Insurance + access not equal to health care: typology of barriers to health care access for low-income families

Nurse-led telehealth and mobile health care models for type 2 diabetes and hypertension in low-income US populations: A scoping review

BACKGROUND

Increasing numbers of underserved people with chronic diseases and decreasing providers in rural areas have contributed to the care shortage in the United States. Nurse-led telehealth/mobile care models have potential benefits for this population. However, there is a substantial gap in the literature regarding this topic.

PURPOSE

To examine the available literature on nurse-led telehealth/mobile health care models with a particular focus on care model settings, nursing roles, care components, achieved outcomes, and the identification of both facilitative factors and encountered challenges. The ultimate goal is to offer recommendations based on these findings, thereby aiding the development or refinement of evidence-based care models that meet to the unique needs of low-income populations.

METHODOLOGY

Literature published from 2010 to 2023 was searched in six electronic databases (Cumulative Index to Nursing and Allied Health Literature, Communication and Mass Media Complete, Medline, APA PsycINFO, Social Sciences Index, and Web of Science databases).

RESULTS

Commonalities identified among included studies with significant improvements were the provision of home monitors and education to participants, multiple engagements, and extensive community and/or family involvement.

CONCLUSIONS

Nurse-led telehealth/mobile health care models for chronic diseases are an emerging approach. Nurse educators must ensure that future nurses are adept in diverse telehealth modes, collaborating across disciplines. Leveraging advanced practice registered nurses and interdisciplinary teams provides holistic care.

IMPLICATIONS

Our review outlined recent research findings that suggest enhanced patient outcomes through technology, communication, and community support. In addition, we offered suggestions for future research and practice, emphasizing the importance of exploring the requirements of diverse and underserved communities.

Care seeking for childhood illnesses in rural Mtwara, south-east Tanzania: a mixed methods study

BACKGROUND

Care seeking was assessed in preparation for a study of the health impact of novel design houses in rural Mtwara, Tanzania.

METHODS

A total of 578 residents of 60 villages participated in this mixed-methods study from April to August 2020. Among them, 550 participated in a healthcare-seeking survey, 17 in in-depth interviews and 28 in key informant interviews.

RESULTS

The decision to seek care was based on symptom severity (95.4% [370]). Caregivers first visited non-allopathic healthcare providers or were treated at home, which led to delays in seeking care at healthcare facilities. More than one-third (36.0% [140]) of respondents took >12 h seeking care at healthcare facilities. The majority (73.0% [282]) visited healthcare facilities, whereas around one-fifth (21.0% [80]) sought care at drug stores. Treatment costs deterred respondents from visiting healthcare facilities (61.4% [338]). Only 10 (3.6%) of the households surveyed reported that they were covered by health insurance.

CONCLUSIONS

Quality of care, related to institutional factors, impacts timely care seeking for childhood illnesses in Mtwara, Tanzania. Ensuring accessibility of facilities is therefore not sufficient.

The cost implications of Wilson disease among hospitalized patients: analysis of USA hospitals

BACKGROUND AND AIM

In this study, we used a national cohort of patients with Wilson's disease (WD) to investigate the admissions, mortality rates, and costs over the captured period to assess specific subpopulations at higher burden.

METHODS

Patients with WD were selected using 2016-2019 National Inpatient Sample (NIS). The weighted estimates and patient data were stratified using demographics and medical characteristics. Regression curves were graphed to derive goodness-of-fit for each trend from which R2 and P values were calculated.

RESULTS

Annual total admissions per 100 000 hospitalizations due to WD were 1075, 1180, 1140, and 1330 ( R2  = 0.75; P  = 0.13) from 2016 to 2019. Within the demographics, there was an increase in admissions among patients greater than 65 years of age ( R2  = 0.90; P  = 0.05) and White patients ( R2  = 0.97; P  = 0.02). Assessing WD-related mortality rates, there was an increase in the mortality rate among those in the first quartile of income ( R2  = 1.00; P  < 0.001). The total cost for WD-related hospitalizations was $20.90, $27.23, $24.20, and $27.25 million US dollars for the years 2016, 2017, 2018, and 2019, respectively ( R2  = 0.47; P  = 0.32). There was an increasing total cost trend for Asian or Pacific Islander patients ( R2  = 0.90; P  = 0.05). Interestingly, patients with cirrhosis demonstrated a decreased trend in the total costs ( R2  = 0.97; P  = 0.02).

CONCLUSION

Our study demonstrated that certain ethnicity groups, income classes and comorbidities had increased admissions or costs among patients admitted with WD.

Does Insurance Provide Adequate Coverage for Physical Therapy Visits for Common Orthopedic Diagnoses? A Survey Study

OBJECTIVES

This study aimed to analyze the association between physical therapists' recommended number of visits for a full recovery from common orthopedic injuries/surgeries and the extent of insurance coverage for these visits.

METHODS

A prospective observational study was conducted with board-certified physical therapists. A qualitative questionnaire was used to gather physical therapists' demographics and the recommended number of physical therapy visits to achieve a full recovery after 11 common orthopedic diagnoses. Physical therapists also were asked to report whether they believe that insurance provides an adequate number of visits overall. In addition to the qualitative survey, insurance coverage details of major Alabama companies were obtained for comparison. Descriptive statistics of the participating therapists were analyzed for sex, age, degree/training, and years of experience. Kruskal-Wallis statistics were used to analyze variance between the aforementioned groupings when compared with the reported average number of sessions.

RESULTS

The survey (N = 251) collected data on the average number of physical therapy sessions that are necessary for a complete recovery as recommended by physical therapists for 11 common orthopedic diagnoses. From this survey, the average number of necessary visits ranged from 11.3 visits (ankle sprains) to 37.3 visits (anterior cruciate ligament reconstruction), with the overall average number of visits being 23.8. Only 24% of physical therapists believed that insurance companies provided enough coverage. Insurance coverage varied but often required additional procedures to allocate the adequate number of visits for the studied orthopedic pathologies.

CONCLUSIONS

The majority of practicing physical therapists in Alabama perceive insufficient insurance coverage for physical therapy visits for most orthopedic diagnoses. This study has implications for healthcare decision making and patient-centered rehabilitation goals. Physicians and physical therapists can use this information to optimize treatment decisions and rehabilitation goals. Patients will benefit from improved physical and economic well-being. This study has the potential to drive further research and influence national insurance policies to better serve patients' needs.

Analyzing the association between social vulnerability indexes and surgically underserved areas in the Inland Empire

Background

The United States lacks equitable surgical access, prompting us to investigate whether there is an inverse relationship between Social Vulnerability Indices and the number of surgeons in a census tract, using the Inland Empire as a model.

Methods

The Centers for Disease Control's (CDC) SVI 2018 database, composed of 823 census tracts, was compared against demographics of 1008 surgeons, from the American Medical Association's (AMA) 2018 Physician Masterfile. Analysis was performed via Spearman's bivariate and multiple regression.

Results

An inverse relationship exists between surgeon number and overall social vulnerability (ρ = -0.266 [95 % CI -0.330 to -0.199], p < .001), and between surgeon number and each category of social vulnerability: Socioeconomic (ρ = -0.345 [95 % CI -0.0405 to -0.281], p < .001), Household Composition and Disability (ρ = -0.121 [95 % CI -0.190 to -0.051], p < .001), Minority Status and Language (ρ = -0.0317 [95 % CI -0.379 to -0.252], p < .001), and Housing Type and Transportation (ρ = -0.093 [95 % CI -0.153 to -0.023], p = .005). Multiple regression analysis revealed that the following were associated with a higher number of surgeons: higher "Per Capita Income" (B = 0.000151 [95 % CI 0.000079 to 0.000223], t(820) = 4.104, p < .001), larger Daytime Population (B = 0.000143 [95 % CI 0.000072 to 0.000214]; t(820) = 3.956, p < .001), larger Total Population (B = -0.013 [95 % CI -0.022 to -0.003]; t(820) = -2.672, p = .008), and smaller number of Persons aged 17 and younger (B = -0.005 [95 % CI -0.008 to -0.001]; t(820) = -2.794, p = .005).

Conclusions

This study concludes that social vulnerability is predictive of, and significantly linked to, differences in surgical access and continues to advocate for research into understanding the surgeon's role in both individual and population health.

Key message

Our work demonstrates that the number of surgeons in a census tract is inversely proportional to the census tract's overall Social Vulnerability Indices. Thus, this research can serve to educate the public, physicians, and other healthcare providers about the importance of incorporating social determinants of health into the construction of healthcare policy and practice, as well as the importance of continued funding for local and national social service programs as a means to alleviate specific health inequities, such as language and transportation.

Health equity in pediatrics: Current concepts for the care of children in the 21st century (Dis Mon)

This is an analysis of important aspects of health equity in caring for children and adolescents written by a multidisciplinary team from different medical centers. In this discussion for clinicians, we look at definitions of pediatric health equity and the enormous impact of social determinants of health in this area. Factors involved with pediatric healthcare disparities that are considered include race, ethnicity, gender, age, poverty, socioeconomic status, LGBT status, living in rural communities, housing instability, food insecurity, access to transportation, availability of healthcare professionals, the status of education, and employment as well as immigration. Additional issues involved with health equity in pediatrics that are reviewed will include the impact of the COVID-19 pandemic, behavioral health concepts, and the negative health effects of climate change. Recommendations that are presented include reflection of one's own attitudes on as well as an understanding of these topics, consideration of the role of various healthcare providers (i.e., community health workers, peer health navigators, others), the impact of behavioral health integration, and the need for well-conceived curricula as well as multi-faceted training programs in pediatric health equity at the undergraduate and postgraduate medical education levels. Furthermore, ongoing research in pediatric health equity is needed to scrutinize current concepts and stimulate the development of ideas with an ever-greater positive influence on the health of our beloved children. Clinicians caring for children can serve as champions for the optimal health of children and their families; in addition, these healthcare professionals are uniquely positioned in their daily work to understand the drivers of health inequities and to be advocates for optimal health equity in the 21st century for all children and adolescents.

Low-Income, Poor Physical Health, Poor Mental Health, and Other Social Risk Factors Are Associated With Decreased Access to Care in Patients With Carpal Tunnel Syndrome

BACKGROUND

Carpal Tunnel Syndrome (CTS) is associated with a significant personal and societal burden. Evaluating access to care can identify barriers, limitations, and disparities in the delivery of healthcare services in this population. The purpose of this study was to evaluate access to overall healthcare and healthcare utilization among patients with CTS.

METHODS

This is a retrospective cohort study conducted with the All of Us database. Patients diagnosed with CTS that completed the access to care survey were included and matched to a control group. The primary outcomes were access to care across 4 domains: (1) delayed care, (2) could not afford care, (3) skipped medications, and (4) over 1 year since seeing provider. Secondary analysis was then performed to identify patient-specific factors associated with reduced access to care.

RESULTS

In total, 7649 patients with CTS were included and control matched to 7649 patients without CTS. In the CTS group, 33.7% (n = 2577) had delayed care, 30.4% (n = 2323) could not afford care, 15.4% (n = 1180) skipped medications, and 1.6% (n = 123) had not seen a provider in more than 1 year. Within the CTS cohort, low-income, worse physical health, and worse mental health were associated with poor access to care.

CONCLUSION

Patients experience notable challenges with delayed care, affordability of care, and medication adherence regardless of having a diagnosis of CTS. Targeted interventions on modifiable risk factors such as low income, poor mental health, and poor physical health are important opportunities to improve access to care in this population.

Current trends in digital camera-based bioassays for point-of-care tests

Point-of-care and bedside tests are analytical devices suitable for a growing role in the current healthcare system and provide the opportunity to achieve an exact diagnosis by an untrained person and in various conditions and sites where it is necessary. Using a digital camera integrated into a well-accessible device like a smartphone brings a new way in which a colorimetric point-of-care diagnostic test can provide unbiased data. This review summarizes basic facts about the colorimetric point-of-care tests, principles of how to use a portable device with a camera in the assay, applications of digital cameras for the current tests, and new devices described in the recent papers. An overview of the recent literature and a discussion of recent developments and future trends are provided.

The Influence of Hospital Type, Insurance Type, and Patient Income on 30-Day Complication and Readmission Rates Following Lumbar Spine Fusion

BACKGROUND CONTEXT

Several studies have shown that factors such as insurance type and patient income are associated with different readmission rates following certain orthopaedic procedures. The literature, however, remains sparse with regard to these demographic characteristics and their associations to perioperative lumbar spine fusion outcomes.

PURPOSE

The purpose of this study was to assess the associations between hospital type, insurance type, and patient median income to both 30-day complication and readmission rates following lumbar spine fusion.

PATIENT SAMPLE

Patients who underwent primary lumbar spine fusion (n = 596,568) from 2010-2016 were queried from the National Readmissions Database (NRD).

OUTCOME MEASURES

Incidence of 30-day complication and readmission rates.

METHODS

All relevant diagnoses and procedures were identified using International Classification of Disease, 9th and 10th Edition (ICD-9, 10) codes. Hospital types were categorized as metropolitan non-teaching (n = 212,131), metropolitan teaching (n = 364,752), and rural (n = 19,685). Insurance types included: Medicare (n = 213,534), Medicaid (n = 78,520), private insurance (n = 196,648), and out-of-pocket (n = 45,025). Patient income was divided into the following quartiles: Q1 (n = 112,083), Q2 (n = 145,755), Q3 (n = 156,276), and Q4 (n = 147,289), wherein quartile 1 corresponded to lower income ranges and quartile 4 to higher ranges. Statistical analysis was conducted in R. Kruskal-Wallis tests with Dunn's pairwise comparisons were performed to analyze differences in 30-day readmission and complication rates in patients who underwent lumbar spine fusion. Complications analyzed included infection, wound injury, hematoma, neurological injury, thromboembolic event, and hardware failure.

RESULTS

30-day readmission was significantly higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals and rural hospitals (P < .05). Patients from metropolitan teaching hospitals had significantly higher rates of infection (P < .001), wound injury (P < .001), hematoma (P = .018), and hardware failure (P < .002) compared to those treated at metropolitan non-teaching hospitals. Privately insured patients were significantly less likely to be readmitted at 30 days than those paying with Medicare or Medicaid (P < .01). Patients with private insurance also experienced significantly lower rates of hematoma formation than Medicare beneficiaries and out-of-pocket payers (P < .01), postoperative wound injury compared to Medicaid patients and out-of-pocket payers (P < .005), and infection compared to all other groups (P < .001). Patients in Quartile 4 experienced significantly greater rates of hematoma formation compared to those in Quartiles 1 and 2 and were more likely to experience a thromboembolic event compared to all other groups.

CONCLUSION

Patients undergoing lumbar spine fusion at metropolitan non-teaching hospitals and paying with private insurance had significantly lower 30-day readmission rates than their counterparts. Complications within 30 days following lumbar spine fusion were significantly higher in patients treated at metropolitan teaching hospitals and in Medicare and Medicaid beneficiaries. Aside from a few exceptions, however, patient income was generally not associated with differential complication rates.

Digital Storytelling as a Tool to Increase Colorectal Cancer Screening Intention in a Latinx Church Community

Although colorectal cancer screening (CRCS) rates have improved for all racial groups due to wider availability of screening, Latinx continue to have lower screening rates and are more likely to be diagnosed with later stages of colorectal cancer compared to non-Latinx whites. More culturally tailored educational interventions are needed to reach this population. This study introduced a digital storytelling (DST) intervention in a church community setting and explored its potential to influence CRCS intention and perception among Latinx and the acceptability of the DST intervention. Participants (n=20) between the ages of 50 and 75 who were not up-to-date with CRCS were recruited to view digital stories developed by fellow church members with previous CRCS experience. They completed surveys assessing their intention to complete CRCS before and after the viewing and were asked to participate in focus groups to understand, qualitatively, how the digital stories influenced their perceptions and intentions related to CRCS. Analysis of participant narratives revealed three overarching themes related to their perceptions and intentions of CRCS after the DST intervention: (1) the duality of the faith-health connection and fatalism, (2) willingness to consider other screening methods, and (3) the push-pull of individual barriers and interpersonal facilitators. Participants felt the DST intervention humanized the CRCS process and that it would be acceptable and well received in other church settings. The introduction of a community-based DST intervention within a church setting is a novel strategy with the potential to influence members of the Latinx church population to complete CRCS.

Trends in the Prevalence of Hepatitis C Infection During Pregnancy and Maternal-Infant Outcomes in the US, 1998 to 2018

Importance

Injection drug use is the primary risk factor for hepatitis C virus (HCV) infection in adults. More than one-third of newly reported HCV cases occur in women, particularly among persons aged 20 to 39 years. However, nationally representative data on HCV during pregnancy are limited.

Objective

To estimate the temporal trend of HCV-positive pregnancies during the opioid epidemic and identify HCV-associated maternal and perinatal outcomes.

Design, Setting, and Participants

A cross-sectional study was performed with data from the US, from calendar year 1998 through 2018. Data analysis was conducted from November 14, 2021, to May 14, 2023. Participants included women during in-hospital childbirth or spontaneous abortion in the National Inpatient Sample of the Healthcare Cost and Utilization Project.

Exposure

Maternal HCV infection.

Main Outcomes and Measures

The main outcome was the temporal trend, measured as change in the annual prevalence, in the prevalence of HCV positivity among pregnant women since the start of the opioid epidemic in the late 1990s. Secondary outcomes were the associations shown as relative odds between maternal HCV infection and maternal and perinatal adverse events.

Results

During the study period, more than 70 million hospital admissions resulted in childbirth or spontaneous abortion. Among them, 137 259 (0.20%; 95% CI, 0.19%-0.21%) involved mothers with HCV; these individuals were more often White (77.4%; 95% CI, 76.1%-78.6%), low-income (40.0%; 95% CI, 38.6%-41.5%), and likely to have histories of tobacco (41.7%; 95% CI, 40.6%-42.9%), alcohol (1.8%; 95% CI, 1.6%-2.0%), and opioid (28.9%; 95% CI, 27.3%-30.6%) use compared with HCV-negative mothers. The median age of women with HCV was 28.0 (IQR, 24.3-32.2) years, and the median age of HCV-negative women was 27.2 (IQR, 22.7-31.8) years. The prevalence of HCV-positive pregnancies increased 16-fold during the study period, reaching 5.3 (95% CI, 4.9-5.7) cases per 1000 pregnancies in 2018. Age-specific prevalence increases ranged from 3-fold (age, 41-50 years) to 31-fold (age, 21-30 years). Higher odds of cesarean delivery, preterm labor, poor fetal growth, or fetal distress were associated with HCV-positivity during pregnancy. However, no significant differences were observed in gestational diabetes, preeclampsia, eclampsia, or stillbirths.

Conclusions and Relevance

In this cross-sectional study, the prevalence of HCV-positive pregnancies increased markedly, and maternal HCV infection was associated with increased risks for adverse perinatal outcomes. These data may support recent recommendations for universal HCV screening with each pregnancy.

Cost-effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors for the Treatment of Heart Failure With Preserved Ejection Fraction

Importance

Adding a sodium-glucose cotransporter-2 inhibitor (SGLT2-I) to standard-of-care treatment in patients with heart failure with preserved ejection fraction (HFpEF) reduces the risk of a composite outcome of worsening heart failure or cardiovascular mortality, but the cost-effectiveness in US patients with HFpEF is uncertain.

Objective

To evaluate the lifetime cost-effectiveness of standard therapy plus an SGLT2-I compared with standard therapy in individuals with HFpEF.

Design, Setting, and Participants

In this economic evaluation conducted from September 8, 2021, to December 12, 2022, a state-transition Markov model simulated monthly health outcomes and direct medical costs. Input parameters including hospitalization rates, mortality rates, costs, and utilities were extracted from HFpEF trials, published literature, and publicly available data sets. The base-case annual cost of SGLT2-I was $4506. A simulated cohort with similar characteristics as participants of the Empagliflozin in Heart Failure With a Preserved Ejection Fraction (EMPEROR-Preserved) and Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction (DELIVER) trials was used.

Exposures

Standard of care plus SGLT2-I vs standard of care.

Main Outcomes and Measures

The model simulated hospitalizations, urgent care visits, and cardiovascular and noncardiovascular death. Future medical costs and benefits were discounted by 3% per year. Main outcomes were quality-adjusted life-years (QALYs), direct medical costs (2022 US dollars), and incremental cost-effectiveness ratio (ICER) of SGLT2-I therapy from a US health care sector perspective. The ICER of SGLT2-I therapy was evaluated according to the American College of Cardiology/American Heart Association value framework (high value: <$50 000; intermediate value: $50 000 to <$150 000; and low value: ≥$150 000).

Results

The simulated cohort had a mean (SD) age of 71.7 (9.5) years and 6828 of 12 251 participants (55.7%) were male. Standard of care plus SGLT2-I increased quality-adjusted survival by 0.19 QALYs at an increased cost of $26 300 compared with standard of care. The resulting ICER was $141 200 per QALY gained, with 59.1% of 1000 probabilistic iterations indicating intermediate value and 40.9% indicating low value. The ICER was most sensitive to SGLT2-I costs and effect of SGLT2-I therapy on cardiovascular death (eg, increasing to $373 400 per QALY gained if SGLT2-I therapy was assumed to have no effect on mortality).

Conclusions and Relevance

Results of this economic evaluation suggest that at 2022 drug prices, adding an SGLT2-I to standard of care was of intermediate or low economic value compared with standard of care in US adults with HFpEF. Efforts to expand access to SGLT2-I for individuals with HFpEF should be coupled with efforts to lower the cost of SGLT2-I therapy.

The Role of Title 1 Secondary School Athletic Trainers in the Primary and Patient-Centered Care of Low Socioeconomic Adolescents

Athletic trainers (ATs) provide regular encounters with a healthcare provider for many Title 1 student-athletes with healthcare access and quality barriers. Thus, they are uniquely positioned to serve as a student-athletes' first point of contact for general medical concerns. This study aimed to describe ATs' experiences providing primary care for Title 1 student-athletes. This qualitative design employing an interpretative phenomenological analysis (IPA) approach used in-depth, virtual focus groups to examine the experiences of ATs practicing at Title 1 secondary schools. The findings reveal that ATs were called upon to evaluate, treat, and, when necessary, refer student-athletes with general medical conditions. However, Title 1 ATs encountered numerous complex social determinants of health (SDoH) preventing efficient and effective referral to specialty healthcare providers. Thus, ATs ultimately felt their most important roles in the primary care of low socioeconomic adolescents were as caregivers who mitigated avoidable healthcare barriers in addition to coordinators of integrated care that assisted student-athletes and their families with navigating the healthcare system. Title I ATs need to be aware of the SDoH affecting their student-athletes and the ability of those SDoH to affect health outcomes as well as overall student-athlete health and well-being.

An evaluation of pelvic floor disorders in a public and private healthcare setting

INTRODUCTION AND HYPOTHESIS

The objectives were to determine whether a difference exists in the duration of pelvic floor disorder (PFD) symptoms among patients presenting to urogynecologists in two healthcare systems: private and county; and to elucidate differences in baseline characteristics, type of PFDs, symptom severity and management, stratified by healthcare plans.

METHODS

A multi-center retrospective study was conducted including new patients presenting to three urogynecology clinics between March 2016 and May 2018: one private clinic (site A) and two public clinics in the same county healthcare system (sites B and C). Baseline data included age, race, BMI, parity, and comorbidities. Primary outcome was "time to presentation" defined as PFD duration in months. Secondary outcomes were symptom severity and PFD management, analyzed by healthcare setting and insurance type.

RESULTS

A total of 1,055 private and 439 public patients were included. Patients in the public setting were younger (54 vs 61 years, p<0.001), largely Hispanic (76% vs 14%, p<0.001), of higher parity (4 vs 3, p=0.001), and had more comorbidities, with a predominance of county-funded healthcare plans. There was no difference in duration of symptoms between the public and private groups respectively (54 vs 56 months, p=0.94). Patients in the public setting had more severe urinary incontinence (3 vs 2 pads/day, p<0.001) and prolapse (stages 3-4, 71% vs 61%, p=0.004); however, they had lower rates of surgical management for stress incontinence and prolapse. Differences in fecal incontinence could not be evaluated owing to small sample size.

CONCLUSIONS

Public patients presented younger with more severe symptoms but had lower rates of surgery for PFDs traditionally managed surgically.

"Why is it so necessary?": African American Parents' Perspectives on Delaying and Refusing HPV Vaccination

INTRODUCTION

This study aimed to describe the perspectives of parents who had delayed and refused human papillomavirus (HPV) vaccination for their children, even when it was discussed or recommended by a health care provider, and to identify the factors related to vaccine hesitancy.

METHOD

Twenty predominantly African American parents of children aged 11-17 years were recruited from various community clinics and organizations to participate in focus groups about their decision-making regarding HPV vaccination. Using deductive content analysis and the Vaccine Hesitancy Determinants Matrix, we describe their perspectives and influences on vaccination decision-making.

RESULTS

Multiple reasons emerged, which included concerns about the age of children, perceived discrimination and mistrust based on race and socioeconomic status, and vaccine safety.

DISCUSSION

Findings support the development of targeted interventions that address vaccine safety concerns, mistrust, patient-provider communication, and parent education about the benefits of HPV vaccination.

Risk Factors for Pediatric Sepsis in the Emergency Department: A Machine Learning Pilot Study

OBJECTIVE

To identify underappreciated sepsis risk factors among children presenting to a pediatric emergency department (ED).

METHODS

A retrospective observational study (2017-2019) of children aged 18 years and younger presenting to a pediatric ED at a tertiary care children's hospital with fever, hypotension, or an infectious disease International Classification of Diseases (ICD)-10 diagnosis. Structured patient data including demographics, problem list, and vital signs were extracted for 35,074 qualifying ED encounters. According to the Improving Pediatric Sepsis Outcomes Classification, confirmed by expert review, 191 patients met clinical sepsis criteria. Five machine learning models were trained to predict sepsis/nonsepsis outcomes. Top features enabling model performance (N = 20) were then extracted to identify patient risk factors.

RESULTS

Machine learning methods reached a performance of up to 93% sensitivity and 84% specificity in identifying patients who received a hospital diagnosis of sepsis. A random forest classifier performed the best, followed by a classification and regression tree. Maximum documented heart rate was the top feature in these models, with importance coefficients (ICs) of 0.09 and 0.21, which represent how much an individual feature contributes to the model. Maximum mean arterial pressure was the second most important feature (IC 0.05, 0.13). Immunization status (IC 0.02), age (IC 0.03), and patient zip code (IC 0.02) were also among the top features enabling models to predict sepsis from ED visit data. Stratified analysis revealed changes in the predictive importance of risk factors by race, ethnicity, oncologic history, and insurance status.

CONCLUSIONS

Machine learning models trained to identify pediatric sepsis using ED clinical and sociodemographic variables confirmed well-established predictors, including heart rate and mean arterial pressure, and identified underappreciated relationships between sepsis and patient age, immunization status, and demographics.

Barriers to Breast Cancer-Screening Adherence in Vulnerable Populations

Breast cancer screening through periodic mammography has been effective in decreasing mortality and reducing the impact of this disease. However, adherence to screening does not meet the desired expectations from all populations. The main objective of this review is to explore the barriers that affect adherence to breast cancer-screening programs in vulnerable populations according to race and/or ethnicity in order to propose measures to reduce the lack of adherence. We conducted a search of publications in the PubMed Central and Scopus databases. The eligible criteria for the articles were as follows: original quantitative studies appearing in SJR- and/or JCR-indexed journals from 2016 to 2021 in English or Spanish. Most of them present common barriers, such as race/ethnicity (47%), low socioeconomic (35.3%) and educational levels (29.4%), no family history of cancer and being single (29.4%), medical mistrust and a health information gap (23.5%), lack of private health insurance (17.6%) and not having annual health checks (17.6%). The target populations with the lowest adherence were Black, Asian, Hispanic and foreign women. Implementing awareness campaigns focused on these populations should be promoted, as well as working on diversity, cultural acceptance and respect with healthcare workers, in order to improve breast cancer-screening adherence worldwide.

Addressing Financial Barriers to Health Care Among People Who are Low-Income and Insured in New York City, 2014–2017

While health care-associated financial burdens among uninsured individuals are well described, few studies have systematically characterized the array of financial and logistical complications faced by insured individuals with low household incomes. In this mixed methods paper, we conducted 6 focus groups with a total of 55 residents and analyzed programmatic administrative records to characterize the specific financial and logistic barriers faced by residents living in public housing in East and Central Harlem, New York City (NYC). Participants included individuals who enrolled in a municipal community health worker (CHW) program designed to close equity gaps in health and social outcomes. Dedicated health advocates (HAs) were explicitly paired with CHWs to provide health insurance and health care navigational assistance. We describe the needs of 150 residents with reported financial barriers to care, as well as the navigational and advocacy strategies taken by HAs to address them. Finally, we outline state-level policy recommendations to help ameliorate the problems experienced by participants. The model of paired CHW–HAs may be helpful in addressing financial barriers for insured populations with low household income and reducing health disparities in other communities.

A Qualitative Study of Two Oregon Family Medicine Clinics to Explain Parent and Child Healthcare Initiation and Engagement

Background: Parental factors are associated with children's receipt of recommended care but not adequately described. Methods: We conducted a qualitative study of patients with at least two visits who were a primary caregiver for a child who also had at least two visits at the same clinic in 1/2018-12/2019 from two Oregon family medicine clinics. We stratified patients by child age and number of caregiver visits and randomly selected caregivers. Participants were interviewed in accordance with approval by our Institutional Review Board between 12/2020 and 4/2021. The data were analyzed using a grounded theory approach. Results: 12 caregivers (termed parents) were interviewed; half were single parents and three-quarters had a history of substance use disorder and/or a mental health condition. Parents focused on the importance of keeping themselves healthy to keep their families healthy. They described similar reasons for choosing to initiate and continue care for themselves and their children at the same clinic, including: convenience, trust, relationships, and receiving whole-person and whole-family care. Many valued having a healthcare "home" for their entire family. We developed a figure that highlights three themes that capture the interrelated factors parents identified as supporting healthcare use for themselves and their families. These overarching themes included: healthcare initiation; healthcare engagement and continuity; and parent bringing child to the same clinic for healthcare. Conclusion: Our data suggests that long-standing patient-clinic relationships for parents and children can support family-focused healthcare.

Reaching Target Communities in a Community Preschool Vision Screening Program

PURPOSE

To develop a method to identify preschools with the greatest need for vision screening, correlations between socioeconomic status, preschool capacity, and rates of pediatric vision screenings performed by a community vision screening program were investigated. Geoinformatics mapping software was used to visually display the areas of greatest need.

METHODS

Vision screening data from a community vision screening program, child care facility data from California Department of Social Services, and income data from the U.S. Census Bureau through ArcGIS software (Esri) were collected. When possible, data were consolidated at the ZIP code level. Kolmogorov-Smirnov analysis was used to determine correlations between data elements. Licensed child care facilities were scored on a scale (from 1 to 5) based on the socioeconomic status of the ZIP code and the facility capacity. The scoring system prioritized larger facilities in lower income communities to most efficiently use vision screening program resources.

RESULTS

There was a positive correlation between the capacity of the child care facility and the median household income (P = .005). Second, we found a positive correlation between child care capacity and the median household income (P = .005). Licensed child care facilities were mapped and colored using GIS software according to their cumulative score.

CONCLUSIONS

Challenges to vision screening in under-served communities include the lack of child care facilities and smaller facility size. The use of a scoring system and mapping software can direct vision screening programs to reach a greater number of children with the most efficient use of resources. [J Pediatr Ophthalmol Strabismus. 2022;59(6):375-379.].

Inequities in spatial accessibility to COVID-19 testing in 30 large US cities

Testing for SARS-CoV-2 infection has been a key strategy to mitigate and control the COVID-19 pandemic. Wide spatial and racial/ethnic disparities in COVID-19 outcomes have emerged in US cities. Previous research has highlighted the role of unequal access to testing as a potential driver of these disparities. We described inequities in spatial accessibility to COVID-19 testing locations in 30 large US cities. We used location data from Castlight Health Inc corresponding to October 2021. We created an accessibility metric at the level of the census block group (CBG) based on the number of sites per population in a 15-minute walkshed around the centroid of each CBG. We also calculated spatial accessibility using only testing sites without restrictions, i.e., no requirement for an appointment or a physician order prior to testing. We measured the association between the social vulnerability index (SVI) and spatial accessibility using a multilevel negative binomial model with random city intercepts and random SVI slopes. Among the 27,195 CBG analyzed, 53% had at least one testing site within a 15-minute walkshed, and 36% had at least one site without restrictions. On average, a 1-decile increase in the SVI was associated with a 3% (95% Confidence Interval: 2% - 4%) lower accessibility. Spatial inequities were similar across various components of the SVI and for sites with no restrictions. Despite this general pattern, several cities had inverted inequity, i.e., better accessibility in more vulnerable areas, which indicates that some cities may be on the right track when it comes to promoting equity in COVID-19 testing. Testing is a key component of the strategy to mitigate transmission of SARS-CoV-2 and efforts should be made to improve accessibility to testing, particularly as new and more contagious variants become dominant.

Where Have All the FLOWERS Gone? A Multicenter Investigation of Frequent Users of Midwest Emergency Department Services During the COVID-19 Stay-at-home Orders

Introduction: In this study we aimed to determine the impact of the mandatory coronavirus disease 2019 (COVID-19) pandemic stay-at-home order on the proportional makeup of emergency department (ED) visits by frequent users and super users. Methods: We conducted a secondary analysis of existing data using a multisite review of the medical records of 280,053 patients to measure the impact of the COVID-19 pandemic stay-at-home order on ED visits. The primary outcomes included analysis before and during the lockdown in determining ED use and unique characteristics of non-frequent, frequent, and super users of emergency services. Results: During the mandatory COVID-19 stay-at-home order (lockdown), the percentage of frequent users increased from 7.8% (pre-lockdown) to 21.8%. Super users increased from 0.7% to 4.7%, while non-frequent users dropped from 91.5% to 73.4%. Frequent users comprised 23.7% of all visits (4% increase), while super user encounters (4.7%) increased by 53%. Patients who used Medicaid and Medicare increased by 39.3% and 4.6%, respectively, while those who were uninsured increased ED use by 190.3% during the lockdown. Conclusion: When barriers to accessing healthcare are implemented as part of a broader measure to reduce the spread of an infectious agent, individuals reliant on these services are more likely to seek out the ED for their medical needs. Policymakers considering future pandemic planning should consider this finding to ensure that vital healthcare resources are allocated appropriately.

Cost Burden Impacts Cancer Patient Service Utilization Behavior in a US Commercial Plan

Objectives: The burden of affording high-cost medical treatment (eg, cancer therapy) may impact whether some patients choose to access other needed health services within US commercial plans. However, deferring needed care for a mental or behavioral health (M/BH) condition could result in preventable hospital utilization. This research investigates how income level and total out-of-pocket costs (OOPC) interact to influence the service utilization behavior of insured adult cancer patients with a comorbid M/BH diagnosis. Methods: A cross-sectional, retrospective analysis was performed using medical service claims (July 2017-June 2018) and administrative data from eligible members of a large US commercial health benefits plan ( N =5,054). Nonparametric tests were used to examine variation in mean utilization by patient income level and OOPC decile. Negative binomial regression modeling was performed to analyze independent variable effects on count outcomes for outpatient behavioral visits and emergency department (ED) visits. Results: There was significant variation in patient service utilization by income level and total OOPC. Overall, as OOPC increased patients used less outpatient behavioral care ( p <.000). Compared to average and higher incomes, those with lower incomes (<$50,000/year) utilized significantly fewer outpatient visits ( p <.000) and significantly more ED visits ( p <.001) relative to increasing OOPC. Conclusions: The interaction of income level and OOPC (ie, cost burden) could inhibit patients' decision to access supportive behavioral care in the commercial plan. The cumulative cost burden from cancer treatment may promote underutilization of outpatient services and greater ED reliance, particularly among lower income plan members.

Effectiveness of Preoperative Symptom Screening in Identifying Pediatric SARS-CoV-2 Infections: A Retrospective Cohort Analysis

Evidence-based protocols identifying COVID-19 cases in pediatric preoperative settings are lacking. With COVID-19 positioned to remain a threat to children, this study examines effectiveness of preoperative COVID-19 symptom screening in pediatric patients.

The Effects of a Prenatal Mindfulness Intervention on Infant Autonomic and Behavioral Reactivity and Regulation

OBJECTIVE

Maternal health and wellness during pregnancy are associated with long-term health outcomes in children. The current study examined whether infants of women who participated in a mindfulness-based intervention during pregnancy that reduced levels of stress and depression, increased physical activity, and improved glucose tolerance differed on biobehavioral markers of psychopathological and physical health risk compared with infants of women who did not.

METHODS

Participants were 135 mother-infant dyads drawn from a racially and ethnically diverse, low-income sample experiencing high stress. The women participated in an intervention trial during pregnancy that involved assignment to either mindfulness-based intervention or treatment-as-usual (TAU). Infants of women from both groups were assessed at 6 months of age on sympathetic (preejection period), parasympathetic (respiratory sinus arrhythmia), and observed behavioral (negativity and object engagement) reactivity and regulation during the still face paradigm. Linear mixed-effects and generalized linear mixed-effects models were used to examine treatment group differences in infant outcomes.

RESULTS

Relative to those in the intervention group, infants in the TAU group showed a delay in sympathetic activation and subsequent recovery across the still face paradigm. In addition, infants in the intervention group engaged in higher proportions of self-regulatory behavior during the paradigm, compared with the TAU group. No significant effect of intervention was found for parasympathetic response or for behavioral negativity during the still face paradigm.

CONCLUSIONS

Findings provide evidence that maternal participation in a short-term, group mindfulness-based intervention during pregnancy is associated with the early development of salutary profiles of biobehavioral reactivity and regulation in their infants. Because these systems are relevant for psychopathology and physical health, prenatal behavioral interventions may benefit two generations.

Health Insurance Literacy Perceptions and the Needs of a Working-Class Community

Background:

Despite increases in the number of insured Americans, consumers continue to face barriers in accessing care. Low levels of health insurance literacy (HIL) are associated with suboptimal use of health insurance coverage. There remains a need to further contextualize the relationship between HIL and access to care, especially among insured working-class people.

Objective

This study was conducted to understand the pathways through which HIL affects health care decision-making and access to care in an urban working-class population.

Methods:

Using a qualitative descriptive approach, we conducted five focus groups with 45 adult residents of South Louisville, Kentucky. The questions explored participants' experiences of insurance enrollment, use, and health care system navigation, as well as their perceptions and needs regarding accessing health insurance information. Using inductive thematic analysis, transcripts were open coded independently by team members, a focused coding framework was agreed upon, and emergent themes were identified through constant comparison techniques.

Key Results:

Most participants placed high value on their insurance, considering it the most important benefit employers offer. Despite having adequate HIL, most participants expressed frustration with the amount of time and effort they spent to determine the best insurance plan, obtain covered health services, and settle claims, often with ineffective results. Despite having insurance, cost considerations influenced many participants' decisions to accept certain tests or treatments, in some cases resulting in delayed or foregone care.

Conclusions:

The findings of this qualitative study indicate that obtaining health care is strongly influenced both by the individual context of HIL knowledge, experience, and life circumstances, and by the structural context of the complex, bureaucratic, and costly health care system. Interventions to improve HIL should include practical examples and real-life scenarios, because HIL gained from experiential narratives was the most useful in navigating the health care system.[HLRP: Health Literacy Research and Practice. 2022;6(2):e61–e69.]

Plain Language Summary:

By conducting focus groups with a working-class population, this study contextualizes the pathways through which HIL affects consumers' health care decision-making and access to care. Findings demonstrate that obtaining health care is strongly influenced both by the individual context of HIL knowledge, experience, and life circumstances, and by the structural context of the complex, bureaucratic, and costly health care system.

Telehealth Adoption by Mental Health and Substance Use Disorder Treatment Facilities in the COVID-19 Pandemic

OBJECTIVE

The study examined temporal and geographic trends in telehealth availability at U.S. behavioral health treatment facilities and risk factors for not offering telehealth.

METHODS

Longitudinal data on 15,691 outpatient behavioral health treatment facilities were extracted daily from the Substance Abuse and Mental Health Services Administration's Behavioral Health Treatment Services Locator between January 20, 2020, and January 20, 2021. Facilities operated by the Department of Veterans Affairs were excluded. Bivariate analyses were used to assess trends in telehealth availability in 2020 and 2021. Multivariable regression analysis was used to examine facility- and county-level characteristics associated with telehealth availability in 2021.

RESULTS

Telehealth availability increased by 77% from 2020 to 2021 for mental health treatment facilities and by 143% for substance use disorder treatment facilities. By January 2021, 68% of outpatient mental health facilities and 57% of substance use disorder treatment facilities in the sample were offering telehealth. Mental health and substance use disorder treatment facilities that did not accept Medicaid as a form of payment were less likely to offer telehealth in 2021, compared with facilities that accepted Medicaid. Mental health and substance use disorder treatment facilities that accepted private insurance were more likely to offer telehealth in 2021, compared with facilities that did not accept private insurance.

CONCLUSIONS

Although 2020 saw a dramatic increase in telehealth availability at behavioral health treatment facilities, 32% of mental health treatment facilities and 43% of substance use disorder treatment facilities did not offer telehealth in January 2021, nearly 1 year into the pandemic.

Beyond Disease Intervention: Exploring an Expanded Role for Partner Services in the MATRix-NC Demonstration Project

BACKGROUND

Disease intervention specialists (DIS) provide partner services for sexually transmitted infections (STIs). We assessed an expansion of DIS services for clients with HIV and/or syphilis, and contacts within their social and sexual networks.

METHODS

Black and Latinx cisgender men and transgender women who have sex with men diagnosed with HIV and/or syphilis in 4 urban North Carolina counties were referred to designated DIS, who were trained to recruit clients as "seeds" for chain-referral sampling of sociosexual network "peers." All received HIV/STI testing and care; referrals for preexposure prophylaxis (PrEP) and social, behavioral, and non-STI medical services were offered. Participants completed baseline, 1-month, and 3-month computerized surveys.

RESULTS

Of 213 cases referred to DIS from May 2018 to February 2020, 42 seeds (25 with syphilis, 17 with HIV) and 50 peers participated. Median age was 27 years; 93% were Black and 86% were cisgender men. Most peers came from seeds' social networks: 66% were friends, 20% were relatives, and 38% were cisgender women. Incomes were low, 41% were uninsured, and 10% experienced recent homelessness. More seeds than peers had baseline PrEP awareness; attitudes were favorable, but utilization was poor. Thirty-seven participants were referred for PrEP 50 times; 17 (46%) accessed PrEP by month 3. Thirty-nine participants received 129 non-PrEP referrals, most commonly for housing assistance, primary care, Medicaid navigation, and food insecurity.

CONCLUSIONS

Chain-referral sampling from partner services clients allowed DIS to access persons with significant medical and social service needs, demonstrating that DIS can support marginalized communities beyond STI intervention.

Examining access to care in clinical genomic research and medicine: Experiences from the CSER Consortium

Introduction:

Ensuring equitable access to health care is a widely agreed-upon goal in medicine, yet access to care is a multidimensional concept that is difficult to measure. Although frameworks exist to evaluate access to care generally, the concept of “access to genomic medicine” is largely unexplored and a clear framework for studying and addressing major dimensions is lacking.

Methods:

Comprised of seven clinical genomic research projects, the Clinical Sequencing Evidence-Generating Research consortium (CSER) presented opportunities to examine access to genomic medicine across diverse contexts. CSER emphasized engaging historically underrepresented and/or underserved populations. We used descriptive analysis of CSER participant survey data and qualitative case studies to explore anticipated and encountered access barriers and interventions to address them.

Results:

CSER’s enrolled population was largely lower income and racially and ethnically diverse, with many Spanish-preferring individuals. In surveys, less than a fifth (18.7%) of participants reported experiencing barriers to care. However, CSER project case studies revealed a more nuanced picture that highlighted the blurred boundary between access to genomic research and clinical care. Drawing on insights from CSER, we build on an existing framework to characterize the concept and dimensions of access to genomic medicine along with associated measures and improvement strategies.

Conclusions:

Our findings support adopting a broad conceptualization of access to care encompassing multiple dimensions, using mixed methods to study access issues, and investing in innovative improvement strategies. This conceptualization may inform clinical translation of other cutting-edge technologies and contribute to the promotion of equitable, effective, and efficient access to genomic medicine.

Social Determinants of Health May Predict End of Life Portable Orders for Life Sustaining Treatment Form Completion and Treatment Selections

BACKGROUND

End of life (EOL) care planning is important for aging adults given the growing prevalence of chronic medical conditions in the US. The Portable Orders for Life Sustaining Treatment (POLST) program promotes communication between clinicians and patients with advanced illness about EOL treatment preferences. Despite growing resources for EOL care, utilization remains unequal based on social determinants of health (SDOH), including race, language, urbanization, and education. We evaluated the relationship between POLST form selections and completion rates and SDOH.

METHODS

Oregon POLST Registry and American Community Survey data from 2013 to 2017 were analyzed retrospectively. POLST form completion rates and selections, and various SDOH, including age, income, insurance status, urbanization, etc. were recorded. Data were merged based on ZIP codes and analyzed using χ² or Wilcoxon-Mann-Whitney tests. Logistic regression was performed.

RESULTS

127,588 POLST forms from 319 ZIP codes were included. POLST form completion rates were highest among urban ZIP codes, and urban registrants more often selected CPR and full treatment. ZIP codes with higher incomes tended to select CPR. ZIP codes with higher rates of private insurance completed POLST forms, and selected CPR and full treatment more frequently. ZIP codes with higher rates of Bachelor's degrees (or higher) completed POLST forms and selected full treatment more frequently.

CONCLUSIONS

Various SDOH-specifically, urbanization, insurance status, income level and educational level achieved-may influence POLST form completion rates and selections. The expanding socioeconomic diversity and growth of urban communities, highlight the need for broader access to EOL planning and POLST.

Increased morbidity and mortality of hepatocellular carcinoma patients in lower cost of living areas

BACKGROUND

The incidence and mortality rates of hepatocellular carcinoma (HCC) are increasing in the United States. However, the increases in different racial and socioeconomic groups have not been homogeneous. Access to healthcare based on socioeconomic status and cost of living index (COLI), especially in HCC management, is under characterized.

AIM

The aim was to investigate the relationship between the COLI and tumor characteristics, treatment modalities, and survival of HCC patients in the United States.

METHODS

A retrospective study of the Surveillance, Epidemiology, and End Results (SEER) database was conducted to identify patients with HCC between 2007 and 2015 using site code C22.0 and the International Classification of Disease for Oncology, 3rd edition (ICD-O-3) codes 8170-8173, and 8175. Cases of fibrolamellar HCC were excluded. Variables collected included demographics, COLI, insurance status, marital status, stage, treatment, tumor size, and survival data. Interquartile ranges for COLI were obtained. Based on the COLI, the study population was separated into four groups: COLI ≤ 901, 902-1044, 1045-1169, ≥ 1070. The χ² test was used to compare categorical variables, and the Kruskal-Wallis test was used to compare continuous variables without normal distributions. Survival was estimated by the Kaplan-Meier method. We defined P < 0.05 as statistically significant.

RESULTS

We identified 47,894 patients with HCC. Patients from the highest COLI areas were older (63 vs 61 years of age), more likely to be married (52.8% vs 48.0%), female (23.7% vs 21.1%), and of Asian and Pacific Islander descent (32.7% vs 4.8%). The patients were more likely to have stage I disease (34.2% vs 32.6%), tumor size ≤ 30 mm (27.1% vs 23.1%), received locoregional therapy (11.5% vs 6.1%), and undergone surgical resection (10.7% vs 7.0%) when compared with the lowest quartile. The majority of patients with higher COLIs resided in California, Connecticut, Hawaii, and New Jersey. Patients with lower COLIs were more likely to be uninsured (5.7% vs 3.4%), have stage IV disease (15.2% vs 13%), and have received a liver transplant (6.6% vs 4.4%) compared with patients from with the highest COLI. Median survival increased with COLI from 8 (95%CI: 7-8), to 10 (10-11), 11 (11-12), and 14 (14-15) mo (P < 0.001) among patients with COLIs of ≤ 901, 902-1044, 1045-1169, ≥ 1070, respectively. After stratifying by year, a survival trend was present: 2007-2009, 2010-2012, and 2013-2015.

CONCLUSION

Our study suggested that there were racial and socioeconomic disparities in HCC. Patients from lower COLI groups presented with more advanced disease, and increasing COLI was associated with improved median survival. Future studies should examine this further and explore ways to mitigate the differences.

Reach and Power of Physician-Initiated Tweets in a Twitter Inflammatory Bowel Disease Community

Background

Inflammatory bowel disease (IBD) specialist Twitter engagement and thematic content was assessed.

Methods

The nature of interaction between IBD specialists and users who responded to them was analyzed based on (1) content analysis of stakeholders who responded to them; (2) nature of interaction through a manual thematic content analysis of IBD specialist tweets and responses; (3) prominence of interaction by employing descriptive analysis and statistical inferences relative to the number of replies, likes, and retweets. Analyzed samples included of tweets (n = 320) compiled from 16 IBD specialists, and associated replies (n = 299), retweets (n = 869), and likes (n = 4068).

Results

Healthcare professionals (HCPs) more often engaged with peer-HCPs, compared to other stakeholders. When it comes to the nature of exchanges, of original tweets, the most common content was for knowledge sharing (58%) and endorsement (28%). In the knowledge sharing category, research accounted for more than half of those tweets (53%). Of replies, knowledge sharing occurred most frequently with a subtheme of IBD management (62%).

Conclusions

HCP-HCP Twitter engagement was more frequent than HCP-other Twitter stakeholder interaction. The primary purpose for this engagement was found to obtain real-time information, professionally network, and disseminate research.

Risk and implications of COVID-19 among the community supervised population

RESEARCH SUMMARY

Despite growing national awareness that COVID-19 in jails and prisons constitutes a public health emergency in the United States, remarkably little attention has been paid to understanding how the virus affects people under community supervision. We used data from the National Survey on Drug Use and Health (NSDUH) to explore differences in the extent to which men under community supervision are vulnerable to COVID-19 and have access to care during the pandemic, relative to men who are not involved with the U.S. criminal legal system. Results from this study highlight the greater levels of risk for serious illness or death from COVID-19 and the disproportionate lack of health insurance among men under community supervision.

POLICY IMPLICATIONS

Jurisdictions across the United States are currently relying on decarceration to contain the spread of COVID-19 in jails and prisons. Decarceration efforts alone, however, are insufficient for addressing the spread of COVID-19 among people involved with the U.S. criminal legal system. People released from jails and prisons or diverted from incarceration during the pandemic must be given the opportunity to receive the COVID-19 vaccination upon their transitions. Likewise, individuals under community supervision must be prioritized for immediate vaccination against COVID-19. People involved with the U.S. criminal legal system should also be eligible for emergency Medicaid during the COVID-19 crisis, and their health insurance coverage should remain available beyond the pandemic.

Forgoing Care in Southernmost Texas: Compounding Hardship and Health Among Latinx Immigrant Border Residents

This study examines how material hardship and perceived discrimination are associated with health care access and self-rated health among lower Rio Grande Valley residents. Of respondents to surveys administered at 2 clinic systems (N = 546), approximately 67% reported forgoing medical care in the past 12 months. Regression results suggested that perceived discrimination (odds ratio [OR] = 1.05, P < .05) and material hardship (OR = 1.63, P < .001) increased the odds of forgoing care. Also, discrimination (OR = 1.04, P < .01) and material hardship (OR = 1.24, P < .001) were independently associated with worse self-rated health. Service providers should consider screening for hardship experiences to target resources to address these stressors on patient health.

COVID-19 Testing and Social Determinants of Health Among Disadvantaged Baltimore Neighborhoods: A Community Mobile Health Clinic Outreach Model

The objective was to summarize data on coronavirus disease 2019 (COVID-19) testing uptake, social determinants of health, and patient satisfaction with mobile health clinic services within underserved minority and low-income communities. This COVID-19 pilot project was conducted during June and July 2020 in low-income residential neighborhoods in West Baltimore, Maryland. Quantitative data were collected and assessed cross-sectionally. Demographically, 85% of the patients identified as Black or African American (n = 265) and 58.2% as female (n = 184). The COVID-19 test was administered by the registered nurse to 78.2% (n = 288) of the patients. More than 90% of patients confirmed high levels of satisfaction with the services they received from the community mobile health clinic. Social determinants were assessed and females reported significantly worse health literacy than their male counterparts (P < 0.05). Study findings suggest that the community mobile health clinic model was effective in attracting hard-to-reach and marginalized individuals, who otherwise may have gone untested or undiagnosed. This care delivery model can be one solution to disparities by improving access to COVID-19 testing and primary care for communities with higher vulnerability to COVID-19 complications.

Assessing Colorectal Cancer Screening Barriers in Rural Appalachia

OBJECTIVES

The age-appropriate colorectal cancer (CRC) screening rate in the rural Appalachian area is low compared with the national rate, which may account for the overall higher incidence of CRC in this area. The purpose of this study was to explore potential barriers to CRC screening in the West Virginia Appalachian area.

METHODS

A cross-sectional survey was designed to identify patient-reported barriers to CRC screening using the health belief model to assess their attitudes and behaviors. Autonomous paper-based surveys were randomly handed to individuals older than 50 years at various locations, including healthcare and nonhealthcare facilities. All of the responses were then categorized into two groups: the screened group and the unscreened group. Differences among both groups were statistically analyzed.

RESULTS

There were three main areas that significantly accounted for the discrepancies between the screened and unscreened groups: perceptions of discomfort from screening tests, psychological and behavior deterrents in CRC screening and diagnosis, and limited resources for accessing care, especially transportation. In particular, psychological and behavioral deterrents in CRC screening appeared to play a role in promoting aversion to CRC screening.

CONCLUSIONS

Lack of CRC screening awareness and knowledge may be responsible for fatalism regarding CRC and aversion to screening. Thus, multidisciplinary interventions that provide education about CRC screening, early intervention prognosis, and treatment options, as well as addressing systemic barriers to screening, such as assistance with scheduling, prep instructions, and transportation, can improve the screening rate in Appalachia and eventually lead to better outcomes through the early diagnosis of CRC.

Interventions to increase patient portal use in vulnerable populations: a systematic review

BACKGROUND

More than 100 studies document disparities in patient portal use among vulnerable populations. Developing and testing strategies to reduce disparities in use is essential to ensure portals benefit all populations.

OBJECTIVE

To systematically review the impact of interventions designed to: (1) increase portal use or predictors of use in vulnerable patient populations, or (2) reduce disparities in use.

MATERIALS AND METHODS

A librarian searched Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Reviews for studies published before September 1, 2018. Two reviewers independently selected English-language research articles that evaluated any interventions designed to impact an eligible outcome. One reviewer extracted data and categorized interventions, then another assessed accuracy. Two reviewers independently assessed risk of bias.

RESULTS

Out of 18 included studies, 15 (83%) assessed an intervention's impact on portal use, 7 (39%) on predictors of use, and 1 (6%) on disparities in use. Most interventions studied focused on the individual (13 out of 26, 50%), as opposed to facilitating conditions, such as the tool, task, environment, or organization (SEIPS model). Twelve studies (67%) reported a statistically significant increase in portal use or predictors of use, or reduced disparities. Five studies (28%) had high or unclear risk of bias.

CONCLUSION

Individually focused interventions have the most evidence for increasing portal use in vulnerable populations. Interventions affecting other system elements (tool, task, environment, organization) have not been sufficiently studied to draw conclusions. Given the well-established evidence for disparities in use and the limited research on effective interventions, research should move beyond identifying disparities to systematically addressing them at multiple levels.

Frequency and source of prescription eyewear insurance coverage in Ontario: a repeated population-based cross-sectional study using survey data

BACKGROUND

Insurance coverage may reduce cost barriers to obtain vision correction. Our aim was to determine the frequency and source of prescription eyewear insurance to understand how Canadians finance optical correction.

METHODS

We conducted a repeated population-based cross-sectional study using 2003, 2005 and 2013-2014 Canadian Community Health Survey data from respondents aged 12 years or older from Ontario, Canada. In this group, the cost of prescription eyewear is not covered by the government unless one is registered with a social assistance program or belongs to a specific population. We determined the frequency and source of insurance coverage for prescription eyewear in proportions. We used survey weights provided by Statistics Canada in all analyses to account for sample selection, a complex survey, and adjustments for seasonal effect, poststratification, nonresponse and calibration. We compared unadjusted proportions and adjusted prevalence ratios (PRs) of having insurance.

RESULTS

Insurance covered all or part of the costs of prescription eyewear for 62% of Ontarians in all 3 survey years. Of those insured, 84.1%-86.0% had employer-sponsored coverage, 9.0%-10.3% had government-sponsored coverage, and 5.7%-6.8% had private plans. Employer-sponsored coverage remained constant for those in households with postsecondary graduation but decreased significantly for those in households with less than secondary school graduation, from 67.0% (95% confidence interval [CI] 63.2%-70.8%) (n = 175 000) in 2005 to 54.6% (95% CI 50.1%-59.2%) (n = 123 500) in 2013-2014. Government-sponsored coverage increased significantly for those in households with less than secondary school graduation, from 29.2% (95% CI 25.5%-32.9%) (n = 76 400) in 2005 to 41.7% (95% CI 37.2%-46.1%) (n = 93 900) in 2013-2014. In 2013-2014, Ontarians in households with less than secondary school graduation were less likely than those with secondary school graduation to report employer-sponsored coverage (adjusted PR 0.79, 95% CI 0.75-0.84) but were more likely to have government-sponsored coverage (adjusted PR 1.27, 95% CI 1.06-1.53).

INTERPRETATION

Sixty-two percent of Ontarians had prescription eyewear insurance in 2003, 2005 and 2013-2014; the largest source of insurance was employers, primarily covering those with higher education levels, whereas government-sponsored insurance increased significantly among those with lower education levels. Further research is needed to elucidate barriers to obtaining prescription eyewear and the degree to which affordability impairs access to vision correction.

Gestational weight gain disparities in South Carolina: Temporal trends, 2004-2015

BACKGROUND

Few studies have examined secular trends in gestational weight gain (GWG) and findings are inconsistent. Parallel to increasing trends in pre-pregnancy obesity, we hypothesised similar increasing GWG trends.

OBJECTIVES

The study examined trends in GWG in South Carolina (SC), using methods to reduce bias. We also examined whether the 12-year trends in GWG varied according to race/ethnicity and pre-pregnancy weight.

METHODS

Data came from SC birth certificates, 2004 to 2015. We calculated standardised GWG z-scores (GWGZ), using smoothed reference values to account for gestational age and pre-pregnancy body mass index. Quantile regression was used to examine trends in GWGZ, adjusting for pre-pregnancy weight status, race/ethnicity, parity, WIC participation, smoking during pregnancy, residence, age, and birth cohort.

RESULTS

Among 615 093 women, the mean GWGZ was -0.4 (SD = 1.3), which increased from -0.4 in 2004-2005 to -0.2 in 2014-2015. GWGZ increased at the 5th, 10th, 25th, 50th, and 75th percentiles (ranging 0.04 to 0.73 units), with differential trends observed in sub-groups by pre-pregnancy weight and racial/ethnic group. Notably, non-Hispanic White women showed larger increasing trends (0.89 units) compared to non-Hispanic Black (0.55 units) and Hispanic (0.76 units) women in the 5th percentile. Decreasing trends were seen overall for the 90th (-0.02) and 95th percentile (-0.06 units) but positive trends were not seen among women experiencing obese class 1 (no change in 90th and 95th), and 2 (0.01 units in 90th, -0.02 units in 95th).

CONCLUSIONS

This study shows increasing GWGZ trends from the 5th to the 75th percentiles and decreasing trends in 90th and 95th percentiles in SC for the last decade. Racial/ethnic and pre-pregnancy weight disparities did not improve over the study period. Future research is needed to confirm these findings in other states and to develop strategies to narrow racial and pre-pregnancy weight disparities at the highest and lowest percentiles.

Development, Implementation, and Results from a COVID-19 Messaging Campaign to Promote Health Care Seeking Behaviors Among Community Clinic Patients

Care-delays can further exacerbate racial and ethnic health disparities in novel coronavirus disease 2019 (COVID-19) related complications. The purpose of our study was to describe and evaluate a Patient Engagement Messaging campaign (PEM campaign) promoting health care seeking behaviors among community and rural clinic patients in North Carolina. Text and voice messages were delivered over 3-weeks. Messages encouraged patients to call a regional operation call center (ROC) line for information related to health care appointments and testing. A cross-sectional evaluation was conducted on the total population (n = 48,063) and a sample without recent health care contact (n = 29,214). Among the sample, logistic regression was used to model determinants of calls to the ROC-line and associations between calling the ROC-line and health care seeking behaviors (scheduling any health care appointment or receiving a COVID-19 test). 69.9% of text messages and 89% of voice messages were delivered. Overall, 95.4% of the total population received at least 1 message. Successful delivery was lower among Black patients and higher among patients with moderate health-risk comorbidities. Among the sample, 7.4% called the ROC-line, with higher odds of calling among minority patients (vs. White) and among Medicaid and uninsured (vs. private insurance). Calling the ROC-line was associated with higher odds of scheduling any health care appointment (OR: 4.14; 95% CI 2.93–5.80) and receiving a COVID-19 test (OR: 2.39; 95% CI 1.64–3.39). Messaging campaigns may help disconnected patients access health care resources and reduce disparities, but are likely still limited by existing barriers.

Psychosocial status and prenatal care of unintended pregnancies among low-income women

Background

Nearly half of all pregnancies in the United States are reported as unintended and rates are highest among women of low socioeconomic status. The purpose of this study was to examine the associations between unintended pregnancies and maternal mental health and timing of prenatal care among low-income women.

Methods

In this cross-sectional study, 870 women, whom were participating in the First 1000 Days program in three community health centers in the Boston area, were enrolled at their first prenatal visit from August 2016 – September 2017. We assessed pregnancy intention by self-report using the Pregnancy Risk Assessment Monitoring System. We used self-reported survey information and electronic health record data to assess the following outcomes: current stress, current depression, and timing of initial prenatal visit. We used multivariable logistic regression models to examine associations and adjusted for sociodemographic factors.

Results

Women were a mean (SD) age of 29.3 (6.1), and 39.2% reported that their pregnancy was unintended. 50.6% of women were Hispanic, 28.4% were White, 10.1% were Black, and 10.9% were other races. 78.9% of women reported an annual household income <$50,000. Overall, 26.7% of women reported current stress, 8.2% reported current depression, and 18.3% of women initiated prenatal care after their first trimester. In multivariable analyses, women with unintended pregnancies had higher odds of experiencing current stress (OR: 1.72; 95% CI: 1.22, 2.41), current depression (OR: 1.83; 95% CI: 1.04, 3.20), and initiation of prenatal care post-first trimester (OR: 1.84; 95% CI: 1.23, 2.74).

Conclusions

Unintended pregnancies were associated with current stress and depression, and delayed prenatal care in this sample of low-income women suggesting the importance of identifying high-risk women and tailoring interventions to support women’s needs.

Trial registration

ClinicalTrials.gov (NCT03191591; Retrospectively registered on June 19, 2017).

Decomposition and Spatio-temporal analysis of health care access challenges among reproductive age women in Ethiopia, 2005-2016

Background

The high maternal mortality, home delivery, unwanted pregnancies, incidence of unsafe abortion, and unmeet family planning needs are maternal health gaps attributed to health care access barriers and responsible for the observed health care disparities. Over the last decades remarkable achievements have made in relation to maternal health problems and the reduction of health care access barriers. Thus, this study aimed to assess the decomposition and spatial-temporal analysis of health care access challenges among reproductive-age women in Ethiopia.

Methods

Secondary data analysis was conducted based on the three consecutive Ethiopian Demographic and Health Surveys (2005–2016 EDHSs). A total weighted sample of 46,235 reproductive-age women was included in this study. A logit based multivariate decomposition analysis was employed for identifying factors contributing to the overall decrease in health care access challenges over time. For the spatial analysis, ArcGIS version 10.6 and SaTScan™ version 9.6 were used to explore hotspot areas of health care access challenges in Ethiopia over time. Variables with p-value < 5% in the multivariable Logit based multivariate decomposition analysis were considered as significantly contributed predictors for the decrease in health care access challenges over time.

Result

The mean age of the women was 27.8(±9.4) years in 2005, 27.7(±9.2) years in 2011, and 27.9 (±9.1) years in 2016. Health care access challenges have been significantly decreased from 96% in 2005 to 70% in 2016 with the Annual Rate of Reduction (ARR) of 2.7%. In the decomposition analysis, about 85.2% of the overall decrease in health care access challenge was due to the difference in coefficient and 14.8% were due to differences in the composition of the women (endowment) across the surveys. Socio-demographic characteristics (age, residence, level of education, female household head, better wealth and media exposure) and service utilization history before the survey (facility delivery and had ANC follow up) contribute to the observed decrease over time. The spatial analysis revealed that health care access challenges were significantly varied across the country over time. The SaTScan analysis identified significant hotspot areas of health care access challenges in the southern, eastern, and western parts of Ethiopia consistently over the surveys.

Conclusion

Perceived health care access challenges have shown a remarkable decrease over time but there was variation in barriers to health care access across Ethiopia. Media exposure improved mothers’ health care access in Ethiopia. Public health programs targeting rural, uneducated, unemployed, and women whose husband had no education would be helpful to alleviate health care access problems in Ethiopia. Besides, improving mother’s media exposure plays a significant role to improve mothers’ health care access. Health care access challenges have significantly varied across the country. This suggests that further public health interventions are important for further reduction of health care access barriers through the uplifting socio-demographic and economic status of the population.

Where you live matters: A National Cancer Database study of Medicaid expansion and endometrial cancer outcomes

OBJECTIVE

To determine associations between adoption of Medicaid expansion (ME) and changes in insurance status, early stage diagnosis, and cancer survival among women with endometrial carcinoma (EC).

METHODS

The National Cancer Database (NCDB) was queried for patients diagnosed with EC between the age 40-64 from 2004 to 2015. Difference-in-differences analysis quantified the impact of ME on the proportion of new EC diagnoses with insurance (vs. uninsured), the proportion diagnosed with stage I (vs. II-IV), and overall survival.

RESULTS

156,253 patients were included. Among 65,019 women living in ME states, ME is associated with an increase in the percent of EC cases who are insured of 1.4% (95% CI 0.9-2.0%, p < 0.0001), with strongest effects among Hispanic women, women in the lowest income quartile, and women in the second age quartile (age 53-57). There was no overall impact of ME on stage, though an increase of early stage diagnoses by 2.4% (95% CI 0.3-4.5%, p = 0.022) was observed among women age 53-57. There was a trend towards improved overall survival with ME, which was strongest in women age 53-57 (HR = 0.83, 95% CI 0.70-0.99, p = 0.037).

CONCLUSIONS

Among women with EC, ME positively impacted insurance coverage, an important hurdle in accessing health care. In women aged 53-57, ME was associated with earlier stage at diagnosis and improved survival, suggesting that the magnitude of the improvement in insurance coverage may correlate with important clinical outcomes. Efforts should continue to understand the complexity of barriers to health care access and to develop effective strategies to surmount them.

Exploring pathways to Hospital Care for Patients with Alzheimer's disease and related dementias in rural South Western Uganda

BACKGROUND

In order to analyze use of health services and identify sources of delays in accessing the right care for patients with Alzheimer's disease and related dementias (AD/ADRD), understanding of care seeking pathways is needed. The objectives of this study were: (i) to explore pathways to hospital care for patients with AD/ADRD and (ii) to describe challenges experienced by the patients and their families while seeking health care.

METHODS

Using purposive sampling, 30-in-depth, semi-structured interviews were conducted among caregivers of older adults diagnosed with dementia from rural Southwestern, Uganda. Data was analyzed using ATLAS. Ti software.

RESULTS

There was variability in pathways to care from individual to individual. There was one broader theme captured: points of care choice with four broader categories: hospitals, clinics, places of religious worship and traditional healers' shrines, each with its facilitating factors, outcomes and challenges encountered. Most of the respondents reported use of hospitals at first and second visit to the health care point but places of religious worship became more common from third to sixth health care encounter. Major improvements (58.1%) were observed on hospital use but little or no help with prayers, clinics and traditional healers. The challenges experienced with formal points of care focused on lack and cost of prescribed drugs, weakening effect of the drugs, lack of skills to manage the condition, and lack of improvement in quality of life. These challenges together with knowledge gap about the disease and belief in spiritual healing facilitated the shift from formal to informal health care pathways, more particularly the places of religious worship.

CONCLUSIONS

Our study findings indicate that caregivers/families of patients with dementia went to different places both formal and informal care settings while seeking health care. However, hospital point of care was more frequent at initial health care visits while places of worship took the lead at subsequent visits. Although no specific pathway reported, most of them begin with hospital (formal) and end with non-formal. We recommend that health systems carry out public awareness on dementia.

Unmet healthcare needs among migrants without medical insurance in Montreal, Canada

While access to healthcare for permanent residents in Canada is well known, this is not the case for migrants without healthcare coverage. This is the first large-scale study that examines the unmet healthcare needs of migrants without healthcare coverage in Montreal. 806 participants were recruited: 436 in the community and 370 at the NGO clinic. Proportions of individuals reporting unmet healthcare needs were similar (68.4% vs. 69.8%). The main reason invoked for these unmet needs was lacking money (80.6%). Situations of not working or studying, not having had enough food in the past 12 months, not having a medical prescription to get medication and having had a workplace injury were all significantly associated with higher odds of having unmet healthcare needs. Unmet healthcare needs were more frequent among migrants without healthcare coverage than among recent immigrants or the citizens with health healthcare coverage (69%, 26%, 16%). Canada must take measures to enable these individuals to have access to healthcare according to their needs in order to reduce the risk of worsening their health status, something that may have an impact on the healthcare system and population health. The Government of Quebec announced that all individuals without any healthcare coverage will have access to COVID-19 related health care. We hope that this right, the application of which is not yet obvious, can continue after the pandemic for all health care.

After encounters: revealing patients’ unseen work through their pathways to care

Purpose

Research has long focused on the notion of access and the trajectory towards a healthcare encounter but has neglected what happens to patients after these initial encounters. This paper focuses attention on what happens after an initial healthcare encounter leading to a more nuanced understanding of how patients from a diverse range of backgrounds make sense of medical advice, how they mix this knowledge with other forms of information and how they make decisions about what to do next.

Design/methodology/approach

Drawing on 160 in-depth interviews across four European countries the paper problematizes the notion of access; expands the definition of “decision partners”; and reframes the medical encounter as a journey, where one encounter leads to and informs the next.

Findings

This approach reveals the significant unseen, unrecognised and unacknowledged work that patients undertake to solve their health concerns.

Originality/value

De-centring the professional from the healthcare encounter allows us to understand why patients take particular pathways to care and how resources might be more appropriately leveraged to support both patients and professionals along this journey.

Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study

PURPOSE

We undertook a study to evaluate variation in the availability of primary care new patient appointments for Medi-Cal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion.

METHODS

We placed simulated calls by purported Medi-Cal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of Medi-Cal managed care plans. Data from the California Health Interview Survey, Medi-Cal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county.

RESULTS

Availability of PCC new patient appointments to Medi-Cal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by Medi-Cal enrollees.

CONCLUSIONS

In contrast to findings from other states, access to primary care in Northern California was limited for new patient Medi-Cal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by Medi-Cal enrollees.