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A recent Senate Select Committee has tabled its report into the provision of and access to dental care in Australia. The Senate Committee heard: There are significant barriers for many people accessing dental care, including high costs, trauma and fear, long waiting times and inaccessible services.There are service gaps, including a lack of special needs dentists, limited mobile services, very few Aboriginal dentists and sparse services in regional areas.There are significant impacts of poor oral health, including pain and suffering, shame and low self‐esteem, poor nutrition and poorer general health.There are benefits to good oral health, including the ability to smile, eat and talk, improved confidence, increased productivity and being more employable. There were 35 recommendations for reform centred around the need to put the mouth back in the body and covered by five broad themes: More equitable access.Better integration.National data and coordination.Awareness and education.Culturally safe and accessible care. This paper provides an overview of the problem and focuses on the recommended funding reforms necessary to improve access to dental care. [ABSTRACT FROM AUTHOR]

Introduction: Special needs dentistry (SND) is an emerging dental specialty, with ongoing developments in education and clinical practice focused towards the tailored management of individuals with special needs (SN). Patients with SN have a higher prevalence of oral diseases and unmet dental needs compared to the general population. Although inadequate training and experience in managing patients with SN has been highlighted as a significant barrier to accessing care, there is limited data about the extent of SND teaching at the entry‐to‐practice or higher levels. Methods: This work is the first to map SND curricula globally, across 180 countries and 1265 dental schools. Results: Although 74.62% of dental schools were found in developing economies, the distribution of programs that reported SND in their courses was highly skewed towards developed countries. In terms of advanced degrees, beyond basic entry‐to‐practice training, the USA delivered 60% of the SND programs, followed by Canada (15.56%), UK (13.33%), and Australia (8.89%). The term SND appeared in 33.95% of entry‐to‐practice level program curricula and was less commonly used in transitioning economies. Only 112 SND‐specialized practitioners enter the workforce globally each year from developed economies, and all but three advanced degrees are found in G7 countries. Conclusion: By exploring the impact of economic status on its distribution, this paper highlighted the lack of SND representation in dental curricula, especially amongst programs in transitioning or developing economies. Education of both general dentists and specialists is critical as a collaborative effort is needed to manage the growing population of patients with SN. [ABSTRACT FROM AUTHOR]

The sociology of diagnosis has shown that diagnosis not only serves to label the underlying cause of disease but also to provide access to services and resources. Elaborating on this double‐affordance of diagnosis, this article examines how precision medicine reconfigures diagnosis as a label and as a process in regulatory and clinical settings. Reporting from an ethnographic case study of the introduction of immunotherapy for lung cancer, the paper unfolds the uncertainties involved in dissecting diagnosis into layers and examines the efforts and negotiations it takes to enable these layers to work both as clinical entities and regulative entities with the purpose of delineating access to treatment. I suggest that the work of subdividing diseases into molecularly defined categories for the purpose of delineating treatment‐eligible populations can be labelled 'diagnostic sub‐stratification' and argue that it is pertinent to understand the political capacity of this strategy. Diagnostic sub‐stratification involves a push of diagnosis from the clinic 'up' into the regulatory system and 'out' into the laboratories, obscuring who is accountable for the diagnostic categories employed to define patients' treatment access. [ABSTRACT FROM AUTHOR]

Background: Delivering dental care to patients in their home or residential institutions is known as "portable dentistry". The demand for portable dental services is on the rise, but dentists remain reluctant to adopt portable practices.Objectives: To explore the literature on portable dental services and understand (a) the process of planning and delivering portable dental services and (b) the benefits and challenges of portable dentistry for service providers and patients.Methods: A systematic scoping search was conducted. We retrieved 3994 documents, 28 of which were included in the final synthesis. Three authors read the papers and conducted thematic content analyses independently.Results: We present a synthesis of the literature and proposed a model of portable dentistry containing three levels with the patient is at the centre surrounded by concentric rings representing the dentist (dental team) and society. At each of these levels, our model is further subdivided into three components: 1) organisation of the service; 2) arrival and set-up of the service; and 3) delivery of the service. In addition, each level includes 1) human factors, which are related either to the dental professional or the patient; 2) non-human factors, which refer to either the equipment or the physical environment; and 3) financial factors, which are related to cost and remuneration.Conclusions: We propose a model for portable dentistry that dentists and dental educators interested in this practice should find useful. [ABSTRACT FROM AUTHOR]

Background: Long Covid is an emerging long‐term condition, with those affected raising concerns about lack of healthcare support. Objective: We conducted a qualitative study to identify facilitators and barriers to healthcare access for people with Long Covid, aiming to enhance our understanding of the specific nature of these barriers and how patient experiences may vary. Setting and Participants: In the context of the Symptoms, Trajectory, Inequalities and Management: Understanding Long‐COVID to Address and Transform Existing Integrated Care Pathways (STIMULATE‐ICP) Delphi study, a nationally distributed online survey was conducted. Eight patients and eight healthcare practitioners (HCP) were interviewed via telephone or video call. Framework analysis, sensitised by the candidacy theory, was used to identify barriers and facilitators over four levels of access to care. Results: Three themes were identified: (i) patients' efforts to navigate emerging pathways for Long Covid, (ii) the patient–HCP interaction and (iii) service resources and structural constraints. Barriers to specialist care included long waiting times, communication gaps across services and a lack of continuity in care. Facilitators included collaborative, patient‐centred approaches, patients' active role in their healthcare and blended approaches for appointments. The perspectives of both patients and HCPs largely aligned. Discussion: The candidacy framework was valuable in understanding the experiences of people with Long Covid seeking access to healthcare. Individuals perceived themselves as eligible for care, but they often encountered obstacles in obtaining the expected level of care or, in some cases, did not receive it at all. Our findings are discussed in the context of the candidacy model through multiple processes of identification, negotiation, permeability and appearances at health services. These themes seem to be especially important for the emerging new pathway model and are relevant to both primary and secondary care. Conclusions: This study highlights that despite these interviews being conducted two years after the start of the COVID‐19 pandemic, people with Long Covid still struggle to access healthcare, emphasising the ongoing need to provide equitable timely healthcare access for people with Long Covid. Patient or Public Contribution: People with Long Covid advised on all stages of this research. [ABSTRACT FROM AUTHOR]

Policy PointsPolicymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures.Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities.Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long‐term policy solutions including reparations are needed to address these underlying processes. Context: The growing rate of rural hospital closures elicits concerns about declining access to hospital‐based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure—Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care. Methods: To calculate spatial access, we estimated the network travel distance and time between the census tract–level population‐weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital‐based care in 2018, we estimated three‐level (tract, county, state‐level) generalized linear models. Findings: We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital. Conclusions: Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for. [ABSTRACT FROM AUTHOR]

Objectives: To summarise data on human immunodeficiency virus (HIV) services available to farmworkers in sub‐Saharan Africa (SSA). Methods: We conducted a systematic review to understand which HIV prevention and care services were accessed by farm workers in SSA. MEDLINE (PubMed), Embase, CINAHL (EBSCO Host), Cochrane library, African Index Medicus, Scopus, Google Scholar, Open Grey, and Web of Science Proceedings Citation Index were searched. Studies were eligible for inclusion if they measured or reported on the presence of HIV workplace policy frameworks, guidelines, or programmes for HIV prevention, treatment and care services, and other treatment modalities specifically targeting farmworkers. Results: Nine studies published between 2005 and 2019 were included in the review. Six themes emerged from included studies, which include HIV policy, HIV prevention (awareness, education, and condom supply), voluntary counselling and testing, antiretroviral therapy (ART), linkage to care, and mobile clinic. Though availability of an HIV policy was inadequate, a significant positive impact of the HIV policy in influencing behaviour change was reported. Most of the farm workers could access HIV education and condom supply in their places of work. Access to ART, treatment support, and linkage to care was inadequate, but community outreach programmes and mobile clinics showed success in reaching a high number of workers with HIV testing and treatment. A majority of farm workers faced barriers in accessing government health facilities. Conclusions: The findings suggest that there is poor access to HIV services for farmworkers in SSA. There is a dire need to scale up HIV services and programmes, including mobile health facilities, in agricultural settings. Due to high labour migration patterns among farmworkers, we recommend cross‐country HIV programmes that allow continuity of care across borders. [ABSTRACT FROM AUTHOR]

Objective: Test whether racial‐ethnic disparities in the access and use of care differ between Traditional Medicare (TM) and Medicare Advantage (MA). Data Source: Secondary data from the 2015–2018 Medicare Current Beneficiary Survey (MCBS). Study Design: Measure Black‐White and Hispanic‐White disparities in access to care and use of preventive services within TM, within MA, and assess the difference‐in‐disparities between the two programs with and without controls for factors that could influence enrollment, access, and use. Data Collection/Extraction: Pool 2015–2018 MCBS data and restrict to non‐Hispanic Black, non‐Hispanic White, or Hispanic respondents. Principal Findings: Black enrollees have worse access to care relative to White enrollees in TM and MA, particularly for cost‐related measures such as not having problems paying medical bills (11–13 pp. lower for Black enrollees; p < 0.05) and satisfaction with out‐of‐pocket costs (5–6 pp. lower; p < 0.05). We find no difference in Black‐White disparities between TM and MA. Hispanic enrollees have worse access to care relative to White enrollees in TM but similar access relative to White enrollees in MA. Hispanic‐White disparities in not delaying care due to cost and not reporting problems paying medical bills are narrower in MA relative to TM by about 4 pp (significant at the p < 0.05 level) each. We find no consistent evidence that Black‐White or Hispanic‐White differences in the use of preventive services differ between TM and MA. Conclusions: Across the measures of access and use studied here, racial and ethnic disparities in MA are not substantially narrower than in TM for Black and Hispanic enrollees relative to White enrollees. For Black enrollees, this study suggests that system‐wide reforms are required to reduce existing disparities. For Hispanic enrollees, MA does narrow some disparities in access to care relative to White enrollees but, in part, because White enrollees do not do as well in MA as they do in TM. [ABSTRACT FROM AUTHOR]

Introduction: The HIV response has long recognized that certain "key populations" such as individuals in detention, adolescent girls and young women, sex workers, people who use drugs, LGBTQ individuals, migrants and others face higher barriers to access to, uptake of, and retention in HIV prevention and treatment services. One approach to addressing these barriers is the training of community paralegals to advocate for the rights of individuals and to address discrimination in health settings. Discussion: Community paralegal programmes have been able to successfully address rights violations that impact access to health services and underlying determinants of health across a range of countries and populations, focusing upon issues such as discrimination and the denial of health services; unlawful detention of outreach workers, sex workers, persons who use drugs and men who have sex with men; and harmful traditional practices and gender‐based violence. In addition to resolving specific cases, evaluations of paralegal programmes have found that these programmes increased legal literacy among key populations at risk of HIV and increased understanding of human rights among healthcare providers, resulting in improved access to HIV services. Some evaluations have noted challenges related to the sustainability of paralegal programmes similar to those raised with community health worker programmes more broadly. Conclusions: To achieve global HIV goals, funding for legal literacy and paralegal programmes should be increased and interventions should be rigorously evaluated. Efforts should target discrimination in access to HIV prevention and treatment and criminalization of key populations, two key barriers to ensuring access to HIV prevention and treatment services. [ABSTRACT FROM AUTHOR]

Objective: To describe the development of a platform for image collection and annotation that resulted in a multi‐sourced international image dataset of oral lesions to facilitate the development of automated lesion classification algorithms. Materials and Methods: We developed a web‐interface, hosted on a web server to collect oral lesions images from international partners. Further, we developed a customised annotation tool, also a web‐interface for systematic annotation of images to build a rich clinically labelled dataset. We evaluated the sensitivities comparing referral decisions through the annotation process with the clinical diagnosis of the lesions. Results: The image repository hosts 2474 images of oral lesions consisting of oral cancer, oral potentially malignant disorders and other oral lesions that were collected through MeMoSA® UPLOAD. Eight‐hundred images were annotated by seven oral medicine specialists on MeMoSA®ANNOTATE, to mark the lesion and to collect clinical labels. The sensitivity in referral decision for all lesions that required a referral for cancer management/surveillance was moderate to high depending on the type of lesion (64.3%–100%). Conclusion: This is the first description of a database with clinically labelled oral lesions. This database could accelerate the improvement of AI algorithms that can promote the early detection of high‐risk oral lesions. [ABSTRACT FROM AUTHOR]

Purpose: To investigate whether rural‐urban differences in quality of care for Medicare Advantage (MA) enrollees vary between females and males. Methods: Data for this study came from the 2019 Healthcare Effectiveness Data and Information Set. Linear regression was used to investigate urban‐rural differences in individual MA enrollee scores on 34 clinical care measures grouped into 7 categories, and how those differences varied by sex (through evaluation of statistical interactions). Findings: Across all 7 categories of measures, scores for rural residents were worse than scores for urban residents. For 4 categories—care for patients with (suspected) chronic obstructive pulmonary disease, avoiding prescription misuse, behavioral health, and diabetes care—the average difference across measures in the category was greater than 3 percentage points. Across all 34 measures, there were 15 statistically significant rural‐by‐sex interactions that exceeded 1 percentage point. In 11 of those cases, the deficit associated with living in a rural area was greater for males than for females. In 3 cases, the deficit associated with living in a rural area was larger for females than for males. In 1 case involving Follow‐up After Hospitalization for Mental Illness, rural residents had an advantage, and it was larger for males than for females. Conclusions: Interventions may help address patient‐ (eg, health literacy and patient activation), provider‐ (eg, workforce recruitment and retention), and structural‐level issues contributing to these disparities, especially for rural males. [ABSTRACT FROM AUTHOR]

Background: Global data on the treatment rate with direct‐acting antivirals (DAAs) for chronic hepatitis C (CHC) are sparse. We aimed to evaluate the CHC treatment rate and barriers to treatment in the DAA era. Methods: We searched PubMed, EMBASE and Cochrane from inception to 5 August 2021, for relevant articles. Patients treated with DAAs without interferon (IFN) therapy were categorized as IFN‐free DAAs. Patients receiving DAA with IFN or unclear IFN status were categorized as DAA/IFN. Results: We identified and analysed data from 146 studies (1 760 352 CHC patients). DAA/IFN treatment rate was 16.0% (95% CI: 9.9–23.3, 49 studies, 886 535 patients). IFN‐free DAA treatment rate was 52.3% (95% CI: 46.2–58.4, 123 studies, 1 276 754 patients): 45.4% in North America, 64.2% in South America (1 study), 90.4% in Africa (most data from Egypt), 54.4% in Europe, 60.7% in Australia and 60.5% in Asia, (p <.0001); 49% with hepatitis B co‐infection and 32.3% with hepatocellular carcinoma (HCC). Treatment was not a priority in 22.8% of patients in Europe and 16.7% in Australia, compared to only 4.8% in North America and 2.1% in Asia (p <.0001). Poor adherence to clinical follow‐up was the cause of no treatment in 74.7% of patients in Australia, 37.0% in North America, 7.9% in Europe and 14.3% in Asia (p <.0001). Conclusion: Though a marked improvement from IFN/DAA, the treatment rate with IFN‐free DAA remains suboptimal (52.3% overall, 32.3% in HCC patients). Non‐adherence to clinical follow‐up and lack of disease awareness were treatment barriers. [ABSTRACT FROM AUTHOR]

Purpose: The COVID‐19 pandemic highlighted disparities in healthcare access and outcomes, particularly among individuals with chronic conditions. A positive outcome of the pandemic was an increased use of telehealth and the creation of innovative models of care. In many organizations, nurses became the leaders for these new models. Before this change, pediatric medicine had far fewer telehealth models than adult medicine due to limited Medicaid reimbursement and equipment that was not designed with children in mind. This article describes a new model of care for children with diabetes. We will review how a nurse‐led initiative with the incorporation of telehealth modalities can improve access and outcomes while reducing cost. Successful models of care will be reviewed, as well as programmatic planning, financial implications, and regulatory considerations. Conclusions: It is no longer necessary for families living in rural communities to drive long distances, missing school and work, to attend the frequent appointments needed for optimal management of pediatric diabetes. Telemedicine can bridge gaps in access to specialty care, and is feasible, reimbursable, and well‐accepted by families and providers. Practice Implications: Nurses in both primary care and pediatric specialty offices can initiate and support innovative telehealth models of care, such as this proposal. To win the backing of practice leadership, the availability of cost‐effective videoconferencing equipment and software, improvements in telehealth reimbursement prompted by the pandemic, and enhanced patient and parent satisfaction and outcomes should be emphasized. [ABSTRACT FROM AUTHOR]

Objective: To estimate the effects of changes in Veterans Health Administration (VHA) mental health services staffing levels on suicide‐related events among a cohort of Veterans. Data Sources: Data were obtained from the VHA Corporate Data Warehouse, the Department of Defense and Veterans Administration Infrastructure for Clinical Intelligence, the VHA survey of enrollees, and customized VHA databases tracking suicide‐related events. Geographic variables were obtained from the Area Health Resources Files and the Centers for Medicare and Medicaid Services. Study Design: We used an instrumental variables (IV) design with a Heckman correction for non‐random partial observability of the use of mental health services. The principal predictor was a measure of provider staffing per 10,000 enrollees. The outcome was the probability of a suicide‐related event. Data Collection/Extraction Methods: Data were obtained for a cohort of Veterans who recently separated from active service. Principal Findings: From 2014 to 2018, the per‐pay period probability of a suicide‐related event among our cohort was 0.05%. We found that a 1% increase in mental health staffing led to a 1.6 percentage point reduction in suicide‐related events. This was driven by the first tertile of staffing, suggesting diminishing returns to scale for mental health staffing. Conclusions: VHA facilities appear to be staffing‐constrained when providing mental health care. Targeted increases in mental health staffing would be likely to reduce suicidality. [ABSTRACT FROM AUTHOR]

Objective: Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower‐quality plans, measured by a 5‐star quality rating system. We examine whether differential access to high‐rated plans was associated with this differential enrollment in high‐rated plans by race and ethnicity among MA enrollees. Data Sources: The Medicare Master Beneficiary Summary File and MA Landscape File for 2016. Study Design: We first examined county‐level MA plan offerings by race and ethnicity. We then examined the association of racial and ethnic differences in enrollment by star rating by controlling for the following different sets of covariates: (1) individual‐level characteristics only, and (2) individual‐level characteristics and county‐level MA plan offerings. Data Collection/Extraction Methods: Not applicable Principal Findings: Racial and ethnic minority enrollees had, on average, more MA plans available in their counties of residence compared to White enrollees (16.1, 20.8, 20.2, vs. 15.1 for Black, Asian/Pacific Islander, Hispanic, and White enrollees), but had fewer number of high‐rated plans (4‐star plans or higher) and/or more number of low‐rated plans (3.5‐star plans or lower). While racial and ethnic minority enrollees had lower enrollment in 4–4.5 star plans than White enrollees, this difference substantially decreased after accounting for county‐level MA plan offerings (−9.1 to −0.5 percentage points for Black enrollees, −15.9 to −5.0 percentage points for Asian/Pacific Islander enrollees, and −12.7 to 0.6 percentage points for Hispanic enrollees). Results for Black enrollees were notable as the racial difference reversed when we limited the analysis to those who live in counties that offer a 5‐star plan. After accounting for county‐level MA plan offerings, Black enrollees had 3.2 percentage points higher enrollment in 5‐star plans than White enrollees. Conclusions: Differences in enrollment in high‐rated MA plans by race and ethnicity may be explained by limited access and not by individual characteristics or enrollment decisions. [ABSTRACT FROM AUTHOR]

Policy PointsCommunity mental health facilities often do not offer the full range of evidence‐based clinical and support services for individuals with serious mental illness. Facilities were no more likely to offer six of seven services studied in 2019 compared with 2010 in both Medicaid expansion and nonexpansion states.For‐profit facilities generally experienced the largest declines in service availability, while public facilities experienced the smallest declines with small increases in availability of select services.New payment models that incentivize the offer of specialty support services may be needed to encourage adoption of clinical and support services by specialty mental health organizations. Context: Community mental health facilities often do not offer the full range of evidence‐based clinical and support services for individuals with serious mental illness. This creates equity issues, particularly when low‐income and minority communities have access to fewer facilities. Medicaid expansion might encourage facilities to offer these services. However, this decision may also be affected by facility ownership type or mediated by service cost structure, particularly in the absence of innovative payment mechanisms. In this study, we determine whether and how Medicaid expansion and facility ownership are associated with changes in specialty mental health service availability in organized settings over time. Methods: We estimated two‐way fixed effects models using six cross‐sections of the National Mental Health Services Survey and compared changes in facility‐reported offering of seven services from 2010 to 2019 (54,885 facility years): psychotropic medication, case management, family psychoeducation, psychiatric emergency walk‐in services, supported employment, assertive community treatment, illness management, and recovery services. We tested whether Medicaid expansion and facility ownership (private for‐profit, private not‐for‐profit, public) were associated with differential changes in service availability from 2010 to 2019. Findings: Overall, facilities were no more likely to offer nearly all services in 2019 than 2010. We found smaller declines for psychotropic medication and psychiatric emergency walk‐in services among facilities in Medicaid expansion states compared to declines in non‐Medicaid expansion states (6.3 (95% CI 95% CI = 1.8‐10.7) and 5.5 (95% CI = 0.2‐10.8) percentage points respectively). For‐profit facilities experienced the largest declines in availability from 2010 to 2019, while public facilities experienced the smallest declines and some increases in availability of select services. Conclusions: Specialty mental health services are still not widely offered in community outpatient settings despite significant investments in Medicaid, although Medicaid expansion was associated with slower declines in availability. New payment models that incentivize outpatient facilities to offer clinical and support services may be needed. [ABSTRACT FROM AUTHOR]

Objective: Hip and knee osteoarthritis guidelines internationally provide consistent first‐line care recommendations. However, uptake of these recommendations remains suboptimal. This qualitative study explores factors influencing guideline‐based care from the perspectives of physiotherapists working in specialised osteoarthritis services across different models of care. Methods: Nineteen semi‐structured interviews were conducted with physiotherapists working in specialist osteoarthritis services across three different Australian models of care (OsteoArthritis Hip and Knee Service n = 10; OsteoArthritis Chronic Care Programme n = 4; Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services n = 5). Interviews were audio recorded and transcribed verbatim. Data were coded and analysed inductively using thematic analysis. Results: The overarching theme to emerge was that accessing first‐line osteoarthritis care is complex and difficult, regardless of model of care. Subthemes indicated that: (i) services are either unavailable or inadequately funded, (ii) referral pathways are labyrinthine and lengthy, (iii) patients and other health professionals often believe that surgery is the only/best option and (iv) managing patient co‐morbidities is challenging. Conclusion: Physiotherapists working in specialised osteoarthritis services perceive multiple and complex factors influencing adherence to first‐line care. Barriers occur at various levels in all models of care, including patient and health professional beliefs, health service, and system levels. These results suggest improving healthcare for people with osteoarthritis requires urgent system reform. [ABSTRACT FROM AUTHOR]

Objective: Research suggests Medicaid expansion led to modest increases in the use of dental services among low‐income adults, especially in states with more generous Medicaid dental benefits. We expand upon this research by examining whether the effect of Medicaid expansion differed across important socioeconomic subgroups. Methods: Using Behavioral Risk Factor Surveillance System data from 2012 to 2016, we employed a difference‐in‐differences framework to estimate the effect of Medicaid expansion on annual use of dental services overall and by whether states offered more‐than‐emergency Medicaid dental benefits. We used generalized linear mixed‐effects model trees to estimate effects across socioeconomic subgroups (e.g., age, education, race, income). Results: The effect of Medicaid expansion varied by state's generosity of Medicaid dental coverage and combinations of socioeconomic subgroups. Overall, there was no significant association between Medicaid expansion and probability of using dental services (−0.1 pp percentage points [pp], p = 0.914). Medicaid expansion was associated with a modest increase in the probability of using dental services in states with more‐than‐emergency Medicaid dental benefits (2.3 pp, p < 0.001) and with a modest decrease in states with no or emergency‐only benefits (−4.3 pp, p < 0.001). Among adults aged 21–35 without a high school diploma, Medicaid expansion was associated with an 8.1 pp (p = 0.003) increase in dental use probability, but there were no associated effects of Medicaid expansion for other subgroups. Conclusions: While Medicaid expansion alone is not sufficient to ensure adults receive recommended dental care, some vulnerable subgroups appear to have benefited. Efforts to mitigate barriers to dental care may be needed to increase uptake of dental services by low‐income adults. [ABSTRACT FROM AUTHOR]

Objective: To estimate the effect of wait times on patients' choice of provider and simulate changes in choice of provider due to compliance with VA MISSION Act wait time targets. Data Sources: We use nationwide administrative data (2014–2017) on Veterans who are enrolled in Medicare and the Veterans Health Administration (VHA), the Survey of VHA Enrollees, Area Health Resource Files, and other data provided by the Centers for Medicare & Medicaid Services. Study Design: We use an instrumental variables approach to identify the effect of VHA wait times on the proportion of total (Medicare and VHA) services that are paid for by the VHA ("reliance"). We exploit shocks to VHA provider supply to isolate supply‐driven changes in wait times and estimate the effect on VHA reliance. We control for market and time fixed effects and local demand factors. Data Collection/Extraction Methods: We use monthly aggregated data on 140 markets (groups of counties). VHA reliance is computed among patients aged 65 years or older who are dually enrolled in VHA and Medicare. VHA wait times and reliance are calculated for multiple specialties: cardiology, gastroenterology, orthopedics, urology, dermatology, and ophthalmology/optometry. Principal Findings: A 10% increase in the mean wait time (+2.8 days) reduces VHA reliance by 2.3 percentage points (95% CI: 2.3, 2.7), or 7.9% of the sample mean. This implies that meeting the MISSION Act wait time targets may have multi‐billion‐dollar budgetary impacts. Effects vary across specialties. For example, a 10% increase in the mean wait time for cardiology services (+2.0 days) reduces reliance by 1.8 percentage points (95% CI: 1.6, 2.1), or 6.3% of the sample mean for cardiology services. Conclusions: Meeting statutory wait time targets may have substantial unforeseen impacts on federal health care spending as patients sort to providers who have lower wait times. [ABSTRACT FROM AUTHOR]

Background: Sensory over‐responsivity has been linked to oral care challenges in children with special healthcare needs. Parents of children with Down syndrome (cDS) have reported sensory over‐responsivity in their children, but the link between this and oral care difficulties has not been explored. Aim: To investigate the relationship between sensory over‐responsivity and oral care challenges in cDS. Design: An online survey examined parent‐reported responses describing the oral care of their cDS (5–14 years; n = 367). Children were categorized as either sensory over‐responders (SORs) or sensory not over‐responders (SNORs). Chi‐square analyses tested associations between groups (SORs vs. SNORs) and dichotomous oral care variables. Results: More parents of SOR children than of SNOR reported that child behavior (SOR:86%, SNOR:77%; p <.05) and sensory sensitivities (SOR:34%, SNOR:18%; p <.001) make dental care challenging, their child complains about ≥3 types of sensory stimuli encountered during care (SOR:39%, SNOR:28%; p =.04), their dentist is specialized in treating children with special healthcare needs (SOR:45%, SNOR:33%; p =.03), and their child requires full assistance to brush teeth (SOR:41%, SNOR:28%; p =.008). No intergroup differences were found in items examining parent‐reported child oral health or care access. Conclusions: Parents of SOR children reported greater challenges than parents of SNOR children at the dentist's office and in the home, including challenging behaviors and sensory sensitivities. [ABSTRACT FROM AUTHOR]

Resource‐constrained delivery systems often have access issues, causing patients to wait a long time to see a provider. We develop theoretical and empirical models of wait times and apply them to primary care delivery by the U.S. Veterans Health Administration (VHA). Using instrumental variables to handle simultaneity issues, we estimate the effect of clinician supply on new patient wait times. We find that it has a sizable impact. A 10% increase in capacity reduces wait times by 2.1%. Wait times are also associated with clinician productivity, scheduling protocols, and patient access to alternative sources of care. The VHA has adopted our models to identify underserved areas as specified by the MISSION Act of 2018. [ABSTRACT FROM AUTHOR]

Objectives: To examine the implementation of a community‐based clinical education (CBCE) program at the University of California, Los Angeles School of Dentistry (SOD) and the preliminary outcomes on dental students and affiliated clinics. Methods: A retrospective review was carried out of SOD CBCE program implementation and program data between March 2018 and June 2019 related to patient encounters, pre‐ and post‐rotation student self‐assessments, student exit surveys and surveys administered to faculty within affiliate clinics. Results: In five academic quarters, 133 students delivered care for 7556 patients and completed 12,467 procedures in underserved communities. Students reported increased confidence across 14 areas of self‐assessment. The percentage of students reporting future plans of working in public health clinics upon graduation increased from 6% to 19%. Affiliate clinic faculty indicated increased care delivery for underserved patients, appointment availability, and job satisfaction. Conclusions: The newly implemented UCLA SOD CBCE program preliminarily yielded immediate positive outcomes for SOD students and affiliate community clinics. [ABSTRACT FROM AUTHOR]

Background and Objective: Comprehensive headache care involves numerous specialties and components that have not been well documented or standardized. This study aimed to elicit best practices and characterize important elements of care to be provided in multidisciplinary headache centers. Methods: Qualitative, semi‐structured telephone interviews with a purposive sample of headache neurology specialists from across the US, using open‐ended questions. Interviews were recorded, transcribed, and coded. Coded data were further analyzed using immersion/crystallization techniques for final interpretation. Results: Mean years providing headache care was 17.7 (SD = 10.6). Twelve of the 13 participants held United Council for Neurologic Subspecialties headache certification. Six described their practice site as providing multidisciplinary headache care. Participants explained most of their patients had seen multiple doctors over many years, and had tried numerous unsuccessful treatments. They noted patients with chronic headache frequently present with comorbidities and become stigmatized. All participants asserted successful care depends on taking time to talk with and listen to patients, gain understanding, and earn trust. All participants believed multidisciplinary care is essential within a comprehensive headache center, along with staffing enough headache specialists, implementing detailed headache intake and follow‐up protocols, and providing the newest medications, neuromodulation devices, botulinum toxin injections, monoclonal antibodies, nerve blocks and infusions, and treatment from a health psychologist. Other essential services for a headache center are other behavioral health practitioners providing cognitive behavioral therapy, mindfulness, biofeedback and pain management; and autonomic neurology, neuropsychology, vestibular audiology, sleep medicine, physical therapy, occupational therapy, exercise physiology, speech therapy, nutrition, complementary integrative health modalities, and highly trained support staff. Conclusion: While headache neurology specialists form the backbone of headache care, experts interviewed for this study maintained their specialty is just one of many types of care needed to adequately treat patients with chronic headache, and this is best provided in a comprehensive, multidisciplinary center. [ABSTRACT FROM AUTHOR]

Purpose: To contrast trends in rural and urban pediatric home health care use among Medicaid enrollees. Methods: Medicaid administrative claims data were used to assess differences in home health care use for child members in a large pediatric accountable care organization (ACO) in Ohio. Descriptive statistics assessed rural and urban differences in health care use over a 10‐year period between 2010 and 2019. Findings: Pediatric home health care use increased markedly in the low‐income (CFC) and disabled (ABD) Medicaid categories. Over the past 10 years, CFC‐enrolled children from urban communities have seen more home health visits, fewer emergency department (ED) visits, and more well child visits compared to rural CFC‐enrolled children. Children enrolled due to disabilities in urban communities have also seen more home health visit use but fewer preventive care visits than their rural counterparts. Conclusions: Within a pediatric ACO, rural home health care use has remained relatively stagnant over a 10‐year period, a stark contrast to increases in home health care use among comparable urban populations. There are likely multiple explanations for these differences, including overuse in urban communities, lack of access in rural communities, and changes to home health reimbursement. More can be done to improve rural home health access. Such improvement will likely necessitate large‐scale changes to home health care delivery, workforce, and financing. Improvements should be evaluated for return‐on‐investment not only in terms of direct costs, that is, reduced inpatient or ED costs, but also in terms of patient and family quality‐of‐life or key indicators of child well‐being such as educational attainment. [ABSTRACT FROM AUTHOR]

Purpose: We examined the impact on geographic distribution of medications to treat opioid use disorder (MOUD) in Oregon after the Comprehensive Addiction and Recovery Act (CARA) was implemented in February 2017 to include nurse practitioner (NP) prescribers. Methods: We conducted interrupted time series analysis with linear regression on prescriptions dispensed for buprenorphine used for MOUD in the Oregon Prescription Drug Monitoring Database written by physician (MD/DO) and NP prescribers January 1, 2016, to December 31, 2018. We analyzed total prescriptions by prescriber type and pharmacy ZIP Code using STATA 16.1. Findings: From January 1, 2016, to December 31, 2018, 420,765 eligible prescriptions were written by waivered MD/DO and/or NP prescribers. Prior to CARA, buprenorphine use was increasing steadily at 140 prescriptions per month (95% CI: 78‐201; P <.01). Following CARA, dispensing increased by 88 prescriptions per month (95% CI: 23‐152; P =.01). The absolute number increased in rural areas immediately after CARA implementation (368 prescriptions; 95% CI: 124‐613; P <.01). NP contribution to total buprenorphine prescribing increased significantly in both urban and rural areas (0.44% per month [95% CI: 0.30%‐0.57%; P <.01] and 0.74% per month [95% CI: 0.62%‐0.85%; P <.01]). The contribution of NPs had a particularly large impact for very rural (frontier) areas, where NPs provided 36% of all buprenorphine prescriptions by the end of 2018. Conclusion: Changes in federal law regarding MOUD had a positive impact on both supply and geographic distribution in Oregon, particularly in frontier areas comprising 10 of 36 counties (27%). [ABSTRACT FROM AUTHOR]

Purpose: To examine potential indicators of health need for primary care in spatial equity research, and evidence of the Inverse Care Law in the Waikato region of New Zealand. Methods: A cross‐sectional analysis of 7 health need indicators (ambulatory sensitive hospitalizations; cancer rate; mortality rate; New Zealand index of multiple deprivation‐health domain; age; New Zealand index of deprivation; smoking rate) that were identified through a systematic review was carried out. Values of indicators were mapped and analyzed using geographic information systems (GIS). Spearman's correlations were calculated between indicators, and clusters of high need were identified through spatial autocorrelation. The impact of incorporating indicator‐based weightings into an accessibility model was tested using analysis of variance and Spearman's correlations. General practice service spatial equity was assessed by comparing clusters of high access versus need, and quantified through the Gini coefficient. Findings: Ambulatory sensitive hospitalization (ASH) rates were significantly correlated with all indicators. Health needs were significantly clustered, but incorporating indicator weightings into the spatial accessibility analysis did not impact accessibility scores. A misalignment of access and need, and a Gini coefficient of 0.281 suggest that services are not equitably distributed. Conclusion: ASH rates seem a robust indicator of health need. However, data access issues may restrict their use. Area‐level socioeconomic deprivation measures incorporate some social determinants of health, and they have potential for wider use. High need clusters vary spatially according to the indicator used. GIS techniques can identify "hot‐spots" of need, but these can be masked in accessibility models. [ABSTRACT FROM AUTHOR]

Objectives: To test the feasibility and preliminary effectiveness of the NIATx model for organizational change to reduce appointment no‐shows in dental care settings. Methods: The NIATx Dental Pilot Study used a clustered prepost interventional design and a mixed‐methods approach. Five independent dental clinics serving Medicaid enrollees were recruited. Quantitative data on the impact of the NIATx model were complemented by qualitative assessment information collected from dental staff. The NIATx model was applied through a multisite learning collaborative that engaged participating organizations in adopting targeted no‐show best practices. The primary outcome measure was no‐show data collected at the preintervention phase (5 months), intervention phase (7 months), and postintervention phase (3 months). Results: Female patients were in the majority (median 54.5 percent). Mean age ranged from 8 to 50 (median 35.2) years. The median percentage for Hispanics was 11.0 percent, and the proportion of uninsured patients was 25 percent. Preintervention no‐show rates ranged from 14 percent (clinic B) to 38 percent (clinic E). All clinics had lower no‐show rates during the postintervention period, with decreases ranging from 1 percent (clinic B) to 13 percent (clinic E). Overall, the no‐show rates decreased in the study. Conclusions: The study demonstrated the feasibility of applying the NIATx model to reduce no‐show rates, with some difficulty observed with sustainability across dental practices during the postintervention period. [ABSTRACT FROM AUTHOR]

Background: Patients of color are disproportionately impacted by vitiligo. Access to treatment depends greatly on insurance coverage. We, therefore, assessed current vitiligo treatment coverage policies across major United States health insurers to determine current patterns and coverage gaps for vitiligo. Methods: The study surveyed 15 commercial health care insurers, 50 BlueCross BlueShield (BCBS) plans, Medicare, Medicaid, and Veterans Affairs. Information on treatment coverage for vitiligo, specifically pimecrolimus and tacrolimus, excimer laser therapy, PUVA, and narrow‐band (nb)UVB, was collected via an online review of insurance policy documents, confirmed with phone calls to organization representatives, or via a survey of Medicaid providers, and state Medicaid directors. Results: Of 17 organizations with regional or national coverage policies, 12% did not cover topical calcineurin inhibitors, 56% did not cover nbUVB phototherapy, 53% did not cover PUVA phototherapy, and 41% did not cover laser therapy. For BCBS, pimecrolimus and tacrolimus were not covered in 39% and 35% of states, respectively. NbUVB and PUVA therapy were not covered in 20% and 10% of states, respectively. Excimer laser therapy was not covered in 82% of states. Out of 32 states with accessible Medicaid information, 11 did not cover topicals, 5 did not cover nbUVB, 4 did not cover PUVA, and 7 did not cover laser. Two commonly cited reasons for coverage denial were that the treatment indication was considered cosmetic, and certain therapies are not FDA‐approved. Conclusions: There is inequity in the distribution of health among vitiligo patients given current patterns of insurance coverage for treatment, which may have disproportionate impact on patients of color. [ABSTRACT FROM AUTHOR]

Background: Probability and nonprobability‐based studies of US transgender persons identify different disparities in health and health care access. Objectives: We used TransPop, the first US national probability survey of transgender persons, to describe and compare measures of health and health access among transgender, nonbinary, and cisgender participants. We directly compared the results with 2015 US Transgender Survey (USTS) data and with previously published analyses from the Behavioral Risk Factor Surveillance System (BRFSS). Methods: All participants were screened by Gallup Inc., which recruited a probability sample of US adults. Transgender people were identified using a two‐step screening process. Eligible participants completed self‐administered questionnaires (transgender n = 274, cisgender n = 1162). We obtained weighted proportions/means, then tested for differences between gender groups. Logistic regression was performed to evaluate associations. Bivariate analyses were conducted using the weighted USTS data set for shared variables in USTS and TransPop. Results: Transgender participants were younger and more racially diverse compared to the cisgender group. Despite equally high insurance coverage, transgender people more often avoided care due to cost concerns. Nonbinary persons were less likely to access transgender‐related health care providers/clinics than transgender men and women. Transgender respondents more often rated their health as fair/poor, with more frequently occuring poor physical and mental health days compared to cisgender participants. Health conditions including HIV, emphysema, and ulcer were higher among transgender people. TransPop and USTS, unlike BRFSS‐based analyses, showed no differences in health or health access. Discussion: Transgender persons experience health access disparities centered on avoidance of care due to cost beyond insured status. Health disparities correspond with models of minority stress, with nonbinary persons having distinct health/health access patterns. Despite different sampling methods, USTS and TransPop appear more similar than BRFSS studies regarding health/health access. Conclusion: Future research should elucidate health care costs for transgender and nonbinary people, while addressing methodology in national studies of transgender health. [ABSTRACT FROM AUTHOR]

Background: Shortages of anesthesia providers in rural areas have long resulted in access limitations in many US states. This situation prompted federal legislation designed to promote increased usage of certified registered nurse anesthetists (CRNAs) in hospitals. Starting in 2001, state governors were afforded the option to adopt "opt‐out" provisions, giving facilities in their states flexibility in utilizing CRNAs; specifically, adopting the opt‐out policy removes physician oversight requirements for Medicare billing purposes. Methods: We used mixed effects generalized linear models to identify predictors of CRNA service provision in hospitals from 2011‐2015. Results: We found that being located in an opt‐out state does not result in increased odds of CRNA service provision in US hospitals. Higher levels of deprivation in counties, being located in rural geographic areas, and being a teaching hospital all influenced CRNA service provision. Conclusions: Given that we found no evidence that being in an opt‐out state increases the odds of using CRNAs in hospitals, we contribute to the growing literature suggesting that states adopting the opt‐out policy have not realized increased health care access or reduced health care costs. As a result of other contextual restrictions on hospitals' decision‐making, simply adopting the opt‐out policy has not been enough to address anesthesia provider shortages. [ABSTRACT FROM AUTHOR]