Traveling towards disease: transportation barriers to health care access

Treatment engagement in comorbid alcohol use disorder and alcohol-related liver disease: A qualitative exploration of barriers and facilitators with service users

BACKGROUND

Effective interventions to improve patient outcomes in comorbid alcohol use disorder (AUD) and alcohol-related liver disease (ARLD) remain a clinical unmet need. While the choice of abstinence is the cornerstone for the prevention of disease progression and mortality, evidence suggests a suboptimal engagement with treatment supporting recovery. This qualitative investigation aims to understand barriers and facilitators to treatment as experienced by this clinical population by applying a multidimensional adherence model proposed by the World Health Organization.

METHODS

Twenty-four participants with comorbid AUD and ARLD were recruited from an inpatient clinical setting. Data for this study were collected through semistructured, in-depth interviews. Deductive analysis was organized by the Framework method, and theory-driven themes were identified according to the multidimensional adherence model. This included factors across the social and economic, patient, condition, treatment, and healthcare system levels.

RESULTS

The findings in this study indicate systematic challenges in maintaining continuity between primary, secondary, and community care. Aspects related to social and economic context, treatment, and healthcare systems were found to hinder engagement. Identified facilitators to engagement included the participatory role of family, shared lived experience of addiction/recovery, and therapeutic alliance with healthcare providers.

CONCLUSION

The understanding of these barriers and facilitators from a service user's perspective can bridge the treatment gap for this clinical population. This can provide an opportunity for the implementation of effective interventions and inform the development of policies promoting accessible care. Government and public health bodies have fundamental roles in shifting treatment paradigms in comorbid AUD and ARLD.

Exploring adolescent-facing US clinicians' perceptions of their contraceptive counseling and use of shared decision-making: A qualitative study

BACKGROUND

Adolescent contraceptive decision-making is influenced by a number of patient and clinician-driven factors. Although the AAP continues to endorse an efficacy-based model of contraceptive counseling, many professional organizations are shifting to a shared decision-making model as the optimal approach for providing unbiased and patient-driven contraceptive counseling. While SDM is intended to reduce the influence of clinician bias, it can exacerbate inequity if a clinician tailors a conversation based on their assumptions of a patient's goals or preferences. In this qualitative study, we explored self-reported contraceptive counseling practices among US-based clinicians who see adolescent patients to assess how these practices create barriers or facilitators to SDM and person-centered contraceptive care.

METHODS

We interviewed 16 clinicians at the 2022 AAP Annual Meeting who counsel adolescent patients about contraception. We used thematic content analysis to analyze interview transcripts using Dedoose.

RESULTS

We identified six aspects of contraceptive counseling that clinicians commonly employed with adolescent patients. These were: (1) sociodemographic characteristics driving counseling, (2) reliance on tiered effectiveness counseling, (3) initiating counseling conversations using "ask then explain" or "explain then ask" approaches, (4) emphasis on teen pregnancy prevention, (5) the influence of method accessibility on counseling, and (6) parental involvement in decision-making and patient confidentiality. We describe how these themes align with or diverge from each component of the SDM framework.

CONCLUSION

Clinicians in this study frequently engaged in non-patient-centered techniques during contraceptive counseling with adolescents. These findings can inform practice recommendations to support clinicians in providing high-quality contraceptive counseling using shared decision-making.

"Hate has chipped away at my sense of security": A survey study of the impacts of anti-Asian hate on the health of older Asians

BACKGROUND

Since the beginning of the COVID-19 pandemic, older Asians have experienced a rise in racism and discrimination based on their race and ethnicity. This study examines how anti-Asian hate impacts older Asians' mental, social, and physical health.

METHODS

From March 18, 2022 to January 24, 2023, we conducted a cross-sectional survey study of community-dwelling Asian/Asian American adults aged ≥50 years from the San Francisco Bay Area. Measures included perceptions of anti-Asian hate; direct encounters with hate incidents; indirect experiences with hate incidents (e.g. knowing a friend who was a victim); reports of anxiety, depression, loneliness, and changes in daily activities; ways to address these issues; and discussions with clinicians about hate incidents.

RESULTS

Of the 293 older Asians, 158 (54%) were Vietnamese and 97 (33%) Chinese. Eighty-five (29%) participants were direct victims of anti-Asian hate, 112 (38%) reported anxiety, 105 (36%) reported depression, 161 (55%) reported loneliness, and 142 (48%) reported decreased daily activities. Compared with those who were "not-at-all" to "moderately" worried about hate incidents, participants who were "very" to "extremely" worried experienced heightened anxiety (42% versus 16%), loneliness (30% versus 14%), and changes in daily activities (66% versus 31%), p < 0.01 for all. Most participants (72%) felt comfortable discussing hate incidents with clinicians; however, only 31 (11%) reported that a clinician had talked with them about these incidents.

CONCLUSION

Both directly and indirectly, anti-Asian hate negatively impacts older Asians' mental, social, and physical health. Clinicians have a role in addressing the health impacts of anti-Asian hate.

Lung cancer statistics, 2023

Despite decades of declining mortality rates, lung cancer remains the leading cause of cancer death in the United States. This article examines lung cancer incidence, stage at diagnosis, survival, and mortality using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Over the past 5 years, declines in lung cancer mortality became considerably greater than declines in incidence among men (5.0% vs. 2.6% annually) and women (4.3% vs. 1.1% annually), reflecting absolute gains in 2-year relative survival of 1.4% annually. Improved outcomes likely reflect advances in treatment, increased access to care through the Patient Protection and Affordable Care Act, and earlier stage diagnosis; for example, compared with a 4.6% annual decrease for distant-stage disease incidence during 2013-2019, the rate for localized-stage disease rose by 3.6% annually. Localized disease incidence increased more steeply in states with the highest lung cancer screening prevalence (by 3%-5% annually) than in those with the lowest (by 1%-2% annually). Despite progress, disparities remain. For example, Native Americans have the highest incidence and the slowest decline (less than 1% annually among men and stagnant rates among women) of any group. In addition, mortality rates in Mississippi and Kentucky are two to three times higher than in most western states, largely because of elevated historic smoking prevalence that remains. Racial and geographic inequalities highlight longstanding opportunities for more concerted tobacco-control efforts targeted at high-risk populations, including improved access to smoking-cessation treatments and lung cancer screening, as well as state-of-the-art treatment.

Patient perception of group consultations for knee osteoarthritis and influence of area-level deprivation: A service evaluation in a physiotherapy musculoskeletal setting

INTRODUCTION

Group consultations are considered valuable for managing musculoskeletal (MSK) conditions. This service evaluation aimed to assess the perception of knee osteoarthritis (OA) patients regarding group consultations in NHS Lanarkshire's MSK service. It also explored the impact of area-level deprivation on patient engagement.

METHODS

Surveys were developed to gauge patient satisfaction, preferences, and experiences in virtual and face-to-face (FTF) group consultations. Patients were categorised into opt-out, did not attend (DNA), or opt-in groups. We used the Scottish Index of Multiple Deprivation for area-level deprivation analysis. Descriptive statistics were used for quantitative data, while qualitative data were thematically analysed.

RESULTS

A total of 84 patients participated, and area-level deprivation was similar across groups. Common engagement barriers included disinterest and transportation issues in opt-out and DNA groups, and IT problems in the DNA virtual group. Most patients expressed a preference for one-on-one consultations. FTF opt-in patients reported high satisfaction and increased confidence in managing their condition post-consultation. Virtual opt-in patients had a more neutral satisfaction level and mixed confidence. They were also less comfortable interacting with others during the consultation. Thematic analysis revealed positive experiences, and areas for improvement such as individual privacy concerns and additional resources.

CONCLUSION

Overall, patients were generally satisfied with group consultations for knee OA. The evaluation identified strategies to enhance engagement. Area-level deprivation did not significantly impact patient participation in group consultations.

Differences in time to patient access to innovative cancer medicines in six European countries

Patients across Europe face inequity regarding access to anticancer medicines. While access is typically evaluated through reimbursement status or sales data, patients can receive first access through early access programs (EAPs) or off-label use. This study aims to assess the time to patient access at the hospital level, considering different indications and countries. (Pre-)registered access to six innovative medicines (Olaparib, Niraparib, Ipilimumab, Osimeritinib, Nivolumab and Ibritunib) was measured using a cross-sectional survey. First patient access to medicines and indications were collected using the hospital databases. Nineteen hospitals from Hungary, Italy, the Netherlands, Belgium, Switzerland and France participated. Analysis showed that some hospitals achieved patient access before national reimbursement, primarily through EAPs. The average time from EMA-approval to patient access for these medicines was 2.1 years (Range: -0.9-7.1 years). Hospitals in Italy and France had faster access compared to Hungary and Belgium. Variation was also found within countries, with specialized hospitals (x̄: -0.9 years; SD: 2.0) more likely to provide patient access prior to national reimbursement than general hospitals (x̄: 0.4 years; SD: 2.9). Contextual differences were observed, with EAPs or off-label use being more prevalent in Switzerland than Hungary. Recent EMA-approved indications and drug combinations reached patients at a later stage. Substantial variation in patient access time was observed between and within countries. Improving pricing and reimbursement timelines, fostering collaboration between national health authorities and market authorization holders, and implementing nationally harmonized, data-generating EAPs can enhance timely and equitable patient access to innovative cancer treatments in Europe.

Transit and treatment: Aligning systems to address substance use in Connecticut

OBJECTIVE

Test hypotheses that proximity to new transit improves substance use disorder treatment provider cost efficiency (i.e., economies of scale and scope).

DATA SOURCES AND STUDY SETTING

Connecticut substance uses disorder treatment providers/programs. A 2015 rapid transit line opening with 10 stations, near some providers/programs. Providers' annual operating costs from publicly available federal tax forms (2013-2018). Annual client counts, service-type (including substance use disorder and/or mental health, among others), and location data, for 50 providers and their programs, from Department of Mental Health and Addiction Services, with an unbalanced panel of 285 provider-years.

STUDY DESIGN

Economies of scale occur when the percent change in operating costs is less than the percentage change in clients. Economies of scope occur when operating costs fall as providers treat clients with multiple service needs. With our quasi-experimental, multivariate regressions approach, we test hypotheses that proximity to a new transit line enhances economies of scale and scope (i.e., lowers unit operating costs).

DATA COLLECTION/EXTRACTION METHODS

Annual provider-level operating costs merged with new transit station locations and Department of Mental Health and Addiction Services program/provider-level secondary data (locations, client counts/completions/dates, service types, and average demographics).

PRINCIPAL FINDINGS

For providers with programs within 1-mile of new transit (compared with a "control" sample beyond 1-mile of new transit), (i) a 10% increase in clients leads to a 0.12% lower operating costs per client; (ii) a 10% increase in clients completing treatment results in a 1.5% decrease in operating costs per client; (iii) a 10% increase in clients receiving treatment for multiple services causes a 0.81% lower operating costs per client; (iv) offering multiple services leads to 6.3% lower operating costs.

CONCLUSIONS

New transit proximity causes operating cost savings for substance use disorder/mental health treatment providers. System alignment may benefit transit and health care sectors.

Travel-associated cost savings to patients and the health system through provision of specialist head and neck surgery outreach clinics in rural New South Wales, Australia

INTRODUCTION

Centralisation of head and neck surgical services means that patients in regional and remote Australia need to travel long distances for treatment and follow-up, imparting a significant financial burden on patients and the health system.

OBJECTIVE

To estimate costs of travel to local outreach clinics and determine potential cost savings to patients and the health system by avoiding patient travel to major cities for head and neck surgical care.

DESIGN

Retrospective audit of three head and neck surgery outreach clinics in New South Wales, Australia over 4 years (2017-2020). Direct costs of travel from a patient's residence to their local outreach clinic were estimated. Costs of travel and accommodation to Sydney for an appointment were calculated for different travel modes. Estimated reimbursements for travel through government support schemes were calculated based on published rates.

FINDINGS

Some 657 patients attended the three clinics, accounting for 1981 appointments. Depending on mode of travel, the estimated median cost of return travel (including accommodation) to Sydney was $379 to $739 per patient per trip and the median government reimbursement ranged from $182 to $279 per trip. In comparison, the cost of return travel by car to local outreach clinics ranged from $28 to $163 per appointment. Outreach clinics were estimated to save patients a median of $285 per trip and avoided government reimbursements of $215 per trip.

DISCUSSION

Despite uptake in telehealth, outreach medical services remain an important asset for people living in regional areas to address inequities in access. However, the cost benefits are likely to be underestimated as our approach did not account for indirect costs associated with travel.

CONCLUSION

Outreach head and neck surgical services located in regional areas can reduce the financial burden on both patients and the healthcare system. Greater investment in outreach clinics could ensure sustainability of services to promote equitable access to specialised surgical services.

Social determinants of health and US cancer screening interventions: A systematic review

There remains a need to synthesize linkages between social determinants of health (SDOH) and cancer screening to reduce persistent inequities contributing to the US cancer burden. The authors conducted a systematic review of US-based breast, cervical, colorectal, and lung cancer screening intervention studies to summarize how SDOH have been considered in interventions and relationships between SDOH and screening. Five databases were searched for peer-reviewed research articles published in English between 2010 and 2021. The Covidence software platform was used to screen articles and extract data using a standardized template. Data items included study and intervention characteristics, SDOH intervention components and measures, and screening outcomes. The findings were summarized using descriptive statistics and narratives. The review included 144 studies among diverse population groups. SDOH interventions increased screening rates overall by a median of 8.4 percentage points (interquartile interval, 1.8-18.8 percentage points). The objective of most interventions was to increase community demand (90.3%) and access (84.0%) to screening. SDOH interventions related to health care access and quality were most prevalent (227 unique intervention components). Other SDOH, including educational, social/community, environmental, and economic factors, were less common (90, 52, 21, and zero intervention components, respectively). Studies that included analyses of health policy, access to care, and lower costs yielded the largest proportions of favorable associations with screening outcomes. SDOH were predominantly measured at the individual level. This review describes how SDOH have been considered in the design and evaluation of cancer screening interventions and effect sizes for SDOH interventions. Findings may guide future intervention and implementation research aiming to reduce US screening inequities.

Racial disparities in cancer care, an eyeopener for developing better global cancer management strategies

BACKGROUND

In the last few decades, advancements in cancer research, both in the field of cancer diagnostics as well as treatment of the disease have been extensive and multidimensional. Increased availability of health care resources and growing awareness has resulted in the reduction of consumption of carcinogens such as tobacco; adopting various prophylactic measures; cancer testing on regular basis and improved targeted therapies have greatly reduced cancer mortality among populations, globally. However, this notable reduction in cancer mortality is discriminate and reflective of disparities between various ethnic populations and economic classes. Several factors contribute to this systemic inequity, at the level of diagnosis, cancer prognosis, therapeutics, and even point-of-care facilities.

RECENT FINDINGS

In this review, we have highlighted cancer health disparities among different populations around the globe. It encompasses social determinants such as status in society, poverty, education, diagnostic approaches including biomarkers and molecular testing, treatment as well as palliative care. Cancer treatment is an active area of constant progress and newer targeted treatments like immunotherapy, personalized treatment, and combinatorial therapies are emerging but these also show biases in their implementation in various sections of society. The involvement of populations in clinical trials and trial management is also a hotbed for racial discrimination. The immense progress in cancer management and its worldwide application needs a careful evaluation by identifying the biases in racial discrimination in healthcare facilities.

CONCLUSION

Our review gives a comprehensive evaluation of this global racial discrimination in cancer care and would be helpful in designing better strategies for cancer management and decreasing mortality.

Global rural health disparities in Alzheimer's disease and related dementias: State of the science

INTRODUCTION

Individuals living in rural communities are at heightened risk for Alzheimer's disease and related dementias (ADRD), which parallels other persistent place-based health disparities. Identifying multiple potentially modifiable risk factors specific to rural areas that contribute to ADRD is an essential first step in understanding the complex interplay between various barriers and facilitators.

METHODS

An interdisciplinary, international group of ADRD researchers convened to address the overarching question of: "What can be done to begin minimizing the rural health disparities that contribute uniquely to ADRD?" In this state of the science appraisal, we explore what is known about the biological, behavioral, sociocultural, and environmental influences on ADRD disparities in rural settings.

RESULTS

A range of individual, interpersonal, and community factors were identified, including strengths of rural residents in facilitating healthy aging lifestyle interventions.

DISCUSSION

A location dynamics model and ADRD-focused future directions are offered for guiding rural practitioners, researchers, and policymakers in mitigating rural disparities.

HIGHLIGHTS

Rural residents face heightened Alzheimer's disease and related dementia (ADRD) risks and burdens due to health disparities. Defining the unique rural barriers and facilitators to cognitive health yields insight. The strengths and resilience of rural residents can mitigate ADRD-related challenges. A novel "location dynamics" model guides assessment of rural-specific ADRD issues.

Evaluation of a pediatric dermatology electronic consult program in a rural state with subanalysis of infantile hemangioma cases

An electronic consultation (e-Consult) store-and-forward teledermatology program was implemented to improve access to dermatologic care in Maine. While initially designed to triage potential skin cancers, we found this program to be heavily used for pediatric patients, especially infants. Our findings suggest e-Consult expedites care for pediatric dermatology patients, particularly those with infantile hemangiomas. The addition of dermoscopy to e-Consult platforms has the potential to expand e-Consult effectiveness.

Travel experience and health service amongst older people from the perspective of social exclusion: Policy implications of alleviating transport deprivation

The vulnerable population are often faced with the transport deprivation resulting in social exclusion (e.g. lack of access to healthcare service or suffering from lower health service quality). The disparity in travel experience can lead to different results of healthcare service seeking amongst the vulnerable population such as older adults with and without disabilities. This study applies Heckman's two-stage procedure and the data from China Health and Retirement Longitudinal Study. Based on having controlled the influence of individual financial situation and self-rated health, results show that longer travel time is observed in older adults who have paid the visit to the higher class healthcare facilities (HHCF). Besides, the visit to HHCF is negatively associated with disability and positively with travel mode with less discomfort. Further, the relationship between disability and the class of visited healthcare facilities is found to be conditioned on the travel time and travel mode, wherein such relationship could be intensified by longer travel time and be alleviated by travel mode with less discomfort. Therefore, social policies to alleviate transport deprivation are critical for accessing better healthcare services amongst older people with disabilities.

Healthcare disparities for the development of airway stenosis from the medical intensive care unit

Objectives/hypothesis

Study design

Methods

Results

Conclusion

Level of evidence

The effect of a public transportation expansion on no-show appointments

OBJECTIVE

To test whether there were fewer missed medical appointments ("no-shows") for patients and clinics affected by a significant public transportation expansion.

STUDY SETTING

A new light rail line was opened in a major metropolitan area in June 2014. We obtained electronic health records data from an integrated health delivery system in the area with over three million appointments at 97 clinics between 2013 and 2016.

STUDY DESIGN

We used a difference-in-differences research design to compare whether no-show appointment rates differentially changed among patients and clinics located near versus far from the new light rail line after it opened. Models included fixed effects to account for underlying differences across clinics, patient zip codes, and time.

DATA EXTRACTION METHODS

We obtained data from an electronic health records system representing all appointments scheduled at 97 outpatient clinics in this system. We excluded same-day, urgent care, and canceled appointments.

PRINCIPAL FINDINGS

The probability of no-show visits differentially declined by 0.5 percentage points (95% confidence interval [CI]: -0.9 to -0.1), or 4.5% relative to baseline, for patients living near the new light rail compared to those living far from it, after the light rail opened. The effects were stronger among patients covered by Medicaid (-1.6 percentage points [95% CI: -2.4 to -0.8] or 9.5% relative to baseline).

CONCLUSIONS

Improvements to public transit may improve access to health care, especially for people with low incomes.

Physician versus Practice-Level Primary Care Continuity and Association with Outcomes in Medicare Beneficiaries

OBJECTIVE

To compare physician versus practice-level primary care continuity and their association with expenditure and acute care utilization among Medicare beneficiaries and evaluate if continuity of outpatient primary care at either/both physician or/and practice level could be useful quality measures.

DATA SOURCE

Medicare Fee-For-Service claims data for community dwelling beneficiaries without End-Stage Renal Disease who were attributed to a national random sample of primary care practices billing Medicare (2011-2017).

STUDY DESIGN

Retrospective secondary data analysis at per Medicare beneficiary per year level. We used multivariable linear regression with practice-level fixed effects to estimate continuity of care score at physician vs. practice level and their associations with outcomes.

DATA COLLECTION/EXTRACTION METHOD

We calculated clinician and practice level Bice-Boxerman continuity of care index scores, ranging from 0 to 1, using primary care outpatient claims. Medicare expenditures, hospital admissions, emergency department visits, and readmissions were obtained from the Medicare Beneficiary Summary File: Cost and Utilization Segment. Ambulatory care sensitive conditions (ACSC) were defined using diagnosis codes on inpatient claims.

PRINCIPAL FINDINGS

We studied 2,359,400 beneficiaries who sought care from 13,926 physicians. Every 0.1 increase in physician continuity score was associated with a $151 reduction in expenditures per beneficiary per year (P<0.01), and every 0.1 increase in practice continuity score was associated with $282 decrease (P<0.01) per beneficiary per year. Both physician- and practice-level continuity were associated with lower Medicare expenditures among small, medium, and large practices. Both physician- and practice-level continuity were associated with lower probabilities of hospitalization, emergency department visit, admissions for ACSC, and readmission.

CONCLUSIONS

Primary care continuity of care could serve as a potent value-based care quality metric. Physician-level continuity is a unique value center that cannot be supplanted by practice level continuity.