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Background: Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner. Objective: To examine differences in Veterans' experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021. Design: Observational analyses of Veterans' ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors. Participants: Respondents to the 2016–2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey. Measures: Care ratings in nine domains. Key Results: The sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from − 0.04 to − 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted. Conclusions: This study identified small but persistent racial and ethnic differences in Veterans' experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans' patient experience could advance equity in VA community care. [ABSTRACT FROM AUTHOR]

Background: Studies assessing equity in the prevention of atherosclerotic cardiovascular disease (ASCVD) for Latinos living in the USA collectively yield mixed results. Latino persons are diverse in many ways that may influence cardiovascular health. The intersection of Latino nativity and ASCVD prevention is understudied. Objective: To determine whether disparities in ASCVD screening, detection, and prescribing differ for US Latinos by country of birth. Design: A retrospective cohort design utilizing 2014–2020 electronic health record data from a network of 320 community health centers across 12 states. Analyses occurred October 1, 2022, to September 30, 2023. Participants: Non-Hispanic White and Latino adults age 20–75 years, born in Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, and the USA. Exposures: Ethnicity and country of birth. Main Measures: Outcome measures included prevalence of statin eligibility, of having insufficient data to establish eligibility, odds of having a documented statin prescription, and rates of statin prescriptions and refills. We used covariate-adjusted logistic and generalized estimating equations logistic and negative binomial regressions to generate absolute and relative measures. Key Results: Among 108,672 adults, 23% (n = 25,422) were statin eligible for primary or secondary prevention of ASCVD using American College of Cardiology/American Heart Association guidelines. Latinos, born in and outside the USA were more likely eligible than Non-Hispanic White patients were (US-born Latino OR = 1.55 (95% CI = 1.37–1.75); non-US-born Latino OR = 1.63 (95% CI = 1.34–1.98)). The eligibility criteria that was met differed by ethnicity and nativity. Latinos overall were less likely missing data to establish eligibility and differences were again observed by specific non-US country of origin. Among those eligible, we observed no statistical difference in statin prescribing between US-born Latinos and non-Hispanic White persons; however, disparities varied by specific non-US country of origin. Conclusion: Efforts to improve Latino health in the USA will require approaches for preventing and reversing cardiovascular risk factors, and statin initiation that are Latino subgroup specific. [ABSTRACT FROM AUTHOR]

Background: Policy initiatives have attempted to reduce healthcare inequalities in the USA, but evidence on whether these initiatives have reduced racial and ethnic disparities in pain treatment in primary care is lacking. Objective: To determine whether racial and ethnic disparities in medication prescribed for pain in primary care settings have diminished over a 21-year period from 1999 to 2019. Design: An annual, representative cross-sectional probability sample of visits to US primary care physicians, taken from the National Ambulatory Medical Care Survey. Patients: Pain-related visits to primary care physicians. Main Measures: Prescriptions for opioid and non-opioid analgesics. Key Results: Of 599,293 (16%) sampled visits, 94,422 were pain-related, representing a population-weighted estimate of 143 million visits made annually to primary care physicians for pain. Relative risk analysis controlling for insurance, pain type, and other potential confounds showed no difference in pain medication prescribed between Black and White patients (p =.121). However, White patients were 1.61 (95% CI 1.32–1.97) and Black patients 1.57 (95% CI 1.26–1.95) times more likely to be prescribed opioids than a more underrepresented group consisting of Asian, Native-Hawaiian/Pacific-Islander, and American-Indian/Alaska-Natives (ps <.001). Non-Hispanic/Latino patients were 1.32 (95% CI 1.18–1.45) times more likely to receive opioids for pain than Hispanic/Latino patients (p <.001). Penalized cubic spline regression found no substantive narrowing of disparities over time. Conclusions: These findings suggest that additional intervention strategies, or better implementation of existing strategies, are needed to eliminate ethnic and racial disparities in pain treatment towards the goal of equitable healthcare. [ABSTRACT FROM AUTHOR]

Background: Gender minorities and cisgender women face barriers to healthcare access. Prior work suggests cost may represent a particular barrier to accessing care for transgender and gender diverse (TGD) individuals. Objective: To examine odds of delaying care for any reason and, secondarily, for 7 specific reasons among TGD individuals and cisgender women compared with cisgender men in the All of Us Research Program. Design: We calculated the odds of delayed care by gender identity relative to cisgender men using multivariable-adjusted logistic regression, with adjustment for age, race, income, education, and Charlson comorbidity index. Participants: We examined 117,806 All of Us participants who completed the healthcare access and utilization survey. Main Measures: The primary outcome was self-reported delayed care in the past 12 months for any of 7 potential reasons: cost (out-of-pocket cost, co-payment costs, and/or high deductible), lack of childcare, lack of eldercare, nervousness associated with visiting the healthcare provider, rurality, inability to take time off work, and lack of transportation. Key Results: Compared with cisgender men, the multivariable-adjusted odds ratio (OR) for delaying care for any reason was 1.48 (95% CI, 1.44–1.53; P < 0.001) among cisgender women, 1.65 (95% CI, 1.24–2.21; P < 0.001) among TGD individuals assigned male at birth, and 2.76 (95% CI, 2.26–3.39; P < 0.001) among TGD individuals assigned female at birth. Results were consistent across multiple sensitivity analyses. TGD individuals were substantially more likely to cite nervousness with visiting a healthcare provider as a barrier, whereas cisgender women were more likely to delay care due to lack of childcare coverage. Conclusions: Cisgender women and TGD individuals were more likely to delay seeking heath care compared with cisgender men, and for partially different reasons. These findings highlight the need to address common and distinct barriers to care access among marginalized groups. [ABSTRACT FROM AUTHOR]

Background: Sub-optimal HbA1c control is a driver of disparities in diabetes outcomes among Hispanic patients. Differences in medication adherence may underlie racial/ethnic differences in HbA1c level. Objective: To examine the relationship between medication adherence and disparities in HbA1c level among Hispanic patients, relative to other racial/ethnic groups, obtaining care in the University of California Health System (UC Health). Design: This study used clinical, administrative, and prescription dispensing data (January–December 2021) derived from the electronic health records of 5 Academic Medical Centers in UC Health, and linear regression models (LRMs) to conduct a cross-sectional analysis of the association between medication adherence, race/ethnicity, and HbA1c level. Adjusted LRMs were run with and without the measure of medication adherence to assess this relationship. Participants: Patients with a UC Health primary care physician (PCP), with ≥ 1 PCP visit within the last 3 years, ages 18–75, reporting Asian, Hispanic, or White race/ethnicity, and who had ≥ 2 encounters with an ICD diagnosis of diabetes or had a prescription for a diabetes medication within the last 2 years, as of 12/31/21 (N = 27, 542; Asian = 6253, Hispanic = 7216, White = 14,073). Main Measures: Our measure of medication adherence was the proportion of days covered (PDC) for diabetes medications in 2021. Our outcome was the most recent HbA1c value. Key Results: In the LRM excluding the PDC, Hispanic ethnicity was positively associated with HbA1c level (β = 0.31, p = < 0.001). In the LRM model including PDC, PDC was negatively associated with HbA1c level (β = − 0.18, p = < 0.001). However, the positive relationship between Hispanic ethnicity and HbA1c level did not change (β = 0.31, p = < 0.001). Conclusions: The findings of this study suggest that the relationship between Hispanic ethnicity, HbA1c level, and factors outside of medication adherence should be explored among primary care patients receiving care in Academic Medical Centers. [ABSTRACT FROM AUTHOR]

Background: While nonpharmacologic treatments are increasingly endorsed as first-line therapy for low back pain (LBP) in clinical practice guidelines, it is unclear if use of these treatments is increasing or equitable. Objective: Examine national trends in chiropractic care and physical rehabilitation (occupational/physical therapy (OT/PT)) use among adults with LBP. Design/Setting: Serial cross-sectional analysis of the National Health Interview Survey, 2002 to 2018. Participants: 146,087 adults reporting LBP in prior 3 months. Methods: We evaluated the association of survey year with chiropractic care or OT/PT use in prior 12 months. Logistic regression with multilevel linear splines was used to determine if chiropractic care or OT/PT use increased after the introduction of clinical guidelines. We also examined trends in use by age, sex, race, and ethnicity. When trends were similar over time, we present differences by these demographic characteristics as unadjusted ORs using data from all respondents. Results: Between 2002 and 2018, less than one-third of adults with LBP reported use of either chiropractic care or OT/PT. Rates did not change until 2016 when uptake increased with the introduction of clinical guidelines (2016–2018 vs 2002–2015, OR = 1.15; 95% CI: 1.10–1.19). Trends did not differ significantly by sex, race, or ethnicity (p for interactions > 0.05). Racial and ethnic disparities in chiropractic care or OT/PT use were identified and persisted over time. For example, compared to non-Hispanic adults, either chiropractic care or OT/PT use was lower among Hispanic adults (combined OR = 0.62, 95% CI: 0.65–0.73). By contrast, compared to White adults, Black adults had similar OT/PT use (OR = 0.98; 95% CI: 0.94–1.03) but lower for chiropractic care use (OR = 0.50; 95% CI: 0.47–0.53). Conclusions: Although use of chiropractic care or OT/PT for LBP increased after the introduction of clinical guidelines in 2016, only about a third of US adults with LBP reported using these services between 2016 and 2018 and disparities in use have not improved. [ABSTRACT FROM AUTHOR]

Background: Uptake of lung cancer screening (LCS) has been slow with less than 20% of eligible people who currently or formerly smoked reported to have undergone a screening CT. Objective: To determine individual-, health system-, and neighborhood-level factors associated with LCS uptake after a provider order for screening. Design and Subjects: We conducted an observational cohort study of screening-eligible patients within the Population-based Research to Optimize the Screening Process (PROSPR)–Lung Consortium who received a radiology referral/order for a baseline low-dose screening CT (LDCT) from a healthcare provider between January 1, 2015, and June 30, 2019. Main Measures: The primary outcome is screening uptake, defined as LCS-LDCT completion within 90 days of the screening order date. Key Results: During the study period, 18,294 patients received their first order for LCS-LDCT. Orders more than doubled from the beginning to the end of the study period. Overall, 60% of patients completed screening after receiving their first LCS-LDCT order. Across health systems, uptake varied from 41 to 87%. In both univariate and multivariable analyses, older age, male sex, former smoking status, COPD, and receiving care in a centralized LCS program were positively associated with completing LCS-LDCT. Unknown insurance status, other or unknown race, and lower neighborhood socioeconomic status, as measured by the Yost Index, were negatively associated with screening uptake. Conclusions: Overall, 40% of patients referred for LCS did not complete a LDCT within 90 days, highlighting a substantial gap in the lung screening care pathway, particularly in decentralized screening programs. [ABSTRACT FROM AUTHOR]

Background: Food insecurity (FI) often co-exists with other social risk factors, which makes addressing it particularly challenging. The degree of association between FI and other social risk factors across different levels of income and before and during the COVID-19 pandemic is currently unknown, impeding the ability to design effective interventions for addressing these co-existing social risk factors. Objective: To determine the association between FI and other social risk factors overall and across different levels of income-poverty ratios and before (2019) and during (2020–2021) the pandemic. Design: We used nationally representative data from the 2019–2021 National Health Interview Survey for our cross-sectional analysis. Social risk factors available in NHIS included difficulties paying for medical bills, difficulties paying for medications, receiving income assistance, receiving rental assistance, and "not working last week". Subjects: 93,047 adults (≥18 years old). Key Results: Individuals with other social risk factors (except receiving income assistance) were more likely to report FI, even after adjusting for income and education inequalities. While poverty leads to a higher prevalence of FI, associations between FI and other social risk factors were stronger among people with higher incomes, which may be related to their ineligibility for social safety net programs. Associations were similar before and during the pandemic, perhaps due to the extensive provision of social safety net programs during the pandemic. Conclusions: Future research should explore how access to a variety of social safety net programs may impact the association between social risk factors. With the expiration of most pandemic-related social supports, further research and monitoring are also needed to examine FI in the context of increasing food and housing costs. Our findings may also have implications for the expansion of income-based program eligibility criteria and screening for social risk factors across all patients and not only low-income people. [ABSTRACT FROM AUTHOR]

Background: The unprecedented use of telemedicine during the COVID-19 pandemic provided an opportunity to examine its uptake among individuals with limited English proficiency (LEP). Objective: To assess telemedicine use among nonelderly adults with LEP and the association between use of telehealth and emergency department (ED) and hospital visits. Design: Cross-sectional study using the National Health Interview Survey (July 2020–December 2021) Participants: Adults (18–64 years), with LEP (N=1488) or English proficiency (EP) (N=25,873) Main Measures: Telemedicine, ED visits, and hospital visits in the past 12 months. We used multivariate logistic regression to assess (1) the association of English proficiency on having telemedicine visits; and (2) the association of English proficiency and telemedicine visits on having ED and hospital visits. Key Results: Between July 2020 and December 2021, 22% of adults with LEP had a telemedicine visit compared to 35% of adults with EP. After controlling for predisposing, enabling, and need factors, adults with LEP had 20% lower odds of having a telemedicine visit than adults with EP (p=0.02). While English proficiency was not associated with ED or hospital visits during this time, adults with telemedicine visits had significantly greater odds of having any ED (aOR: 1.80, p<0.001) and hospital visits (aOR: 2.03, p<0.001) in the past 12 months. Conclusions: While telemedicine use increased overall during the COVID-19 pandemic, its use remained much less likely among adults with LEP. Interventions targeting structural barriers are needed to address disparities in access to telemedicine. More research is needed to understand the relationship between English proficiency, telemedicine visits, and downstream ED and hospital visits. [ABSTRACT FROM AUTHOR]

Background: Race/ethnic disparities in preventable diabetes-specific hospital care may exist among adults with diabetes who have Medicaid coverage. Objective: To examine race/ethnic disparities in utilization of preventable hospital care by adult Medicaid enrollees with diabetes across nine states over time. Design: Using serial cross-sectional state discharge records for emergency department (ED) visits and inpatient (IP) hospitalizations from the Healthcare Cost and Utilization Project, we quantified race/ethnicity-specific, state-year preventable diabetes-specific hospital utilization. Participants: Non-Hispanic Black, non-Hispanic White, and Hispanic adult Medicaid enrollees aged 18–64 with a diabetes diagnosis (excluding gestational or secondary diabetes) who were discharged from hospital care in Arizona, Iowa, Kentucky, Florida, Maryland, New Jersey, New York, North Carolina, and Utah for the years 2008, 2011, 2014, and 2017. Main Measures: Non-Hispanic Black-over-White and Hispanic-over-White rate ratios constructed using age- standardized state-year, race/ethnicity-specific ED, and IP diabetes-specific utilization rates. Key Results: The ratio of Black-over-White ED utilization rates for preventable diabetes-specific hospital care increased across the 9 states in our sample from 1.4 (CI 95, 1.31–1.50) in 2008 to 1.73 (CI 95, 1.68–1.78) in 2017. The cross-year-state average non-Hispanic Black-over-White IP rate ratio was 1.46 (CI 95, 1.42–1.50), reflecting increases in some states and decreases in others. The across-state-year average Hispanic-over-White rate ratio for ED utilization was 0.67 (CI 95, 0.63–0.71). The across-state-year average Hispanic-over-White IP hospitalization rate ratio was 0.72 (CI 95, 0.69–0.75). Conclusions: Hospital utilization by non-Hispanic Black Medicaid enrollees with diabetes was consistently greater and often increased relative to utilization by White enrollees within state programs between 2008 and 2017. Hispanic enrollee hospital utilization was either lower or indistinguishable relative to White enrollee hospital utilization in most states, but Hispanic utilization increased faster than White utilization in some states. Among broader patterns, there is heterogeneity in the magnitude of race/ethnic disparities in hospital utilization trends across states. [ABSTRACT FROM AUTHOR]

Background: Patients experiencing systemic patterns of disadvantage, such as racial/ethnic minorities and those with limited English proficiency, are underrepresented in research. This is particularly true for large pragmatic trials of potentially sensitive research topics, such as advance care planning (ACP). It is unclear how phone outreach may affect research participation by underrepresented individuals. Objective: To assess the effect of phone outreach, in addition to standard mail survey recruitment, in a population-based ACP pragmatic trial at three academic health systems in California. Design: Retrospective cohort study Patients: Primary care patients with serious illness were mailed a survey in their preferred language. Patients who did not initially respond by mail received up to three reminder phone calls with the option of survey completion by phone. Main measures: Effect of phone outreach on survey response rate associated with respondent demographic characteristics (e.g., Social Vulnerability Index [SVI], range 0 (low) to 1 (high)). Results: Across the health systems, 5998 seriously ill patients were mailed surveys. We obtained completed surveys from 1215 patients (20% response rate); 787 (65%) responded after mail alone and 428 (35%) participated only after phone outreach. Patients recruited after phone outreach compared to mail alone were more socially vulnerable (SVI 0.41 v 0.35, P < 0.001), were more likely to report being a racial/ethnic minority (35% v 28%, P = 0.006), and non-English speaking (16% v 10%, P = 0.005). Age and gender did not differ significantly. The inclusion of phone outreach resulted in a sample that better represented the baseline population than mail alone in racial/ethnic minority (28% mail alone, 30% including phone outreach, 36% baseline population), non-English language preference (10%, 12%, 15%, respectively), and SVI (0.35, 0.37, 0.38, respectively). Conclusions: Phone outreach for a population-based survey in a pragmatic trial concerning a potentially sensitive topic significantly enhanced recruitment of underrepresented seriously ill patients. [ABSTRACT FROM AUTHOR]

Background: Insurance status may influence quality of opioid analgesic (OA) prescribing among patients seen by the same clinician. Objective: To explore how high-risk OA prescribing varies by payer type among patients seeing the same prescriber and identify clinician characteristics associated with variable prescribing Design: Retrospective cohort study using the 2016–2018 IQVIA Real World Data – Longitudinal Prescription Participants: New OA treatment episodes for individuals ≥ 12 years, categorized by payer and prescriber. We created three dyads: prescribers with ≥ 10 commercial insurance episodes and ≥ 10 Medicaid episodes; ≥ 10 commercial insurance episodes and ≥ 10 self-pay episodes; and ≥ 10 Medicaid episodes and ≥ 10 self-pay episodes. Main Outcome(s) and Measure(s): Rates of high-risk episodes (initial opioid episodes with > 7-days' supply or prescriptions with a morphine milliequivalent daily dose >90) and odds of being an unbalanced prescriber (prescribers with significantly higher percentage of high-risk episodes paid by one payer vs. the other payer) Key Results: There were 88,352 prescribers in the Medicaid/self-pay dyad, 172,392 in the Medicaid/commercial dyad, and 122,748 in the self-pay/commercial dyad. In the Medicaid/self-pay and the commercial-self-pay dyads, self-pay episodes had higher high-risk episode rates than Medicaid (16.1% and 18.4%) or commercial (22.7% vs. 22.4%). In the Medicaid/commercial dyad, Medicaid had higher high-risk episode rates (21.1% vs. 20.4%). The proportion of unbalanced prescribers was 11–12% across dyads. In adjusted analyses, surgeons and pain specialists were more likely to be unbalanced prescribers than adult primary care physicians (PCPs) in the Medicaid/self-paydyad (aOR 1.2, 95% CI 1.16–1.34 and aOR 1.2, 95% CI 1.03–1.34). For Medicaid/commercial and self-pay/commercial dyads, surgeons had lower odds of being unbalanced compared to PCPs (aOR 0.6, 95% CI 0.57–0.66 and aOR 0.6, 95% CI 0.61–0.68). Conclusions: Clinicians prescribe high-risk OAs differently based on insurance type. The relationship between insurance and opioid prescribing quality goes beyond where patients receive care. [ABSTRACT FROM AUTHOR]

Background: Income disparities may affect patients' care transition home. Evidence among patients who have access to publicly funded healthcare coverage remains limited. Objective: To evaluate the association between low income and post-discharge health outcomes and explore patient and caregiver perspectives on the role of income disparities. Design: Mixed-methods secondary analysis conducted among participants in a double-blind randomized controlled trial. Participants: Participants from a multicenter study in Ontario, Canada, were classified as low income if annual self-reported salary was below $29,000 CAD, or between $30,000 and $50,000 CAD and supported ≥ 3 individuals. Main Measures: The associations between low income and the following self-reported outcomes were evaluated using multivariable logistic regression: patient experience, adherence to medications, diet, activity and follow-up, and the aggregate of emergency department (ED) visits, readmission, or death up to 3 months post-discharge. A deductive direct content analysis of patient and caregivers on the role of income-related disparities during care transitions was conducted. Key Results: Individuals had similar odds of reporting high patient experience and adherence to instructions regardless of reported income. Compared to higher income individuals, low-income individuals also had similar odds of ED visits, readmissions, and death within 3 months post-discharge. Low-income individuals were more likely than high-income individuals to report understanding their medications completely (OR 1.9, 95% CI: 1.0–3.4) in fully adjusted regression models. Two themes emerged from 25 interviews which (1) highlight constraints of publicly funded services and costs incurred to patients or their caregivers along with (2) the various ways patients adapt through caregiver support, private services, or prioritizing finances over health. Conclusions: There were few quantitative differences in patient experience, adherence, ED visits, readmissions, and death post-discharge between individuals reporting low versus higher income. Several hidden costs for transportation, medications, and home care were reported however and warrant further research. [ABSTRACT FROM AUTHOR]

Background: Patients with limited-English proficiency (LEP) face multiple barriers to equitable healthcare. Interventions that go beyond interpretation, such as the use of bicultural-bilingual patient navigators, hold promise for addressing multi-level barriers. However, data about how to operationalize the tasks that are key to such interventions across diverse LEP communities are lacking. Objective: Using our health system's bicultural-bilingual caseworker-cultural mediator (CCM) program serving Amharic-, Cambodian/Khmer-, Somali-, Spanish-, and Vietnamese-speaking patients, we sought to understand the key tasks that comprise the CCMs' role and how these tasks enable them to address barriers to healthcare for patients with LEP. Design: Semi-structured interviews were conducted in 2019 with a purposive sample (n=23) of clinicians, CCMs, and patients with LEP or their family members from all language groups. Participants: Patients or family members receiving CCM services, CCMs, and clinicians who referred patients to the program. Approach: Content analysis consisting of a hybrid deductive-inductive qualitative approach. Key Results: Seven CCM tasks were identified: advocacy, care coordination, navigation, interpretation, education, mediation, and emotional support. Additionally, four key impacts emerged that described the ways in which these tasks enabled the CCMs to facilitate equitable care: bridging the patient, family, community, clinical team, and healthcare system; impacting knowledge of cultural issues and of the healthcare system; troubleshooting cultural barriers and problem solving; and enhancing relationship building. Conclusions: We identified several tasks and impacts that enabled CCMs to address multi-level barriers to care experienced by patients with LEP and their families across diverse cultural and linguistic groups. Findings suggest opportunities for the generalizability of programs such as ours for multiple LEP populations. Additionally, interventions having a greater scope than interpretation and including relationships with communities may be more successful in addressing barriers to equitable care at the individual, system, and community levels. [ABSTRACT FROM AUTHOR]

Background: There are approximately 25.6 million individuals with limited English proficiency (LEP) in the USA, and this number is increasing. Objective: Investigate associations between LEP and access to care in adults. Design: Cross-sectional nationally representative survey. Participants: Adults with (n = 18,908) and without (n = 98,060) LEP aged ≥ 18 years identified from the 2014–2018 Medical Expenditure Panel Survey Main Measures: Associations between LEP and access to healthcare and preventive services were evaluated with multivariable logistic regression models, stratified by age group (18–64 and ≥ 65 years). The official government definition of LEP (answers "not at all/not well/well" to the question "How well do you speak English?") was used. Access to care included having a usual source of care (and if so, distance from usual source of care, difficulty contacting usual source of care, and provision of extended hours), visiting a medical provider in the past 12 months, having to forego or delay care, and having trouble paying for medical bills. Preventive services included blood pressure and cholesterol check, flu vaccination, and cancer screening. Key Results: Adults aged 18–64 years with LEP were significantly more likely to lack a usual source of care (adjusted odds ratios [aOR] = 2.48; 95% confidence interval [CI] = 2.27–2.70), not have visited a medical provider (aOR = 2.02; CI = 1.89–2.16), and to be overdue for receipt of preventive services, including blood pressure check (aOR = 2.00; CI = 1.79–2.23), cholesterol check (aOR = 1.22; CI = 1.03–1.44), and colorectal cancer screening (aOR = 1.58; CI = 1.37–1.83) than adults without LEP. Results were similar among adults aged ≥ 65 years. Conclusions: Adults with LEP had consistently worse access to care than adults without LEP. System-level interventions, such as expanding access to health insurance coverage, providing language services, improving provider training in cultural competence, and increasing diversity in the medical workforce may minimize barriers and improve equity in access to care. [ABSTRACT FROM AUTHOR]

Background: People with limited English proficiency (LEP) face greater barriers to accessing medical care than those who are English proficient (EP). Language-related differences in the use of outpatient care across the full spectrum of physician specialties have not been studied. Objective: To compare outpatient visit rates to physicians in 28 specialties by people with LEP vs EP. Design: Multivariable negative binomial regression analysis of nationally representative data from the Medical Expenditure Panel Survey (pooled 2013–2018) with adjustment for age, sex, and self-reported health status. Participants: 149,611 survey respondents aged 18 and older. Exposure: LEP, defined as taking the survey in a language other than English. Main Measures: Annual per capita adjusted visit rate ratios (ARRs) comparing visit rates by LEP and EP persons to individual specialties, and to three categories of specialties: (1) primary care (internal or family medicine, geriatrics, general practice, or obstetrics/gynecology), (2) medical-subspecialties, or (3) surgical specialties. Key Results: Patients with LEP were underrepresented in 26 of 28 specialties. Disparities were particularly large for the following: pulmonology (ARR, 0.26; 95% CI, 0.20–0.35), orthopedics (ARR, 0.35; 95% CI, 0.30–0.40), otolaryngology (ARR, 0.40; 95% CI, 0.27–0.59), and psychiatry (ARR, 0.43; 95% CI, 0.32–0.58). Among individuals with several specific common chronic conditions, LEP-EP disparities in visits to specialties in those conditions generally persisted. Disparities were larger for medical subspecialties (ARR, 0.41; 95% CI, 0.36–0.46) and surgical specialties (ARR, 0.46; 95% CI, 0.42–0.50) than for primary care (ARR, 0.76; 95% CI, 0.72 to 0.79). Conclusions: Patients with LEP are underrepresented in most outpatient specialty practices, particularly medical subspecialties and surgical specialties. Our findings highlight the need to remove language barriers to physician services in order to ensure access to the full spectrum of outpatient specialty care for people with LEP. [ABSTRACT FROM AUTHOR]

Background: Tubal ligation remains common in the USA, especially among low-income patients. Objective: To compare the effectiveness and safety of intrauterine contraceptives (IUC) to laparoscopic tubal ligation for Medicaid clients. Design: We partnered with patient and clinician stakeholders to conduct a retrospective cohort study using California Medicaid claims for patients who had an IUC placed or laparoscopic tubal ligation performed in 2008–2014, excluding procedures performed within 42 days of a birth. We applied log-linear (Poisson) event-history regression models for clustered person-period data to adjust for sociodemographic variables and pre-procedure health status when examining associations between these contraceptive procedures and claims related to contraceptive failure, complications, and pain in the first year post-procedure. Key Results: We identified 35,705 patients who had a levonorgestrel IUC placed, 23,628 patients who had a copper IUC placed, and 23,965 patients who underwent laparoscopic tubal ligation. In unadjusted analyses, rates of pregnancy within 1 year were similar following levonorgestrel IUC (2.40%) or copper IUC placement (2.99%) or tubal ligation (2.64%). In adjusted analyses, compared to tubal ligation, pregnancy was less common following placement of a levonorgestrel IUC (adj IRR 0.72, 95% CI 0.64–0.82) and similar with placement of a copper IUC (adj IRR 0.92, 95% CI 0.82–1.05). Procedural complications such as infection (0.35% vs. 2.91%) were significantly less common with IUC placement than tubal ligation. Claims for pelvic and abdominal pain decreased in frequency with time since all procedures; 6 to 12 months post-procedure, pelvic pain claims were less common after levonorgestrel IUC (adj IRR 0.69, 95% CI 0.65–0.73) or copper IUC placement (adj IRR 0.70, 95% CI 0.66–0.75) than tubal ligation. Conclusions: IUC appears at least as effective as laparoscopic tubal ligation at 1-year post-procedure with lower rates of infection and pelvic pain 6 to 12 months post-procedure. Clinical Trial Registration: NCT03438682 [ABSTRACT FROM AUTHOR]

Objectives: The global rise in overweight, obesity, and related diseases is undeniable; however, the pathogenesis of obesity and obesity-associated diseases is heterogeneous, with varied complications and a discordant response to treatment. Intriguingly, men have a shorter lifespan than women, despite being half as likely to be obese. This paradox suggests a potential gender disparity in the impact of obesity on mortality, with men potentially being more vulnerable to obesity-associated health risks.This retrospective study utilized Global Burden of Diseases data from 204 countries/territories to bridge the knowledge gap in understanding gender disparities in obesity-related mortality. Outcomes were obesity-associated mortality, years of life lost, years lived with disability, and disability-adjusted life years (DALYs).In 2019, the global overweight/obesity-related disease burden reached 160.2 million DALYs, with 5.02 million associated deaths. From 1990 to 2019, the age-standardized death rates increased in males (from 58.19 to 66.55 per 100,000 person-years, APC = 0.36%, 95% CI: 0.30 to 0.42%, P < 0.001), while females experienced a decrease in age-standardized death rates (from 59.31 to 58.14 per 100,000 person-years, APC = -0.22%, 95% CI: -0.29% to -0.14%, P < 0.001). Age-standardized DALYs increased more in males (1632.5 to 2070.34 per 100,000 years, APC = 0.74%, 95% CI: 0.70% to 0.78%, P < .001) compared to females (1618.26 to 1789.67 per 100,000 years, APC = 0.24%, 95% CI: 0.19% to 0.29%, P < 0.001). Disparities were more pronounced in countries with a higher socioeconomic status and predominantly affected younger populations.Overweight/obesity-related morbidity and mortality are higher among male sex. Identifying differences in pathogenesis, complications and treatment response is crucial to develop targeted interventions and equitable public health policies to combat this global burden.Methods: The global rise in overweight, obesity, and related diseases is undeniable; however, the pathogenesis of obesity and obesity-associated diseases is heterogeneous, with varied complications and a discordant response to treatment. Intriguingly, men have a shorter lifespan than women, despite being half as likely to be obese. This paradox suggests a potential gender disparity in the impact of obesity on mortality, with men potentially being more vulnerable to obesity-associated health risks.This retrospective study utilized Global Burden of Diseases data from 204 countries/territories to bridge the knowledge gap in understanding gender disparities in obesity-related mortality. Outcomes were obesity-associated mortality, years of life lost, years lived with disability, and disability-adjusted life years (DALYs).In 2019, the global overweight/obesity-related disease burden reached 160.2 million DALYs, with 5.02 million associated deaths. From 1990 to 2019, the age-standardized death rates increased in males (from 58.19 to 66.55 per 100,000 person-years, APC = 0.36%, 95% CI: 0.30 to 0.42%, P < 0.001), while females experienced a decrease in age-standardized death rates (from 59.31 to 58.14 per 100,000 person-years, APC = -0.22%, 95% CI: -0.29% to -0.14%, P < 0.001). Age-standardized DALYs increased more in males (1632.5 to 2070.34 per 100,000 years, APC = 0.74%, 95% CI: 0.70% to 0.78%, P < .001) compared to females (1618.26 to 1789.67 per 100,000 years, APC = 0.24%, 95% CI: 0.19% to 0.29%, P < 0.001). Disparities were more pronounced in countries with a higher socioeconomic status and predominantly affected younger populations.Overweight/obesity-related morbidity and mortality are higher among male sex. Identifying differences in pathogenesis, complications and treatment response is crucial to develop targeted interventions and equitable public health policies to combat this global burden.Results: The global rise in overweight, obesity, and related diseases is undeniable; however, the pathogenesis of obesity and obesity-associated diseases is heterogeneous, with varied complications and a discordant response to treatment. Intriguingly, men have a shorter lifespan than women, despite being half as likely to be obese. This paradox suggests a potential gender disparity in the impact of obesity on mortality, with men potentially being more vulnerable to obesity-associated health risks.This retrospective study utilized Global Burden of Diseases data from 204 countries/territories to bridge the knowledge gap in understanding gender disparities in obesity-related mortality. Outcomes were obesity-associated mortality, years of life lost, years lived with disability, and disability-adjusted life years (DALYs).In 2019, the global overweight/obesity-related disease burden reached 160.2 million DALYs, with 5.02 million associated deaths. From 1990 to 2019, the age-standardized death rates increased in males (from 58.19 to 66.55 per 100,000 person-years, APC = 0.36%, 95% CI: 0.30 to 0.42%, P < 0.001), while females experienced a decrease in age-standardized death rates (from 59.31 to 58.14 per 100,000 person-years, APC = -0.22%, 95% CI: -0.29% to -0.14%, P < 0.001). Age-standardized DALYs increased more in males (1632.5 to 2070.34 per 100,000 years, APC = 0.74%, 95% CI: 0.70% to 0.78%, P < .001) compared to females (1618.26 to 1789.67 per 100,000 years, APC = 0.24%, 95% CI: 0.19% to 0.29%, P < 0.001). Disparities were more pronounced in countries with a higher socioeconomic status and predominantly affected younger populations.Overweight/obesity-related morbidity and mortality are higher among male sex. Identifying differences in pathogenesis, complications and treatment response is crucial to develop targeted interventions and equitable public health policies to combat this global burden.Conclusions: The global rise in overweight, obesity, and related diseases is undeniable; however, the pathogenesis of obesity and obesity-associated diseases is heterogeneous, with varied complications and a discordant response to treatment. Intriguingly, men have a shorter lifespan than women, despite being half as likely to be obese. This paradox suggests a potential gender disparity in the impact of obesity on mortality, with men potentially being more vulnerable to obesity-associated health risks.This retrospective study utilized Global Burden of Diseases data from 204 countries/territories to bridge the knowledge gap in understanding gender disparities in obesity-related mortality. Outcomes were obesity-associated mortality, years of life lost, years lived with disability, and disability-adjusted life years (DALYs).In 2019, the global overweight/obesity-related disease burden reached 160.2 million DALYs, with 5.02 million associated deaths. From 1990 to 2019, the age-standardized death rates increased in males (from 58.19 to 66.55 per 100,000 person-years, APC = 0.36%, 95% CI: 0.30 to 0.42%, P < 0.001), while females experienced a decrease in age-standardized death rates (from 59.31 to 58.14 per 100,000 person-years, APC = -0.22%, 95% CI: -0.29% to -0.14%, P < 0.001). Age-standardized DALYs increased more in males (1632.5 to 2070.34 per 100,000 years, APC = 0.74%, 95% CI: 0.70% to 0.78%, P < .001) compared to females (1618.26 to 1789.67 per 100,000 years, APC = 0.24%, 95% CI: 0.19% to 0.29%, P < 0.001). Disparities were more pronounced in countries with a higher socioeconomic status and predominantly affected younger populations.Overweight/obesity-related morbidity and mortality are higher among male sex. Identifying differences in pathogenesis, complications and treatment response is crucial to develop targeted interventions and equitable public health policies to combat this global burden. [ABSTRACT FROM AUTHOR]

Background: There are unmet primary care needs among people with serious mental illness that might be improved with integrated care and medical care management. Many healthcare organizations have attempted to address this problem, but few interventions have been rigorously studied and found to be effective. Objective: Study the implementation and effectiveness of a novel, specialized primary care medical home designed to improve the healthcare of patients with serious mental illness. Design, Setting, and Participants.: Clustered controlled trial for a median of 401 days. One Veterans Health Administration medical center was assigned to intervention and two were assigned to usual care (control). Thirty-nine clinicians and managers were included in the study, as well as 331 patients who met eligibility criteria. Intervention.: A specialized medical home with systematic patient engagement, proactive nurse panel management, a collaborative care psychiatrist, and a primary care physician providing care that included psychiatric treatment. Main Measures.: Quality of care, chronic illness care and care experience, symptoms, and quality of life. Key Results.: Sixty-five intervention patients (40%) moved all psychiatric care to the primary care team. No adverse events were attributable to the intervention. Compared with control, intervention patients had greater improvement over time in appropriate screening for body mass index, lipids, and glucose (χ2 = 6.9, 14.3, and 3.9; P's <.05); greater improvement in all domains of chronic illness care (activation, decision support, goal-setting, counseling, coordination) and care experience (doctor-patient interaction, shared decision-making, care coordination, access; F for each 10–24, P's <.05); and greater improvement in mental health-related quality of life (F = 3.9, P =.05) and psychotic symptoms (F = 3.9, P =.05). Conclusion: A primary care medical home for serious mental illness can be feasible to implement, safe, and more effective than usual care. Trial Registration.: ClinicalTrials.gov Identifier: NCT01668355. [ABSTRACT FROM AUTHOR]

Background: We previously found that a 6-month multidimensional diabetes program, TIME (Telehealth-Supported, Integrated Community Health Workers, Medication-Access) resulted in improved clinical outcomes. Objective: To follow TIME participant clinical outcomes for 24 months Participants: Low-income Latino(a)s with type 2 diabetes Design and Intervention: We collected post-intervention clinical data for five cohorts (n = 101, mean n = 20/cohort) who participated in TIME programs from 2018 to 2020 in Houston, Texas. Main Measures: We gathered HbA1c (primary outcome), weight, body mass index (BMI), and blood pressure data at baseline, 6 months (intervention end), and semiannually thereafter until 24 months after baseline to assess sustainability. We also evaluated participant loss to follow-up until 24 months. Key Results: Participants decreased HbA1c levels during the intervention (p < 0.0001) and maintained these improvements at each timepoint from baseline to 24 months (p range: < 0.0001 to 0.015). Participants reduced blood pressure levels during TIME and maintained these changes at each timepoint from baseline until 18 months (systolic p range < 0.0001 to 0.0005, diastolic p range: < 0.0001 to 0.008) but not at 24 months (systolic: p = 0.065; diastolic: p = 0.85). There were no significant weight changes during TIME or post-intervention: weight (p range = 0.07 to 0.77), BMI (p range = 0.11 to 0.71). Attrition rates (loss to follow-up during the post-intervention period) were 5.9% (6 months), 24.8% (12 months), 35.6% (18 months), and 41.8% (24 months). Conclusions: It is possible for vulnerable populations to maintain long-term glycemic and blood pressure improvements using a multiple dimensional intervention. Attrition rates rose over time but show promise given the majority of post-intervention timepoints occurred during the COVID-19 pandemic when low-income populations were most susceptible to suboptimal healthcare access. Future studies are needed to evaluate longitudinal outcomes of diabetes interventions conducted by local clinics rather than research teams. [ABSTRACT FROM AUTHOR]

Background: Eliminating health disparities among different segments of the US population is an overarching goal of the US Healthy People 2020 objectives. Objective: Examine changes in educational, rural-urban, and racial disparities in premature mortality during the past 10 years. Design and Participants: Descriptive analysis of US mortality data from 2007 to 2017. Main Measures: Relative and absolute rural-urban, educational attainment, and Black-White disparities in premature mortality for all-cause and top 10 causes of death among persons ages 25–74 years, estimated as rate ratios and rate differences between ≤12 and ≥16 years of education, rural versus urban, and non-Hispanic Black (Black) versus non-Hispanic White (White), respectively, in 2007 and 2017. Key Results: During 2007–2017, mortality rates in persons aged 25–74 years in the USA increased for several leading causes of death, especially in persons with <16 years of education, rural residents, and White people. As a result, disparity in mortality between 2007 and 2017 widened on both relative and absolute scales for all-cause and for 6 of the top 10 causes of death by education and for all-cause and for 9 of the top 10 causes by rural/urban residence. In contrast, Black-White disparities narrowed for all-cause and for all 7 causes that Black people had a higher rate than White people. For all-cause mortality for example, absolute disparities in the number of deaths per 100,000 person-years between 2007 and 2017 increased from 454.0 (95%CI, 446.0–462.1) to 542.7 (535.6–549.7) for educational attainment and from 85.8 (82.8–88.8) to 140.5 (137.6–143.4) for rural versus urban; in contrast, absolute Black-White disparity decreased from 315.3 (311.0–319.7) to 221.7 (218.1–225.3). Conclusions: Educational and rural-urban disparities in premature mortality widened, whereas Black-White disparities narrowed in the USA between 2007 and 2017, though overall rates remained considerably higher in Black people. [ABSTRACT FROM AUTHOR]

Background: Timely diagnosis of cognitive impairment is a key goal of the National Plan to Address Alzheimer's Disease, but studies of factors associated with a timely diagnosis are limited. Objective: To identify patient characteristics associated with a timely diagnosis of dementia and mild cognitive impairment (MCI). Design: Retrospective observational study using survey data from the Health and Retirement Study (HRS) from 1995-2016 (interview waves 3-13). Participants: 4,760 respondents with incident dementia and 1,864 with incident MCI identified using longitudinal measures of cognitive functioning. Main measures: Timely or delayed diagnosis based on the timing of a self or proxy report of a healthcare provider diagnosis in relation to respondents first dementia or MCI-qualifying cognitive score, sociodemographic characteristics, health status, health care utilization, insurance provider, and year of first qualifying score. Key results: Only 26.0% of the 4,760 respondents with incident dementia and 11.4% of the 1,864 respondents with incident MCI received a timely diagnosis. Non-Hispanic Black respondents and respondents with less than a college degree were significantly less likely to receive a timely diagnosis of either dementia or MCI than Non-Hispanic White respondents (dementia odds ratio (OR): 0.61, 95% CI: 0.50, 0.75; MCI OR: 0.40, 95% CI: 0.23, 0.70) and those with a college degree (dementia OR for less than high school degree: 0.30, 95% CI: 0.23, 0.38; MCI OR: 0.36, 95% CI: 0.22, 0.60). Respondents that lived alone were also less likely to receive a timely diagnosis of dementia (OR: 0.69, 95% CI: 0.59, 0.81), though not MCI. Timely diagnosis of both conditions increased over time. Conclusions: Targeting resources for timely diagnosis of cognitive impairment to individuals from racial and ethnic minorities, lower educational attainment, and living alone may improve detection and reduce disparities around timely diagnosis of dementia and MCI. [ABSTRACT FROM AUTHOR]

Background: Though awareness of health care structures that are racist and oppressive is increasing among health care professionals, there is a gap in continuing education curricula focused on antiracist anti-oppressive practices, and limited faculty and staff development to guide individuals towards action. Aim: To develop, implement, and evaluate a novel antiracist faculty and staff development program called the Tea House Series. Setting and Participants: A five-part continuing education series with an accompanying online community for faculty and staff at the divisions of Hospital Medicine in one institution in the western United States. Program Description: The four foundational pillars integral to the Tea House Series were as follows: educational framework based on the pedagogy of Paulo Freire, local disparities data, welcoming space to establish a community of practice and accountability. Each session contained participant dialogue in small group activities. Program Evaluation: Qualitative analysis of participant survey responses demonstrated transformation towards a hope to act with a sense of community. Quantitative analysis measured increased confidence for the program learning objectives. Discussion: The Tea House Series may be used as a model for continuing education to provide the tools and the community to confront systems of racism and oppression in any institution. [ABSTRACT FROM AUTHOR]

Background: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package.To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest (“top”) and genital (“bottom”) surgeries.Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023.A total of 6653 Veterans (54% response rate) completed the survey.Self-reported “top” and “bottom” GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region.Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18–39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master’s degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery.GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.Objective: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package.To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest (“top”) and genital (“bottom”) surgeries.Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023.A total of 6653 Veterans (54% response rate) completed the survey.Self-reported “top” and “bottom” GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region.Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18–39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master’s degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery.GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.Design: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package.To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest (“top”) and genital (“bottom”) surgeries.Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023.A total of 6653 Veterans (54% response rate) completed the survey.Self-reported “top” and “bottom” GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region.Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18–39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master’s degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery.GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.Participants: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package.To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest (“top”) and genital (“bottom”) surgeries.Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023.A total of 6653 Veterans (54% response rate) completed the survey.Self-reported “top” and “bottom” GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region.Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18–39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master’s degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery.GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.Main Measures: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package.To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest (“top”) and genital (“bottom”) surgeries.Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023.A total of 6653 Veterans (54% response rate) completed the survey.Self-reported “top” and “bottom” GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region.Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18–39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master’s degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery.GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.Key Results: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package.To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest (“top”) and genital (“bottom”) surgeries.Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023.A total of 6653 Veterans (54% response rate) completed the survey.Self-reported “top” and “bottom” GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region.Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18–39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master’s degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery.GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.Conclusions: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package.To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest (“top”) and genital (“bottom”) surgeries.Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023.A total of 6653 Veterans (54% response rate) completed the survey.Self-reported “top” and “bottom” GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region.Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18–39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master’s degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery.GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans. [ABSTRACT FROM AUTHOR]

Background: Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.ClinicalTrials.gov Identifier: NCT05278806.Objective: Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.ClinicalTrials.gov Identifier: NCT05278806.Design: Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.ClinicalTrials.gov Identifier: NCT05278806.Participants: Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.ClinicalTrials.gov Identifier: NCT05278806.Interventions: Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.ClinicalTrials.gov Identifier: NCT05278806.Main Measures: Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.ClinicalTrials.gov Identifier: NCT05278806.Key Results: Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.ClinicalTrials.gov Identifier: NCT05278806.Conclusions: Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.ClinicalTrials.gov Identifier: NCT05278806.Trial Registration: Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.ClinicalTrials.gov Identifier: NCT05278806. [ABSTRACT FROM AUTHOR]

Background: Asian Americans are the fastest-growing ethnic minority in the USA, but we know little about the end-of-life care for this population. Objective: Compare invasive mechanical ventilation (IMV) use between older Asian and White decedents with hospitalization in the last 30 days of life. Design: Population-based retrospective cohort study. Participants: A 20% random sample of 2000–2017 Medicare fee-for-service decedents who were 66 years or older and had a hospitalization in the last 30 days of life. Exposure: White and Asian ethnicity as collected by the Social Security Administration. Main Measures: We identified IMV using validated procedural codes. We compared IMV use between Asian and White fee-for-service decedents using random-effects logistic regression analysis, adjusting for sociodemographics, admitting diagnosis, comorbidities, and secular trends. Key Results: From 2000 to 2017, we identified 2.1 million White (54.5% female, 82.4±8.1 mean age) and 28,328 Asian (50.8% female, 82.6±8.1 mean age) Medicare fee-for-service decedents hospitalized in the last 30 days. Compared to White decedents, Asian fee-for-service decedents have an increased adjusted odds ratio (AOR) of 1.42 (95%CI: 1.38–1.47) for IMV. In sub-analyses, Asians' AOR for IMV differed by admitting diagnoses (cancer AOR=1.32, 95%CI: 1.15–1.51; congestive heart failure AOR=1.75, 95%CI: 1.47–2.08; dementia AOR=1.93, 95%CI: 1.70–2.20; and chronic obstructive pulmonary disease AOR=2.25, 95%CI: 1.76–2.89). Conclusions: Compared to White decedents, Asian Medicare decedents are more likely to receive IMV when hospitalized at the end-of-life, especially among patients with non-cancer admitting diagnoses. Future research to better understand the reasons for these differences and perceived quality of end-of-life care among Asian Americans is urgently needed. [ABSTRACT FROM AUTHOR]

Keywords: substance use disorder; alcohol use disorder; MAT; disparities; Medicaid; COVID-19 EN substance use disorder alcohol use disorder MAT disparities Medicaid COVID-19 266 268 3 01/20/23 20230101 NES 230101 INTRODUCTION Drug overdose death rates rose from 2018 through May 2020 during the COVID-19 pandemic, with larger increases for Black and Hispanic Americans compared to their White counterparts.[1] Racial and ethnic disparities in substance use disorder (SUD) treatment access and quality have been identified across age, sex, and care settings. A recent paper examining treatment for opioid use disorder among Medicaid beneficiaries across 11 states (2014-2018) found that Black beneficiaries had significantly lower treatment rates compared to White beneficiaries (adjusted relative ratio of 0.72).[6] We found large disparities in MAT rates, especially between Black and White Louisiana Medicaid beneficiaries, before and during the COVID-19 pandemic. Substance use disorder, alcohol use disorder, MAT, disparities, COVID-19, Medicaid. [Extracted from the article]

Background: At the same time that federal policymakers have enforced restrictive immigration policies, healthcare systems across the USA are developing, and have implemented, interventions aimed at addressing immigration-related stressors faced by immigrant communities. Yet, little is known about the contextual determinants that influence their implementation success. Using the Consolidated Framework for Implementation Research (CFIR), this study identifies factors enabling or challenging the implementation of interventions aimed at mitigating immigration-related stressors in the healthcare context. Methods: We used a qualitative research design to conduct 38 semi-structured interviews with stakeholders involved in implementation of interventions at 25 healthcare facilities across 5 states with the highest undocumented immigrant populations (California, Texas, New York, Florida, and Illinois). Interviews were conducted from May through August 2018. Constant comparative analysis was used to identify barrier and facilitator themes. Deductive coding was thereafter used to categorize themes according to CFIR domain. Results: Barriers to implementation included perceptions of legal complexity and challenges to adopting such systemic strategies. Facilitators included a national policy climate that had brought immigrant health to the forefront, allowing for leveraging momentum towards institutional change; communication among healthcare personnel; existing community partnerships with immigrant rights and service organizations; and a shared sense of mission centering health equity. Local variation in immigration-related policies (e.g., local law agencies enforcing federal immigration laws) and heterogeneity of local immigrant communities also impacted implementation. Champions and informal leaders were integral to institutional efforts but not sufficient for sustainability. Perceived urgency to act superseded evaluation considerations, with all interventions in initial phases of implementation. Future iterations and evaluations of these interventions are needed to establish best practices and implementation determinants. Conclusion: This is the first systematic study describing implementation determinants of immigration-related interventions across health systems. Identifying these determinants provides guidance to other healthcare organizations to effectively strategize and ensure implementation success. [ABSTRACT FROM AUTHOR]

Background: Social risk factors (SRFs) such as minority race-and-ethnicity or low income are associated with quality-of-care, health, and healthcare outcomes. Organizations might prioritize improving care for easier-to-treat groups over those with SRFs, but measuring, reporting, and further incentivizing quality-of-care for SRF groups may improve their care. Objective: To develop, as a proof-of-concept, a Health Equity Summary Score (HESS): a succinct, easy-to-understand score that could be used to promote high-quality care to those with SRFs in Medicare Advantage (MA) health plans, which provide care for almost twenty million older and disabled Americans and collect extensive quality measure and SRF data. Design: We estimated, standardized, and combined performance scores for two sets of quality measures for enrollees in 2013–2016 MA health plans, considering both current levels of care, within-plan improvement, and nationally benchmarked improvement for those with SRFs (specifically, racial-and-ethnic minority status and dual-eligibility for Medicare and Medicaid). Participants: All MA plans with publicly reported quality scores and 500 or more 2016 enrollees. Main Measures: Publicly reported clinical quality and patient experience measures. Key Results: Almost 90% of plans measured for MA Star Ratings received a HESS; plans serving few patients with SRFs were excluded. The summary score was moderately positively correlated with publicly reported overall Star Ratings (r = 0.66–0.67). High-scoring plans typically had sizable enrollment of both racial-and-ethnic minorities (38–42%) and dually eligible beneficiaries (29–38%). Conclusions: We demonstrated the feasibility of developing and estimating a HESS that is intended to promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible MA enrollees. The HESS measures SRF-specific performance and does not simply duplicate overall plan Star Ratings. It also identifies plans that provide excellent care to large numbers of those with SRFs. Our methodology could be extended to other SRFs, quality measures, and settings. [ABSTRACT FROM AUTHOR]

Background: The HERO registry was established to support research on the impact of the COVID-19 pandemic on US healthcare workers.Objective: Describe the COVID-19 pandemic experiences of and effects on individuals participating in the HERO registry.Design: Cross-sectional, self-administered registry enrollment survey conducted from April 10 to July 31, 2020.Setting: Participants worked in hospitals (74.4%), outpatient clinics (7.4%), and other settings (18.2%) located throughout the nation.Participants: A total of 14,600 healthcare workers.Main Measures: COVID-19 exposure, viral and antibody testing, diagnosis of COVID-19, job burnout, and physical and emotional distress.Key Results: Mean age was 42.0 years, 76.4% were female, 78.9% were White, 33.2% were nurses, 18.4% were physicians, and 30.3% worked in settings at high risk for COVID-19 exposure (e.g., ICUs, EDs, COVID-19 units). Overall, 43.7% reported a COVID-19 exposure and 91.3% were exposed at work. Just 3.8% in both high- and low-risk settings experienced COVID-19 illness. In regression analyses controlling for demographics, professional role, and work setting, the risk of COVID-19 illness was higher for Black/African-Americans (aOR 2.32, 99% CI 1.45, 3.70, p < 0.01) and Hispanic/Latinos (aOR 2.19, 99% CI 1.55, 3.08, p < 0.01) compared with Whites. Overall, 41% responded that they were experiencing job burnout. Responding about the day before they completed the survey, 53% of participants reported feeling tired a lot of the day, 51% stress, 41% trouble sleeping, 38% worry, 21% sadness, 19% physical pain, and 15% anger. On average, healthcare workers reported experiencing 2.4 of these 7 distress feelings a lot of the day.Conclusions: Healthcare workers are at high risk for COVID-19 exposure, but rates of COVID-19 illness were low. The greater risk of COVID-19 infection among race/ethnicity minorities reported in the general population is also seen in healthcare workers. The HERO registry will continue to monitor changes in healthcare worker well-being during the pandemic.Trial Registration: ClinicalTrials.gov identifier NCT04342806. [ABSTRACT FROM AUTHOR]

Background: The impact of race and socioeconomic status on clinical outcomes has not been quantified in patients hospitalized with coronavirus disease 2019 (COVID-19). Objective: To evaluate the association between patient sociodemographics and neighborhood disadvantage with frequencies of death, invasive mechanical ventilation (IMV), and intensive care unit (ICU) admission in patients hospitalized with COVID-19. Design: Retrospective cohort study. Setting: Four hospitals in an integrated health system serving southeast Michigan. Participants: Adult patients admitted to the hospital with a COVID-19 diagnosis confirmed by polymerase chain reaction. Main Measures: Patient sociodemographics, comorbidities, and clinical outcomes were collected. Neighborhood socioeconomic variables were obtained at the census tract level from the 2018 American Community Survey. Relationships between neighborhood median income and clinical outcomes were evaluated using multivariate logistic regression models, controlling for patient age, sex, race, Charlson Comorbidity Index, obesity, smoking status, and living environment. Key Results: Black patients lived in significantly poorer neighborhoods than White patients (median income: $34,758 (24,531–56,095) vs. $63,317 (49,850–85,776), p < 0.001) and were more likely to have Medicaid insurance (19.4% vs. 11.2%, p < 0.001). Patients from neighborhoods with lower median income were significantly more likely to require IMV (lowest quartile: 25.4%, highest quartile: 16.0%, p < 0.001) and ICU admission (35.2%, 19.9%, p < 0.001). After adjusting for age, sex, race, and comorbidities, higher neighborhood income ($10,000 increase) remained a significant negative predictor for IMV (OR: 0.95 (95% CI 0.91, 0.99), p = 0.02) and ICU admission (OR: 0.92 (95% CI 0.89, 0.96), p < 0.001). Conclusions: Neighborhood disadvantage, which is closely associated with race, is a predictor of poor clinical outcomes in COVID-19. Measures of neighborhood disadvantage should be used to inform policies that aim to reduce COVID-19 disparities in the Black community. [ABSTRACT FROM AUTHOR]

Background: Mobility disability is the most common disability among adult Americans, estimated at 13.7% of the US population. Cancer prevalence is higher among people with mobility disability compared with the general population, yet people with disability experience disparities in cancer screening and treatment.Objective: We explored experiences of patients with mobility disability with the process of cancer diagnosis.Design: Open-ended individual interviews, which reached data saturation. Interviews were transcribed verbatim for conventional content analysis.Participants: We interviewed 20 participants with pre-existing mobility disability that required the use of an assistive device or assistance with performance of activities of daily living and who were subsequently diagnosed with cancer (excluding melanoma).Key Results: Concerns coalesced around five broad categories: inaccessibility of medical diagnostic equipment affecting the process of cancer diagnosis, attitudes of clinical staff about accommodating disability, dismissal of cancer signs/symptoms as emotional responses to chronic health conditions, misattributing cancer signs/symptoms to underlying disability, and attitudes about pursuing legal action for substandard care. Participants provided examples of how erroneous assumptions and potentially biased attitudes among clinicians interfered with the process of their cancer diagnosis, sometimes contributing to an insufficient workup and diagnostic delays.Conclusions: Physical and attitudinal barriers affect the process of cancer diagnosis in people with mobility disability. Though people with mobility disability may be clinically complex, clinicians should be aware of the risks of diagnostic overshadowing (i.e., the misattribution of cancer signs/symptoms to underlying disability) and other erroneous assumptions that may affect timeliness of cancer diagnosis and quality of care. Further efforts, including educating clinicians about challenges in caring for persons with disability, should be considered to improve the process of cancer diagnosis for this population.Trial Registration: N/A. [ABSTRACT FROM AUTHOR]

Background: To ensure a next generation of female leaders in academia, we need to understand challenges they face and factors that enable fellowship-prepared women to thrive. We surveyed woman graduates of the Robert Wood Johnson Clinical Scholars Program (CSP) from 1976 to 2011 regarding their experiences, insights, and advice to women entering the field. Methods: We surveyed every CSP woman graduate through 2012 (n = 360) by email and post. The survey, 12 prompts requiring open text responses, explored current work situation, personal definitions of success, job negotiations, career regrets, feelings about work, and advice for others. Four independent reviewers read overlapping subsets of the de-identified data, iteratively created coding categories, and defined and refined emergent themes. Results: Of the 360 cohort, 108 (30%) responded. The mean age of respondents was 45 (range 32 to 65), 85% are partnered, and 87% have children (average number of children 2.15, range 1 to 5). We identified 11 major code categories and conducted a thematic analysis. Factors common to very satisfied respondents include personally meaningful work, schedule flexibility, spousal support, and collaborative team research. Managing professional-personal balance depended on career stage, clinical specialty, and children's age. Unique to women who completed the CSP prior to 1995 were descriptions of "atypical" paths with career transitions motivated by discord between work and personal ambitions and the emphasis on the importance of maintaining relevance and remaining open to opportunities in later life. Conclusions: Women CSP graduates who stayed in academic medicine are proud to have pursued meaningful work despite challenges and uncertain futures. They thrived by remaining flexible and managing change while remaining true to their values. We likely captured the voices of long-term survivors in academic medicine. Although transferability of these findings is uncertain, these voices add to the national discussion about retaining clinical researchers and keeping women academics productive and engaged. [ABSTRACT FROM AUTHOR]

Background: After non-fatal opioid overdoses, opioid prescribing patterns are often unchanged and the use of medications for opioid use disorder (MOUDs) remains low. Whether such prescribing differs by race/ethnicity remains unknown.Objective: To assess the association of race/ethnicity with the prescribing of opioids and MOUDs after a non-fatal opioid overdose.Design: Retrospective cohort study.Participants: Patients prescribed ≥ 1 opioid from July 1, 2010, to September 30, 2015, with a non-fatal opioid overdose in the Veterans Health Administration (VA).Main Measures: Primary outcomes were the proportion of patients prescribed: (1) any opioid during the 30 days before and after overdose and (2) MOUDs within 30 days after overdose by race and ethnicity. We conducted difference-in-difference analyses using multivariable regression to assess whether the change in opioid prescribing from before to after overdose differed by race/ethnicity. We also used multivariable regression to test whether MOUD prescribing after overdose differed by race/ethnicity.Key Results: Among 16,210 patients with a non-fatal opioid overdose (81.2% were white, 14.3% black, and 4.5% Hispanic), 10,745 (66.3%) patients received an opioid prescription (67.1% white, 61.7% black, and 65.9% Hispanic; p < 0.01) before overdose. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively, with no significant difference-in-difference in opioid prescribing by race/ethnicity (p = 0.23). After overdose, 526 (3.2%) patients received MOUDs (2.9% white, 4.6% black, and 5.5% Hispanic; p < 0.01). Blacks (adjusted OR (aOR) 1.6; 95% CI 1.2, 1.9) and Hispanics (aOR 1.8; 95% CI 1.2, 2.6) had significantly larger odds of receiving MOUDs than white patients.Conclusions: In a national cohort of patients with non-fatal opioid overdose in VA, there were no racial/ethnic differences in changes in opioid prescribing after overdose. Although blacks and Hispanics were more likely than white patients to receive MOUDs in the 30 days after overdose, less than 4% of all groups received such therapy. [ABSTRACT FROM AUTHOR]

Background: In the USA, people with limited English proficiency (LEP) disproportionately experience gaps in health insurance coverage and access to care. The Patient Protection and Affordable Care Act (ACA) of 2010 included reforms that could improve these outcomes.Objective: To describe changes in insurance coverage and access to health care by English language proficiency over 2006-2016.Design: We used regression models to estimate changes in coverage and access after 2010 for adults with high vs. limited English proficiency, adjusting for socio-economic status, demographic characteristics, and health care needs. We used difference-in-differences models to assess adjusted changes in disparities by English proficiency after 2010. Supplemental analyses used nearest-neighbor propensity score matching to balance the characteristics of respondents.Participants: Respondents aged 18-64 in the Medical Expenditure Panel Survey over 2006-2016, with high (n = 174,214) or limited (n = 16,484) English language proficiency.Main Measures: Insurance coverage was a binary variable indicating any health insurance coverage during the past 12 months. Access to care was measured using binary variables indicating whether the respondent had a usual source of care and received necessary medical, dental, and preventive care.Key Results: Gains in health insurance coverage after 2010 were significant for adults with high English proficiency (1.7 percentage points, p < 0.001) and adults with limited English proficiency (4.6 percentage points, p = 0.007); gains did not significantly vary by English proficiency. Adults with LEP showed larger improvements than adults with high English proficiency in having a usual source of care (5 percentage points, p = 0.007) and receiving needed medical care and dental care (1.4 percentage points, p = 0.013, and 2.8 percentage points, p = 0.009, respectively). Findings remained similar when matching was used to balance the measured characteristics of respondents with high vs. limited English proficiency.Conclusions: Disparities in health care access by English proficiency narrowed after 2010, the year of passage of the ACA. [ABSTRACT FROM AUTHOR]

Background: Effective type 2 diabetes care remains a challenge for patients including those receiving primary care in safety net settings.Objective: The Partnership to Improve Diabetes Education (PRIDE) trial team and leaders from a regional department of health evaluated approaches to improve care for vulnerable patients.Design: Cluster randomized controlled trial.Patients: Adults with uncontrolled type 2 diabetes seeking care across 10 unblinded, randomly assigned safety net clinics in Middle TN.Interventions: A literacy-sensitive, provider-focused, health communication intervention (PRIDE; 5 clinics) vs. standard diabetes education (5 clinics).Main Measures: Participant-level primary outcome was glycemic control [A1c] at 12 months. Secondary outcomes included select health behaviors and psychosocial aspects of care at 12 and 24 months. Adjusted mixed effects regression models were used to examine the comparative effectiveness of each approach to care.Key Results: Of 410 patients enrolled, 364 (89%) were included in analyses. Median age was 51 years; Black and Hispanic patients represented 18% and 25%; 96% were uninsured, and 82% had low annual income level (< $20,000); adequate health literacy was seen in 83%, but numeracy deficits were common. At 12 months, significant within-group treatment effects occurred from baseline for both PRIDE and control sites: adjusted A1c (- 0.76 [95% CI, - 1.08 to - 0.44]; P < .001 vs - 0.54 [95% CI, - 0.86 to - 0.21]; P = .001), odds of poor eating (0.53 [95% CI, 0.33-0.83]; P = .01 vs 0.42 [95% CI, 0.26-0.68]; P < .001), treatment satisfaction (3.93 [95% CI, 2.48-6.21]; P < .001 vs 3.04 [95% CI, 1.93-4.77]; P < .001), and self-efficacy (2.97 [95% CI, 1.89-4.67]; P < .001 vs 1.81 [95% CI, 1.1-2.84]; P = .01). No significant difference was observed between study arms in adjusted analyses.Conclusions: Both interventions improved the participant's A1c and behavioral outcomes. PRIDE was not more effective than standard education. Further research may elucidate the added value of a focused health communication program in this setting. [ABSTRACT FROM AUTHOR]

Objective: To describe how access to primary and specialty care differs for Medicaid patients relative to commercially insured patients, and how these differences vary across rural and urban counties, using comprehensive claims data from Oregon.Design: Cross-sectional study of risk-adjusted access rates for two types of primary care providers (physicians; nurse practitioners (NPs) and physician assistants (PAs)); four types of mental health providers (psychiatrists, psychologists, advanced practice NPs or PAs specializing in mental health care, behavioral specialists); and four physician specialties (obstetrics and gynecology, general surgery, gastroenterology, dermatology).Participants: 420,947 Medicaid and 638,980 commercially insured adults in Oregon, October 2014-September 2015.Outcome: Presence of any visit with each provider type, risk-adjusted for sex, age, and health conditions.Results: Relative to commercially insured individuals, Medicaid enrollees had lower rates of access to primary care physicians (- 11.82%; CI - 12.01 to - 11.63%) and to some specialists (e.g., obstetrics and gynecology, dermatology), but had equivalent or higher rates of access to NPs and PAs providing primary care (4.33%; CI 4.15 to 4.52%) and a variety of mental health providers (including psychiatrists, NPs and PAs, and other behavioral specialists). Across all providers, the largest gaps in Medicaid-commercial access rates were observed in rural counties. The Medicaid-commercial patient mix was evenly distributed across primary care physicians, suggesting that access for Medicaid patients was not limited to a small subset of primary care providers.Conclusions: This cross-sectional study found lower rates of access to primary care physicians for Medicaid enrollees, but Medicaid-commercial differences in access rates were not present across all provider types and displayed substantial variability across counties. Policies that address rural-urban differences as well as Medicaid-commercial differences-such as expansions of telemedicine or changes in the workforce mix-may have the largest impact on improving access to care across a wide range of populations. [ABSTRACT FROM AUTHOR]

Background: Although research shows produce prescription (PRx) programs increase fruit and vegetable (FV) consumption, little is known about how participants experience them.Objective: To better understand how participants experience a PRx program for hypertensive adults at 3 safety net clinics partnered with 20 farmers' markets (FMs) in Cleveland, OH.Design: We conducted semi-structured interviews with 5 program providers, 23 patient participants, and 2 FM managers.Participants: Patients interviewed were mainly middle-aged (mean age 62 years), African American (100%), and women (78%). Providers were mainly middle-aged men and women of diverse races/ethnicities.Intervention: Healthcare providers enrolled adult patients who were food insecure and diagnosed with hypertension. Participating patients attended monthly clinic visits for 3 months. Each visit included a blood pressure (BP) check, dietary counseling for BP control, a produce prescription, and produce vouchers redeemable at local FMs.Approach: Patient interviews focused on (1) beliefs about food, healthy eating, and FMs; (2) clinic-based program experiences; and (3) FM experiences. Provider and market manager interviews focused on program provision. All interviews were audio-taped, transcribed, and analyzed thematically.Key Results: We identified four central themes. First, providers and patients reported positive interactions during program activities, but providers struggled to integrate the program into their workflow. Second, patients reported greater FV intake and FM shopping during the program. Third, social interactions enhanced program experience. Fourth, economic hardships influenced patient shopping and eating patterns, yet these hardships were minimized in some participants' views of patient deservingness for program inclusion.Conclusions: Our findings highlight promises and challenges of PRx programs for economically disadvantaged patients with a chronic condition. Patient participants reported improved interactions with providers, increased FV consumption, and incorporation of healthy eating into their social networks due to the program. Future efforts should focus on efficiently integrating PRx into clinic workflows, leveraging patient social networks, and including economic supports for maintenance of behavior change. [ABSTRACT FROM AUTHOR]

Background: Though Asian Americans made gains in coverage following the Affordable Care Act (ACA), substantial variations in access to care remain across different ethnic subgroups. Several states are considering adoption of policies to collect health data for Asian Americans that is disaggregated by ethnic subgroup, which may identify disparities in access to care.Objective: We examined coverage and access to care between non-Hispanic White and Asian American adults following the ACA in California. We first compared outcomes in non-Hispanic White adults with all Asian Americans in our sample, and then evaluated whether we detect disparities when data is disaggregated into five of the most populous ethnic subgroups (Chinese, Korean, Filipino, Vietnamese, and Japanese).Design: Cross-sectional California Health Interview Survey data were collected between January 2014 and December 2016.Participants: Our sample included 19,201 non-Hispanic White and 3077 Asian American non-elderly adults age 18 to 64 living in California.Main Measures: Our outcomes were (1) being uninsured, (2) having a usual source of care, (3) delaying necessary medical care, and (4) delaying necessary prescription medications. Using multivariable logistic regression models, we examined our outcomes, adjusting for predisposing, enabling, need, and acculturation factors.Key Results: Compared with non-Hispanic Whites, some subgroups of Asian Americans reported significantly worse access to care: disaggregated, adjusted analyses revealed that Koreans were significantly less likely to report a usual source of care (adjusted odds ratio [AOR] = 0.31, p < 0.01) relative to non-Hispanic Whites. Chinese (AOR = 0.42, p < 0.01) and Vietnamese (AOR = 0.34, p < 0.01) adults were significantly less likely to delay necessary care.Conclusions: Disaggregated analyses identified differences in access to care for Asian American subgroups following the ACA. State policies to collect disaggregated health data for Asian Americans may reveal heterogeneity in experiences of care and inform specific policies to reduce disparities in access to care. [ABSTRACT FROM AUTHOR]

Keywords: rural; disparities; healthcare; value EN rural disparities healthcare value 16 17 2 03/29/23 20230302 NES 230302 At a food bank distribution event in rural Idaho, our Community Health Workers (CHWs) are conducting one of their free health screenings. If we are to move effectively to address health inequities, the high cost of care, and improve the health and overall experience of care in our rural communities, CHWs are an essential ingredient in that solution. [Extracted from the article]

Renal replacement therapy is guaranteed for all US citizens with end-stage renal disease (ESRD). Undocumented immigrants with ESRD are a particularly vulnerable subset of renal failure patients. There is no federal legislation for these patients except for the requirement to treat them during "emergency medical conditions" and federal legislation excluding them from the guarantee of renal replacement therapy described above. Different states have developed different methods for dealing with this problem, with variation in management even addressed on a center by center basis. This review of the original studies published in the literature reveals the medical, ethical, and financial problems with this situation. These patients frequently have delayed presentation to care, poor access to routine care, increased complications, increased utilization of services, and increased morbidity and mortality in an emergent dialysis model compared to chronic outpatient care. They present an ethical dilemma for practitioners who know they are providing substandard care and occasionally making decisions on how to allocate resources. Emergent dialysis is associated with inadequate reimbursement, increased threat to sustained unemployment, and an overburdening of our healthcare infrastructure. This practice puts patients at risk, places an unfair ethical burden on providers and is financially unsustainable. Special considerations described for kidney transplant and peritoneal dialysis are considered and considerations for a new model are reviewed in the paper. Ultimately accommodations must be made with the input of government, healthcare practitioners, and facilities needs to be reached to protect these vulnerable patients. [ABSTRACT FROM AUTHOR]

Background: Individuals with limited English proficiency (LEP) have worse healthcare access and report lower quality of care compared to individuals who are proficient in English. Policy efforts to improve patient-provider communication for LEP individuals have been going on for decades but linguistic disparities persist.Objective: To describe trends in patient-provider communication by limited English proficiency (LEP) from 2006 to 2015.Design: We estimated interrupted time series models for three measures of patient-provider communication, testing for differences in both means (intercepts) and trends (slopes) before and after 2010 and differences in differences by English proficiency.Participants: A nationally representative sample of the US non-institutionalized population with at least one office-based medical visit from the 2006-2015 Medical Expenditure Panel Survey (N = 27,001).Main Measures: Patient-provider communication is measured with three variables indicating whether individuals reported that their providers always explained things in a way that was easy to understand, showed respect for what they had to say, and listened carefully.Key Results: Although patient-provider communication improved for all groups over the study period, before 2010, it was getting worse among LEP individuals and disparities in patient-provider communication were widening. After 2010, patient-provider communication improved for LEP individuals and language disparities by English proficiency either narrowed or remained the same. For example, between 2006 and 2010, the percent of LEP individuals reporting that their provider explained things clearly declined by, on average, 1.4 percentage points per year (p value = 0.102); after 2010, it increased by 3.0 percentage points per year (p value = 0.003).Conclusions: Our study sheds light on trends in patient-provider communication before and after 2010, a year that marked substantial efforts to reform the US healthcare system. Though patient-provider communication among LEP individuals has improved since 2010, linguistic disparities persist and constitute a formidable challenge to achieving healthcare equity, a long-standing US policy goal. [ABSTRACT FROM AUTHOR]

Background: Health disparities exist in HIV risk in the USA among the lesbian-gay-bisexual-transgender-queer (LGBTQ) community. There is also scarce literature on curricula for HIV prevention and pre-exposure prophylaxis (PrEP) for trainees.Aim: To create a curriculum to train residents to perform inclusive sexual history taking and HIV prevention care. The curriculum covers sexual history, LGBTQ health, sexually transmitted infections, and HIV risk assessment and risk reduction counseling including use of PrEP.Setting: A dedicated PrEP Clinic was created within an Academic Medical Center Outpatient HIV Clinic. Patients were primarily LGBTQ identified, but also included HIV sero-discordant couples, cisgender individuals, heterosexual invididuals, and those with experience of homelessness, sex work, and substance abuse.Participants: Thirty-four internal medicine residents completed the course between November 2017 and May 2018.Program Description: The curriculum was delivered as Just in Time Teaching (JiTT) via online virtual patient cases followed by directly observed clinical care at a large urban PrEP clinic.Program Evaluation and Results: The effectiveness of the curriculum was assessed through paired pre/post-self-assessment surveys (n = 19), additional post-surveys on the online modules (n = 22), and interviews (n = 9). Many respondents reported no prior training or inadequate prior training in the course content. As a result of the course, participants reported statistically significant increased confidence and comfort in all seven HIV prevention topic areas, with the greatest gains in safe sex counseling for LGBTQ patients and in discussing PrEP (mean changes of 1.21, 1.58 on 5-point Likert scale, respectively, p < 0.0001). Six of nine interviewees post-course had applied what they learned to patient care; five indicated their learning would benefit patients.Discussion: An HIV prevention curriculum focused on cultural humility in care can improve trainee's skills in HIV risk reduction counseling, including PrEP, among all patients including those identifying as LGBTQ. [ABSTRACT FROM AUTHOR]

Background: African Americans suffer more than non-Hispanic whites from type 2 diabetes, but diabetes self-management education (DSME) has been less effective at improving glycemic control for African Americans. Our objective was to determine whether a novel, culturally tailored DSME intervention would result in sustained improvements in glycemic control in low-income African-American patients of public hospital clinics.Research Design and Methods: This randomized controlled trial (n = 211) compared changes in hemoglobin A1c (A1c) at 6, 12, and 18 months between two arms: (1) Lifestyle Improvement through Food and Exercise (LIFE), a culturally tailored, 28-session community-based intervention, focused on diet and physical activity, and (2) a standard of care comparison group receiving two group DSME classes. Cluster-adjusted ANCOVA modeling was used to assess A1c changes from baseline to 6, 12, and 18 months, respectively, between arms.Results: At 6 months, A1c decreased significantly more in the intervention group than the control group (- 0.76 vs - 0.21%, p = 0.03). However, by 12 and 18 months, the difference was no longer significant (12 months - 0.63 intervention vs - 0.45 control, p = 0.52). There was a decrease in A1c over 18 months in both the intervention (β = - 0.026, p = 0.003) and the comparison arm (β = - 0.018, p = 0.048) but no difference in trend (p = 0.472) between arms. The intervention group had greater improvements in nutrition knowledge (11.1 vs 6.0 point change, p = 0.002) and diet quality (4.0 vs - 0.5 point change, p = 0.018) while the comparison group had more participants with improved medication adherence (24% vs 10%, p < 0.05) at 12 months.Conclusions: The LIFE intervention resulted in improved nutrition knowledge and diet quality and the comparison intervention resulted in improved medication adherence. LIFE participants showed greater A1c reduction than standard of care at 6 months but the difference between groups was no longer significant at 12 and 18 months.Nih Trial Registry Number: NCT01901952. [ABSTRACT FROM AUTHOR]

Background: Thirty-day readmission penalties implemented with the Hospital Readmission Reduction Program (HRRP) place a larger burden on safety-net hospitals which treat a disproportionate share of racial minorities, leading to concerns that already large racial disparities in readmissions could widen.Objective: To examine whether there were changes in Black-White disparities in 30-day readmissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia following the passage and implementation of HRRP, and to compare disparities across safety-net and non-safety-net hospitals.Design: Repeated cross-sectional analysis, stratified by safety-net status.Subjects: 1,745,686 Medicare patients over 65 discharged alive from hospitals in 5 US states: NY, FL, NE, WA, and AR.Main Measures: Odds ratios comparing 30-day readmission rates following an index admission for AMI, CHF, or pneumonia for Black and White patients between 2007 and 2014.Key Results: Prior to the passage of HRRP in 2010, Black and White readmission rates and disparities in readmissions were decreasing. These reductions were largest at safety-net hospitals. In 2007, Blacks had 13% higher odds of readmission if treated in safety-net hospitals, compared with 5% higher odds in 2010 (P < 0.05). These trends continued following the passage of HRRP.Conclusions: Prior to HRRP, there were large reductions in Black-White disparities in readmissions at safety-net hospitals. Although HRRP tends to assess higher penalties for safety-net hospitals, improvements in readmissions have not reversed following the implementation of HRRP. In contrast, disparities continue to persist at non-safety-net hospitals which face much lower penalties. [ABSTRACT FROM AUTHOR]

Background: Different conceptual frameworks guide how an organization can change its policies and practices to make care and outcomes more equitable for patients, and how the organization itself can become more equitable. Nonetheless, healthcare organizations often struggle with implementing these frameworks.Objective: To assess what guidance frameworks for health equity provide for organizations implementing interventions to make care and outcomes more equitable.Study Design: Fourteen inequity frameworks from scoping literature review 2000-2017 that provided models for improving disparities in quality of care or outcomes were assessed. We analyzed how frameworks addressed key implementation factors: (1) outer and inner organizational contexts; (2) process of translating and implementing equity interventions throughout organizations; (3) organizational and patient outcomes; and (4) sustainability of change over time.Participants: We conducted member check interviews with framework authors to verify our assessments.Key Results: Frameworks stressed assessing the organization's outer context, such as population served, for tailoring change strategies. Inner context, such as existing organizational culture or readiness for change, was often not addressed. Most frameworks did not provide guidance on translation of equity across multiple organizational departments and levels. Recommended evaluation metrics focused mainly on patient outcomes, leaving organizational measures unassessed. Sustainability was not addressed by most frameworks.Conclusions: Existing equity intervention frameworks often lack specific guidance for implementing organizational change. Future frameworks should assess inner organizational context to guide translation of programs across different organizational departments and levels and provide specific guidelines on institutionalization and sustainability of interventions. [ABSTRACT FROM AUTHOR]

Background: Electronic patient-portals offer the potential to enhance patient-physician communication and health outcomes but differential use may create or worsen disparities. While prior studies identified patient characteristics associated with patient-portal use, the role of physician factors is less known. We investigated differences in overall and patterns of portal use for patients with resident and attending primary care providers (PCPs).Methods: Cross-sectional study of all established patients with a resident or attending PCP seen at an academic internal medicine practice (two sites) between May 1, 2014, and April 30, 2015. We defined patient-portal use as having accessed any "active" (secure messaging, medication refill request), or "passive" (viewing labs, after visit summaries, or appointments) patient-portal function more than once over the study period. We used generalized linear models clustered on PCP to examine the odds of patient-portal use by PCP type, adjusted for patient age, gender, preferred language, race/ethnicity, insurance, and visits. Among patient-portal users, we examined the association of PCP type with "active use" utilizing the same method.Results: The mean patient age (n = 17,699) was 54.2 (SD 17.5), with 47.2% White, 23.6% Asian, 8.8% Black, 8.4% Latino, and 12% other/unknown. The majority (61.8%) had private insurance, and attending PCPs (76.9%). Although 72.3% enrolled in the patient-portal, only 53.4% were portal users; 40.0% were active users. There were 47 attending and 62 resident physicians. Patients with resident PCPs had lower odds of using the portal compared to those with attending PCPs (OR = 0.54, 95% CI 0.50-0.59). Similarly, among portal users, residents' patients had lower odds of being active users of the portal (OR = 0.76, 95% CI 0.68-0.87).Conclusion: Given the lower patient-portal use among residents' patients, residency programs should develop curricula to bolster trainee competence in using the patient-portal for communication and to enhance the patient-physician relationship. Future research should explore additional physician factors that impact portal use. [ABSTRACT FROM AUTHOR]

Coverage, Affordability, and Care for Low-Income People with Diabetes: 4 Years after the Affordable Care Act's Medicaid Expansions Keywords: diabetes; Medicaid expansions; access to care; disparities EN diabetes Medicaid expansions access to care disparities 2222 2224 3 07/13/20 20200701 NES 200701 INTRODUCTION Diabetes is one of the most common and expensive diseases in the USA. Although the positive impact of the Affordable Care Act (ACA)'s Medicaid expansions on insurance coverage, access, and health have been extensively studied in the general population,[1], [2] the extent to which the ACA Medicaid expansions affect people with diabetes is unclear. [Extracted from the article]

Background: Transgender people, those whose gender identity does not match their sex assigned at birth, face barriers to receiving health care. These include discrimination, prohibitive cost, and difficulty finding transgender-inclusive providers. As transgender identities are not typically recognized in public health research, the ability to compare the health of the transgender population to the overall population is limited.Objective: The Colorado Transgender Health Survey sought to explore current disparities and their effects on the health of transgender people in Colorado.Design and Participants: The Colorado Transgender Health Survey, based on the Behavioral Risk Factor Surveillance System (BRFSS), was developed by the Colorado Department of Public Health and Environment, transgender advocates, and transgender community members. Outreach was targeted to transgender-inclusive events and organizations.Main Measures: Responses to the 2014 Colorado Transgender Health Survey were compared side by side to Colorado 2014 BRFSS data.Results: Results from 406 transgender or gender-nonconforming adults who live in Colorado were included in the analysis. Forty percent of respondents report delaying medical care due to cost, inadequate insurance, and/or fear of discrimination. Respondents report significant mental health concerns, with 43% reporting depression, 36% reporting suicidal thoughts, and 10% attempting suicide in the past year. Respondents with a transgender-inclusive provider were more likely to receive wellness exams (76 versus 48%), less likely to delay care due to discrimination (24 versus 42%), less depressed (38 versus 54%), and less likely to attempt suicide (7 versus 15%) than those without.Conclusions: The transgender community in Colorado faces significant disparities, especially around mental health. However, a transgender-inclusive provider is associated with improved mental and physical health and health behaviors. Further population-level research and provider education on transgender health should to be incorporated into national efforts to eliminate health disparities. [ABSTRACT FROM AUTHOR]

Background: Previous studies have documented income differences between male and female physicians. However, the implications of these differences are unclear, since previous studies have lacked detailed data on the quantity and composition of work hours. We sought to identify the sources of these income differences using data from a novel survey of physician work and income.Objective: To compare differences in income between male and female physicians.Design: We estimated unadjusted income differences between male and female physicians. We then adjusted these differences for total hours worked, composition of work hours, percent of patient care time spent providing procedures, specialty, compensation type, age, years in practice, race, ethnicity, and state and practice random effects.Participants: We surveyed 656 physicians in 30 practices in six states and received 439 responses (67% response rate): 263 from males and 176 from females.Main Measure: Self-reported annual income.Key Results: Male physicians had significantly higher annual incomes than female physicians (mean $297,641 vs. $206,751; difference $90,890, 95% CI $27,769 to $154,011) and worked significantly more total hours (mean 2470 vs. 2074; difference 396, 95% CI 250 to 542) and more patient care hours (mean 2203 vs. 1845; difference 358, 95% CI 212 to 505) per year. Male physicians were less likely than female physicians to specialize in primary care (49.1 vs. 70.5%), but more likely to perform procedures with (33.1 vs. 15.5%) or without general anesthesia (84.3 vs. 73.1%). After adjustment, male physicians' incomes were $27,404 (95% CI $3120 to $51,688) greater than female physicians' incomes.Conclusions: Adjustment for multiple possible confounders, including the number and composition of work hours, can explain approximately 70% of unadjusted income differences between male and female physicians; 30% remains unexplained. Additional study and dedicated efforts might be necessary to identify and address the causes of these unexplained differences. [ABSTRACT FROM AUTHOR]