

Analyses were conducted using Stata MP, version 15.1 (StataCorp). We performed descriptive analyses to characterize the study population at baseline and identify bivariate differences between the tapered and nontapered samples.

We performed 2 key sets of analyses. First, we compared tapered and nontapered patient months and their associated risk of overdose and mental health crisis. To account for potential overdispersion of study outcomes, we used negative binomial regression to estimate adjusted incidence rates and incidence rate ratios (IRRs) for the 2 outcomes. We accounted for variable follow-up time by using a discrete time regression framework, with follow-up months nested in patients with eligible baseline periods. In adjusted analyses, models included the time-varying taper history variable and fixed patient-level covariates, including age, sex, education status, rurality, insurance status, Elixhauser comorbidities, baseline opioid dose, co-prescription of benzodiazepines, baseline overdose events, baseline depression/anxiety, and study year. In main analyses, a missing category was included for education (missing for 5.6% of patients), while the small percentage of patients with missing rurality data (0.2%) were grouped with the “small town/rural” category. We used postestimation commands to estimate adjusted incidence rates by tapering status. We used the same analytic approach in modeling associations between tapering and alternative specifications of the count outcomes (ie, all drug overdose; opioid-only overdose; or depression, anxiety, or suicide events). All analyses used cluster robust standard errors to account for clustering of multiple eligible baseline periods in individual patients. All tests were 2-sided with significance level of α = .05. Because of the potential for type I error due to multiple comparisons, findings for analyses of secondary end points should be interpreted as exploratory.

To examine whether tapering associations varied by covariates that we expected to be associated with overdose or mental health crisis, we assessed for meaningful 2-way interactions between tapering status and key covariates using Akaike’s information criterion and χ² tests for the significance of interaction terms. Statistically significant interaction effects were displayed graphically.

In the second set of analyses, we used negative binomial regression to examine associations between maximum dose reduction velocity and overdose and mental health outcomes. We included the time-varying independent variable maximum velocity of dose reduction first as a continuous measure and then as categorized above. These models adjusted for the same covariates described above. Regression analyses of maximum velocity of dose reduction only included patients who accrued follow-up time in month 3 of follow-up or later, which was the first month when maximum velocity of dose reduction could be defined based entirely on prior dosing. Thus, 4395 patients were not included in maximum velocity of dose reduction analyses due to early censoring events (3.9% of total).

We conducted additional sensitivity analyses, as described in the eMethods in the Supplement. Briefly, these analyses assessed the effect of alternative specifications of the study outcomes or the tapering measure. For example, to account for the potential bias that could have arisen from censoring due to death, we repeated main analyses wherein death was counted as an overdose or a mental health crisis event in the respective models. In addition, to account for the potential endogeneity arising from a patient’s propensity to undergo dose tapering, we conducted analyses with inverse probability weighting by a propensity score for the likelihood of undergoing tapering.

Results

The study cohort consisted of 113 618 patients prescribed stable, long-term, higher-dose opioid therapy for at least 12 months who contributed a total of 203 920 baseline periods (mean per patient, 1.8; median per patient, 1.0). Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). A total of 18.2% of baseline periods were followed by tapering (37 170 tapering events), of which 7620 (20.5%) were discontinued at some point during follow-up (eg, prescribed 0 MME during a 60-day dosing period). The median (interquartile range) maximum velocity of dose reduction was 22.7% (15.0%-41.3%) per month for tapered periods and 3.2% (1.7%-5.9%) per month without tapering.

Table 1 compares the baseline characteristics of patients by tapering status during their most recent baseline period. Patients who underwent tapering had significantly higher baseline opioid doses; were more likely to be co-prescribed benzodiazepines; and had significantly higher baseline rates of overdose, drug use disorder, depression, and anxiety.

Table 2 shows the adjusted incidence rates for the study outcomes by tapering status. Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference [aIRD], 3.8 per 100 person-years [95% CI, 3.0-4.6]; adjusted incidence rate ratio [aIRR], 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (aIRD, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]).

Among patients who underwent tapering and had 1 or more outcome events during follow-up, the median time to first event was 6 months for both outcomes. In secondary analyses of the individual components of the mental health crisis outcome (depression, anxiety, and suicide attempt), tapering was associated with depression events (aIRR, 2.46 [95% CI, 2.05-2.96]), anxiety events (aIRR, 1.79 [95% CI, 1.48-2.15]), and suicide attempts (aIRR, 3.30 [95% CI, 2.19-4.98]). The full regression model for the analysis of main effects is provided in eTable 2 in the Supplement.

In analyses with interaction terms between tapering status and other key covariates, only interactions between baseline dose category and tapering status were found to be both informative (based on reductions in Akaike’s information criterion) and statistically significant, based on χ² tests of significance of the dose category × tapering interaction terms (P < .01). For both outcomes, patients prescribed higher baseline doses had greater risks associated with tapering than patients prescribed lower baseline doses (Table 2; eFigure 2 in the Supplement).

In analyses of maximum monthly dose reduction velocity (n = 109 599 patients followed up for 139 941 person-years), an incremental increase in maximum monthly dose reduction velocity of 10% was associated with an increased aIRR for overdose (1.09 [95% CI, 1.07-1.11]) and mental health crisis (1.18 [95% CI, 1.14-1.21]) (eTable 3 in the Supplement). Higher maximum monthly dose reduction velocity categories (compared with maximum monthly dose reduction velocity <10%) were associated with higher event rates for overdose and mental health crisis (Figure 2; eTable 4 in the Supplement). The associations observed in the main analyses were robust to a series of sensitivity analyses (eTables 5-6 in the Supplement).

Discussion

In a large cohort of patients in the US prescribed stable, long-term, higher-dose opioids, undergoing opioid dose tapering was associated with statistically significant risk of subsequent overdose and mental health crisis, including suicidality.

Guidelines for opioid tapering published in 2019 by the US Department of Health and Human Services (HHS) cautioned about the potential hazards of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress.⁹ Qualitative studies suggest that many patients experience the tapering process as emotionally challenging,^25,26 and both the HHS and CDC guidelines advise clinicians to monitor patients carefully during tapering and to provide psychosocial support. In the current study, tapering was associated with absolute differences in rates of overdose or mental health crisis events of approximately 3 to 4 events per 100 person-years compared with nontapering. These findings suggest that adverse events associated with tapering may be relatively common and support HHS recommendations for more gradual dose reductions when feasible and careful monitoring for withdrawal, substance use, and psychological distress.⁹

Previous research has examined adverse outcomes associated with discontinuing long-term opioids.^10-14 This analysis demonstrated associations between adverse outcomes and a more sensitive indicator of opioid dose reduction (≥15% from baseline). The associations persisted in sensitivity analyses that excluded patients who discontinued opioids during follow-up, suggesting that the observed associations between tapering and overdose and mental health crisis are not entirely explained by events occurring in patients discontinuing opioids. Additionally, all categories of maximum dose reduction velocity demonstrated higher relative rates of outcomes compared with the lowest (<10% per month), suggesting that risks were not confined to patients undergoing rapid tapering.

Patients undergoing tapering from higher baseline opioid doses had higher associated risk for the study outcomes compared with patients undergoing tapering from lower baseline doses. Due to physiologic opioid tolerance,²⁷ patients receiving higher doses may have heightened intolerance of opioid dose disruption, potentially warranting additional caution in patients tapering from higher doses.

The risks of long-term opioids are well-documented, particularly at higher doses and in the presence of other risk factors for opioid toxicity,⁴ and clinicians and patients must carefully weigh risks and benefits of both opioid continuation and tapering in decisions regarding ongoing opioid therapy.²⁸ The risks associated with opioid tapering warrant further exploration to inform clinical guidelines regarding patient selection for tapering, optimal rates of dose reduction, and how best to monitor and support patients during periods of dose transition.

Limitations

This study has several limitations. First, although it included a number of key covariates, unmeasured factors may have contributed to increased risk for adverse events in the population who underwent tapering. Nevertheless, the findings are consistent with recent studies of opioid discontinuation^10-15,29,30 and were robust to adjustment for baseline overdose, mental health conditions, and a range of sensitivity analyses. Second, the analyses could not assess tapering circumstances. Recent evidence has shown that the majority of opioid tapering and discontinuation is clinician-initiated,³¹ and risks may differ with voluntary vs involuntary tapering.^32,33 Third, the study design considered any dose reduction of greater than or equal to 15% of the baseline dose as a taper initiation but did not account for subsequent dose trajectory. Fourth, the data set lacked an accurate measure of race, limiting the ability to account for the potential differential opioid prescribing and tapering trends between racial and ethnic groups. Fifth, the data set does not measure illicit opioid use or account for methadone administered in certified treatment programs. Sixth, administrative claims data have inherent measurement error. Seventh, these data were claims from commercially-insured and Medicare Advantage patients in the US, and the generalizability of these findings is uncertain.

Conclusions

Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

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Article Information

Corresponding Author: Alicia Agnoli, MD, MPH, MHS, Department of Family and Community Medicine, University of California, Davis, 4860 Y St, Ste 2300, Sacramento, CA 95817 (aagnoli@ucdavis.edu).

Accepted for Publication: June 21, 2021.

Author Contributions: Drs Agnoli and Fenton had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Agnoli, Magnan, Jerant, Fenton.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Agnoli, Jerant, Fenton.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Xing, Tancredi, Magnan, Fenton.

Obtained funding: Agnoli, Fenton.

Administrative, technical, or material support: Agnoli, Magnan, Jerant.

Supervision: Agnoli, Magnan, Jerant, Fenton.

Conflict of Interest Disclosures: Dr Agnoli reported receiving grants from the University of California Davis School of Medicine Dean's Office (scholar in women's health research; BIRCWH/K12) during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was supported by a University of California–OptumLabs Research Credit and the Department of Family and Community Medicine, University of California, Davis. Dr Agnoli was supported by the University of California, Davis School of Medicine Dean’s Office (Dean’s Scholarship in Women’s Health Research).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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