Traveling towards disease: transportation barriers to health care access

How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders?

BACKGROUND

Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown.

METHODS

Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share").

RESULTS

The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only.

CONCLUSIONS

Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.

A Case Series Study Assessing an Equity-Focused Implementation of Self-Monitoring Blood Pressure Programs Using Telehealth

CONTEXT

Self-monitoring blood pressure (SMBP) programs are an evidence-based hypertension management intervention facilitated through telehealth. SMBP programs can provide a continuum of care beyond a clinical setting by facilitating hypertension management at home; however, equitable access to SMBP is a concern.

OBJECTIVES

To evaluate the implementation of telehealth SMBP programs using an equity lens in 5 federally qualified health centers (FQHCs) in Massachusetts (MA).

DESIGN

A prospective case series study.

SETTING

Five FQHCs.

PARTICIPANTS

The MA Department of Public Health (MDPH) selected 5 FQHCs to implement SMBP programs using telehealth. FQHCs were selected if their patient population experiences inequities due to social determinants of health and has higher rates of cardiovascular disease. Each of the 5 FQHCs reported data on patients enrolled in their SMBP programs totaling 241 patients examined in this study.

INTERVENTION

SMBP programs implemented through telehealth.

MAIN OUTCOME MEASURE

Systolic blood pressure and diastolic blood pressure.

RESULTS

Approximately 53.5% of SMBP participants experienced a decrease in blood pressure. The average blood pressure decreased from 146/87 to 136/81 mm Hg. Among all patients across the 5 FQHCs, the average blood pressure decreased by 10.06/5.34 mm Hg (P < .001). Blood pressure improved in all racial, ethnic, and language subgroups.

CONCLUSIONS

Five MA FQHCs successfully implemented equitable telehealth SMBP programs. SMBP participants enrolled in the programs demonstrated notable improvements in their blood pressure at the conclusion of the program. A flexible, pragmatic study design that was adjusted to meet unique patient needs; engaging nonphysician team members, particularly community health workers; adapting health information technology; and partnerships with community-based organizations were critical facilitators to program success.

Travel Burden and Timely Linkage to Care Among People Newly Diagnosed with HIV Infection in South Carolina from 2005 to 2020

This retrospective study explored the association between travel burden and timely linkage to care (LTC) among people with HIV (PWH) in South Carolina. HIV care data were derived from statewide all-payer electronic health records, and timely LTC was defined as having at least one viral load or CD4 count record within 90 days after HIV diagnosis before the year 2015 and 30 days after 2015. Travel burden was measured by average driving time (in minutes) to any healthcare facility visited within six months before and one month after the initial HIV diagnosis. Multivariable logistic regression models with the least absolute shrinkage and selection operator were employed. From 2005 to 2020, 81.2% (3,547 out of 4,366) of PWH had timely LTC. Persons who had longer driving time (adjusted Odds Ratio (aOR): 0.37, 95% CI: 0.14-0.99), were male versus female (aOR: 0.73, 95% CI: 0.58-0.91), had more comorbidities (aOR: 0.73, 95% CI: 0.57-0.94), and lived in counties with a higher percentage of unemployed labor force (aOR: 0.21, 95% CI: 0.06-0.71) were less likely to have timely LTC. However, compared to those aged between 18 and 24 years old, those aged between 45 and 59 (aOR:1.47, 95% CI: 1.14-1.90) or older than 60 (aOR:1.71, 95% CI: 1.14-2.56) were more likely to have timely LTC. Concentrated and sustained interventions targeting underserved communities and the associated travel burden among newly diagnosed PWH who are younger, male, and have more comorbidities are needed to improve LTC and reduce health disparities.

Childcare needs as a barrier to healthcare among women in a safety-net health system

BACKGROUND

Childcare needs are an understudied social determinant of health. The effect of childcare needs on access to healthcare must be understood to inform health system interventions and policy reform. This study sought to characterize childcare needs, access to childcare, and prior experience with navigating childcare needs in healthcare settings among women in a safety-net population.

METHODS

We conducted a cross-sectional study of patient-reported survey data collected in-person between April and October 2019. Surveys were administered in waiting rooms of ambulatory services in a large, urban safety-net health system in Dallas, Texas. Survey respondents were derived from a random convenience sample of women waiting for outpatient appointments. Participants were screened for having children under the age of 13 and/or childcare responsibilities for inclusion in the sample. Outcomes of interest included self-reported delayed or missed care, reasons for delayed or missed care, perceived difficulty in accessing childcare, prior methods for managing childcare during healthcare appointments, and prior experience with childcare centers.

RESULTS

Among the 336 respondents (96.7% response rate), 121 (36.0%) reported delaying or missing a mean 3.7 appointments/year. Among women with delayed or missed care, 54.5% reported childcare barriers as the primary reason for deferral of care, greater than transportation (33%) or insurance (25%) barriers. Respondents rated childcare access as more difficult than healthcare access. Delayed or missed care due to childcare was more common among White (68.8%) and Black (55.0%) women compared to Hispanic women (34.3%). Common methods of navigating childcare needs during scheduled appointments included bringing children to appointments (69.1%) and re-scheduling or missing the scheduled appointment (43.0%). 40.6% of patients reported leaving an appointment before completion due to childcare needs.

CONCLUSIONS

Childcare needs are a leading barrier to healthcare among women accessing care in safety-net settings. Unmet childcare needs result in deferral of care, which may impact health outcomes. Childcare access is perceived as more challenging than healthcare access itself. Health system and policy interventions are needed to address childcare as a social determinant of health.

Pharmacist perceptions of delivering patient care through telehealth

PURPOSE

To evaluate pharmacists' perceptions of the benefits of and barriers to telehealth as experienced in actual telehealth visits with patients.

METHODS

This qualitative study used virtual focus groups and a validated questionnaire (the Health Optimum Telemedicine Acceptance [HOTA] survey) to assess telehealth facilitators and barriers. Participants were included if they were licensed pharmacists utilizing telehealth in the outpatient setting. Pharmacist focus group responses were transcribed and analyzed using Miles and Huberman's qualitative data analysis model.

RESULTS

Six pharmacists participated in this study. Their responses were placed into 2 categories: clinical effectiveness and patient experience. All participants had performed at least 20 virtual visits, and all agreed that telehealth improved patients' health status. Respondents agreed that telehealth results in more frequent patient interactions and allows for provision of multiple types of care virtually. However, technological difficulties and the inability to provide physical examinations and obtain laboratory values were identified limitations. The surveyed pharmacists agreed that the main benefit that patients gained from telehealth was the elimination of transportation concerns, allowing increased access to care. However, pharmacists voiced their concern for patient privacy and barriers to educating patients on proper use of medical devices.

CONCLUSION

Pharmacists felt that telehealth was useful in several clinical scenarios. However, they also identified opportunities to improve its development in clinical practice. Further investigation must be done to better grasp impediments to telehealth in order to provide the most effective patient care.

Use of telemedicine to obtain contraception among young adults: Inequities by health insurance

OBJECTIVES

The objective of this study was to describe the use of telemedicine for contraception in a sample of young adults and examine differences by health insurance coverage.

STUDY DESIGN

We analyzed survey data collected from May 2020 to July 2022 from individuals at risk of pregnancy aged 18 to 29 recruited at 29 community colleges in California and Texas. We used multivariable mixed-effects logistic regression models with random effects for site and individual to compare the use of telemedicine to obtain contraception by insurance status, sociodemographic characteristics, and state.

RESULTS

Our analytic sample included 6465 observations from 1630 individuals. Participants reported using a contraceptive method obtained through telemedicine in just 6% of observations. Uninsured participants were significantly less likely than those privately insured to use contraception obtained through telemedicine (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.31-0.97), as were participants who did not know their insurance status (aOR, 0.54; 95% CI, 0.29-0.99). Texas participants were less likely to use contraception obtained via telemedicine than those in California (aOR, 0.42; CI: 0.25-0.69).

CONCLUSIONS

Few young people in this study obtained contraception through telemedicine, and insurance was crucial for access in both states.

IMPLICATIONS

Although telemedicine holds promise for increasing contraceptive access, we found that few young adults were using it, particularly among the uninsured. Efforts are needed to improve young adults' access to telemedicine for contraception and address insurance disparities.

Black-White Disparities in Asthma Hospitalizations and ED Visits Among Medicaid-Enrolled Children

BACKGROUND AND OBJECTIVES

Asthma is a common, potentially serious childhood chronic condition that disproportionately afflicts Black children. Hospitalizations and emergency department (ED) visits for asthma can often be prevented. Nearly half of children with asthma are covered by Medicaid, which should facilitate access to care to manage and treat symptoms. We provide new evidence on racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children.

METHODS

We used comprehensive Medicaid claims data from the Transformed Medicaid Statistical Information System. Our study population included 279 985 Medicaid-enrolled children with diagnosed asthma. We identified asthma hospitalizations and ED visits occurring in 2019. We estimated differences in the odds of asthma hospitalizations and ED visits for non-Hispanic Black versus non-Hispanic white children, adjusting for sex, age, Medicaid eligibility group, Medicaid plan type, state, and rurality.

RESULTS

In 2019, among Black children with asthma, 1.2% had an asthma hospitalization and 8.0% had an asthma ED visit compared with 0.5% and 3.4% of white children with a hospitalization and ED visit, respectively. After adjusting for other characteristics, the rates for Black children were more than twice the rates for white children (hospitalization adjusted odds ratio 2.45, 95% confidence interval 2.23-2.69; ED adjusted odds ratio 2.42; 95% confidence interval 2.33-2.51).

CONCLUSIONS

There are stark racial disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children with asthma. To diminish these disparities, it will be important to implement solutions that address poor quality care, discriminatory treatment in health care settings, and the structural factors that disproportionately expose Black children to asthma triggers and access barriers.

Age of Robotic Surgery and Telemedicine: Is Pakistan Lagging Behind?

Robotic surgery and telemedicine have revolutionized the healthcare industry, offering improved patient outcomes and access to medical knowledge. However, Pakistan lags behind in adopting these cutting-edge technologies due to several challenges, including limited infrastructure, budget constraints, and low awareness among patients and healthcare professionals. This article provides an in-depth analysis of the current state of the healthcare system in Pakistan, highlighting the need for investment and policy reforms to integrate robotic surgery and telemedicine effectively. The potential benefits, including medical tourism, enhanced facilities, and skilled workforce retention, are discussed as incentives for the government to embrace digital medicine and bridge the healthcare gap. Through increased awareness, training programs, and collaborations with other nations, Pakistan can pave the way for a digitally empowered healthcare future.

An exploration of barriers to access to healthcare in Hancock County, Tennessee: A qualitative study

OBJECTIVE

Explore barriers to healthcare access in Hancock County, Tennessee using a conceptual framework for access to healthcare.

METHODS

We collected data from 30 participants in Hancock County during 1 week in April 2023 using a combination of network and purposive sampling. We analyzed the data using thematic analysis and the conceptual framework of healthcare access.

RESULTS

All dimensions of the conceptual framework of healthcare access presented barriers to healthcare access for participants of the study. A lack of acceptability of local healthcare among participants manifested in a perceived lack of availability of healthcare. This resulted in participants travelling or considering it necessary to travel long distances for care, even in a life-threatening emergency, despite the local availability of a hospital with an emergency department.

CONCLUSIONS

A lack of acceptability can create healthcare access barriers similar to a lack of availability of healthcare facilities.

PATIENT OR PUBLIC CONTRIBUTION

The research team met several times with the leader of a local community organization to discuss this research in Hancock County. These conversations helped to inform the study design and provided necessary background to conduct in-depth interviews. Members of the community organization helped identify individuals to interview and provide access to Remote Area Medical clinic patients. The research team discussed the final themes with the primary community collaborator.

Revising the Logic Model Behind Health Care's Social Care Investments

Policy Points This article summarizes recent evidence on how increased awareness of patients' social conditions in the health care sector may influence health and health care utilization outcomes. Using this evidence, we propose a more expansive logic model to explain the impacts of social care programs and inform future social care program investments and evaluations.

Barriers to Adopting Healthy Lifestyle and Health Promotion among Ethnic Minority Bedouin Women in Southern Israel: A Qualitative Study

BACKGROUND

A healthy lifestyle is a crucial step in disease prevention and management, as well as a significant predictor of health promotion. Yet, despite an increase in chronic morbidity among Bedouin women in southern Israel, little research has been conducted on their health behaviors. Therefore, the aim of this study is to examine barriers to adopting a healthy lifestyle and health promotion among ethnic minority Bedouin women in southern Israel.

METHODS

This qualitative study was based on data collected through focus groups during June and July 2021. Participants included 44 Bedouin women aged 18-55. Focus groups were recorded and transcribed. Transcriptions were thematically analyzed and coded using the ecological model.

RESULTS

We found multiple barriers at various levels that prevent Bedouin women from adopting a healthy lifestyle and health promotion. At the individual level, such factors included the impact of financial limitations on healthful nutrition, as well as a lack of awareness or knowledge regarding healthy lifestyle and health promotion. At the organizational level, barriers include a lack of clinics, accessibility, and availability of health services and cultural incompatibility of the health services. At the community level, impediments to a healthy lifestyle include inaccessibility to sports facilities and suppression of physical activity. At the public policy level, participants, especially those living in unrecognized villages, described difficult living conditions related to environmental and social neglect as affecting their health status and ability to maintain a healthy lifestyle.

CONCLUSION

Study findings emphasize the need for policymaking and a systemic approach to address health disparities and ensure equal health promotion for the Bedouin population.

Impact of early primary care physician follow-up on hospital readmission following gastrointestinal cancer surgery

BACKGROUND

We sought to examine the association between primary care physician (PCP) follow-up on readmission following gastrointestinal (GI) cancer surgery.

METHODS

Patients who underwent surgery for GI cancer were identified using the Surveillance, Epidemiology and End Results (SEER) database. Multivariable regression was performed to examine the association between early PCP follow-up and hospital readmission.

RESULTS

Among 60 957 patients who underwent GI cancer surgery, 19 661 (32.7%) visited a PCP within 30-days after discharge. Of note, patients who visited PCP were less likely to be readmitted within 90 days (PCP visit: 17.4% vs. no PCP visit: 28.2%; p < 0.001). Median postsurgical expenditures were lower among patients who visited a PCP (PCP visit: $4116 [IQR: $670-$13 860] vs. no PCP visit: $6700 [IQR: $870-$21 301]; p < 0.001). On multivariable analysis, PCP follow-up was associated with lower odds of 90-day readmission (OR: 0.52, 95% CI: 0.50-0.55) (both p < 0.001). Moreover, patients who followed up with a PCP had lower risk of death at 90-days (HR: 0.50, 95% CI: 0.40-0.51; p < 0.001).

CONCLUSION

PCP follow-up was associated with a reduced risk of readmission and mortality following GI cancer surgery. Care coordination across in-hospital and community-based health platforms is critical to achieve optimal outcomes for patients.

Social Medical Insurances, Choices of Medical Institutions and the 'Siphon Effect' in the Health Service Market: Evidence from 2021 Yangtze River Delta Region of China

Purpose

The siphon effect in the health service market is notably pronounced in many countries. How to measure and identify the determinants contributing to the siphon effect presents a substantial challenge. This study aimed to analyse the effect of two different social medical insurances, the Basic Medical Insurance System for Urban Employees (BMISUE), and the Basic Medical Insurance System for Urban and Rural Residents (BMISURR), on the siphon effect in the health services market.

Methods

The data used in this study were from the 2021 Health Life Satisfaction Survey of Yangtze River Delta (HLSSYRD) conducted by Shanghai Jiao Tong University. The logistic model was used to evaluate the association between social medical insurances and individual choices of medical institutions, and the Propensity Score Matching method (PSM) was used to check the robustness of basic results.

Results

Residents covered by BMISUE were more likely to choose a general hospital when they first sought medical treatment (OR = 5.377, 95% CI: 4.887, 5.915) relative to those insured by BMISURR. Further analysis showed that BMISUE would accelerate the siphon effect of general hospitals, people insured by BMISUE were still more likely to choose general hospitals despite being close to primary hospitals compared to those insured by BMISURR (OR = 3.240, 95% CI: 2.945, 3.565). Heterogeneity analysis indicated BMISUE had a greater impact on residents aged 15-59 years and those with high income compared to older people and individuals with low income.

Conclusion

Different social medical insurances can substantially affect residents' first choice of medical institutions. BMISUE with higher benefits level could exacerbate the siphon effect in the health service market. More equitable medical security system should be strengthened to bridge the benefits gap between BMISUE and BMISURR.

Integrating Virtual Mindfulness-Based Stress Reduction Into Inflammatory Bowel Disease Care: Mixed Methods Feasibility Trial

BACKGROUND

Individuals with inflammatory bowel disease (IBD) experience cycles of aggressive physical symptoms including abdominal pain, diarrhea, and fatigue. These acute symptoms regress and return, and chronic symptoms and complications often linger. The nature of the disease can also cause individuals to experience psychological distress including symptoms of anxiety and depression; however, unlike the physical symptoms of IBD, these psychological symptoms often remain untreated.

OBJECTIVE

This study aims to evaluate the feasibility, acceptability, and effectiveness of virtual mindfulness-based stress reduction (v-MBSR) for adults with IBD.

METHODS

IBD patients with self-reported anxiety or depression were recruited from clinics in Alberta, Canada to participate in an 8-week v-MSBR intervention. Eligible patients participated in v-MBSR delivered by psychiatrists using a videoconferencing platform. Primary feasibility outcomes included trial uptake, adherence, attendance, and attrition rates. Secondary effectiveness outcomes included measures of anxiety, depression, quality of life (QoL), and mindfulness. Effectiveness data were collected at 3 time points: baseline, at intervention completion, and 6 months after completion. To further assess feasibility and acceptability, participants were invited to participate in a semistructured interview after completing v-MBSR.

RESULTS

A total of 16 of the 64 (25%) referred patients agreed to participate in v-MBSR with the most common reason for decline being a lack of time while 7 of the 16 (43.8%) participants completed the program and experienced encouraging effects including decreased anxiety and depression symptoms and increased health-related QoL with both improvements persisting at 6-month follow-up. Participants described improved coping strategies and disease management techniques as benefits of v-MBSR.

CONCLUSIONS

Patients with IBD were interested in a psychiatrist-led virtual anxiety management intervention, but results demonstrate v-MBSR may be too time intensive for some patients with IBD patients. v-MBSR was acceptable to those who completed the intervention, and improvements to anxiety, depression, and QoL were promising and sustainable. Future studies should attempt to characterize the patients with IBD who may benefit most from interventions like v-MBSR.

The accessibility of pharmacist prescribing and impacts on medicines access: A systematic review

BACKGROUND

Pharmacist prescribing has been introduced in several countries as a strategy to improve access to health care and medicines. However, the direct impacts of pharmacist prescribing on medicines access, and the overall accessibility of pharmacist prescribing services, are not well known.

OBJECTIVES

This systematic review aimed to assess the direct impacts of pharmacist prescribing on medicines access, and the accessibility of pharmacist prescribing services, in community and primary care settings.

METHODS

PubMed, Embase, and CINAHL were searched for studies published in English between 01 January 2003 to 15 June 2023. Both quantitative and qualitative primary studies were included if they described pharmacist prescribing in a primary care setting. Outcomes included findings related to access to medicines as a result of pharmacist prescribing (primary outcome), and access to pharmacist prescribing services overall (secondary outcome). Narrative synthesis of outcomes was undertaken.

RESULTS

A total of 47 studies were included from four countries (United States, United Kingdom, Canada, New Zealand). Thirteen studies provided evidence that pharmacist prescribing may improve medicines access in several ways, including: increasing the proportion of eligible people receiving medicines, increasing the number of overall dispensed prescriptions, or reducing time to receipt of treatment. The remainder of the included studies reported on the accessibility of pharmacist prescribing services. Published studies highlight that pharmacist prescribers practicing in community settings are generally accessible, with pharmacist prescribers viewed by patients as easy and convenient to consult. There was limited evidence about the affordability of pharmacy prescribing services, and a number of potential equity issues were observed, including reduced access to pharmacist prescribers in more socioeconomically disadvantaged areas and those with greater proportions of populations at risk of health inequities, such as culturally and linguistically diverse communities.

CONCLUSIONS

This systematic review found that pharmacist prescribing services were both highly accessible and beneficial in improving access to medicines. However, measures of medicines access varied, and few studies included direct measures of medicines access as an outcome of pharmacist prescribing, highlighting a need for future studies to incorporate direct measures of medicines access when assessing the impact of pharmacist prescribing services.

Association of COVID-19 Pandemic with Colorectal Cancer Screening: Impact of Race/Ethnicity and Social Vulnerability

BACKGROUND

The COVID-19 pandemic disrupted health care delivery, including cancer screening practices. This study sought to determine the impact of the COVID-19 pandemic lockdown on colorectal cancer (CRC) screening relative to social vulnerability.

METHODS

Using the Medicare Standard Analytic File, individuals 65 years old or older who were eligible for guideline-concordant CRC screening between 2019 and 2021 were identified. These data were merged with the Center for Disease Control Social Vulnerability Index (SVI) dataset. Changes in county-level monthly screening volumes relative to the start of the COVID-19 pandemic (March 2020) and easing of restrictions (March 2021) were assessed relative to SVI.

RESULTS

Among 10,503,180 individuals continuously enrolled in Medicare with no prior diagnosis of CRC, 1,362,457 (12.97%) underwent CRC screening between 2019 and 2021. With the COVID-19 pandemic, CRC screening decreased markedly across the United States (median monthly screening: pre-pandemic [n = 76,444] vs pandemic era [n = 60,826]; median Δn = 15,618; p < 0.001). The 1-year post-pandemic overall CRC screening utilization generally rebounded to pre-COVID-19 levels (monthly median screening volumes: pandemic era [n = 60,826] vs post-pandemic [n = 74,170]; median Δn = 13,344; p < 0.001). Individuals residing in counties with the highest SVI experienced a larger decline in CRC screening odds than individuals residing in low-SVI counties (reference, low SVI: pre-pandemic high SVI [OR, 0.85] vs pandemic high SVI [OR, 0.81] vs post-pandemic high SVI [OR, 0.85]; all p < 0.001).

CONCLUSIONS

The COVID-19 pandemic was associated with a decrease in CRC screening volumes. Patients who resided in high social vulnerability areas experienced the greatest pandemic-related decline.

Local government spending and mental health: Untangling the impacts using a dynamic modelling approach

This study investigated the impact of local government spending on mental health in England between 2013 and 2019. Guided by the "Health in All Policies" vision, which encourages the integration of health in all decision-making areas, we explored how healthcare and multiple nonmedical budgeting decisions related to population mental health. We used random curve general cross-lagged modelling to dynamically partition effects into the short-run (from t to t + 1) and long-run (from t to t + 2) impacts, account for unobserved area-level heterogeneity and reverse causality from health outcomes to financial investments, and comprehensive modelling of budget items as an interconnected system. Our findings revealed that spending in adult social care, healthcare, and law & order predicted long-term mental health gains (0.004-0.081 SDs increase for each additional 10% in expenditure). However, these sectors exhibited negative short-term impulses (0.012-0.077 SDs decrease for each additional 10% in expenditure), markedly offsetting the long-term gains. In turn, infrastructural and environmental spending related to short-run mental health gains (0.005-0.031 SDs increase for each additional 10% in expenditure), while the long-run effects were predominantly negative (0.005-0.028 SDs decrease for each additional 10% in expenditure). The frequent occurrence of short-run and long-run negative links suggested that government resources may not be effectively reaching the areas that are most in need. In the short-term, negative effects could also imply temporary disruptions to service delivery largely uncompensated by later mental health improvements. Nonetheless, some non-health spending policies, such as law & order and infrastructure, can be related to long-lasting positive mental health impacts.

Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the heart team

BACKGROUND

Rural patients face known healthcare disparities and worse cardiovascular outcomes compared to urban residents due to inequitable access and delayed care. Few studies have assessed rural-urban differences in outcomes following Transcatheter Aortic Valve Implantation (TAVI). We compared short-term post-TAVI outcomes between rural and urban patients.

METHODS

We performed a retrospective analysis of n = 413 patients who underwent TAVI at our large academic medical center, between 2011 and 2020 (rural/urban patients = 93/320. Rural/urban males = 53/173). Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes included stroke/transient ischemic attack, myocardial infarction, atrial fibrillation, acute kidney injury, bleeding, vascular complications, and length of stay.

RESULTS

The mean age in years was 77 [IQR 70-82] for rural patients and 78 [IQR 72-84] for urban patients. Baseline characteristics were similar between groups, except for a greater frequency of active smokers and diabetics as well as a greater body mass index in the rural group. There were no statistically significant differences in all-cause or cardiovascular mortality between the groups. There was also no statistically significant difference in secondary outcomes.

CONCLUSION

Rural and urban patients had no statistically significant difference in all-cause mortality or cardiovascular mortality following TAVI. Given its minimally invasive nature and quality-centric, multidisciplinary care provided by the TAVI Heart Teams, TAVI may be the preferred modality for the treatment of severe aortic stenosis in rural populations.

Ready for Discharge, but Are They Ready to Go Home? Examining Neighborhood-Level Disadvantage as a Marker of the Social Exposome and the Swallowing Care Process in a Retrospective Cohort of Inpatients With Dementia

PURPOSE

Socioeconomically disadvantaged areas are more resource poor, impacting adherence to swallowing care recommendations. Neighborhood-level disadvantage metrics, such as the Area Deprivation Index (ADI), allow for examination of social determinants of health (SDOH) in a precise region. We examined ADI in a cohort of persons living with dementia (PLWD) to determine representation of those residing in areas of socioeconomic disadvantage (high ADI), distribution of swallowing care provided, and frequency of SDOH-related counseling or resource linking prior to discharge.

METHOD

A retrospective chart abstraction was performed for all inpatients with a diagnosis of dementia (N = 204) seen by the Swallow Service at a large academic hospital in 2014. State ADI Deciles 1 (least) to 10 (most socioeconomic disadvantage) and decile groups (1-3, 4-7, and 8-10) were compared with the surrounding county. Frequency of videofluoroscopic swallowing evaluations (VFSEs) based on ADI deciles was recorded. To determine whether SDOH-related counseling or resource linking occurred for those in high ADI (8-10) neighborhoods, speech-language pathology notes, and discharge summaries were reviewed. Descriptive statistics, independent samples t tests, and one-way analysis of variance were calculated.

RESULTS

ADI was significantly higher in this cohort (M = 3.84, SD = 2.58) than in the surrounding county (M = 2.79, SD = 1.88, p = .000). There was no significant difference in utilization of swallowing services across decile groups (p = .88). Although the majority (85%) in high ADI areas was recommended diet modifications or alternative nutrition likely requiring extra resources, there was no documentation indicating that additional SDOH resource linking or counseling was provided.

CONCLUSIONS

These findings raise important questions about the role and responsibility of speech-language pathologists in tailoring swallowing services to challenges posed by the lived environment, particularly in socioeconomically disadvantaged areas. This underscores the need for further research to understand and address gaps in postdischarge support for PLWD in high-ADI regions and advocate for more equitable provision of swallowing care.

Impact of Insurance Type on Access to Pediatric Surgical Care

Background

This study aimed to measure the impact of insurance type on access to pediatric surgical care, clinical and surgical scheduling decisions, provider-driven cancelations, and missed care opportunities (MCOs). We hypothesize that patients with public health insurance experience longer scheduling delays and more frequently canceled surgical appointments compared with patients with private health insurance.

Methods

This retrospective study reviewed the demographics and clinical characteristics of patients who underwent a surgical procedure within the plastic and oral surgery department at our institution in 2019. Propensity score matching and linear regressions were used to estimate the effect of insurance type on hospital scheduling and patient access outcomes while controlling for procedure type and sex.

Results

A total of 457 patients were included in the demographic and clinical characteristics analyses; 354 were included in propensity score matching analyses. No significant differences in the number of days between scheduling and occurrence of initial consultation or number of clinic cancelations were observed between insurance groups (P > 0.05). However, patients with public insurance had a 7.4 times higher hospital MCO rate (95% CI [5.2-9.7]; P < 0.001) and 4.7 times the number of clinic MCOs (P = 0.007).

Conclusions

No significant differences were found between insurance groups in timely access to surgical treatment or cancelations. Patients with public insurance had more MCOs than patients with private insurance. Future research should investigate how to remove barriers that impact access to care for marginalized patients.

Barriers and facilitators for the implementation and expansion of outpatient parenteral antimicrobial therapy: a systematic review

Outpatient parenteral antimicrobial therapy (OPAT) has been expanding in recent years and serves as a viable solution in reducing the shortage of hospital beds. However, the wider implementation of OPAT faces numerous challenges. This review aimed to assess implementation barriers and facilitators of OPAT services. Studies describing barriers and facilitators of the OPAT service were retrieved from PubMed, Scopus, MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science Proceedings, International Pharmaceutical Abstracts and PsycINFO. All types of study designs published in the English language were included. Studies that did not mention any barrier or facilitator, did not differentiate OPAT and inpatient, focused on specific antimicrobials or diseases, and made no distinction between parenteral and other treatments were excluded. Qualitative analysis was performed using the 'best-fit' framework approach and the Consolidated Framework for Implementation Research (CFIR). The review was PROSPERO registered (CRD42023441083). A total of 8761 studies were screened for eligibility and 147 studies were included. Problems in patient selection, lack of awareness, poor communication and co-ordination, lack of support, lack of structured service and inappropriate prescriptions were identified. OPAT provides safe, effective and efficient treatment while maintaining patients' privacy and comfort, resulting in less daily life disruption, and reducing the risk of infection. Satisfaction and preference for OPAT were very high. Initiatives in strengthening OPAT such as antimicrobial stewardship and telemedicine are beneficial. Challenges to and facilitators of OPAT were identified among patients, health professionals, OPAT service providers and healthcare administrators. Understanding them is crucial to designing targeted initiatives for successful OPAT service implementation.

Assessment of Social Vulnerabilities of Care and Prognosis in Adult Ocular Melanomas in the US

BACKGROUND

Prior works have studied the impact of social determinants on various cancers but there is limited analysis on eye-orbit cancers. Current literature tends to focus on socioeconomic status and race, with sparse analysis of interdisciplinary contributions. We examined social determinants as measured by the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), quantifying eye and orbit melanoma disparities across the United States.

METHODS

A retrospective review of 15,157 patients diagnosed with eye-orbit cancers in the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2017 was performed, extracting 6139 ocular melanomas. SVI scores were abstracted and matched to SEER patient data, with scores generated by weighted averages per population density of county's census tracts. Primary outcome was months survived, while secondary outcomes were advanced staging, high grading, and primary surgery receipt.

RESULTS

With increased total SVI score, indicating more vulnerability, we observed significant decreases of 23.1% in months survival for melanoma histology (p < 0.001) and 19.6-39.7% by primary site. Increasing total SVI showed increased odds of higher grading (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.02-1.43) and decreased odds of surgical intervention (OR 0.94, 95% CI 0.92-0.96). Of the four themes, higher magnitude contributions were observed with socioeconomic status (26.0%) and housing transportation (14.4%), while lesser magnitude contributions were observed with minority language status (13.5%) and household composition (9.0%).

CONCLUSIONS

Increasing social vulnerability, as measured by the CDC SVI and its subscores, displayed significant detrimental trends in prognostic and treatment factors for adult eye-orbit melanoma. Subscores quantified which social determinants contributed most to disparities. This lays groundwork for providers to target the highest-impact social determinant for non-clinical factors in patient care.

Assessing Time to Removal of Tunneled Dialysis Catheters after Arteriovenous Access Creation

BACKGROUND

Tunneled dialysis catheters (TDCs) are a temporary bridge until definitive arteriovenous (AV) access is established. Our objective was to evaluate the time to TDC removal in patients who underwent AV access creations with TDCs already in place.

METHODS

A single-center analysis of all AV access creations in patients with TDCs was performed (2014-2020). Primary outcome was time to TDC removal after access creation.

RESULTS

There were 364 AV access creations with TDCs in place. The average age was 58 years, 44% of patients were female, and 64% were Black. The median time to TDC removal was 113 days (range, 22-931 days) with 71.4% having a TDC >90 days after access creation. Patients with TDC >90 days were often older (60 vs. 54.7), had hypertension (98.1% vs. 93.3%), were diabetic (65.4% vs. 47.1%), and had longer average time to maturation (107.1 vs. 55.4 days, P < 0.001) and first access (114 vs. 59.4 days, P < 0.001). Multivariable analysis showed that older age was associated with prolonged TDC placement (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005) and prosthetic graft use was associated with shorter TDC indwelling time (OR 0.09, 95% CI 0.04-0.23, P ≤ 0.001). Kaplan-Meier analysis showed that 87% of TDCs were removed at 1 year.

CONCLUSIONS

The majority of patients with TDCs who underwent AV access creation had prolonged TDC placement. Prosthetic graft use was associated with shorter catheter times. Close follow-up after access placement, improving maturation times, and access type selection should be considered to shortened TDC times.

Identifying barriers to outpatient appointment attendance in patient groups at risk of inequity: a mixed methods study in a London NHS trust

BACKGROUND

There is significant health inequity in the United Kingdom (U.K.), with different populations facing challenges accessing health services, which can impact health outcomes. At one London National Health Service (NHS) Trust, data showed that patients from deprived areas and minority ethnic groups had a higher likelihood of missing their first outpatient appointment. This study's objectives were to understand barriers to specific patient populations attending first outpatient appointments, explore systemic factors and assess appointment awareness.

METHODS

Five high-volume specialties identified as having inequitable access based on ethnicity and deprivation were selected as the study setting. Mixed methods were employed to understand barriers to outpatient attendance, including qualitative semi-structured interviews with patients and staff, observations of staff workflows and interrogation of quantitative data on appointment communication. To identify barriers, semi-structured interviews were conducted with patients who missed their appointment and were from a minority ethnic group or deprived area. Staff interviews and observations were carried out to further understand attendance barriers. Patient interview data were analysed using inductive thematic analysis to create a thematic framework and triangulated with staff data. Subthemes were mapped onto a behavioural science framework highlighting behaviours that could be targeted. Quantitative data from patient interviews were analysed to assess appointment awareness and communication.

RESULTS

Twenty-six patients and 11 staff were interviewed, with four staff observed. Seven themes were identified as barriers - communication factors, communication methods, healthcare system, system errors, transport, appointment, and personal factors. Knowledge about appointments was an important identified behaviour, supported by eight out of 26 patients answering that they were unaware of their missed appointment. Environmental context and resources were other strongly represented behavioural factors, highlighting systemic barriers that prevent attendance.

CONCLUSION

This study showed the barriers preventing patients from minority ethnic groups or living in deprived areas from attending their outpatient appointment. These barriers included communication factors, communication methods, healthcare the system, system errors, transport, appointment, and personal factors. Healthcare services should acknowledge this and work with public members from these communities to co-design solutions supporting attendance. Our work provides a basis for future intervention design, informed by behavioural science and community involvement.

Characterizing Technology Use and Preferences for Health Communication in South Asian Immigrants With Prediabetes or Diabetes: Cross-Sectional Descriptive Study

BACKGROUND

Type 2 diabetes disproportionately affects South Asian subgroups. Lifestyle prevention programs help prevent and manage diabetes; however, there is a need to tailor these programs for mobile health (mHealth).

OBJECTIVE

This study examined technology access, current use, and preferences for health communication among South Asian immigrants diagnosed with or at risk for diabetes, overall and by sex. We examined factors associated with interest in receiving diabetes information by (1) text message, (2) online (videos, voice notes, online forums), and (3) none or skipped, adjusting for sociodemographic characteristics and technology access.

METHODS

We used baseline data collected in 2019-2021 from two clinical trials among South Asian immigrants in New York City (NYC), with one trial focused on diabetes prevention and the other focused on diabetes management. Descriptive statistics were used to examine overall and sex-stratified impacts of sociodemographics on technology use. Overall logistic regression was used to examine the preference for diabetes information by text message, online (videos, voice notes, or forums), and no interest/skipped response.

RESULTS

The overall sample (N=816) had a mean age of 51.8 years (SD 11.0), and was mostly female (462/816, 56.6%), married (756/816, 92.6%), with below high school education (476/816, 58.3%) and limited English proficiency (731/816, 89.6%). Most participants had a smartphone (611/816, 74.9%) and reported interest in receiving diabetes information via text message (609/816, 74.6%). Compared to male participants, female participants were significantly less likely to own smartphones (317/462, 68.6% vs 294/354, 83.1%) or use social media apps (Viber: 102/462, 22.1% vs 111/354, 31.4%; WhatsApp: 279/462, 60.4% vs 255/354, 72.0%; Facebook: Messenger 72/462, 15.6% vs 150/354, 42.4%). A preference for receiving diabetes information via text messaging was associated with male sex (adjusted odds ratio [AOR] 1.63, 95% CI 1.01-2.55; P=.04), current unemployment (AOR 1.62, 95% CI 1.03-2.53; P=.04), above high school education (AOR 2.17, 95% CI 1.41-3.32; P<.001), and owning a smart device (AOR 3.35, 95% CI 2.17-5.18; P<.001). A preference for videos, voice notes, or online forums was associated with male sex (AOR 2.38, 95% CI 1.59-3.57; P<.001) and ownership of a smart device (AOR 5.19, 95% CI 2.83-9.51; P<.001). No interest/skipping the question was associated with female sex (AOR 2.66, 95% CI 1.55-4.56; P<.001), high school education or below (AOR 2.02, 95% CI 1.22-3.36; P=.01), not being married (AOR 2.26, 95% CI 1.13-4.52; P=.02), current employment (AOR 1.96, 95% CI 1.18-3.29; P=.01), and not owning a smart device (AOR 2.06, 95% CI 2.06-5.44; P<.001).

CONCLUSIONS

Technology access and social media usage were moderately high in primarily low-income South Asian immigrants in NYC with prediabetes or diabetes. Sex, education, marital status, and employment were associated with interest in mHealth interventions. Additional support to South Asian women may be required when designing and developing mHealth interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03333044; https://classic.clinicaltrials.gov/ct2/show/NCT03333044, ClinicalTrials.gov NCT03188094; https://classic.clinicaltrials.gov/ct2/show/NCT03188094.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3711-y.

Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study

BACKGROUND

Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear.

METHODS

Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool.

RESULTS

Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME.

CONCLUSIONS

Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

Sociodemographic factors linked to food allergy diagnosis among high-risk children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a known risk factor for the development of food allergy (FA). Prior work has suggested disparities in diagnosis/management of FA in urban populations.

OBJECTIVE

To determine whether socioeconomic conditions, as measured by the area deprivation index and insurance status, or racial/ethnic self-identity was associated with risk of FA diagnosis (DFA), evaluation by an allergist, or objective FA testing among high-risk children with AD.

METHODS

This is a retrospective cohort study of pediatric patients with physician-diagnosed AD who had received primary care at a single urban academic tertiary care center between 2009 and 2022. Statistical analysis in SPSS (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY) used χ2, analysis of variance, and logistic regression.

RESULTS

In a total of 3365 pediatric subjects, 41.3% identified as non-Hispanic Black, 33.9% Hispanic, 6.9% Asian, and 14.9% non-Hispanic White. Hispanic children with AD and DFA were significantly less likely to be evaluated by an allergist than White or Asian children (65.9% vs 82.8% and 80.3%, P = .001 and P = .02). Non-Hispanic Black children with AD and DFA were more likely to have no objective FA testing than White children (20.9% vs 12.1%, P = .04). The White and Asian children were more likely to undergo the thorough combination of both blood and skin testing for DFA than Black or Hispanic children (15.5% and 22.4% vs 7.1% and 7.9%, respectively, P = .007, P = .00005, P = .03, P = .0008).

CONCLUSION

Labeling at-risk young children with FA without thorough objective testing can affect their nutrition and quality of life. Barriers to equitable evaluation of DFA should be further investigated and addressed.

Patient Factors Associated with Missed Otolaryngology Appointments at an Urban Safety-Net Hospital

OBJECTIVE

To determine if patient factors related to ethnicity, socioeconomic status (SES), medical comorbidities, or appointment characteristics increase the risk of missing an initial adult otolaryngology appointment.

METHODS

This study is a retrospective case control study at Boston Medical Center (BMC) in Boston, Massachusetts, that took place in 2019. Patient demographic and medical comorbidity data as well as appointment characteristic data were collected and compared between those that attended their initial otolaryngology appointment versus those who missed their initial appointment. Chi-square and ANOVA tests were used to calculate differences between attendance outcomes. Multivariate analysis was used to compare the odds of missing an appointment based on various patient- and appointment-related factors.

RESULTS

Patients who were more likely to miss their appointments were more often female, of lower education, disabled, not employed, Black or Hispanic, and Spanish-speaking. Spring and Fall appointments were more likely to be missed. When a multivariate regression was conducted to control for social determinants of health (SDOH) such as race, insurance status, employment, and education status, the odds of females, Spanish-speaking, students, and disabled patients missing their appointment were no longer statistically significant.

CONCLUSION

A majority of patients at BMC come from lower SES backgrounds and have multiple medical comorbidities. Those who reside closer to BMC, often areas of lower average income, had higher rates of missed appointments. Interventions such as decreasing lag time, providing handicap-accessible free transportation, and increasing accessibility of telemedicine for patients could help improve attendance rates at BMC.

LEVEL OF EVIDENCE

IV Laryngoscope, 2024.

Delays in Care by Race, Ethnicity, and Gender Before and During the COVID-19 Pandemic Using Cross-Sectional Data From National Institutes of Health's All of Us Research Program

PURPOSE

Delays in receiving medical care are an urgent problem. This study aims to determine whether the odds of, and reasons for, experiencing care delays differ by gender, race-ethnicity, and survey completion before versus during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional analysis of survey data from participants age ≥18 in the National Institutes of Health's All of Us Research Program collected from May 6, 2018, to January 1, 2022. Logistic regressions were performed to assess the association of gender, race-ethnicity, and survey completion date with any of nine reasons for delaying care in the past 12 months.

RESULTS

Of 119,983 participants, 37.8% reported delaying care in the past 12 months. After adjusting for employment status, education, income, marital status, health insurance, and age, women of every race-ethnicity and Black and other race-ethnicity men were more likely than white men to report delays in care: Asian women (odds ratio [OR] 1.23; 95% confidence interval [CI] [1.13, 1.34]), Black men (OR 1.15; 95% CI [1.05, 1.25]) and women (OR 1.46; 95% CI [1.38, 1.54]), Hispanic women (OR 1.36; 95% CI [1.28, 1.44]), white women (OR 1.55; 95% CI [1.50, 1.60]), and other race-ethnicity men (OR 1.15; 95% CI [1.05, 1.27]) and women (OR 1.79; 95% CI [1.67, 1.91]). A small but statistically significant difference was seen in reports of care delays for non-pandemic-related reasons during versus before the COVID-19 pandemic (OR 0.88; 95% CI [0.83, 0.93]).

CONCLUSIONS

In this study of diverse U.S. participants, women and Black and other race-ethnicity men were more likely than white men to report delays in care, both before and during COVID-19. Addressing care delays may be necessary to ameliorate health disparities by race-ethnicity and gender.

Effectiveness of Telerehabilitation Programs in Elderly with Hip or Knee Arthroplasty: A Systematic Review

Background: Lower limb osteoarthritis (OA) often generates musculoskeletal pain causing functional impairment and decreasing mobility, autonomy, and quality of life. Patients with OA are commonly prescribed specific care for total hip arthroplasty or total knee arthroplasty (THA or TKA), when patients present symptoms that are refractory to nondrug treatments. Currently, when patients are discharged from orthopedic surgery, they are either referred to a rehabilitation department, or sent directly home with assistance such as remote monitoring by teleconsultation or a mobile application. In recent years, there has been an evolution in digital health and in particular telerehabilitation. To determine utility and effectiveness, the aim of this systematic review was to highlight and evaluate different telerehabilitation programs using new information and communication technologies. Methods: Five databases, ScienceDirect, PubMed, Web of Sciences, Scopus, and Google scholar, were searched until 30 June 30, 2023. All studies written in English and meeting our inclusion criteria were included. Databases were screened for "Total Hip Arthroplasty," "Total Knee Arthroplasty," "Total Hip Replacement," "Total Knee Replacement," "Rehabilitation," "Physical Activity," "Physiotherapy," "Telerehabilitation," "Telecommunication*," "Senior*," and "Elderly" in accordance with PRISMA-ScR guideline. Results: Fourteen articles were selected according to inclusion criteria. Telerehabilitation was offered in seven different ways (video call, applications smartphones, website, etc.). Assessments included were mainly quality of life questionnaires, perceived effort after exercises, field surveys on the tool experience, and physical tests to assess motor functions. Conclusion: This review highlights the importance and relevance of evaluating the contributions and limits of new health technologies to improve patient monitoring and thus enable better remote clinical care.

The impact of multiple deprivation on the management of vestibular schwannomas

PURPOSE

While some factors have been well-shown to affect the decision-making in treating patients with vestibular schwannomas (VS), little is known on the role of deprivation. Our objective was to assess the effect of socioeconomic background on the management of patients with VS.

METHODS

This retrospective cohort study included 460 patients with sporadic VS from West of Scotland. The postcode-based, multifactorial Scottish Index of Multiple Deprivation (SIMD) was used to assess the socioeconomic background of each patient. We performed a multivariate analysis including tumour size, growth and patient age with management modality (observation, stereotactic radiotherapy, microsurgery) being the main outcome measure and outcome (need for additional treatment) an additional measure.

RESULTS

We found no significant difference in the demographics, tumour characteristics and primary treatment choice between patients with different SIMD scores. In addition, there was no statistically significant difference in the growth occurrence rates following first-line treatment (p = 0.964) and in the second-line treatment choice (p = 0.460).

CONCLUSIONS

Multiple deprivation does not affect decision making in patients with VS in the examined cohort. This is probably linked to the centralisation and uniformity of the service and might not necessarily be applicable to other health services without centralisation.

Decomposing the inequalities in the catastrophic health expenditures on the hospitalization in India: empirical evidence from national sample survey data

Introduction

Sustainable Development Goal (SDG) Target 3.8.2 entails financial protection against catastrophic health expenditure (CHE) by reducing out-of-pocket expenditure (OOPE) on healthcare. India is characterized by one of the highest OOPE on healthcare, in conjunction with the pervasive socio-economic disparities entrenched in the population. As a corollary, India has embarked on the trajectory of ensuring financial risk protection, particularly for the poor, with the launch of various flagship initiatives. Overall, the evidence on wealth-related inequities in the incidence of CHE in low- and middle-Income countries has been heterogenous. Thus, this study was conducted to estimate the income-related inequalities in the incidence of CHE on hospitalization and glean the individual contributions of wider socio-economic determinants in influencing these inequalities in India.

Methods

The study employed cross-sectional data from the nationally represented survey on morbidity and healthcare (75th round of National Sample Survey Organization) conducted during 2017-2018, which circumscribed a sample size of 1,13,823 households and 5,57,887 individuals. The inequalities and need-adjusted inequities in the incidence of CHE on hospitalization care were assessed via the Erreygers corrected concentration index. Need-standardized concentration indices were further used to unravel the inter- and intra-regional income-related inequities in the outcome of interest. The factors associated with the incidence of CHE were explored using multivariate logistic regression within the framework of Andersen's model of behavioral health. Additionally, regression-based decomposition was performed to delineate the individual contributions of legitimate and illegitimate factors in the measured inequalities of CHE.

Results

Our findings revealed pervasive wealth-related inequalities in the CHE for hospitalization care in India, with a profound gap between the poorest and richest income quintiles. The negative value of the concentration index (EI: -0.19) indicated that the inequalities were significantly concentrated among the poor. Furthermore, the need-adjusted inequalities also demonstrated the pro-poor concentration (EI: -0.26), denoting the unfair systemic inequalities in the CHE, which are disadvantageous to the poor. Multivariate logistic results indicated that households with older adult, smaller size, vulnerable caste affiliation, poorest income quintile, no insurance cover, hospitalization in a private facility, longer stay duration in the hospital, and residence in the region at a lower level of epidemiological transition level were associated with increased likelihood of incurring CHE on hospitalization. The decomposition analysis unraveled that the contribution of non-need/illegitimate factors (127.1%) in driving the inequality was positive and relatively high vis-à-vis negative low contribution of need/legitimate factors (35.3%). However, most of the unfair inequalities were accounted for by socio-structural factors such as the size of the household and enabling factors such as income group and utilization pattern.

Conclusion

The study underscored the skewed distribution of CHE as the poor were found to incur more CHE on hospitalization care despite the targeted programs by the government. Concomitantly, most of the inequality was driven by illegitimate factors amenable to policy change. Thus, policy interventions such as increasing the awareness, enrollment, and utilization of Publicly Financed Health Insurance schemes, strengthening the public hospitals to provide improved quality of specialized care and referral mechanisms, and increasing the overall budgetary share of healthcare to improve the institutional capacities are suggested.

Association between Adverse Childhood Experiences and Unmet Health Care Needs among Children in the United States

Although studies have investigated and found an association between adverse childhood experiences and poor health and mental health outcomes, there is a dearth of studies investigating the association between adverse childhood experiences and unmet health care needs among children. The objective of this study is to examine the association between adverse childhood experiences and unmet health care needs after adjusting for predisposing, enabling, and need factors of health care service utilization. Data for this study came from the 2016-2017 National Survey of Children's Health. An analytic sample of 46,081 children (51.3% males; average age 11.5 years) was analyzed using negative binomial regression. Based on parent reports, about 3.5% of children had unmet health care needs, and half (50%) of the sample had experienced at least one childhood adversity. Controlling for other factors, children who experienced three or more childhood adversities had 4.51 times higher odds of having unmet health care needs (AOR = 4.51, p < .001, 95% CI = 3.15-6.45) when compared to their counterparts with no childhood adversity. Children with parents who have someone to turn to for everyday emotional support were 31% less likely to have unmet health care needs (AOR = .69, p < .01, 95% CI = .54-.89). Adverse childhood experiences have a detrimental effect on unmet health care needs. The findings of this study offer an important opportunity for further research on how best to prevent adverse childhood experiences and mitigate their impact on families.

Barriers to Accessing Antiretroviral Treatment Among Key Populations in Southwest Nigeria

Background In Nigeria, similar to most of sub-Saharan Africa, the fight against HIV/AIDS is hampered by various barriers. Particularly, key populations (KP) face unique challenges in accessing antiretroviral therapy (ART), attributed to health systems, patient-related, and community-related factors. This study aims to explore these barriers among KP in Nigeria, enhancing understanding to improve ART access and outcomes, thereby contributing to global efforts to end the HIV/AIDS epidemic. Objectives The objective of this study is to explore barriers to accessing ART services among KP living with HIV in the southwest region of Nigeria. Materials and methods This descriptive cross-sectional study, which was carried out in the southwestern Nigerian states of Ondo and Ogun, involved 4,253 KP attending ART clinics. Using a multistage sampling technique, 219 females and 154 males between the ages of 17 and 72 were chosen. Semi-structured survey questions were used to get information to elicit these barriers. SPSS Statistics (version 29.0; IBM Corp., Armonk, NY) was used for quantitative data analysis. Results Specifically, 48.3% of respondents were men, and 58.7% were women; 54.0% were female sexual workers, and the next highest percentages were men who have sex with men (27.0%) and injectable drug users (19.3%); and 79% (51.0% agreed, 28.0% strongly agreed) concurred that the barriers to accessing ART are transportation, distance, and financial challenges. Patients at ART clinics were generally satisfied with the healthcare and health workers' attitude. Measures to protect privacy and confidentiality were considered crucial by the respondents. There are significant associations between ART accessibility and socio-demographic and socio-economic characteristics (p-value <0.05). Conclusion This study probed the complex landscape of barriers to ART access faced by KP in Nigeria, underscoring the critical need for tailored, innovative strategies to overcome these obstacles and offering actionable insights for stakeholders to enhance ART adherence and access thereby significantly improving the quality of life for people living with HIV.

Rate of Emergency Lower Extremity Amputations in the United States Among Medicare Beneficiaries

OBJECTIVE

To determine the rate of emergency versus elective lower extremity amputations in the United States.

BACKGROUND

Lower extremity amputation is a common endpoint for patients with poorly controlled diabetes and multilevel peripheral vascular disease. Although the procedure is ideally performed electively, patients with limited access may present later and require an emergency operation. To what extent rates of emergency amputation for lower extremities vary across the United States is unknown.

METHODS

Evaluation of Medicare beneficiaries who underwent lower extremity amputation between 2015 and 2020. The rate was determined for each zip code and placed into rank order from lowest to highest rate. We merged each beneficiary's place of residence and location of care with the American Hospital Association Annual Survey using Google Maps Application Programming Interface to determine the travel distance for patients to undergo their procedure.

RESULTS

Of 233,084 patients, 66.3% (154,597) were men, 69.8% (162,786) were White. The average age (SD) was 74 years (8). There was wide variation in rates of emergency lower extremity amputation. The lowest quintile of zip codes demonstrated an emergency amputation rate of 3.7%, whereas the highest quintile demonstrated 90%. The median travel distance in the lowest emergency surgery rate quintile was 34.6 miles compared with 10.5 miles in the highest quintile of emergency surgery ( P < 0.001).

CONCLUSIONS

There is wide variation in the rate of emergency lower extremity amputations among Medicare beneficiaries, suggesting variable access to essential vascular care. Travel distance and rate of amputation have an inverse relationship, suggesting that barriers other than travel distance are playing a role.

Can telehealth expansion boost health care utilization specifically for patients with substance use disorders relative to patients with other types of chronic disease?

OBJECTIVE

Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high risk of poor outcomes. Telehealth expansion may boost utilization, but it is unclear whether telehealth can increase utilization for patients with SUDs beyond that expected for other chronic diseases amenable to remote treatment, like type 2 diabetes. This information is needed by health systems striving to improve SUD outcomes, specifically. This study compared the impact of telehealth expansion during the COVID-19 public health emergency (PHE) on utilization for patients with SUDs and diabetes.

METHODS

Using Wisconsin Medicaid administrative, enrollment and claims data 12/1/2018-12/31/2020, this cohort study included nonpregnant, nondisabled adults 19-64 years with SUDs (N = 17,336) or diabetes (N = 8,499). Outcomes included having a primary care visit in the week (any, and telehealth) for any diagnosis, or a SUD or diabetes diagnosis; and the weekly fraction of visits completed by telehealth. Logistic and fractional regression examined outcomes pre- and post-PHE. Covariates included age, sex, race, ethnicity, income, geography, and comorbid medical and psychotic disorders.

RESULTS

Post-PHE, patients with SUDs exhibited greater likelihood of telehealth utilization (percentage point difference (PPD) per person-week: 0.2; 95% CI: 0.001-0.003; p<0.001) and greater fractional telehealth use (PPD: 1.8; 95%CI: 0.002-0.033; p = 0.025) than patients with diabetes despite a larger overall drop in visits (PPD: -0.5; 95%CI: -0.007- -0.003; p<0.001).

CONCLUSIONS

Following telehealth expansion, patients with SUDs exhibited greater likelihood of telehealth utilization than patients with diabetes. This advantage lessened the substantial PHE-induced healthcare disruption experienced by patients with SUDs. Telehealth may boost utilization for patients with SUDs.

Assessing the Frequency of Deferrable Thyroid Nodule Biopsies to De-escalate Low-Value Care

OBJECTIVE

Thyroid nodules are common, yet fewer than 1 in 10 harbors malignancy. When present, thyroid cancer is typically indolent with excellent survival. Therefore, patients who are not candidates for thyroid cancer treatment due to comorbid disease may not require further thyroid nodule evaluation. The goal of this study was to determine the rate of deferrable thyroid nodule biopsies in patients with limited life expectancy.

METHODS

We identified patients who underwent thyroid fine needle aspiration (FNA) between 2015 and 2018 at our institution. The primary outcome was the number of deferrable FNAs, defined as FNAs performed in patients who died within 2 years after biopsy. Secondary outcomes included cytologic Bethesda score, procedure costs, and final diagnosis on surgical pathology. Multivariable logistic and Cox proportional hazards regressions were used to evaluate factors associated with FNA in patients with limited life expectancy.

RESULTS

A total of 2565 FNAs were performed. Most patients were female (79%), and 37 (1.5%) patients died within 2 years. Nonthyroid specialists were significantly more likely to order deferrable FNAs (odds ratio 4.13, P < .001). Of the patients who died within 2 years, most (78%) had a concomitant diagnosis of nonthyroid cancer, and 4 went on to have thyroid surgery (Bethesda scores: 3, 4, 4, and 6). Spending associated with deferrable FNAs and subsequent surgery totaled over $98 000.

CONCLUSIONS

Overall, the rate of deferrable thyroid nodule biopsies was low. However, there is an opportunity to reduce low-value biopsies in patients with a concurrent nonthyroid cancer by partnering with oncology providers.

Social determinants of health influencing the adherence to post-endoscopic mucosal resection surveillance

BACKGROUND AND AIMS

Colorectal cancer (CRC) is a global health challenge, particularly in Alabama, where the incidence rates exceed national averages. This study investigated the factors influencing adherence to post-endoscopic mucosal resection (EMR) colonoscopies, focusing on travel distance and socioeconomic status. This study aimed to provide evidence-based insights to improve patient care in CRC management.

METHODS

This retrospective study in a tertiary care referral center analyzed 465 patients who underwent EMR. The data included demographics, clinical details, and travel-related variables. Descriptive statistics, logistic regression, and spatial analysis were used to assess the factors affecting adherence.

RESULTS

Of 465 patients, 36.6 % had adequate follow-up, 21.8 % had inadequate follow-up, and 41.6 % were lost to follow-up. Noteworthy demographic variations were observed, with median ages differing across adherence groups. Traveled distances showcased compelling insights, indicating a median distance of 22.2 miles for adequate follow-up, 15.7 miles for inadequate follow-up, and 31.6 miles for the lost-to-follow-up group (p<0.001). Longer travel distances were associated with better adherence. Longer travel distances from the hospital were associated with significantly lower odds of inadequate follow-up: 10-25 miles OR:0.29, 25-85 miles OR:0.35, and >80 miles OR:0.24 compared to the first quartile (<10 miles). Socioeconomic factors, particularly educational attainment, significantly influenced the follow-up rates.

CONCLUSIONS

This study revealed suboptimal post-EMR follow-up rates and underscored the impact of travel distance and socioeconomic factors. Targeted interventions addressing distance-related barriers can enhance treatment adherence and ensure timely CRC surveillance after EMR. Further research is needed in diverse healthcare settings.

Mental Health and Care Utilization Among Ethiopian-Israeli Immigrants During the Period of COVID-19

As well as affecting physical health, COVID-19 can impact mental health. Despite this, Israelis may not be getting needed mental health care because of culture-related barriers such as stigma and lack of knowledge about mental health and appropriate care. This is especially likely among vulnerable populations, such as Ethiopian immigrants, yet the topic has been understudied. This study aimed to examine to what extent COVID-19-related mental health stressors and issues are found among Ethiopian-Israelis and the extent of stigma and mental health literacy among Ethiopian-Israelis during the COVID-19 period. It also examined differences between the 1.5th and 2nd generations and potential interventions to improve their mental health. Online surveys were filled out by a convenience sample of 225 Ethiopian-Israelis recruited from a variety of sources in the fall of 2020. Over 40% expressed greater mental distress since COVID-19 started. Stigma and lack of mental health-related knowledge were found among many in this population, serving as potentially important barriers to getting appropriate mental health care. For example, only 52% disagreed with the statement that people with mental illness should not be given any responsibility and only 66% felt confident they could identify having a mental health problem requiring treatment. Variations were found by types of stressors, stigma, and lack of knowledge, as well as by immigration generation, for at least some measures. COVID-19 can negatively impact mental health and appropriate mental health care utilization, especially for a racial/ethnic minority group of immigrants such as Ethiopian-Israelis. Interventions are needed, such as increased education about mental health from a variety of sources, which can help decrease stigma and improve mental health care utilization among this group, especially when appropriately tailored.

Association of Depression, Comorbidities, and Sociodemographic Factors among Home Healthcare Recipients

OBJECTIVES

More than 15 million individuals receive home health care (HHC) for chronic conditions, which allows them to maintain a level of independence and self-sufficiency. Although poor mental health can negatively impact health outcomes, little research has been done on the mental health of these individuals.

METHODS

Utilizing National Health Interview Survey years 2019-2022, we ran a cross-sectional analysis to determine rates of depression among individuals who indicated that they utilized HHC services, based on their sociodemographic statuses and diagnosis, as well as their rate of depression by condition whether they utilized HHC services.

RESULTS

HHC recipients were significantly more likely to be depressed if they reported being female, age 55-64, low income, low educational attainment, American Indian/Alaskan Native, Hispanic, or lived in a rural area. HHC recipients were more likely to be depressed than their non-HHC recipient counterparts.

CONCLUSIONS

These results underscore the need for integrated mental health care in home health. Further, the financial burden of HHC, which may have an additional impact on stress, emphasizes the need for expanded accessibility of these services.

CLINICAL IMPLICATIONS

General practitioners and home health professionals should inquire about mental health concerns of these care recipients, and treat or refer accordingly.

Factors Associated With Onabotulinum Toxin-A Discontinuation in a Diverse Urban Population

IMPORTANCE

Although overactive bladder (OAB) is a common condition, affecting 16% of Americans, few patients continue on to advanced therapies. Furthermore, procedural therapies like intravesical onabotulinum toxin-A (BTX-A), which require ongoing repeat treatments, have discontinuation rates ranging from 25% to 51%.

OBJECTIVES

This study sought to investigate factors associated with dis-continuation of BTX-A injections for idiopathic OAB among a diverse urban population.

STUDY DESIGN

This was a retrospective review of adults 18 years and older who underwent BTX-A injection for idiopathic OAB. Patient demographics, past medical history, symptoms, and postprocedural outcomes such as subjective improvement, urinary retention, and incidence of urinary tract infection were compared between groups.

RESULTS

Onabotulinum toxin-A injections were administered to 246 patients who met study criteria, of whom 211 (85.7%) were women. One hundred (40.7%) patients discontinued BTX-A therapy. Patients discontinuing BTX-A therapy were more likely to have developed postprocedural urinary retention (18.4% vs 9.7%, P < 0.05) and had a higher median income by zip code ($59,000 vs $50,000; P < 0.01). Patients were significantly more likely to continue BTX-A therapy if they reported preprocedural nocturia (57.2% vs 36.8%, P < 0.01) or urgency urinary incontinence (UUI) (78.1% vs 64.6%, P < 0.05).

CONCLUSIONS

Adverse outcomes, such as postprocedural urinary retention, are associated with discontinuation of BTX-A therapy. Patients who reported nocturia and UUI before injection were more likely to continue BTX-A suggesting more severe OAB is more responsive to this therapy. Given the large proportion (>40%) of patients who discontinued BTX-A treatment, further research is needed to identify barriers to continuation of care.

Rural Native Veterans' Perceptions of Care in the Context of Navigator Program Development

INTRODUCTION

American Indian and Alaska Natives serve in the military at one of the highest rates of all racial and ethnic groups. For Veterans, the already significant healthcare disparities Natives experience are aggravated by barriers to accessing care, care navigation, and coordination of health care within the Veterans Health Administration (VHA) between the VHA and tribal health systems. To mitigate these barriers, the VHA is developing a patient navigation program designed specifically for rural Native Veterans. We describe formative work aimed at understanding and addressing barriers to VHA care from the perspective of rural Native Veterans and those who facilitate their care.

METHODS

Thirty-four individuals participated in semi-structured interviews (22 Veterans, 6 family members, and 6 Veteran advocates) drawn from 9 tribal communities across the US.

RESULTS

Participants described many barriers to using the VHA, including perceptions of care scarcity, long travel distances to the VHA, high travel costs, and bureaucratic barriers including poor customer service, scheduling issues, and long waits for appointments. Many Veterans preferred IHS/tribal health care over the VHA due to its proximity, simplicity, ease of use, and quality.

CONCLUSION

Rural Native Veterans must see a clear benefit to using the VHA given the many obstacles to its use. Veteran recommendations for addressing barriers to VHA care within a navigation program include assistance enrolling in, scheduling, and navigating VHA systems; paperwork assistance; cost reimbursement; and care coordination with the IHS/tribal health care.

Assessing catastrophic health expenditure and impoverishment in adult asthma care: a cross-sectional study of patients attending six public health clinics in Klang District, Malaysia

BACKGROUND

In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia.

METHODS

This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis.

RESULTS

We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors.

CONCLUSION

The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship.

Participants' experiences of a counsellor-supported PTSD Coach intervention in a resource-constrained setting

We explored participants' experiences of a counsellor-supported PTSD Coach mobile application intervention (PTSD Coach-CS) in a randomised controlled trial. PTSD Coach-CS participants, who received the intervention and self-completed a custom-designed questionnaire at intervention completion were included (n = 25; female = 20; ages 19-59; isiXhosa = 22). This questionnaire comprised questions regarding the feasibility, acceptability and potential impact of the PTSD Coach-CS intervention, and general psychological support in our setting. Data were analysed using Braun and Clarke's thematic analysis. Three main themes emerged. (i) Participants' largely positive experiences of treatment procedures included the safe space created by the counsellor support in combination with the PTSD Coach application, allowing them to learn about and understand their lived experiences, and to accept their PTSD diagnoses. (ii) Positive perceptions of the PTSD Coach application, yet raising important concerns (e.g., lack of family involvement) for future consideration. (iii) Intervention-specific and systemic treatment barriers (e.g., stigma) providing important information to inform and increase the usefulness of the PTSD Coach-CS intervention. The findings suggest that the PTSD Coach-CS intervention may help address the need for access to suitable care for South African adults with PTSD. Some contextual barriers must be considered in further intervention implementation.

Cost-utility analysis and impact on the environment of videoconference in pressure injury. A randomized controlled trial in individuals with spinal cord injury

STUDY DESIGN

A prospective randomized controlled trial (RCT) in persons with spinal cord injury (SCI) and ongoing pressure injury (PI).

OBJECTIVES

The main aim was to perform a cost-utility analysis (CUA) alongside the RCT comparing regular care to regular care with additional videoconference consultations. Secondary aims were to assess costs and greenhouse gas emission related to transportation in the two study groups.

SETTING

Two spinal cord units in Norway.

METHODS

Participants were allocated to a regular care group (RCG) and a regular care group with additional videoconference (VCG), in a 1-year follow-up between 2016 and 2018. Costs were prospectively collected, and health-related quality of life (HRQoL) data were collected at baseline and 12 months. The outcome was quality-adjusted life years (QALYs), derived from the EQ-5D-5L questionnaire. Results are reported as incremental cost-effectiveness ratio (ICER), expressed as the cost per additional QALY gained. Transportation related costs and environmental emissions were compared by t-tests.

RESULTS

There were 56 participants included, 28 in each group. Of these 27 in the VCG and 26 in the RCG completed. Three participants died. The mean cost per patient was € 8819 in the VCG and € 3607 in the RCG, with 0.1 QALYs gained in the VCG. No significant differences were identified regarding HRQoL or secondary outcomes.

CONCLUSION

The VCG costs € 5212 more for an additional 0.1 QALYs, giving an ICER of € 52,120 per QALY. No significant differences were found regarding transportation-related costs, or emission of greenhouse gases.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov ; NCT02800915, TeleSCIpi. CRISTIN.no. https://app.cristin.no/projects/show.jsf?id=545284 . Sunnaas Rehabilitation hospital's web page, available at https://www.sunnaas.no/fag-og-forskning/fagstoff/sar .

Electrification of Transit Buses in the United States Reduces Greenhouse Gas Emissions

The transportation sector is the largest emitter of greenhouse gas emissions (GHGs) in the United States. Increased use of public transit and electrification of public transit could help reduce these emissions. The electrification of public transit systems could also reduce air pollutant emissions in densely populated areas, where air pollution disproportionally burdens vulnerable communities with high health impacts and associated social costs. We analyze the life cycle emissions of transit buses powered by electricity, diesel, gasoline, and compressed natural gas and model GHGs and air pollutants mitigated for a transition to a fully electric U.S. public transit bus fleet using transit agency-level data. The electrification of the U.S. bus fleet would reduce several conventional air pollutants and has the potential to reduce transit bus GHGs by 33-65% within the next 14 years depending on how quickly the transition is made and how quickly the electricity grid decarbonizes. A levelized cost of driving analysis shows that with falling capital costs and an increase in annual passenger-kilometers of battery electric buses, the technology could reach levelized cost parity with diesel buses when electric bus capital costs fall below about $670 000 per bus.

Cross-sectional analysis of primary care clinics' policies, practices, and availability of patient support services during the COVID-19 pandemic

BACKGROUND

Healthcare accessibility and utilization are important social determinants of health. Lack of access to healthcare, including missed or no-show appointments, can have negative health effects and be costly to patients and providers. Various office-based approaches and community partnerships can address patient access barriers.

OBJECTIVES

(1) To understand provider perceptions of patient barriers; (2) to describe the policies and practices used to address late or missed appointments, and (3) to evaluate access to patient support services, both in-clinic and with community partners.

METHODS

Mailed cross-sectional survey with online response option, sent to all Nebraska primary care clinics (n = 577) conducted April 2020 and January through April 2021. Chi-square tests compared rural-urban differences; logistic regression of clinical factors associated with policies and support services computed odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Response rate was 20.3% (n = 117), with 49 returns in 2020. Perceived patient barriers included finances, higher among rural versus urban clinics (81.6% vs. 56.1%, p =.009), and time (overall 52.3%). Welcoming environment (95.5%), telephone appointment reminders (74.8%) and streamlined admissions (69.4%) were the top three clinic practices to reduce missed appointments. Telehealth was the most commonly available patient support service in rural (79.6%) and urban (81.8%, p =.90) clinics. Number of providers was positively associated with having a patient navigator/care coordinator (OR = 1.20, CI = 1.02-1.40). For each percent increase in the number of privately insured patients, the odds of providing legal aid decreased by 4% (OR = 0.96, CI = 0.92-1.00). Urban clinics were less likely than rural clinics to provide social work services (OR = 0.16, CI = 0.04-0.67) or assist with applications for government aid (OR = 0.22, CI = 0.06-0.90).

CONCLUSIONS

Practices to reduce missed appointments included a variety of reminders. Although finances and inability to take time off work were the most frequently reported perceived barriers for patients' access to timely healthcare, most clinics did not directly address them. Rural clinics appeared to have more community partnerships to address underlying social determinants of health, such as transportation and assistance applying for government aid. Taking such a wholistic partnership approach is an area for future study to improve patient access.

Addressing COVID-19 Vaccine Hesitancy and Uptake Among African Immigrants: Lessons from a Community-Based Outreach Program

In 2021, the African Cultural Alliance of North America (ACANA) implemented a community-based vaccine education and outreach program to decrease hesitancy and increase COVID-19 vaccine uptake among African immigrants in Philadelphia. The program had three components: (1) tailored messaging on the benefits of vaccines by trusted community health navigators in familiar languages/dialects, (2) use of educational/tabling events, and (3) establishment of a vaccine clinic in community settings. Using secondary data analysis, in-depth interviews, focus group discussions and a self-administered survey, we explored (i) the impact and effectiveness of the outreach program and extent of vaccine uptake, (ii) African immigrants' beliefs about the COVID-19 pandemic and the vaccine, and (iii) barriers and facilitators of vaccine knowledge, uptake, and hesitancy. Our analysis showed that ACANA's outreach program was effective in addressing several cultural, logistic, and systematic barriers to vaccine uptake. The program distributed 2000 educational/informational flyers, reached 3000 community members via social media campaigns, and an additional 2320 through other person-to-person outreach events. The program was effective and resulted in the vaccination of 1265 community members over the course of the outreach. The impact of this outreach underscores the critical role of community-based organizations in addressing COVID-19 vaccine hesitancy and increasing vaccine uptake in underserved and minority communities. The paper concludes with suggestions and recommendations for using community-based outreach programs to increase COVID-19 vaccine uptake and decrease hesitancy.

Impact of the coronavirus disease 2019 pandemic on equity of access to hip and knee replacements: a population-level study

PURPOSE

The COVID-19 pandemic had innumerable impacts on healthcare delivery. In Canada, this included limitations on inpatient capacity, which resulted in an increased focus on outpatient surgery for non-emergent cases such as joint replacements. The objective of this study was to assess whether the pandemic and the shift towards outpatient surgery had an impact on access to joint replacement for marginalized patients.

METHODS

Data from Ontario's administrative healthcare databases were obtained for all patients undergoing an elective hip or knee replacement between January 1, 2018 and August 31, 2021. All surgeries performed before March 15, 2020 were classified as "pre-COVID," while all procedures performed after that date were classified as "post-COVID." The Ontario Marginalization Index domains were used to analyze proportion of marginalized patients undergoing surgery pre- and post-COVID.

RESULTS

A total of 102,743 patients were included-42,812 hip replacements and 59,931 knee replacements. There was a significant shift towards outpatient surgery during the post-COVID period (1.1% of all cases pre-COVID to 13.2% post-COVID, p < 0.001). In the post-COVID cohort, there were significantly fewer patients from some marginalized groups, as well as fewer patients with certain co-morbidities, such as congestive heart failure and chronic obstructive pulmonary disease.

CONCLUSION

The most important finding of this population-level database study is that, compared to before the COVID-19 pandemic, there has been a change in the profile of patients undergoing hip and knee replacements in Ontario, specifically across a range of indicators. Fewer marginalized patients are undergoing joint replacement surgery since the COVID-19 pandemic. Further monitoring of access to joint replacement surgery is required in order to ensure that surgery is provided to those who are most in need.