Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care

A Media Advocacy Toolkit for the Allergist-Immunologist

For clinicians involved in improving healthcare for patients with allergic and immunologic conditions, advocacy on a broader level through public outreach is key to advancing value-based care. In this article, we provide a toolkit of strategies and resources that can be used to raise public awareness of important issues through various mediums, including podcasts and social media, newspapers, testimonies, presentations, and interviews. A simple approach to effective media interactions is described using the acronym "RATIO," which stands for Research, Audience, Targeted topic, Interview rephrasing, and Optimism. The acronym also reminds the person who is presenting information that only a fraction of what is discussed will be recalled, and an even smaller proportion will be implemented. Key points should be made early. Examples of key talking points are provided for selected topics, including food allergy, anaphylaxis, asthma, rhinitis, and broader healthcare advocacy.

Barriers to Timely Dementia Diagnosis in Older Latinos With Limited English Proficiency: An Integrative Review

INTRODUCTION

Timely diagnosis is critical for persons with Alzheimer's disease and related dementias (ADRD) to ensure they receive adequate services; however, timely diagnosis may be prevented by a person's English language skills. The purpose of this integrative review was to understand how limited English proficiency (LEP) impacts older Latino's ability to access a timely ADRD diagnosis.

METHODS

Whittemore and Knafl's methodological approach guided the review. Searches in five databases yielded 12 articles for inclusion.

RESULTS

Lack of culturally congruent health care systems, health care providers, and knowledge of ADRD resulted in delays in obtaining a timely ADRD diagnosis among older Latinos with LEP.

DISCUSSION

Latinos with LEP and risk for ADRD benefit from language assistance and support in navigating the health care system. Nurses must be advocates, even when a language barrier is present, and recognize that interpreters are not a single source solution.

Community Health Work and Social Work Collaboration: Integration in Health Care and Public Health Settings: A Conceptual Framework

Community health worker (CHW) and social worker (SW) collaboration is crucial to illness prevention and intervention, yet systems often engage the 2 workforces in silos and miss opportunities for cross-sector alignment. In 2021, a national workgroup of over 2 dozen CHWs, SWs, and public health experts convened to improve CHW/SW collaboration and integration across the United States. The workgroup developed a conceptual framework that describes structural, systemic, and organizational factors that influence CHW/SW collaboration. Best practices include standardized training, delineated roles and scopes of practice, clear workflows, regular communication, a shared system for documentation, and ongoing support or supervision.

Adverse childhood experiences, dental insurance, and developmental disability: Association with unmet dental needs in Ohio

OBJECTIVE

This study investigated whether insurance status and/or developmental disability moderated the association between adverse childhood experiences (ACE) and unmet dental needs among children aged 0 to 17 in Ohio.

METHODS

We utilized cross-sectional data from the 2021 Ohio Medicaid Assessment Survey to assess the dental needs of children. ACE scores, dental insurance status, and developmental disability status were analyzed using multivariable logistic regression to identify their potential association with parental-reported unmet dental needs.

RESULTS

The weighted sample represented 2,752,222 children in Ohio. Over half reported zero ACEs (55.8%) and no dental needs (56.1%). Approximately 1 in 9 lacked dental insurance (11.1%), and 1 in 10 had a developmental disability (9.9%). Children with one to three ACEs had three times the odds of unmet dental needs compared to children with zero ACEs (OR = 3.20; 95%CI [2.10, 4.89]), and children with four or more ACEs had eight times the odds of unmet dental needs (OR = 8.78; 95%CI [5.26, 14.67]). Children lacking dental insurance had over six times higher odds of unmet dental needs compared to children with dental insurance (OR = 6.10; 95%CI [3.92, 9.49]). The presence of developmental disability status did not moderate the presence of unmet dental needs; however, the lack of dental insurance status significantly moderated the association between ACEs and unmet dental needs.

CONCLUSION

Insurance status, not developmental disability, moderated the association between ACEs and unmet dental needs among children in Ohio. Efforts to ensure continuous access to dental insurance are warranted.

Inadequate Use of Newer Treatments and Glycemic Control by Cardiovascular Risk and Sociodemographic Groups in US Adults with Diabetes in the NIH Precision Medicine Initiative All of Us Research Program

PURPOSE

Data are limited on sodium glucose co-transport 2 inhibitors (SGLT2-is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) among real-world cohorts of underrepresented patients. We examined these therapies and glycemic control in US adults with diabetes mellitus (DM) by atherosclerotic cardiovascular disease (ASCVD) risk and sociodemographic factors.

METHODS

In the NIH Precision Medicine Initiative All of Us Research Program, we categorized DM as (1) moderate risk, (2) high risk, and (3) with ASCVD. We examined proportions on DM therapies, including SGLT2-i or GLP-1 RA, and at glycemic control by sociodemographic factors and CVD risk groups.

RESULTS

Our 81,332 adults aged ≥ 18 years with DM across 340 US sites included 22.3% non-Hispanic Black, 17.2% Hispanic, and 1.8% Asian participants; 31.1%, 30.3%, and 38.6% were at moderate risk, high risk, or with ASCVD, respectively. Those with DM and ASCVD were most likely on SGLT2-i (8.6%) or GLP-1 RA (11.9%). SGLT2-i use was < 10% in those with heart failure or chronic kidney disease. The odds (95% CI) of SGLT2-i use were greater among men (1.35 [1.20, 1.53]) and Asian persons (2.31 [1.78, 2.96]), with GLP-1 RA being less common (0.78 [0.70, 0.86]) in men. GLP-1 RA use was greater among those with health insurance, and both GLP-1 RA and SGLT2-i greater within lower income groups. 72.0% of participants had HbA1c < 7%; Hispanic persons were least likely at glycemic control.

CONCLUSIONS

Treatment with SGLT2-is and GLP-1 RAs remains low, even among higher ASCVD risk persons with DM and use is even lower among underserved groups.

Prescription drug spending by payer: Implications for managed care

Background

Brand-name prescription drugs are an important driver of prescription drug spending, but different payers may bear these costs differentially necessitating different policy goals for each payer. But little is known about how the top 10 selling drugs in the U.S. impact spending across payers.

Objective

To estimate the differential spending burden of top prescription drugs on Medicaid, Medicare, commercial coverage, and out-of-pocket (OOP) spending.

Methods

The percentage of total prescription drug spending, total spending, total prescriptions, and average cost per prescription overall and for each of the following payers - Medicaid, Medicare, private insurance, and OOP - was calculated for each of the top 10 selling prescription drugs using 2017-2019 Medical Expenditure Panel Survey data.

Results

These 10 prescription drugs accounted for average annual spending of $83.4 billion and 19.0% of all prescription drug spending. Medicare tended to contribute the highest fraction of spending. The average annual cost per prescription ranged from $500 for Advair to $7400 for Tecfidera. Significant variation in the average annual number of prescriptions filled was observed, ranging from 1.4 million for Tecfidera to 13.6 million for Lantus.

Conclusions

The findings highlight the significant impact of the top 10 selling prescription drugs on U.S. prescription drug spending. The wide variation in per prescription cost as well as contribution to each payer's prescription drug burden emphasizes how policies targeting top-selling drugs may differentially impact payers as well as how payer-specific policies may differ substantially even for top selling drugs.

Health as a Human Right: A Position Paper From the American College of Physicians

The relationship of health to rights or human rights is complex. Although many find no right of any kind to health or health care, and others view health care as a right or human right, the American College of Physicians (ACP) instead sees health as a human right. The College, in the ACP Ethics Manual, has long noted the interrelated nature of health and human rights. Health as a human right also has implications for the social and structural determinants of health, including health care. Any rights framework is imperfect, and rights, human rights, and ethical obligations are not synonymous. Individual physicians and the profession have ethical obligations to patients, and these obligations can go beyond matters of rights. Society, too, has responsibilities-the equitable and universal access to appropriate health care is an ethical obligation of a just society. By recognizing health as a human right based in the intrinsic dignity and equality of all patients and supporting the patient-physician relationship and health systems that promote equitable access to appropriate health care, the United States can move closer to respecting, protecting, and fulfilling for all the opportunity for health.

A Paradigm Shift from International to Transnational Medical Education

In recent years, the number of medical students seeking international opportunities has grown. To satisfy these demands, collaborative international programs have been developed. However, the benefits of these programs are limited as they employ an international medical education (IME) approach where only the students are exchanged. In this commentary, we discuss the current models of IME and propose a paradigm shift to a transnational approach wherein the student, faculty, and curriculum are exchanged allowing for increased integration and awareness of cultural and educational approaches to treatment that can be retained and incorporated into future practice to advance healthcare across the globe.

Preparing for Future Pandemics and Public Health Emergencies: An American College of Physicians Policy Position Paper

The onset of the COVID-19 pandemic revealed significant gaps in the United States' pandemic and public health emergency response system. At the federal level, government responses were undercut by a lack of centralized coordination, inadequately defined responsibilities, and an under-resourced national stockpile. Contradictory and unclear guidance throughout the early months of the pandemic, along with inconsistent funding to public health agencies, also created notable variance in state and local responses. The lack of a coordinated response added pressure to an already overwhelmed health care system, which was forced to resort to rationing care and personal protective equipment, creating moral distress and trauma for health care workers and their patients. Despite these severe shortcomings, the COVID-19 pandemic also highlighted successful policies and approaches, such as Operation Warp Speed, which led to the fastest development and distribution of a vaccine in history. In this position paper, the American College of Physicians (ACP) offers several policy recommendations for enhancing federal, state, and local preparedness for future pandemic and public health emergencies. This policy paper builds on various statements produced by ACP throughout the COVID-19 pandemic, including on the ethical distribution of vaccinations and resources, conditions to resume economic and social activity, and efforts to protect the health and well-being of medical professionals, among others.

Satisfaction of beneficiaries with community-based health insurance and associated factors in Legambo District, North-East Ethiopia: a cross-sectional study

Background

The fundamental concept of community-based health insurance is to strengthen the healthcare financing system to access universal healthcare by reducing costly risk-coping strategies. The scheme's sustainability and the quality of services provided by it are highly dependent on the satisfaction of its beneficiaries. Despite beneficiaries' satisfaction being the key determinant for providing evidence for policy revision and decision-making, it has often been neglected. Therefore, the study investigated the community-based health insurance beneficiaries' satisfaction and associated factors in Legambo district, North-East Ethiopia.

Methods

The study was conducted in the Legambo district with a community-based cross-sectional study design from October to November 2019. The data were collected from 838 households that had been the beneficiaries of the scheme using multi-stage and systematic random sampling. Twelve trained data collectors were employed and gathered the data using a pre-tested, structured questionnaire. We ran descriptive, bivariate, and logistic regression analyses. A value of p less than 0.05 with a 95% CI was used in multivariate logistic regression to determine the association of variables with the beneficiaries' satisfaction.

Results

The overall satisfaction level of the beneficiaries of the scheme was 58.6% and was associated with the following factors: merchandize (AOR = 1.92, 95% CI = 1.02-3.63), living in rural areas (AOR = 1.52, 95% CI = 1.02-2.27), an early office opening time (AOR = 3.81, 95% CI = 2.04-7.10), a short time interval to use benefit packages (AOR = 4.85, 95% CI = 2.08-11.31), an inexpensive membership premium (AOR =10.58, 95% CI = 3.56-31.44), availability of laboratory services (AOR =2.95, 95% CI = 1.71-5.09), presence of referral services (AOR =1.93, 95% CI = 1.33-2.80), having immediate care at health facilities (AOR = 1.73, 95% CI = 1.01-2.97) and non-compulsory enrolment (AOR = 6.31, 95% CI = 1.64-24.20).

Conclusion

The beneficiaries' satisfaction with the scheme was suboptimal and found to be determined by occupation, residence, laboratory and referral services, immediate care, office opening time, time interval to use benefit packages, premium amount, and situation of enrollment, most of which are service-related variables. Thus, to improve the satisfaction level, the stakeholders that should work hard seem to be the health insurance agency (the insurer) and the health facilities (the provider or supplier).

Equivalent Improvements in Sleep Duration and Sleep Quality Regardless of Program Delivery Modality: The SLeep Education for Everyone Program (SLEEP)

Sleep issues are pervasive, and treatment can be difficult to access, if available at all. The purpose of this study was to test whether the delivery modality (online vs. in person) of the SLeep Education for Everyone Program (SLEEP) influenced programmatic outcomes. A total of 60 participants completed the study, 28 in the online group and 32 in the in-person group. Across all participants, SLEEP improved sleep duration, sleep quality, and sleep hygiene behaviors (p < 0.001 for all). When comparing delivery modality, sleep duration and quality improved similarly between groups; however, sleep hygiene behaviors improved more in the in-person group (p = 0.033). Sleep hygiene scores did not correlate with sleep duration or quality after the program. Based on these findings, SLEEP appears to be equally effective in improving sleep duration and quality when delivered online or in person. These findings suggest that SLEEP can be delivered based on the organization's and participant's resources, needs, and preferred style of interaction.

Racial and Ethnic Disparities in Health Insurance Coverage in the USA: Findings from the 2018 National Health Interview Survey

Under the broad context of health care reforms, I explored racial and ethnic disparities in health insurance coverage as well as potential mechanisms that might contribute to these disparities for an extensive list of groups. The study used the 2018 National Health Interview Survey to analyze the effects of race/ethnicity on uninsurance, with adjustment for other predisposing characteristics (age, gender, marital status, and immigration status), enabling resources (education, income, language proficiency, and region), and need (self-reported health status). Results from the study documented an average uninsured rate of 13%, with substantial variations across different racial and ethnic groups, ranging from over 30% among Native Americans and Mexicans to less than 10% among whites and Asian subgroups. Enabling resources significantly reduced uninsurance among African Americans, Puerto Ricans, and Cubans compared to whites. On the other hand, these confounding factors only partially contributed to uninsurance among Native Americans, Mexicans, Mexican Americans, Dominicans, and other Central and South Americans. This study revealed substantial racial/ethnic disparities in uninsured rates, with Native Americans and a few Hispanic subgroups (Mexicans, Mexican Americans, and Dominicans) having higher and Asian Indians having lower rates than whites in uninsurance. Pathways leading to coverage varied by race/ethnicity. The main findings yielded empirical, theoretical, and policy implications that contributed to health care disparity research.

Pharmacist, prescriber, and drug policy expert opinions on gabapentinoid misuse

BACKGROUND

Gabapentinoids (gabapentin and pregabalin) are widely used in clinical practice, but recent evidence indicates that they carry an increased risk of misuse. As healthcare professionals (HCPs) and policymakers plan different strategies to promote harm reduction, it is important to understand different interested party viewpoints.

OBJECTIVE

To explore prescriber, pharmacist, and drug policy expert (DPE) awareness, opinions, and experiences regarding gabapentinoid misuse.

METHODS

A qualitative description study using individual semi-structured virtual interviews was conducted between February and April 2021. Participants included prescribers (physicians, physician assistants [PA], or nurse practitioners [NP]) and pharmacists practicing in outpatient, ambulatory, or community-based healthcare settings; individuals with relevant drug policy expertise were also included. Qualtrics (Provo, Utah) and Zoom (San Jose, California) were used to facilitate quantitative (for initial screening and participant characteristics) and qualitative (interview) data collection. Data were coded and organized into themes in NVivo (QSR International; Burlington, Massachusetts) using thematic analysis steps.

RESULTS

A total of 43 individuals participated in this study, including 16 (37.2%) pharmacists, 13 (30.2%) physicians, seven (16.3%) NPs, four (9.3%) DPEs, two (4.7%) pharmacist/DPEs, and one (2.3%) PA. Results were organized along four themes: (1) challenges/opportunities in gabapentinoid use; (2) gabapentinoid misuse awareness; (3) solutions to gabapentinoid misuse and (4) contributing barriers in pain management. Participants invoked different opinions in their consideration of gabapentinoid misuse, including the desire for harm reduction, the limitations of the current healthcare and insurance system, the lack of options for pain and substance use disorder treatment, and the influence of patient expectations.

CONCLUSIONS

Gabapentinoid misuse was commonly framed in comparative fashion to ongoing concerns with opioids, and proposed solutions often focused less on regulatory control and more toward patient and HCP education and an overhaul of the health system approach to substance use and healthcare overall.

Wellness Program Participation and its Association With Reduction in Health Risks and Health Care Costs: One University's Story

PURPOSE

Evaluate if there is a(n): 1) reduction in health risk behaviors and 2) association between health and wellness initiative participation and claims costs decreases overtime.

DESIGN

Health risk behavior change consisted of the analysis of pre (2009) - post (2019) measures of health questionnaire participants. The medical and pharmaceutical claims costs evaluation consisted of a time-series (2016-2019) design with a comparison group.

SETTING

A large mid-western university with a health system.

SAMPLE

The health risk behavior sample ranged from 5215-5399, depending on the variable of interest. The medical and pharmaceutical costs sample used a cohort of participants (participating all 4 years, n=11114) and non-participants (not participating all 4 years, n=4776).

INTERVENTION

Comprehensive employee health and well-being initiative.

MEASURES/ANALYSIS

McNemar's tests were used to identify bivariate associations between 2009 and 2019 health risks. The claims cost analysis used propensity score matching based on select demographics and linear mixed-effects regression modeling.

RESULTS

Results show statistically significant (P > .001) improvements (ranging from -2.1% to -12.5%) in 7 of 8 health risk behaviors. 2016 and 2019 claims costs have a lower statistically significant (P > .001) percent increase for participants (32.6%) compared to non-participants (47.5%).

CONCLUSION

Employers, may consider implementing a comprehensive health and wellness program as part of their strategy to assist in health behavior risk reduction and health care cost containment.

Public Perceptions of Climate Change and Health-A Cross-Sectional Survey Study

Climate change is inseparably linked to human health. Although there is growing awareness of the threats to human health caused by climate change, it remains unclear how the German population perceives the relevance of climate change and its health consequences. Between May and September 2022, German residents were invited to participate in a cross-sectional online survey that explored three content areas: (1) the relevance of climate change, (2) health risks in connection with climate change and (3) collective and individual options for action against climate change. A total of 697 full data sets were collected for analysis (72% female, 51% ≥55 years old). The majority of participants agreed that human-induced climate change exists (85%), and that it has an impact on human health (83%). They also perceived the global population to be more strongly impacted by climate change than themselves (89% versus 68%). Most participants (76%) claimed to personally contribute to climate protection and 23% felt that their city or council contributed to climate protection. Although the majority of participants saw climate change as a threat to human health, they perceived other population groups to be most strongly affected. Cognitive dissonance might explain this lack of individual concern and one approach to addressing such distorted perceptions might be the dissemination of appropriate risk communication with health professionals involved in the communication.

The TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States

Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.

From sea to shining IV: the current state of OPAT in the United States

First described in the United States, outpatient parenteral antibiotic therapy (OPAT) has become an indispensable part of treating serious infections. The proportion of infectious disease (ID) physicians utilizing a formal OPAT program has increased in recent years, but remains a minority. In addition, many ID physicians have indicated that OPAT programs have inadequate financial and administrative support. Given the medical complexity of patients receiving OPAT, as well as the challenges of communicating with OPAT providers across health care facilities and systems, OPAT programs ideally should involve a multidisciplinary team. The majority of patients in the United States receive OPAT either at home with assistance from home infusion companies and visiting nurses or at a skilled nursing facility (SNF), though the latter has been associated with lower rates of patient satisfaction. Current and future opportunities and challenges for OPAT programs include providing OPAT services for people who inject drugs (PWID) and incorporating the increasing use of oral antibiotics for infections historically treated with parenteral therapy. In this review, we will discuss the current practice patterns and patient experiences with OPAT in the United States, as well as identify future challenges and opportunities for OPAT programs.

Trends in NIH Funding to Medical Schools in 2011 and 2020

PURPOSE

To examine trends in National Institutes of Health (NIH) funding to U.S. medical schools and their academic departments and the amount of awards provided by each of the NIH institutes.

METHOD

All data on NIH awards to U.S. medical schools from 2000 to 2020 are publicly available and were obtained from the NIH Research Portfolio Online Reporting Tools and Blue Ridge Institute for Medical Research. These data include the value and number of awards to each medical school, medical school department, medical school location, principal investigator, and the NIH awarding institute. Trends in the inflation-adjusted awards from 2011 to 2020 were calculated and a comparison of the awards made in 2011 and 2020 was performed.

RESULTS

The total NIH budget increased by 16.1% from 2011 to 2020. The allocation of NIH funds to medical schools increased 26.3% ($13.7 billion to $17.3 billion) during this interval. In 2020, 29.3% of all medical school NIH funds were allocated to departments of internal medicine/medicine. Psychiatry was the second ranking department, which was followed, in order, by pediatrics, neurology, and microbiology/immunology/virology. The National Cancer Institute, National Institute of Allergy and Infectious Diseases, and National Heart, Lung, and Blood Institute were the top medical school funding institutes in 2011 and 2020. Medical schools as a group continue to receive the greatest percentage of NIH funding. Funding to clinical science departments increased by a larger percentage than that to basic science departments (35.3% vs 10.9%, respectively) over the 2011-2020 interval.

CONCLUSIONS

Funding for clinical science departments is increasing at a faster rate than that of basic science departments. However, that so much investigation in basic science and clinical science departments is performed by personnel with a PhD degree indicates the goals and methods of the basic and clinical sciences may not be so different.

Leadership Development to Advance Health Equity: An Equity-Centered Leadership Framework

Enduring questions about equity are front and center at this watershed moment in health care and public health. Inequities that became evident in the COVID-19 pandemic in 2020 have highlighted long-standing disparities in health by race and ethnicity. Current crises require examining and reorienting the systems that have, for decades, produced these health inequities; yet, public health and health care leaders are inadequately prepared to respond. The authors offer an equity-centered leadership framework to support the development of visionary leaders for tomorrow. This framework for leadership development programs interweaves traditional leadership and equity, diversity, and inclusion domains in both conceptual knowledge and skills-based teaching for health care and public health leaders, grouping competencies and skills into 4 domains: personal, interpersonal, organizational, and community and systems. A framework such as this will equip leaders with the mindset and skill set to challenge the paradigms that lead to inequity and health disparities.

Assessment of Healthcare Delivery Systems in Orthopaedic Surgery: A Large Retrospective Cohort Evaluation

INTRODUCTION

The purpose of this study was to assess how quality and volume of common orthopaedic care varies across private, municipal, and federal healthcare delivery systems (HDSs).

METHODS

Hip and knee arthroplasty, knee and shoulder arthroscopy, and hip fracture repair were audited over a two-year period. Electronic medical records were reviewed for demographics, diagnosis, lengths of stay (LoSs), surgical wait times, inpatient complication, readmission, and revision surgery rates. Multivariate regression controlled for differences in age, sex, diagnosis, and Charlson Comorbidity Index to determine how HDS correlated with surgical wait time, length of stay, complication rates, readmission, and revision surgery.

RESULTS

The 5,696 included patients comprise 87.4% private, 8.6% municipal, and 4.0% federal HDSs. Compared with private HDS for arthroplasty, federal surgical wait times were 18 days shorter (95% CI = 9 to 26 days, P < 0.001); federal LoS was 4 days longer (95% CI = 3.6 to 4.3 days, P < 0.001); municipal LoS was 1 day longer (95% CI = 0.8 to 1.4, P < 0.001); municipal 1-year revision surgery odds were increased (odds ratio [OR] = 2.8, 95% CI = 1.3 to 5.4, P = 0.045); and complication odds increased for municipal (OR = 12.2, 95% CI = 5.2 to 27.4, P < 0.001) and federal (OR = 12.0, 95% CI = 4.5 to 30.8, P < 0.001) HDSs. Compared with private HDS for arthroscopy, municipal wait times were 57 days longer (95% CI = 48 to 66 days, P < 0.001) and federal wait times were 34 days longer (95% CI = 21 to 47 days, P < 0.001). Compared with private HDS for fracture repair, municipal wait times were 0.6 days longer (95% CI = 0.2 to 1.0, P = 0.02); federal LoS was 7 days longer (95% CI = 3.6 to 9.4 days, P < 0.001); and municipal LoS was 4 days longer (95% CI = 2.4 to 4.8, P < 0.001). Only private HDS fracture repair patients received bone health consultations.

DISCUSSION

The private HDS provided care for a markedly larger volume of patients seeking orthopaedic care. In addition, private HDS patients experienced reduced surgical wait times, LoSs, and complication odds for inpatient elective cases, with better referral patterns for nonsurgical orthopaedic care after hip fractures within the private HDS. These results may guide improvements for federal and municipal HDSs.

SLeep Education for Everyone Program (SLEEP) Results in Sustained Improvements in Sleep Outcomes at Six Months

OBJECTIVE

Community-delivered sleep education interventions have been demonstrated to be effective in improving sleep outcomes, but whether these benefits persist once the program ends is not well characterized. This study sought to determine whether the previously reported positive effects attributed to the SLeep Education for Elders Program (SLEEP) were maintained six months after program completion.

METHOD

Nineteen participants were surveyed three times: at baseline, program completion (six weeks), and the six-month post-program timepoint. Sleep outcomes for quality, duration, insomnia symptoms, sleep hygiene behaviors, and excessive daytime sleepiness were assessed using validated surveys, including the Pittsburgh Sleep Quality Index (from which duration was also extracted), the Insomnia Severity Index, the Sleep Hygiene Index, and the Epworth Sleepiness Scale.

RESULTS

Longitudinal models adjusted for baseline sleep problems revealed the benefits achieved immediately after the program were retained at six months for sleep quality (estimate: -2.0 (95%CI: -2.7, -1.3)), sleep duration (estimate: 0.9 (95%CI: 0.6, 1.2)), insomnia symptoms (estimate: -3.5 95%CI: (-4.6, -2.3)), and sleep hygiene behaviors (estimate: -2.6 (-4.3, -0.9)).

CONCLUSIONS

These results suggest that a community-delivered sleep education intervention can produce sustained benefits for participants and should be considered as a tool to address uncomplicated sleep issues.

Disease and debt: Findings from the 2019 Panel Study of Income Dynamics in the United States

Medical debt has grown dramatically over the past few decades. While cancer and diabetes are known to be associated with medical debt, little is known about the impact of other medical conditions and health behaviors on medical debt. We analyzed cross-sectional data on 9174 households - spanning lower-income, middle-income, and higher-income based on the Census poverty threshold - participating in the 2019 wave of the nationally representative United States Panel Study of Income Dynamics (PSID). The outcomes were presence of any medical debt and presence of medical debt≥ $2000. Respondents reported on medical conditions (diabetes, cancer, heart disease, chronic lung disease, asthma, arthritis, anxiety disorders, mood disorders) and on health behaviors (smoking, heavy drinking). Medical debt was observed in lower-income households with heart disease (OR = 2.64, p-value = 0.006) and anxiety disorders (OR = 2.16, p-value = 0.02); middle-income households with chronic lung disease (OR = 1.73, p-value = 0.03) and mood disorders (OR = 1.53, p-value = 0.04); and higher-income households with a current smoker (OR = 2.99, p-value<0.001). Additionally, medical debt ≥$2000 was observed in lower-income households with asthma (OR = 2.16, p-value = 0.009) and a current smoker (OR = 1.62, p-value = 0.04); middle income households with hypertension (OR = 1.65, p-value = 0.05). These novel findings suggest that the harms of medical debt extend beyond cancer, diabetes and beyond lower-income households. There is an urgent need for policy and health services interventions to address medical debt in a wider range of disease contexts than heretofore envisioned. Intervention development would benefit from novel conceptual frameworks on the causal relationships between health behaviors, health conditions, and medical debt that center social-ecological influences on all three of these domains.

Designing a pharmacist primary care certificate training program based on employer perceptions

Background

As the pharmacy profession transforms toward practice centered around direct patient care and clinical services, upskilling the existing workforce may be required for pharmacists to take on expanded roles, especially in an increasingly competitive job market.

Objective

To explore pharmacist employer perceptions of a primary care certificate training program including its design, value, and relevance and to develop and implement a pharmacist primary care certificate training program based on study results.

Methods

Focus groups were conducted to a point of saturation in December 2020 via video conference. Participants were identified via the study institution's continuing professional development registrant listserv and invited to participate via self-selection. Interviews were recorded, transcribed, and underwent inductive thematic analysis.

Results

Four focus groups were conducted with 15 pharmacist employers. Employers perceived primary care certificate training as valuable, helping pharmacists sustain shifting roles and increasing opportunities in a competitive job market. A combination of clinical and practice management topics with emphasis on an experiential component was recommended to achieve expected competency levels and favorably influence hiring decisions. The primary care certificate was specifically recommended to pharmacists aiming to transition into primary care or for pharmacists who did not complete residency training.

Conclusions

This study's findings informed development of a pharmacist primary care certificate program containing didactic and experiential training on a variety of key topics. As pharmacists' roles evolve, this program may prepare pharmacists to engage in direct patient care and develop skills and expertise necessary to succeed in outpatient primary care.

Comparison of trend in chronic kidney disease burden between China, Japan, the United Kingdom, and the United States

Chronic kidney disease (CKD) caused heavy burden globally. This study aimed to investigate the patterns and temporal variations in the burden of CKD in China, Japan, the United Kingdom (U.K.), and the United States (U.S.) from 1990 to 2019, and decompose the difference in CKD disease burden between 1990 and 2019 into demographic factors. From 1990 to 2019, although the age-standardized rate (ASR) of incidence remained stable in the four countries, and the ASR of mortality and disability-adjusted life years (DALY) have declined in four countries (except for the increase in U.S.), the number of CKD incidence, death, and DALY increased significantly. The average disease burden per case in U.S. has increased between 1990 and 2019, with an increasing proportion of death-related disease burden. For the CKD due to diabetes and hypertension, whose incidences accounted for < 25% of the total CKD, while it accounts for more than 70% of the deaths (except in U.K. with 54.14% in women and 51.75% in men). CKD due to diabetes and hypertension should be the focus of CKD prevention and control. Considering the high treatment costs of CKD and ESRD, it is urgent and necessary to transform CKD treatment into primary and secondary prevention.

Translating Planetary Health Principles Into Sustainable Primary Care Services

Global anthropogenic environmental degradations such as climate change are increasingly recognized as critical public health issues, on which human beings should urgently act in order to preserve sustainable conditions of living on Earth. "Planetary Health" is a breakthrough concept and emerging research field based on the recognition of the interdependent relationships between living organisms-both human and non-human-and their ecosystems. In that regards, there have been numerous calls by healthcare professionals for a greater recognition and adoption of Planetary Health perspective. At the same time, current Western healthcare systems are facing their limits when it comes to providing affordable, equitable and sustainable healthcare services. Furthermore, while hospital-centrism remains the dominant model of Western health systems, primary care and public health continue to be largely undervalued by policy makers. While healthcare services will have to adapt to the sanitary impacts of environmental degradations, they should also ambition to accompany and accelerate the societal transformations required to re-inscribe the functioning of human societies within planetary boundaries. The entire health system requires profound transformations to achieve this, with obviously a key role for public health. But we argue that the first line of care represented by primary care might also have an important role to play, with its holistic, interdisciplinary, and longitudinal approach to patients, strongly grounded in their living environments and communities. This will require however to redefine the roles, activities and organization of primary care actors to better integrate socio-environmental determinants of health, strengthen interprofessional collaborations, including non-medical collaborations and more generally develop new, environmentally-centered models of care. Furthermore, a planetary health perspective translated in primary care will require the strengthening of synergies between institutions and actors in the field of health and sustainability.

The American Public Health Association Endorses Single-Payer Health System Reform

Health care is a human right. Achieving universal health insurance coverage for all US residents requires significant system-wide reform. The most equitable and cost-effective health care system is a public, single-payer (SP) system. The rapid growth in national health expenditures can be addressed through a system that yields net savings over projected trends by eliminating profit and waste. With universal health insurance coverage through SP financing, providers can focus on optimizing delivery of services, rather than working within a system covered by payers who have incentives to limit costs regardless of benefit. Rather, with a SP, the people act as their own insurer through a partnership with provider organizations where tax dollars work for everyone. Consumer choice is then based on the best care to meet need with no out-of-pocket payments. SP financing is the best option to ensure equity, fairness, and public health priorities align with medical needs, providing incentives for wellness. Consumer choice will drive market forces, not provider network profits or insurer restrictions. This approach benefits public health, as everyone will have universal access to needed care, with treatment plans developed by providers based on what works best for the patient. In 2021, the American Public Health Association adopted a policy statement calling for comprehensive reforms to implement a SP system. The proposed action steps in this policy will help build a healthier nation, saving lives and reducing wasted health care expenditures while addressing inequities rooted in social, demographic, mental health, economic, and political determinants.

Leadership Development in U.S. Undergraduate Medical Education: A Scoping Review of Curricular Content and Competency Frameworks

PURPOSE

To inform research on developing or adopting leadership competency frameworks for use in U.S. undergraduate medical education (UME), this scoping review describes the content of U.S. UME leadership curricula, associated competency frameworks, and content delivery.

METHOD

The authors searched PubMed, Embase, and ERIC databases on June 22, 2020. They included English-language studies that described U.S. UME curricula in which the primary end goal was leadership development. They excluded studies published before January 1, 2000. Data were extracted on leadership competency frameworks and curricular content, audience, duration, electivity, selectivity, learning pedagogies, and outcome measures. The curricular content was coded and categorized within the Medical Leadership Competency Framework (MLCF) using the constant comparative method. A repeated search of the literature on May 14, 2021, did not yield any additional studies.

RESULTS

Of 1,094 unique studies, 25 studies reporting on 25 curricula met inclusion criteria. The course content of the curricula was organized into 91 distinct themes, most of which could be organized into the first 2 competencies of the MLCF: Demonstrating Personal Qualities and Working With Others. Thirteen curricula (52%) aligned with leadership competency frameworks, and 12 (48%) did not appear to use a framework. Number of participants and target learner level varied widely, as did curricula duration, with fewer than half (n = 12, 48%) spanning more than 1 semester. Most curricula (n = 14, 56%) were elective, and many (n = 16, 64%) offered experiential learning. Most studies (n = 16, 64%) reported outcomes as student perception data.

CONCLUSIONS

The authors found wide variation in content of U.S. UME leadership development curricula, and few curricula aligned with an established leadership competency framework. The lack of professional consensus on the scope of medical leadership and how it should be taught thwarts effective incorporation of medical leadership training within UME.

Non-anatomic tunnel position increases the risk of revision anterior cruciate ligament reconstruction

PURPOSE

Anterior cruciate ligament (ACL) graft failure is a complication that may require revision ACL reconstruction (ACL-R). Non-anatomic placement of the femoral tunnel is thought to be a frequent cause of graft failure; however, there is a lack of evidence to support this belief. The purpose of this study was to determine if non-anatomic femoral tunnel placement is associated with increased risk of revision ACL-R.

METHODS

After screening all 315 consecutive patients who underwent primary single-bundle ACL-R by a single senior orthopedic surgeon between January 2012 and January 2017, 58 patients were found to have both strict lateral radiographs and a minimum of 24 months follow-up without revision. From a group of 456 consecutive revision ACL-R, patients were screened for strictly lateral radiographs and 59 patients were included in the revision group. Femoral tunnel placement for each patient was determined using a strict lateral radiograph taken after the primary ACL-R using the quadrant method. The center of the femoral tunnel was measured in both the posterior-anterior (PA) and proximal-distal (PD) dimensions and represented as a percentage of the total distance (normal center of anatomic footprint: PA 25% and PD 29%).

RESULTS

In the PA dimension, the revision group had significantly more anterior femoral tunnel placement compared with the primary group (38% ± 11% vs. 28% ± 6%, p < 0.01). Among patients who underwent revision; those with non-traumatic chronic failure had statistically significant more anterior femoral tunnel placement than those who experienced traumatic failure (41% ± 13% vs. 35% ± 8%, p < 0.03). In the PD dimension, the revision group had significantly more proximal femoral tunnel placement compared with the primary group (30% ± 9% vs 38% ± 9%, p < 0.01).

CONCLUSION

In this retrospective study of 58 patients with successful primary ACL-R compared with 59 patients with failed ACL-R, anterior and proximal (high) femoral tunnels for ACL-R were shown to be independent risk factors for ACL revision surgery. As revision ACL-R is associated with patient- and economic burden, particular attention should be given to achieving an individualized, anatomic primary ACL-R. Surgeons may reduce the risk of revision ACL-R by placing the center of the femoral tunnel within the anatomic ACL footprint.

LEVEL OF EVIDENCE

Level III.

Efficacy and Costs of Three Pharmacotherapies for Patent Ductus Arteriosus Closure in Premature Infants

BACKGROUND

The hemodynamic impact of persistent patent ductus arteriosus (PDA) is associated with neonatal morbidities and mortality in preterm newborns. While there has been considerable debate about optimal management of PDA and its impact on clinical outcomes, there is widespread variation in practice, such as using different pharmacotherapies to achieve closure of hemodynamically significant PDA during the first week of life in very low birth weight infants.

AIMS

The objective was to estimate the efficacy of acetaminophen, ibuprofen, and indomethacin with regard to ductal closure and to compare the costs of these three commonly used medications to treat PDA in preterm infants.

METHODS

PubMed, Embase, and Cochrane Registry were searched for trials from the years 2010-2020. We identified 17 randomized clinical trials (RCTs) and 14 case series that enrolled preterm infants < 37 weeks gestational age for inclusion. Pooled estimates of closure rates for acetaminophen (n = 630), ibuprofen (n = 694), and indomethacin (n = 312) were analyzed using the weighted proportion ratio using a Mantel‑Haenszel random effects model. The chi-squared test of proportions was used to determine significance between groups. We accessed cost estimates of pharmacotherapy from the Lexi-Comp average wholesale price database and utilized a decision tree model to appraise cost benefits for the outcome measure of successful PDA closure.

RESULTS

The pooled proportional point estimates of closure rates from RCTs for acetaminophen, ibuprofen, and indomethacin were 70.1% (95% confidence interval [CI] 60-80), 63.4% (95% CI 52.8-74.1), and 71.5% (95% CI 62.3-80.7), respectively. There was no significant statistical difference in closure rates when RCTs and uncontrolled case series were combined. Pairwise comparisons showed both acetaminophen and indomethacin were each more effective in closing PDA than ibuprofen (acetaminophen vs indomethacin: p = 0.01; ibuprofen vs indomethacin: p = 0.02; acetaminophen vs indomethacin: p = 0.93). Comparing costs for successful closure of PDA, at the average wholesale price of different medications, suggested that treatment with acetaminophen costs significantly less, with a mean of $1487 (95% CI 1300-1737), compared to ibuprofen, with a mean of $2585 (95% CI 2214-3104), and indomethacin, with a mean of $2661 (95% CI 2358-3052), per course of treatment.

CONCLUSIONS

Our meta-analysis suggests acetaminophen is non-inferior to both indomethacin and ibuprofen, and costs relatively less for successful PDA constriction in premature infants. Further clinical trials are warranted to compare acetaminophen's safety, along with short- and long-term effects, to help resolve the clinical conundrum of the necessity of early treatment in the management of PDA, and the optimal pharmacological course, if indicated.

LGBTQ+ Psychosocial Concerns in Nursing and Midwifery Education Programmes: Qualitative Findings from a Mixed-Methods Study

LGBTQ+ people experience significant physical and psychosocial health issues and concerns, and encounter barriers when accessing healthcare services. We conducted a mixed-methods research study across all Schools of Nursing and Midwifery in the United Kingdom and Ireland using a survey and qualitative interviews. This was to identify the current content within nursing and midwifery pre-registration programmes in relation to LGBTQ+ health and to identity best practice and education innovation within these programmes. The survey was completed by 29 academics, with 12 selected to participate in a follow-up in-depth qualitative interview. Analysis of the data from the survey and interviews identified five themes: there is variable programme content; academics are developing their own programmes with no clear consistency; LGBTQ+ health is being linked to equality and diversity; there are barriers to education provision; and these is some evidence of best practice examples. The findings of the study support the need to develop and implement a curriculum for LGBTQ+ health in nursing and midwifery pre-registration programmes with learning aims and outcomes. Academics need support and tools to prepare and deliver LGBTQ+ health content to nurses and midwives as they ultimately have the potential to improve the experiences of LGBTQ+ people when accessing healthcare.

Financial Profit in Medicine: A Position Paper From the American College of Physicians

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.

Working with communities: Meeting the health needs of those living in vulnerable communities when Primary Health Care and Universal Health Care are not available

RATIONALE, AIMS, AND OBJECTIVES

The health care delivery model in the United States does not work; it perpetuates unequal access to care, favours treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low-income minorities (Native Americans, Hispanics, and African-Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for Universal Health Care (UHC) and Primary Health Care (PHC)-with their emphasis on health care for all, population health, and social determinants of health-requires community health scientists to develop innovative local solutions for addressing unmet community health needs.

METHODS

We developed a model community health science approach for improving health in fragile communities, by combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. During the past two decades, our team has collaborated with community residents, local leaders, and many different types of organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action.

RESULTS

From 2000 to 2020, we established a federally funded research programme for testing interventions to improve health outcomes in vulnerable communities, by working in partnership with community organizations and other stakeholders. The partnership goals were reducing chronic disease risk and multimorbidity, by stimulating lifestyle changes, increasing healthy behaviours and health knowledge, improving care seeking and patient self-management, and addressing the social determinants of health and population health. Our programmes have also provided structured community health science training in high-risk communities for hundreds of doctors in training.

CONCLUSION

Our community health science approach demonstrates that the factors contributing to health can only be addressed by working directly with and in affected communities to co-develop health care solutions across the broad range of causal factors. As the United States begins to consider expanding health care options consistent with PHC and UHC principles, our community health science experience provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest assets US health care systems have for better addressing population health and the social determinants of health are the important health-related initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for improving health outcomes and reducing health disparities. This has been the greatest lesson we have learned the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.

The views and experiences of LGBTQ+ people regarding midwifery care: A systematic review of the international evidence

BACKGROUND

There has been growing attention to addressing the health inequalities and concerns of LGBTQ+ people, with research evidence highlighting areas requiring further attention and development. The distinct concerns of LGBTQ+ people when accessing midwifery care and support is an issue requiring a specific focus to ensure needs are met effectively.

AIM

The aim of this systematic review was to critically appraise and synthesise the best available evidence regarding the views and experiences of LGBTQ+ people in relation to midwifery care and supports.

METHOD

A systematic review was undertaken to identify all relevant studies meeting the inclusion criteria. A total of eleven papers were included in the review, utilising the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method. Methodological quality was evaluated using the Mixed Methods Assessment Tool (MMAT).

FINDINGS

Following data analysis, the themes that emerged were: (i) Contemplating pregnancy and ante-natal experiences, (ii) pregnancy and labour issues and concerns, and (iii) post-natal ongoing care and supports.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

It has become apparent from this systematic review that LGBTQ+ individuals have variable experiences when accessing midwifery care and support. Midwifery policies and practice guidelines should be reflective of the distinct needs of LGBTQ+ people and their families and friends. Future studies could focus more on the impact and outcomes of their care experiences within midwifery services.

Transdisciplinary research and clinical priorities for better health

Modern medicine makes it possible for many people to live with multiple chronic diseases for decades, but this has enormous social, financial, and environmental consequences. Preclinical, epidemiological, and clinical trial data have shown that many of the most common chronic diseases are largely preventable with nutritional and lifestyle interventions that are targeting well-characterized signaling pathways and the symbiotic relationship with our microbiome. Most of the research priorities and spending for health are focused on finding new molecular targets for the development of biotech and pharmaceutical products. Very little is invested in mechanism-based preventive science, medicine, and education. We believe that overly enthusiastic expectations regarding the benefits of pharmacological research for disease treatment have the potential to impact and distort not only medical research and practice but also environmental health and sustainable economic growth. Transitioning from a primarily disease-centered medical system to a balanced preventive and personalized treatment healthcare system is key to reduce social disparities in health and achieve financially sustainable, universal health coverage for all. In this Perspective article, we discuss a range of science-based strategies, policies, and structural reforms to design an entire new disease prevention-centered science, educational, and healthcare system that maximizes both human and environmental health.

Multidimensional prognostic index (MPI) predicts successful application for disability social benefits in older people

AIM

The economic recognition of disability is of importance in daily practice, but the tools used in older people are still limited. Therefore, we aimed to investigate the effectiveness of the multidimensional prognostic index (MPI) to identify frail older subjects to be submitted to civil invalidity application for disability benefits including Attendance Allowance (AA) indemnity, Carer's Leave (Law 104) and/or Parking Card for people with disabilities.

METHODS

From March 2018 to January 2019, 80 older people were included. The MPI was calculated from comprehensive geriatric assessment information including eight different domains. Civil benefits included attendance allowance (AA) indemnity by the Local Medico-Legal Committee (MLC-NHS) and by the National Institute of Social Security Committee (INPS), Carer's Leave (Law 104), and Parking Card for people with disabilities.

RESULTS

MPI values were associated with an increased probability to obtain a 100% civil disability, AA indemnity, Carer's Leave and a parking card for people with disabilities. MPI score showed a very good accuracy in predicting the civil invalidity benefits with a area-under-curve (AUC) of 87.3 (95% CI 80.6-97.4) to predict the release of AA indemnity, 81.3 (95% CI 68.5-91.1) to predict Care's leave and 70.7 (95% CI 59.4-84.7) to predict the Parking Card release. Moreover, data showed that a cut-off score of MPI ≥ 0.75 could identify the 100% of older subjects who successfully obtained the indemnity release.

CONCLUSION

MPI is an excellent predictor of social benefits' release by local and national agencies.

Reciprocal longitudinal associations between anxiety sensitivity and alcohol consumption/problems across adolescence: Examining anxiety as a mediator and race/ethnicity as a moderator

The conditions and populations for which anxiety sensitivity (AS; i.e., the tendency to interpret unpleasant physiological sensations as dangerous) relates to adolescent alcohol use is unclear. This study tested latent-variable cross-lagged panel modeling of AS-alcohol relations in a racially/ethnically heterogenous longitudinal youth cohort (N = 3396; 53.4% female, 45.8% Latinx) assessed annually across high school. Anxiety and race/ethnicity were tested as mediators and moderators, respectively, of AS-alcohol associations. AS prospectively predicted alcohol problems (β's = 0.05-0.07) but not alcohol consumption (β's = 0.02-0.04) across high school. Alcohol problems predicted AS at the end (β = 0.09) but not beginning (β's = 0.01-0.03) of high school and alcohol consumption predicted lower AS at the beginning (β = -0.06) but not end (β's = -0.02-0.01) of high school. Anxiety mediated AS's predictive effects on alcohol problems (βindirect's = 0.01, 95% CI [0.003, 0.03]) across high school. Race/ethnicity did not moderate interrelations of AS, anxiety, and alcohol outcomes. These findings lend support to the risk factor model of AS on alcohol problems (but not consumption) through anxiety and the scar/complication model whereby alcohol problems may exacerbate AS later in adolescence. Addressing reciprocal risk processes between AS, anxiety, and alcohol problems warrant consideration in adolescent behavioral health promotion for various racial/ethnic populations.

Haven Health is About to Disrupt the U.S. Healthcare System

Background: Healthcare costs are increasing in the U.S. Healthcare market is fragmented and opaque. The Amazon, JP Morgan Chase, and Berkshire Hathaway partnered to form an independent healthcare company ‘Haven’, designed to support cost-containment in health care and to forge a better patient experience. Limited information is available in the public domain about Haven’s strategy to deliver cost-effective healthcare for their employees.

Objective: To describe the impact of Haven Health of modern healthcare.

Methods: We reviewed literature in Pubmed (MEDLINE database of references and abstracts on life sciences and biomedical topics from the USA National Library of Medicine at the National Institutes of Health) and the public domain.

Results: Amazon’s expertise and abilities in e-commerce such as logistics, supply, and big data management will support Haven’s quest to resolve inefficiencies in health care. Haven may attempt to directly negotiate with providers, bypassing insurance companies, to establish themselves as an independent payor. Additionally, Haven to establish themselves as a provider by building new low-cost primary care clinics, focusing on chronic disease prevention. The new healthcare system may leverage machine learning, artificial intelligence and big data analysis to support its initiatives and other ‘big data’ analytics to drive it all.

Conclusions: Heaven Health may use its expertise to disrupt everything from the pharmaceutical supply chain to primary care and telehealth. More research is needed to evaluate the impact of Haven Healthcare on disease outcomes and healthcare costs.

Kynurenine induces an age-related phenotype in bone marrow stromal cells

Advanced age is one of the important contributing factors for musculoskeletal deterioration. Although the exact mechanism behind this degeneration is unknown, it has been previously established that nutritional signaling plays a vital role in musculoskeletal pathophysiology. Our group established the vital role of the essential amino acid, tryptophan, in aging musculoskeletal health. With advanced age, inflammatory factors activate indoleamine 2,3-dioxygenase (IDO1) and accumulate excessive intermediate tryptophan metabolites such as Kynurenine (KYN). With age, Kynurenine accumulates and suppresses osteogenic differentiation, impairs autophagy, promotes early senescence, and alters cellular bioenergetics of bone marrow stem cells. Recent studies have shown that Kynurenine negatively impacts bone marrow stromal cells (BMSCs) and, consequently, promotes bone loss. Overall, understanding the mechanism behind BMSCs losing their ability for osteogenic differentiation can provide insight into the prevention of osteoporosis and the development of targeted therapies. Therefore, in this article, we review Kynurenine and how it plays a vital role in BMSC dysfunction and bone loss with age.

How Do Various Health Insurance Coverages Affect COVID-19-related Stay-at-Home-Tendencies of People Across US States?

This study investigates the relations between COVID-19-related stay-at-home-tendencies and various health insurance coverages of people across US states. To this aim, the K-means clustering and panel regression analysis with cross-sectional dependence are applied. The main empirical finding reveals that various health insurance coverages have different level impacts on COVID-19-related stay-at-home-tendencies. People who are uninsured tend to stay at home the most as compared with people with private, Medicaid, Medicare and military health insurance coverages. As a result, it may be interpreted that uninsured people have serious concerns about affording healthcare costs associated with COVID-19 and, thereby, stay at home. However, people with private health insurance coverages tend to stay at home the least. This may also lead to the interpretation that people with private health insurance coverages feel safer and better protected against the rising risks of this pandemic outside their homes.

Sleep Education for Elders Program (SLEEP): Promising Pilot Results of a Virtual, Health Educator-Led, Community-Delivered Sleep Behavior Change Intervention

PURPOSE

Sleep problems pose serious public health concerns, and evidence suggests that the problem is worsening. Both sufficient sleep quantity and quality are needed for optimal health, particularly among older adults, but access to sleep care can be difficult. This study examined the efficacy of a six-week sleep behavior change program designed for older adults that was delivered virtually by health educators.

PARTICIPANTS AND METHODS

This quasi-experimental pilot study (intervention n = 22; control n = 31) explored the effects of the Sleep Education for Elders Program (SLEEP) on sleep outcomes, which included: 1) sleep quality, measured by the Pittsburgh Sleep Quality Index (PSQI); 2) sleep duration, extracted from the PSQI; 3) insomnia symptoms, measured by the Insomnia Severity Index; 4) sleep hygiene behaviors, obtained from the Sleep Hygiene Index; and 5) excessive daytime sleepiness, measured by the Epworth Sleepiness Scale.

RESULTS

After SLEEP, the intervention group experienced significantly improved sleep quality (p < 0.001), a reduction in maladaptive sleep hygiene behaviors (p = 0.007), and reduced daytime sleepiness (p < 0.027) compared to the control group. Effect sizes for all five sleep measures were medium or large. In the intervention group, all changes were judged to be clinically meaningful (≥ 0.5 SD) except for improvements in daytime sleepiness.

CONCLUSION

These data support the efficacy of a group-based, virtual behavior change intervention in improving sleep outcomes among older adults.

COVID-19 and Public Policy Imperatives: A Trainee Call to Action

The COVID-19 pandemic has exacerbated the flaws in the U.S. employer-based health insurance system, magnified racial disparities in health and health care, and overwhelmed the country's underfunded public health infrastructure. These are the same systematic failures that have always harmed and killed the nation's most vulnerable. While everyone wishes for an end to this national tragedy, the authors believe a new normal must be defined for the postpandemic period.In the postpandemic period, policies that were once labeled radical and impossible will be urgent and necessary. Examples of such policies include providing universal health care, dismantling the structures that propagate racism and injustice, and reinvesting in public health. Previous research by the authors has shown that their medical student colleagues recognize that it is their responsibility to address policies that harm patients and to support reforms at the scale the authors propose. This commitment to a better future is reflected in the widespread mobilization of medical students seen across the United States. Recognizing that the old normal is unsustainable, the authors call on those who previously benefited from the status quo to instead seek a new postpandemic normal that works for all.

Universal Healthcare in the United States of America: A Healthy Debate

This commentary offers discussion on the pros and cons of universal healthcare in the United States. Disadvantages of universal healthcare include significant upfront costs and logistical challenges. On the other hand, universal healthcare may lead to a healthier populace, and thus, in the long-term, help to mitigate the economic costs of an unhealthy nation. In particular, substantial health disparities exist in the United States, with low socio–economic status segments of the population subject to decreased access to quality healthcare and increased risk of non-communicable chronic conditions such as obesity and type II diabetes, among other determinants of poor health. While the implementation of universal healthcare would be complicated and challenging, we argue that shifting from a market-based system to a universal healthcare system is necessary. Universal healthcare will better facilitate and encourage sustainable, preventive health practices and be more advantageous for the long-term public health and economy of the United States.

Post-transplant survey to assess patient experiences with donor-derived HCV infection

BACKGROUND

Despite increased utilization of hepatitis C virus-infected (HCV+) organs for transplantation into HCV-uninfected recipients, there is lack of standardization in HCV-related patient education/consent and limited data on financial and social impact on patients.

METHODS

We conducted a survey on patients with donor-derived HCV infection at our center transplanted between 4/1/2017 and 11/1/2019 to assess: why patients chose to accept HCV+ organ(s), the adequacy of their pre-transplant HCV education and informed consent process, financial issues related to copays after discharge, and social challenges they faced.

RESULTS

Among 49 patients surveyed, transplanted organs included heart (n = 19), lung (n = 9), kidney (n = 11), liver (n = 4), heart/kidney (n = 4), and liver/kidney (n = 2). Many recipients accepted an HCV-viremic (HCV-V) organ due to perceived reduction in waitlist time (n = 33) and/or trust in their physician's recommendation (n = 29). Almost all (n = 47) felt that pre-transplant education and consent was appropriate. Thirty patients had no copay for direct-acting antivirals (DAA) for HCV, including 21 with household income <$20 000; seven had copays of <$100 and one had a copay >$1000. Two patients reported feeling isolated due to HCV infection and eight reported higher than anticipated medication costs. Patients' biggest concern was potential HCV transmission to partners (n = 18) and family/friends (n = 15). Overall almost all (n = 47) patients reported a positive experience with HCV-V organ transplantation.

CONCLUSION

We demonstrate that real-world patient experiences surrounding HCV-V organ transplantation have been favorable. Almost all patients report comprehensive HCV-related pre-transplant consent and education. Additionally, medication costs and social isolation/exclusion were not barriers to the use of these organs.

Alignment With Market Forces: The "Re-Whithering" of Infectious Diseases

Given constant emergence of new infectious threats, infectious diseases (ID) should be one of the most attractive medical specialties to students and trainees. Yet, ID Fellowship programs continue to not fill in the match, and ID remains among the lowest paid specialties. Approximately 35 years after Dr. Petersdorf first asked the question, we find ourselves once again wondering, "Whither Infectious Diseases?" To answer this question, and align with predominant US market forces, ID experts should push for the following: (1) restrictions regarding utilization of ID diagnostics and antimicrobial agents; (2) pay-for-performance measures regarding antimicrobial prescribing rates; and (3) healthcare reform as called for by the American College of Physicians to move away from fee-for-service medicine. Einstein said, "Continuing to do the same thing over and over and expecting a different result is the definition of insanity." We must move towards alignment with market forces, to benefit our patients, society, and our colleagues.