Abstract
Background:
Maternal and child health are adversely impacted by experiences of violence, unstable living situations and cannabis use during pregnancy. Women who experience intimate partner violence (IPV) are more likely to use cannabis than those who do not experience IPV. However, IPV can be difficult to identify due as patients may not be ready to disclose. As IPV is associated with prior experiences of violence and unsafe/unstable housing, this study aimed to estimate the associations between experiences of current IPV, any past-year violence, and unsafe or unstable living situations with cannabis use during early pregnancy. This study used a large, diverse sample to further our understanding of the relationship between violent experiences and prenatal cannabis use.
Methods:
Using data from 303,178 pregnancies in California from 2014-2023, we used chi-square tests and modified Poisson regression models to estimate associations between experiences of current IPV, past-year violence, and unsafe/unstable living situations with cannabis use during early pregnancy.
Results:
Individuals endorsed current IPV or any past-year violence in less than 1% of the pregnancies (n=324 [0.1%] and n=979 [0.3%], respectively), and about 2% (n=6,284) reported having unsafe/unstable living situations. Over two-thirds (69.1%) of the pregnancies where patients endorsed current IPV also endorsed past-year physical violence or unsafe/unstable living situation. Individuals used cannabis during 7.2% (n=21,868) of the pregnancies. In unadjusted analyses, current IPV, past-year violence, and unsafe/unstable living situations were associated with higher prenatal cannabis use. In adjusted analyses, past-year violence and unsafe/unstable living situations were associated with higher prenatal cannabis use.
Conclusions:
It is crucial for experiences of violence and unsafe living situations to be concurrently assessed and addressed with cannabis use. Interventions that incorporate education, advocacy, and connections to mental health and IPV services could help reduce cannabis use and recurrent violence and improve pregnancy-related outcomes and patient safety.
Keywords: cannabis use, maternal health, intimate partner violence, interpersonal violence
INTRODUCTION
Intimate partner violence (IPV) and cannabis use are persistent public health issues among pregnant individuals.1,2 Generally, individuals who experience IPV have over three times the risk of using cannabis5 and are more likely to experience problems related to cannabis use compared to other substances.6 These associations between IPV and cannabis use and related problems could have a significant impact on maternal and child health and safety. Forty percent of individuals report experiencing IPV around the time of their pregnancy (12 months prior, during, and 12 months after pregnancy).4 IPV and cannabis use are both associated with a wide range of health-related issues, including adverse mental health and pregnancy-related outcomes (e.g., unintended pregnancy, preterm birth, low birth weight).1-3
Cannabis may be used in response to psychological stress and physical IPV,7,8 and addressing the sources of stress (e.g., violence and safety) could help to reduce prenatal cannabis use and related adverse pregnancy-related outcomes. Alternatively, cannabis use could place women at higher risk for violence,2 highlighting the need for particular attention to the co-occurrence of violence and safety and cannabis use among pregnant individuals. Studies have found a direct and indirect (mediated via stress) relationship between IPV and cannabis use during pregnancy.7,9 However, these studies among pregnant individuals mostly include small convenience samples from obstetrics clinics, social services programs, or drug treatment programs and research with large, diverse and generalizable samples is critically needed.
Additionally, individuals may be reluctant to self-report IPV as they may not be ready to disclose due to a variety of reasons (i.e., stigma, healthcare providers being mandated reporters, fear of children being removed from the home, fear of partner retaliation).10 Studies could benefit from including broader screening items that include past-year violence and unsafe or unstable living situation, which patients may be more likely to provide an answer that reflects their experiences and are associated with IPV.2 This study aimed to address these key gaps in the literature by examining the relationship between current IPV, any past-year violence, and unsafe or unstable living situation and cannabis among pregnant individuals in a large, diverse healthcare system. Findings can help inform the development of more tailored prevention and intervention programs for prenatal cannabis use.
METHODS
Kaiser Permanente Northern California (KPNC) provides healthcare to ~4.6 million members, who are demographically similar to the Northern California population.11 This cross-sectional study included KPNC patients whose pregnancies began between 2014–2023 (n=634,274 pregnancies). Pregnancies were included when patients completed universal screeners for self-reported violence and prenatal cannabis use (based on a self-reported questionnaire and a urine toxicology test) at entrance to prenatal care (typically at ~8–10 weeks gestation). Pregnancies were excluded when the patient 1) did not have active KP membership at any time during their pregnancy (n=16,276); 2) did not attend a prenatal care visit (n=119,859); 3) had missing responses to both violence questions (n=154,230); 4) did not complete the questionnaire with the cannabis use question (n=12,426); 5) completed the questionnaire but did not answer the cannabis use question (n=3,741); 6) completed the questionnaire during the 2020 data collection issue that made the cannabis self-report data unreliable (n=24,936); 7) did not complete a cannabis urine toxicology test (n=12,944); or 8) had missing address data (n=86).
Exposures included experiences of violence and unsafe/unstable housing. Questionnaires captured experiences of violence as current IPV (“Are you in a relationship with a person who threatens or physically hurts you?”) and past-year physical violence (“Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone?”). For the study exposures, we included current IPV and any past-year violence, which included both violence measures (past-year physical violence or current IPV) as they encompass violent experiences in the past year. The questionnaire item “Is your living situation unsafe and/or unstable?” captured the unsafe/unstable housing exposure. The violence and unsafe/unstable housing items were all dichotomous measures.
The prenatal cannabis use outcome was measured two ways. Patients could self-report their cannabis use on the universal questionnaire, responding to whether they used “marijuana/cannabis” since their pregnancy began, and they took a urine toxicology test for cannabis at entry to prenatal care. We excluded pregnancies in which the patient did not have a urine toxicology result to reduce bias related to whether the urine toxicology test was performed. We determined there to be prenatal cannabis use if the patient self-reported using cannabis since their pregnancy began or they had a positive urine toxicology result.
We used chi-square tests to test unadjusted associations and modified Poisson regression models to estimate adjusted associations between current IPV, any past-year violence, and unsafe/unstable living situation with any prenatal cannabis use. Models were adjusted for pregnancy onset age, self-reported race and ethnicity, Neighborhood Deprivation Index,12 health insurance type, pregnancy intention, cohabitation, depressive symptoms,13 and pregnancy onset year, and accounted for multiple pregnancies per individual. The Kaiser Permanente Northern California Institutional Review Board approved this study and waived informed consent.
RESULTS
The sample of 303,178 pregnancies was 26.6% Asian, 6.1% Black, 28.3% Hispanic, 34.5% White, 4.5% another race, multiracial, or unknown race and ethnicity. Less than 1% reported current IPV or experiencing any past-year violence (n=324 [0.1%] and n=979 [0.3%], respectively), and about 2% (n=6,284) reported having unsafe/unstable living situations (Table 1). Over two-thirds (69.1%) of the pregnancies where patients endorsed current IPV also endorsed past-year physical violence or unsafe/unstable living situation, about one-third (33.0%) of pregnancies with past-year physical violence also endorsed current IPV or unsafe/unstable living situation, and 3.8% of pregnancies with an unsafe/unstable living situation also endorsed current IPV or past-year physical IPV (Figure 1). Patients in the sample had their prenatal cannabis use evaluated at a median of 8 gestational weeks (interquartile range: 6–10 weeks). Individuals used cannabis during 7.2% (n=21,868) of the pregnancies. Of those with prenatal cannabis use, about half (46.8%, n=10,232) self-reported their use and the urine toxicology tests captured another cannabis use in another 11,636 pregnancies.
Table 1: Sample Characteristics by Intimate Partner Violence, Past-Year Violence, and Unsafe or Unstable Living Situation.
| Current Intimate Partner Violence N=299,252 |
Past-Year Violence N=303,178 |
Unsafe or Unstable Living Situation N=302,473 |
|||||||
|---|---|---|---|---|---|---|---|---|---|
| Characteristic | No | Yes | No | Yes | No | Yes | |||
| N=298,928 | N=324 | p-value | N=302,199 | N=979 | p-value | N=296,189 | N=6,284 | p-value | |
| Age at Pregnancy Onset | 0.063 | <.001 | <.001 | ||||||
| < 25 years | 39,424 (13.2) | 56 (17.3) | 39,693 (13.1) | 296 (30.2) | 39,044 (13.2) | 830 (13.2) | |||
| 25 – 35 years | 168,556 (56.4) | 167 (51.5) | 170,457 (56.4) | 449 (45.9) | 167,196 (56.5) | 3,379 (53.8) | |||
| ≥ 35 years | 90,948 (30.4) | 101 (31.2) | 92,049 (30.5) | 234 (23.9) | 89,949 (30.4) | 2,075 (33.0) | |||
| Weeks Gestation (median [IQR]) | 8 [6–10] | 8 [6–11] | 0.005 | 8 [6–10] | 8 [7–11] | <.001 | 8 [6–10] | 8 [6–10] | 0.083 |
| Race and Ethnicity | <.001 | <.001 | |||||||
| Hispanic | 84,303 (28.2) | 115 (35.5) | 85,347 (28.2) | 324 (33.1) | 83,765 (28.3) | 1,668 (26.5) | <.001 | ||
| Black | 18,132 (6.1) | 39 (12.0) | 18,262 (6.0) | 172 (17.6) | 17,747 (6.0) | 640 (10.2) | |||
| Asian | 79,824 (26.7) | 67 (20.7) | 80,643 (26.7) | 130 (13.3) | 79,466 (26.8) | 1,154 (18.4) | |||
| White | 103,252 (34.5) | 86 (26.5) | 104,384 (34.5) | 295 (30.1) | 101,939 (34.4) | 2,525 (40.2) | |||
| Another or unknown race | 13,417 (4.5) | 17 (5.3) | 13,563 (4.5) | 58 (5.9) | 13,272 (4.5) | 297 (4.7) | |||
| Neighborhood Deprivation Index | 0.441 | <.001 | <.001 | ||||||
| 1st (least deprivation) | 53,917 (18.0) | 52 (16.1) | 54,560 (18.1) | 134 (13.7) | 53,579 (18.1) | 999 (15.9) | |||
| 2nd | 85,442 (28.6) | 85 (26.2) | 86,434 (28.6) | 222 (22.7) | 84,708 (28.6) | 1,772 (28.2) | |||
| 3rd | 87,809 (29.4) | 106 (32.7) | 88,704 (29.4) | 308 (31.5) | 86,847 (29.3) | 1,966 (31.3) | |||
| 4th (most deprivation) | 71,760 (24.0) | 81 (25.0) | 72,501 (24.0) | 315 (32.2) | 71,055 (24.0) | 1,547 (24.6) | |||
| Insurance Type | <.001 | <.001 | <.001 | ||||||
| Public | 38,449 (12.9) | 78 (24.1) | 38,846 (12.9) | 276 (28.2) | 38,009 (12.8) | 976 (15.5) | |||
| Private | 260,479 (87.1) | 246 (75.9) | 263,353 (87.2) | 703 (71.8) | 258,180 (87.2) | 5,308 (84.5) | |||
| Pregnancy Intention | <.001 | <.001 | <.001 | ||||||
| Wanted | 113,005 (37.8) | 88 (27.2) | 115,086 (38.1) | 238 (24.3) | 112,846 (38.1) | 2,218 (35.3) | |||
| Wanted, but not at time | 26,311 (8.8) | 60 (18.5) | 26,795 (8.9) | 151 (15.4) | 26,153 (8.8) | 737 (11.7) | |||
| Did not want | 8,684 (2.9) | 39 (12.04) | 8,826 (2.9) | 87 (8.9) | 8,560 (2.9) | 318 (5.1) | |||
| Unknown | 36,888 (12.3) | 37 (11.4) | 37,250 (12.3) | 121 (12.4) | 36,459 (12.3) | 773 (12.3) | |||
| Not asked | 114,040 (38.2) | 100 (30.9) | 114,242 (37.8) | 382 (39.0) | 112,171 (37.9) | 2,238 (35.6) | |||
| Cohabitating with… | <.001 | <.001 | <.001 | ||||||
| Partner or baby's father | 270,663 (90.5) | 223 (68.8) | 273,806 (90.6) | 582 (59.5) | 268,495 (90.7) | 5,318 (84.6) | |||
| Other family | 17,116 (5.7) | 56 (17.3) | 17,174 (5.7) | 230 (23.5) | 16,815 (5.7) | 530 (8.4) | |||
| Other | 6,988 (2.3) | 40 (12.4) | 7,006 (2.3) | 143 (14.6) | 6,759 (2.3) | 346 (5.5) | |||
| Unknown | 4,161 (1.4) | 5 (1.5) | 4,213 (1.4) | 24 (2.5) | 4,120 (1.4) | 90 (1.4) | |||
| Depressive Symptoms | <.001 | <.001 | <.001 | ||||||
| Moderate/Severe | 29,962 (10.0) | 88 (27.2) | 30,146 (9.1) | 294 (30.0) | 29,430 (9.9) | 906 (14.4) | |||
| None/Mild | 241,760 (80.9) | 208 (64.2) | 244,530 (80.9) | 600 (61.3) | 239,803 (81.0) | 4,801 (76.4) | |||
| Missing | 27,206 (9.1) | 28 (8.6) | 27,523 (9.1) | 85 (8.7) | 26,956 (9.1) | 577 (9.2) | |||
| Cannabis Use (yes) | 21,485 (7.2) | 50 (15.4) | <.001 | 21,656 (7.2) | 212 (21.7) | <.001 | 21,087 (7.1) | 713 (11.4) | <.001 |
Notes: Data are presented as n (%) unless otherwise noted. IQR = interquartile range. Depressive symptoms categories were based on the Patient Health Questionnaire (PHQ-9), score ≥10 indicates moderate/severe symptoms.13 The census-based Neighborhood Deprivation Index was categorized into quartiles using the distribution from the overall KPNC population in 2021.12
Figure 1: Occurrence and Co-Occurrence of IPV, Past-Year Physical Violence and Unsafe/Unstable Living Situation during Pregnancy.
The unadjusted prevalence of prenatal cannabis use was significantly higher among pregnancies where patients reported current IPV (15.4% vs. 7.2%, p<.001), past-year violence (21.7% vs. 7.2%, p<.001), and unsafe/unstable living situations (11.4% vs. 7.1%, p<.001) than those without the respective experiences (Table 1). In adjusted analyses, those with past-year violence (adjusted prevalence ratio [aPR]=1.30; 95%CI:1.14-1.48) and unsafe/unstable living situations (aPR=1.22; 95%CI:1.14-1.30) had a higher prevalence of prenatal cannabis use than those without the respective experiences (Table 2). However, current IPV was not significantly associated with prenatal cannabis use in the adjusted model (aPR=1.15; 95%CI:0.88-1.50).
Table 2: Adjusted Associations Between Violence and Unsafe or Unstable Living Situations and Prenatal Cannabis Use.
| Prenatal Cannabis Use | ||||||
|---|---|---|---|---|---|---|
| aPR (95% CI) | p-value | aPR (95% CI) | p-value | aPR (95% CI) | p-value | |
| Violence/Living Situation (yes vs. no) | ||||||
| Current intimate partner violence | 1.15 (0.88 - 1.50) | 0.302 | -- | -- | -- | -- |
| Past-year violence | -- | -- | 1.30 (1.14 - 1.48) | <.001 | -- | -- |
| Unsafe or unstable living situation | -- | -- | -- | -- | 1.22 (1.14 - 1.30) | <.001 |
| Any | -- | -- | -- | -- | -- | -- |
| Age | ||||||
| < 25 years | 2.56 (2.45 - 2.68) | <.001 | 2.54 (2.43 - 2.66) | <.001 | 2.55 (2.43 - 2.66) | <.001 |
| 25-34 years | 1.39 (1.34 - 1.44) | <.001 | 1.39 (1.33 - 1.44) | <.001 | 1.39 (1.34 - 1.44) | <.001 |
| ≥ 35 years | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. |
| Weeks Gestation | 1.00 (0.99 - 1.00) | 0.009 | 1.00 (0.99 - 1.00) | 0.003 | 1.00 (0.99 - 1.00) | 0.003 |
| Race and Ethnicity | ||||||
| White | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. |
| Hispanic | 0.75 (0.72 - 0.78) | <.001 | 0.75 (0.72 - 0.78) | <.001 | 0.75 (0.72 - 0.78) | <.001 |
| Black | 1.83 (1.75 - 1.90) | <.001 | 1.83 (1.76 - 1.91) | <.001 | 1.83 (1.76 - 1.91) | <.001 |
| Asian | 0.24 (0.22 - 0.25) | <.001 | 0.24 (0.22 - 0.25) | <.001 | 0.24 (0.22 - 0.25) | <.001 |
| Another or unknown race | 1.04 (0.98 - 1.11) | 0.202 | 1.04 (0.98 - 1.10) | 0.225 | 1.04 (0.98 - 1.10) | 0.218 |
| Neighborhood Deprivation Index | ||||||
| 1st (least deprivation) | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. |
| 2nd | 1.25 (1.19 - 1.32) | <.001 | 1.25 (1.19 - 1.32) | <.001 | 1.25 (1.19 - 1.32) | <.001 |
| 3rd | 1.45 (1.38 - 1.53) | <.001 | 1.45 (1.38 - 1.52) | <.001 | 1.45 (1.38 - 1.53) | <.001 |
| 4th (most deprivation) | 1.61 (1.53 - 1.69) | <.001 | 1.61 (1.53 - 1.69) | <.001 | 1.61 (1.53 - 1.69) | <.001 |
| Insurance Type | ||||||
| Public vs. Private | 1.50 (1.45 - 1.54) | <.001 | 1.49 (1.45 - 1.54) | <.001 | 1.50 (1.45 - 1.54) | <.001 |
| Pregnancy Intention | ||||||
| Wanted | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. |
| Wanted, but not at time | 1.52 (1.46 - 1.58) | <.001 | 1.51 (1.46 - 1.57) | <.001 | 1.51 (1.46 - 1.57) | <.001 |
| Did not want | 1.60 (1.51 - 1.68) | <.001 | 1.60 (1.52 - 1.69) | <.001 | 1.60 (1.51 - 1.68) | <.001 |
| Unknown | 1.14 (1.09 - 1.19) | <.001 | 1.14 (1.09 - 1.19) | <.001 | 1.13 (1.08 - 1.18) | <.001 |
| Not asked | 0.97 (0.93 - 1.02) | 0.251 | 0.97 (0.93 - 1.02) | 0.220 | 0.97 (0.93 - 1.02) | 0.195 |
| Parity | ||||||
| 0 | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. |
| 1 | 0.85 (0.82 - 0.87) | <.001 | 0.85 (0.83 - 0.87) | <.001 | 0.85 (0.83 - 0.87) | <.001 |
| 2 or more | 0.82 (0.79 - 0.85) | <.001 | 0.82 (0.79 - 0.85) | <.001 | 0.82 (0.79 - 0.85) | <.001 |
| Cohabitation with… | ||||||
| Partner or baby's father | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. |
| Other family | 1.32 (1.27 - 1.38) | <.001 | 1.32 (1.27 - 1.38) | <.001 | 1.32 (1.27 - 1.37) | <.001 |
| Other | 1.51 (1.43 - 1.59) | <.001 | 1.50 (1.42 - 1.58) | <.001 | 1.50 (1.42 - 1.59) | <.001 |
| Unknown | 1.11 (1.01 - 1.23) | 0.027 | 1.11 (1.00 - 1.22) | 0.041 | 1.11 (1.00 - 1.22) | 0.040 |
| Depressive Symptoms | ||||||
| Moderate/Severe vs. None/Mild | 1.57 (1.52 - 1.62) | <.001 | 1.56 (1.51 - 1.60) | <.001 | 1.55 (1.50 - 1.60) | <.001 |
| Pregnancy Onset Year | 1.03 (1.03 - 1.04) | <.001 | 1.03 (1.03 - 1.04) | <.001 | 1.03 (1.03 - 1.04) | <.001 |
Notes: aPR = adjusted prevalence ratio. Modified Poisson models were adjusted for all characteristics in the table and accounted for multiple pregnancies per individual.
DISCUSSION
In this study utilizing a large, diverse sample of pregnant individuals, experiences of violence and unsafe/unstable living situations were positively associated with prenatal cannabis use. We did not find a significant relationship between current IPV experience and prenatal cannabis use; however, current IPV is difficult to screen for due to timing and patient comfortability or readiness to disclose.10 In our study, current IPV was commonly endorsed with experiences of prior violence and unsafe/unstable living situation, which aligns with prior research where previous experience of violence and housing instability is associated with IPV.4,14-16 Notably, IPV does not have to occur in a current relationship for its impacts to be current. Individuals may be experiencing current IPV from a former partner or need help with prior occurrences of violence as they may also influence their cannabis use.7,8,14
National estimates indicated a rise in prenatal cannabis use from 2002 to 2020, particularly in the first trimester (from 6.3% to 16.0%) compared to the second and third trimester (from about 2% to about 4.5% for each trimester).17 In our sample, the prevalence of prenatal cannabis use was lower than the national estimates. While our sample used data primarily from the first trimester, we also included pregnancies that were past 13 weeks. This could account for the difference between the prenatal cannabis prevalence we found and the national estimates for early pregnancy as the prevalence decreases over the prenatal period.
Addressing IPV, housing instability, and cannabis use among prenatal individuals is critical for patient health and safety. The American College of Obstetricians and Gynecologists recommends routine screening for IPV, housing instability, and cannabis use during pregnancy.18-20 Our study findings on the overlapping issues of current IPV and unsafe/unstable living situation highlight how often they can co-occur. Additionally, as IPV is one of the biggest contributors to homelessness among women,18 it is likely that a significant portion in our sample who reported unsafe/unstable living situations did not report their IPV experience. Therefore, those reporting unsafe/unstable living situations may be at significant risk for IPV. Even if patients do not disclose IPV, healthcare providers can share available IPV resources to all pregnant patients (e.g., mental health services, shelters, legal aid, advocacy groups), particularly those reporting past experiences of violence and unsafe/unstable living situations.
This cross-sectional study expanded on prior evidence by using a large, diverse, healthcare setting-based sample of pregnant individuals. However, the data were restricted to those who attended a prenatal visit, completed cannabis- and violence-related items on a universal questionnaire, and performed a cannabis urine toxicology test during pregnancy. These restrictions may contribute to selection bias that further underestimate the associations between violence and safety concerns and prenatal cannabis use, as those who are the most vulnerable may not be consistently engage in clinical care. Although we included alternatives to IPV to estimate associations between violence, safety, and cannabis use, patient responses may not reflect actual experiences (e.g., comfortability with disclosure), potentially leading to undercounting. Additionally, we were unable to include many pregnancies during the lockdown period of the COVID-19 pandemic in 2020 due to self-report cannabis use data limitations. This data issue could contribute to an underestimation of the association between IPV and cannabis use as another study demonstrated that an increase in IPV experiences among pregnant KPNC patients was associated with the beginning of the pandemic.21
Conclusions
Results from this large study with universal screening for prenatal cannabis use and exposure to IPV during pregnancy suggest that interventions assessing and addressing IPV and cannabis use concurrently among pregnant individuals are needed. The assessment of IPV during pregnancy should include the assessment of current safety and mental wellbeing to respond to dangers and stressors during the perinatal period. Interventions that incorporate education, advocacy, and connections to mental health and IPV services could help reduce cannabis use and recurrent violence and improve pregnancy-related outcomes and patient safety.
Highlights.
Past-year violence is associated with prenatal cannabis use
Current IPV often coincides with other types of violence and safety issues
Comprehensive interventions could improve pregnancy-related outcomes and wellbeing
Funding:
This study was supported by The Permanente Medical Group Delivery Science Fellowship Program and the National Institute on Drug Abuse (R01DA058201; K01DA043604). The funding organizations 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; or decision to submit the manuscript for publication. A portion of the data was obtained through the Kaiser Permanente Northern California Division of Research’s Perinatal Research Unit’s Perinatal Obstetric Database.
Footnotes
Declaration of conflicting interest: The authors declare no conflicts of interest.
Ethical approval statement: The Kaiser Permanente Northern California Institutional Review Board approved this study and waived informed consent.
Data availability statement:
The datasets generated during and/or analyzed during the current study are not publicly available due to potentially identifiable information (e.g., dates of diagnoses) and KPNC privacy regulations. They are available from the corresponding author upon reasonable request, and contingent on appropriate human subjects approval and data use agreements.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and/or analyzed during the current study are not publicly available due to potentially identifiable information (e.g., dates of diagnoses) and KPNC privacy regulations. They are available from the corresponding author upon reasonable request, and contingent on appropriate human subjects approval and data use agreements.