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Background:Telehealth use remains high following the COVID-19 pandemic, but patient satisfaction with telehealth care is unclear. Methods:We used cross-sectional data from the Health Information National Trends Survey (HINTS 6). 2,058 English and Spanish-speaking U.S. adults (≥18 years) with a telehealth visit in the 12 months before March–November 2022 were included in this study. The primary outcomes were telehealth visit modality and satisfaction in the 12 months before HINTS 6. We evaluated sociodemographic predictors of telehealth visit modality and satisfaction via Poisson regression. Analyses were weighted according to HINTS standards. Results:We included 2,058 participants (48.4 ± 16.8 years; 57% women; 66% White), of which 70% had an audio-video and 30% an audio-only telehealth visit. Adults with an audio-video visit were more likely to have health insurance (adjusted prevalence ratio [aPR]: 1.55, 95% confidence interval [CI]: 1.18–2.04) and have an annual household income of ≥$75,000 (aPR: 1.18, 95% CI: 1.00–1.39) and less likely to be ≥65 years (aPR: 0.79, 95% CI: 0.70–0.89), adjusting for sociodemographic characteristics. No further inequities were noted by telehealth modality. Seventy-five percent of participants felt that their telehealth visits were as good as in-person care. No significant differences in telehealth satisfaction were observed across sociodemographic characteristics, telehealth modality, or the participants' primary reason for their most recent telehealth visit in adjusted analysis. Conclusions:Among U.S. adults with a telehealth visit, the majority had an audio-video visit and were satisfied with their care. Telehealth should continue, being offered following COVID-19, as it is uniformly valued by patients. [ABSTRACT FROM AUTHOR]

PURPOSE This mixed methods study sought to describe the extent to which family physicians in urban communities serve socially vulnerable patients and to better understand their practices, their challenges, and the structural supports that could facilitate their patient care. METHODS We conducted a quantitative analysis of questionnaire data from 100% of US physicians recertifying for family medicine from 2017 to 2020. We conducted qualitative analysis of in-depth interviews with 22 physician owners of urban, small, independent practices who reported that the majority of their patients were socially vulnerable. RESULTS In 2020, in urban areas across the United States, 19.3% of family physicians served in independent practices with 1 to 5 clinicians, down from 22.6% in 2017. Nearly one-half of these physicians reported that >10% of their patients were socially vulnerable. Interviews with 22 physicians who reported that the majority of their patients were socially vulnerable revealed 5 themes: (1) substantial time spent addressing access issues and social determinants of health, (2) minimal support from health care entities, such as independent practice associations and health plans, and insufficient connection to community-based organizations, (3) myriad financial challenges, (4) serious concerns about the future, and (5) deep personal commitment to serving socially vulnerable patients in independent practice. CONCLUSIONS Small independent practices serving vulnerable patients in urban communities are surviving because deeply committed physicians are making personal sacrifices. Health equity–focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients continue to have options when seeking primary care. [ABSTRACT FROM AUTHOR]

Low-value testing and treatment contribute to billions of dollars in waste to the United States health care system annually. High frequency, low-cost testing, including prostate-specific antigen (PSA) testing, is a major contributor to this inefficient health care delivery. Despite decreasing mortality of prostate cancer over the last few decades, the reputation of prostate specific antigen (PSA) for prostate cancer screening has fluctuated over the last decade due to lack of clarity of the benefits of screening and high risk for overtreatment. The value of PSA could be improved by efficient implementation of smarter testing strategies that reduce the harms and increase the benefits. [ABSTRACT FROM AUTHOR]

Intensive management programs may improve health care experiences among high-risk and complex patients. We assessed patient experience among (1) prior enrollees (n = 59) of an intensive management program (2014-2018); (2) nonenrollees (n = 356) at program sites; and (3) nonprogram site patients (n = 728), using a patient survey based on the Consumer Assessment of Healthcare Providers and Systems in 2019. Outcomes included patient ratings of patient-centered care; overall health care experience; and satisfaction with their usual outpatient care provider. In multivariate models, enrollees were more satisfied with their current provider versus nonenrollees within program sites (adjusted odds ratio 2.36; 95% confidence interval 1.15-4.85). [ABSTRACT FROM AUTHOR]

National performance metrics ultimately enhance patient decision-making and promote meaningful improvements in health care delivery, which makes having valid and reliable measures essential. This study examined US News and World Report metrics from 2019 to 2012 and used electronic health record data, combined with detailed chart review across 3 in-system hospitals, to assess the provision of care compared to the attribution of patients assigned to the ear, nose, and throat (ENT) mortality group. Of the initial 47 ENT-attributed deaths, 23 of those were verified, dimensioning the mortality rate from 1.7% to just 0.8%. These results underscore the necessity of rethinking measures and mortality attribution methodologies to be more accurate. Current methods use Medicare Severity Diagnosis Related Group billing coding to map the attribution. We suggest transitioning away from specialty ranking approaches and towards a procedure and condition "rating" approach to ensure that these ranking types capture data about the provision of care within a given encounter., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Food is Medicine (FIM) interventions reflect the critical links between food security, nutrition security, health, and health equity, integrated into health care delivery. They comprise programs that provide nutritionally tailored food, free of charge or at a discount, to support disease management, disease prevention, or optimal health, linked to the health care system as part of a patient's treatment plan. Such programs often prioritize health equity. On 26-27 April, 2023, Tufts University's Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy and Food & Nutrition Innovation Institute held a 2-day National Food is Medicine Summit with leaders, practitioners, and individuals with diverse lived experiences in health care, research, government, advocacy, philanthropy, and the private sector to identify challenges and opportunities to sustainably incorporate FIM services into the health care system and at scale. This report of a meeting describes key themes of the Summit, based on presentations and discussions on momentum around FIM, incorporating FIM in health care, tradeoffs and unintended consequences of various FIM models, scaling of programs, financing and payment mechanisms, educating and engaging the health care workforce, and federal and state government actions and opportunities on FIM. Speakers highlighted examples of recent public and private sector actions on FIM and innovative cross-sector partnerships, including state Medicaid waivers, academic and philanthropic research initiatives, health care system screenings and interventions, and collaborations including community-based organizations and/or entities outside of the food and health care sectors. Challenges and opportunities to broader implementation and scaling of FIM programs identified include incorporating FIM into health care business models, educating the health care workforce, and sustainably scaling FIM programs while leveraging the local connections of community-based organizations. This meeting report highlights recent advances, best practices, challenges, and opportunities discussed at the National Summit to inform future actions on FIM., Competing Interests: Conflict of interest The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To describe policy and system-level interventions with potential to improve cancer care at six sites., Methods: In 2016, six institutions received foundation support to develop unique multi-component interventions aimed at improving cancer care for underserved populations. These organizations, located across the United States, participated in a cross-site evaluation to assess the overall initiative impact and to identify potentially promising policy and system-level solutions for dissemination and broader implementation. A health system and policy tracking tool was developed to collect data from each site and included a description of their efforts, strategies employed, and changes achieved (e.g., new policies, clinical protocols). Tracking tool data were analyzed using rapid qualitative analyses and a matrix approach. Semi-structured interviews were conducted with site leaders (N = 65) and were analyzed by thematic analysis., Results: Sites reported 20 system and policy efforts, which resulted in improvements to electronic health records and telehealth strategies, changes to hospital/health system policies, and standardized clinical protocols/guidelines, among others. Efforts were aimed at: (1) coordinating care across multiple providers, supported by patient navigators; (2) expanding psychosocial and supportive care; (3) improving patient-provider communication; and (4) addressing barriers to accessing care. Interview analyses provided insights into successful strategies, challenges, and implications of the COVID-19 pandemic on cancer care., Conclusions and Implications for Cancer Survivors: Despite advances in diagnosis and treatment, cancer care remains inequitable. System-level improvements aimed at eliminating common barriers faced by underserved populations offer opportunities to improve the delivery of equitable, effective, and efficient care., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The COVID-19 pandemic was a stress test that revealed critical weaknesses in the foundation of the US health care delivery system, which left unresolved will ultimately lead to catastrophic population health consequences. Primary care and public health are the most fragile and important parts of that foundation. Collapse of either of these disciplines would lead to cascading failures harming the health of individuals and the health security of the nation. Primary care and public health are inextricably entwined as the cornerstones of health security and population health, and there is an urgent need to adequately fund both.As policy makers debate the importance of enhanced funding for either primary care or public health it would be good to consider the ways in which these disciplines are critical to securing the health of the nation as well as the ways in which they complement one another. Funding for both opens the door for greater integration that could build on the nascent synergies resulting in even stronger, more efficient and more sustainable foundation for the overall health care delivery system. Every day and in every corner of the world primary care and public health are already relying on each other in many ways. However, this relationship most often functions without formal acknowledgment. To better understand this intimate relationship, it is useful to first describe the core components of each., Competing Interests: Conflict of interest: None., (© Copyright 2024 by the American Board of Family Medicine.)

Background: In recent years, organizational leaders have faced growing pressure to respond to social and political issues. Although previous research has examined the experiences of corporate CEOs engaging in these issues, less is known about the perspectives of healthcare leaders., Objective: To explore the experiences of healthcare CEOs engaging in health-related social and political issues, with a specific focus on systemic racism and abortion policy., Design: Qualitative study using semi-structured interviews from February to July 2023., Participants: CEOs of US-based hospitals or health systems., Approach: One-on-one interviews which were audio recorded, professionally transcribed, and analyzed using thematic analysis., Key Results: This study included 25 CEOs of US-based hospitals or health systems. Almost half were between ages 60 and 69 (12 [48%]), 19 identified as male (76%), and 20 identified as White (80%). Approximately half self-identified as Democrats (13 [55%]). Most hospitals and health systems were private non-profits (15 [60%]). The interviews organized around four domains: (1) Perspectives on their Role, (2) Factors Impacting Engagement, (3) Improving Engagement, and (4) Experiences Responding to Recent Polarizing Events. Within these four domains, nine themes emerged. CEOs described increasing pressure to engage and had mixed feelings about their role. They identified personal, organizational, and political factors that affect their engagement. CEOs identified strategies to measure the success of their engagement and also reflected on their experiences speaking out about systemic racism and abortion legislation., Conclusions: In this qualitative study, healthcare CEOs described mixed perspectives on their role engaging in social and political issues and identified several factors impacting engagement. CEOs cited few strategies to measure the success of their engagement. Given that healthcare leaders are increasingly asked to address policy debates, more work is needed to examine the role and impact of healthcare CEOs engaging in health-related social and political issues., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Racial and ethnic minoritized groups report disproportionately lower trust in the health-care system. Lower health-care system trust is potentially related to increased exposure to racial discrimination in medical settings, but this association is not fully understood. We examined the association between racial discrimination in medical care and trust in the health-care system among people with and without a personal cancer history., Methods: We examined racial discrimination and trust in a nationally representative American adult sample from the Health Information National Trends Survey 6. Racial discrimination was defined as any unfair treatment in health care on the basis of race or ethnicity. Trust in the health-care system (eg, hospitals and pharmacies) was grouped into low, moderate, and high trust. Multinomial logistic regression models were used to compare low and moderate trust relative to high trust in the health-care system and estimate odds ratios (ORs) and 95% confidence intervals (CIs)., Results: A total of 5813 respondents (15% with a personal cancer history) were included; 92% (n = 5355) reported no prior racial discrimination experience during medical treatment. Prior experiences of racial discrimination were positively associated with low (OR = 6.12, 95% CI = 4.22 to 8.86) and moderate (OR = 2.70, 95% CI = 1.96 to 3.72) trust in the health-care system relative to high trust. Similar associations were observed when stratifying by personal cancer history., Conclusion: Respondents who reported racial discrimination during medical encounters had lower trust in the health-care system, especially respondents with a personal cancer history. Our findings highlight the need to address racial discrimination experiences during medical care to build patient trust and promote health-care access., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Primary care informatics (PCI) professionals address workflow and technology solutions in a wide spectrum of health, ranging from optimizing the experience of the individual patient in the clinic room to supporting the health of populations and augmenting the work of frontline primary care clinical teams. PCI overlaps uniquely with 2 disciplines with an impact on societal health-primary care and health informatics. Primary care is a gateway to health care access and aims to synthesize and coordinate numerous, complex elements of patients' health and medical care in a holistic manner. However, over the past 25 years, primary care has become a specialty in crisis: in a post-COVID-19 world, workforce shortages, clinician burnout, and continuing challenges in health care access all contribute to difficulties in sustaining primary care. Informatics professionals are poised to change this trajectory. In this viewpoint, we aim to inform readers of the discipline of PCI and its importance in the design, support, and maintenance of essential primary care services. Although this work focuses on primary care in the United States, which includes general internal medicine, family medicine, and pediatrics (and depending on definition, includes specialties such as obstetrics and gynecology), many of the principles outlined can also be applied to comparable health care services and settings in other countries. We highlight (1) common global challenges in primary care, (2) recent trends in the evolution of PCI (personalized medicine, population health, social drivers of health, and team-based care), and (3) opportunities to move forward PCI with current and emerging technologies using the 4Cs of primary care framework. In summary, PCI offers important contributions to health care and the informatics field, and there are many opportunities for informatics professionals to enhance the primary care experience for patients, families, and their care teams., (©Jacqueline Guan-Ting You, Tiffany I Leung, Deepti Pandita, Matthew Sakumoto. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 15.10.2024.)

Competing Interests: Disclosures: Disclosure forms are available with the article online.

Advances in radiology are crucial not only to the future of the field but to medicine as a whole. Here, we present three emerging areas of medicine that are poised to change how health care is delivered-hospital at home, artificial intelligence, and precision medicine-and illustrate how advances in radiological tools and technologies are helping to fuel the growth of these markets in the United States and across the globe., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Many Veterans receive Department of Veterans Affairs (VA)-purchased care from non-VA facilities but little is known about factors that Veterans consider for this choice. Between May 2020 and August 2021, we surveyed VA-purchased care-eligible VA patients about barriers and facilitators to choosing where to receive care. We examined the association between travel time to their VA facility and their choice of VA-purchased care (VA-paid health care received in non-VA settings) versus VA facility and whether this association was modified by distrust. We received 1,662 responses and 692 (42%) chose a VA facility. Eighty percent reported quality care was in their top three factors that influenced their decision. Respondents with the highest distrust and who lived >1 hr from the nearest VA facility had the lowest predicted probability (PP) of choosing VA (PP 15%; 95% confidence interval: 10%-20%). Veterans value quality of care. VA and other health care systems should consider patient-centered ways to improve and publicize quality and reduce distrust., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Primary care is the foundation of the health care workforce and the only part that extends life and improves health equity. Previous research on the geographic and specialty distribution of physicians has relied on the American Medical Association's Masterfile, but these data have limitations that overestimate the workforce.Methods: We present a pragmatic, systematic, and more accurate method for identifying primary care physicians using the National Plan and Provider Enumeration System (NPPES) and the Virginia All-Payer Claims Database (VA-APCD). Between 2015 and 2019, we identified all Virginia physicians and their specialty through the NPPES. Active physicians were defined by at least 1 claim in the VA-APCD. Specialty was determined hierarchically by the NPPES. Wellness visits were used to identify non-family medicine physicians who were providing primary care.Results: In 2019, there were 20,976 active physicians in Virginia, of whom 5,899 (28.1%) were classified as providing primary care. Of this primary care physician workforce, 52.4% were family medicine physicians; the remaining were internal medicine physicians (18.5%), pediatricians (16.8%), obstetricians and gynecologists (11.8%), and other specialists (0.5%). Over 5 years, the counts and relative percentages of the workforce made up by primary care physicians remained relatively stable.Conclusions: Our novel method of identifying active physicians with a primary care scope provides a realistic size of the primary care workforce in Virginia, smaller than some previous estimates. Although the method should be expanded to include advanced practice clinicians and to further delineate the scope of practice, this simple approach can be used by policy makers, payers, and planners to ensure adequate primary care capacity. [ABSTRACT FROM AUTHOR]

Background: Expansion of healthcare insurance coverage to bariatric surgeries has led to an increased demand from patients for post-bariatric contouring surgeries. This study examined the relationship between the use of contouring procedures on post-bariatric surgery patients, clinical need and sociodemographic factors.Methods: Data were extracted from the Healthcare Cost and Utilization Project (HCUP) Nationwide Ambulatory Surgery Sample (NASS) regarding hospital-owned ambulatory surgical centres in the US. Episodes without missing values relating to patients, 18 years old or above were the primary unit of analysis. Episodes were excluded if the field regarding expected payer was reported as "no charge." The primary outcome was the likelihood of panniculectomy, abdominoplasty, and mastopexy among post-bariatric surgery patients; and the degree to which uptake of these types of contouring surgery were associated with age, gender, median households' income, expected payer, patient's location, and comorbidity.Results: A total of 66,368 weighted episodes of care received by patients who had had bariatric surgery were extracted (54,684 female [82.4%]; mean age, 51.3 [SD, 12.1]; 6219 episodes had contouring surgeries [9.37%]). Panniculectomy was the most common post-bariatric contouring procedure (3.68%). Uptake of post-bariatric contouring procedures was associated with age, sex, payment type, area-based measures of median household income, and patient location. Compared to Medicare insured patients, the odds of receiving contouring surgery among self-payers were 1.82 (95% CI, 1.47 to 2.26) for panniculectomy, 14.79 (95% CI, 12.19 to 17.93) for abdominoplasty and 47.97 (95% CI, 32.76 to 70.24) for mastopexy. Rank order of comorbidity profiles also differed between insured and self-paying recipients of contouring surgery.Conclusions: Insurance status of bariatric surgery patients and their sex were strongly associated with receipt of a range of contouring procedures. Self-payments were associated with a doubling of the odds of having panniculectomy and an increase in the odds to approximately 14 times for abdominoplasty and 48 times for mastopexy. Thus, access to contouring surgery by post-bariatric patients may be disproportionately dependent on personal preference supported by ability to pay rather than clinical need. Further research is needed to examine the impact of contouring or delayed/denied contouring on health status. [ABSTRACT FROM AUTHOR]

The high lethality of ovarian cancer in the United States and associated complexities of the patient journey across the cancer care continuum warrant an assessment of current practices and barriers to quality care in the United States. The objectives of this study were to identify and assess key components in the provision of high‐quality care delivery for patients with ovarian cancer, identify challenges in the implementation of best practices, and develop corresponding quality‐related recommendations to guide multidisciplinary ovarian cancer programs and practices. This multiphase ovarian cancer quality‐care initiative was guided by a multidisciplinary expert steering committee, including gynecologic oncologists, pathologists, a genetic counselor, a nurse navigator, social workers, and cancer center administrators. Key partnerships were also established. A collaborative approach was adopted to develop comprehensive recommendations by identifying ideal quality‐of‐care program components in advanced epithelial ovarian cancer management. The core program components included: care coordination and patient education, prevention and screening, diagnosis and initial management, treatment planning, disease surveillance, equity in care, and quality of life. Quality‐directed recommendations were developed across 7 core program components, with a focus on ensuring high‐quality ovarian cancer care delivery for patients through improved patient education and engagement by addressing unmet medical and supportive care needs. Implementation challenges were described, and key recommendations to overcome barriers were provided. The recommendations emerging from this initiative can serve as a comprehensive resource guide for multidisciplinary cancer practices, providers, and other stakeholders working to provide quality‐directed cancer care for patients diagnosed with ovarian cancer and their families. Quality‐directed recommendations for ovarian cancer care delivery are developed across 7 core program components, with a focus on ensuring high‐quality care delivery by addressing unmet medical and supportive care needs. These recommendations can serve as a comprehensive resource guide for multidisciplinary cancer practices, providers, and other stakeholders working to provide quality‐directed cancer care for patients diagnosed with ovarian cancer and their families. [ABSTRACT FROM AUTHOR]

My Family Health Portrait is a tool from the United States Surgeon General to assist users with creating a family health history. This tool allows users to learn about health risks that reappear in families and can be taken to health care providers to assist with diagnoses and treatments. This tool was developed by the National Institutes of Health and is maintained by the Centers for Disease Control and Prevention. Utilizing the My Family Health Portrait can encourage people to stay healthy by being aware of their family health history. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate the interest in practice ownership among pediatric dentistry residents and influencing factors, particularly educational debt. Methods: An invitation to participate in an anonymous survey was sent to 933 pediatric dentistry residents training in the United States in the spring of 2020. Results: The survey response rate was 32.9 percent. Of the respondents, 61.2 percent reported being extremely or very interested in practice ownership and 49.8 percent anticipated becoming a practice owner within five years of graduation. An inverse relationship was seen between one's level of comfort in assuming a business loan to acquire a practice and having an educational debt burden of $400,000 or greater (P=0.002). Practice management preparation was the most common concern related to future practice ownership. Those feeling completely, very, or moderately prepared to manage a dental practice were over 40 percent more likely to be extremely or very interested in practice ownership than were those who felt slightly or not at all prepared (P<0.001). Conclusions: There appears to be broad interest in practice ownership among pediatric dentistry residents. Relatively high educational debt may negatively influence future practice ownership, but it may be less influential than other factors. [ABSTRACT FROM AUTHOR]

Purpose: Active video gaming (AVG) is used in physical therapy (PT) to treat individuals with a variety of diagnoses across the lifespan. The literature supports improvements in balance, cardiovascular endurance, and motor control; however, evidence is lacking regarding the implementation of AVG in PT education. This study investigated doctoral physical therapy (DPT) students' confidence following active exploration of AVG systems as a PT intervention in the United States. Methods: This pretest-posttest study included 60 DPT students in 2017 (cohort 1) and 55 students in 2018 (cohort 2) enrolled in a problem-based learning curriculum. AVG systems were embedded into patient cases and 2 interactive laboratory classes across 2 consecutive semesters (April--December 2017 and April--December 2018). Participants completed a 31-question survey before the intervention and 8 months later. Students' confidence was rated for general use, game selection, plan of care, set-up, documentation, setting, and demographics. Descriptive statistics and the Wilcoxon signed-rank test were used to compare differences in confidence pre- and post-intervention. Results: Both cohorts showed increased confidence at the post-test, with median (interquartile range) scores as follows: cohort 1: pretest, 57.1 (44.3--63.5); post-test, 79.1 (73.1--85.4); and cohort 2: pre-test, 61.4 (48.0--70.7); post-test, 89.3 (80.0--93.2). Cohort 2 was significantly more confident at baseline than cohort 1 (P<0.05). In cohort 1, students' data were paired and confidence levels significantly increased in all domains: use, Z=-6.2 (P<0.01); selection, Z=-5.9 (P<0.01); plan of care, Z=-6.0 (P<0.01); set-up, Z=-5.5 (P<0.01); documentation, Z=-6.0 (P<0.01); setting, Z=-6.3 (P<0.01); and total score, Z=-6.4 (P<0.01). Conclusion: Structured, active experiences with AVG resulted in a significant increase in students' confidence. As technology advances in healthcare delivery, it is essential to expose students to these technologies in the classroom. [ABSTRACT FROM AUTHOR]

Background: The Department of Veterans Affairs (VA), the largest nationally integrated health system in the United States, is transitioning from its homegrown electronic health record (EHR) to a new vendor-based EHR, Oracle Cerner. Experiences of the first VA site to transition have been widely discussed in the media, but in-depth accounts based on rigorous research are lacking., Objective: We sought to explore employee perspectives on the rationale for, and value of, transitioning from a VA-tailored EHR to a vendor-based product., Methods: As part of a larger mixed methods, multisite, formative evaluation of VA clinician and staff experiences with the EHR transition, we conducted semistructured interviews at the Mann-Grandstaff VA Medical Center before, during, and after going live in October 2020. In total, we completed 122 interviews with 26 participants across multiple departments., Results: Before the new vendor-based EHR went live, participants initially expressed cautious optimism about the transition. However, in subsequent interviews following the go-live, participants increasingly critiqued the vendor's understanding of VA's needs, values, and workflows, as well as what they perceived as an inadequate fit between the functionalities of the new vendor-based EHR system and VA's characteristic approach to care. As much as a year after going live, participants reiterated these concerns while also expressing a desire for substantive changes to the transition process, with some questioning the value of continuing with the transition., Conclusions: VA's transition from a homegrown EHR to a vendor-based EHR system has presented substantial challenges, both practical and cultural in nature. Consequently, it is a valuable case study for understanding the sociotechnical dimension of EHR-to-EHR transitions. These findings have implications for both VA leadership and the broader community of policy makers, vendors, informaticists, and others involved in large-scale health information technology implementations., (©Ekaterina Anderson, Megan Moldestad, Julian Brunner, Sherry Ball, Christian Helfrich, Jay Orlander, Seppo Rinne, George Sayre. Originally published in JMIR Formative Research (https://formative.jmir.org), 10.09.2024.)

Introduction: The objective of this study is to evaluate severe maternal morbidity (SMM) of rural parturients delivering at rural compared to urban hospitals in the US., Methods: We identified patients aged 18-40 years in a multi-institutional claims database who lived in a rural ZIP code and delivered at a rural or urban hospital between October-December of 2015 and October-December of 2022. The primary outcome was SMM, and the secondary outcome was SMM exclusive of blood transfusions. We combined exact ZIP code matching and propensity score matching to compare SMM risk among patients living in the same rural community and delivering in urban as compared to rural hospitals., Results: A total of 214 296 patients from 571 ZIP codes were identified, including 47% delivering at rural facilities and 53% delivering at urban facilities. The SMM rate was 1.1% (0.3% excluding blood transfusions). After matching, urban versus rural delivery was associated with increased odds of SMM other than blood transfusion (odds ratio 2.44; 95% confidence interval 1.81-3.28), but was not associated with differences in risk of any SMM., Conclusion: There was no evidence of reduced SMM for rural patients delivering at an urban rather than a rural hospital. SMM exclusive of blood transfusions was increased for rural patients delivering at urban hospitals after matching on ZIP code and predictors of urban hospital delivery. Our findings undermine the assumption that delivery at a rural facility has inherently greater risks relative to delivery at an urban facility. As some health systems face challenges to maintain rural labor and delivery units, patient safety must be considered if confronted with the possibility of unit or hospital closures.

Competing Interests: The author declares no conflicts of interest.

Among the rapid integration of artificial intelligence in clinical settings, large language models (LLMs), such as Generative Pre-trained Transformer-4, have emerged as multifaceted tools that have potential for health-care delivery, diagnosis, and patient care. However, deployment of LLMs raises substantial regulatory and safety concerns. Due to their high output variability, poor inherent explainability, and the risk of so-called AI hallucinations, LLM-based health-care applications that serve a medical purpose face regulatory challenges for approval as medical devices under US and EU laws, including the recently passed EU Artificial Intelligence Act. Despite unaddressed risks for patients, including misdiagnosis and unverified medical advice, such applications are available on the market. The regulatory ambiguity surrounding these tools creates an urgent need for frameworks that accommodate their unique capabilities and limitations. Alongside the development of these frameworks, existing regulations should be enforced. If regulators fear enforcing the regulations in a market dominated by supply or development by large technology companies, the consequences of layperson harm will force belated action, damaging the potentiality of LLM-based applications for layperson medical advice., Competing Interests: Declaration of interests SG is an advisory group member of the EY-coordinated study on regulatory governance and innovation in the field of medical devices conducted on behalf of the Directorate General for Health and Food Safety of the European Commission. SG has or has had consulting relationships with Una Health, Lindus Health, Flo, Thymia, FORUM Institut für Management, High-Tech Gründerfonds Management, and Ada Health, and holds share options in Ada Health. JNK received funding from GlaxoSmithKline; has or has had consulting relationships with Owkin, DoMore Diagnostics, Histofy, and Panakeia; received honoraria for lectures and events from Bayer, Eisai, Merck Sharp & Dohme, Bristol Myers Squibb, Roche, Pfizer, and Fresenius; participated on boards of Bayer, Eisai, Merck Sharp & Dohme, Bristol Myers Squibb, Roche, and Pfizer; and has a leadership role and holds stock in StratifAI. OF has worked as a freelance doctor for Clinical Research Services Berlin, and has a leadership role and holds stock in WhalesDontFly. ICW declares no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Context: The "community-based workforce" is an umbrella term used by a workgroup of U.S. Department of Health and Human Services (HHS) leaders to characterize a variety of job titles and descriptions for positions in the public health, health care delivery, and human service sectors across local communities., Approach: Definitions, expectations of the scope of work, and funding opportunities for this workforce vary. To address some of these challenges, a workgroup of HHS agencies met to define the roles of this workforce and identify existing opportunities for training, career advancement, and compensation., Discussion: The community-based workforce has demonstrated success in improving poor health outcomes and addressing the social determinants of health for decades. However, descriptions of this workforce, expectations of their roles, and funding opportunities vary. The HHS workgroup identified that comprehensive approaches are needed within HHS and via public health sectors to meet these challenges and opportunities., Conclusion: Using the common term "community-based workforce" across HHS can encourage alignment and collaboration. As the environment for this public health and health care community-based workforce shifts, it will be important to understand the value and opportunities available to ensure long-term sustainability for this workforce to continue to advance health equity., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Policy Points Artificial intelligence (AI) is disruptively innovating health care and surpassing our ability to define its boundaries and roles in health care and regulate its application in legal and ethical ways. Significant progress has been made in governance in the United States and the European Union. It is incumbent on developers, end users, the public, providers, health care systems, and policymakers to collaboratively ensure that we adopt a national AI health strategy that realizes the Quintuple Aim; minimizes race-based medicine; prioritizes transparency, equity, and algorithmic vigilance; and integrates the patient and community voices throughout all aspects of AI development and deployment., (© 2024 The Author(s). The Milbank Quarterly published by Wiley Periodicals LLC on behalf of The Milbank Memorial Fund.)

Context: Interventions to improve the quality of care for people affected by serious illness commonly fail to reach patients from marginalized and underserved communities, which include those characterized by racialized or indigenous identity, sexual and gender minority status, and rural living. Interventions to improve care through serious illness conversations have demonstrated benefit, but little is known about their implementation in health systems that predominantly serve these patient groups., Objectives: The study aimed to understand factors influencing implementation of a serious illness communication-focused intervention-the Serious Illness Care Program in health systems who primarily provide care to marginalized and underserved communities., Methods: Qualitative interviews (16) and focus groups (3) were conducted with 19 interdisciplinary team members from six geographically diverse U.S. healthcare systems. Using a template analysis approach, investigators coded data inductively and deductively to identify themes., Results: Three themes emerged: patient factors, intervention elements, and health system contextual factors. Participants highlighted mission-driven efforts, creativity, interprofessional practice, and trainees as enablers of success. They identified weaknesses in the intervention's communication tool-the Serious Illness Conversation Guide as barriers to implementation of conversations. Resource constraints, socio-economic vulnerability, and mistrust in the health system were seen as additional barriers., Conclusions: Health systems that provide care to underserved and marginalized communities face unique challenges implementing the Serious Illness Care Program. They also possess assets, some unique to these settings, that support program adoption. Findings suggest that implementation of similar programs in low-resource healthcare settings may help address unmet needs among marginalized populations., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Policy Points Improving health systems requires the pursuit of both patient-centered care and a supportive environment for health professionals. This Quadruple Aim includes improving the experience of care, improving the health of populations, reducing per capita costs of care, and improving the work life of the care providers. We propose expanding a recently defined Fifth Aim of health equity to include health democracy, ensuring that that the health and health care wants, needs, and responsibilities of populations are being met, and also propose adding a Sixth Aim of preserving and improving the health of the environment to create the best health possible. As social tension and environmental changes continue to impact the structure of our society, this "Hexagonal Aim" might provide additional ethical guiderails as we set our health care goals to foster sustainable and improved population health., (© 2024 The Author(s). The Milbank Quarterly published by Wiley Periodicals LLC on behalf of The Milbank Memorial Fund.)

Background: The Centers for Medicare and Medicaid Services (CMS) introduced chronic care management (CCM) services in 2015 for patients with multiple chronic diseases. Few studies examine the utilization of CCM services by geographic region, sociodemographic, and clinical characteristics., Methods: We used 2014-2019 Medicare claims data from a 5% random sample of fee-for-service beneficiaries aged 65 years or over. We included beneficiaries potentially eligible for CCM services because they had multiple chronic conditions (1,073,729 in 2015 and 1,130,523 in 2019). We calculated the proportion of potentially eligible beneficiaries receiving CCM service each year for the total population and by geographic region, sociodemographic, and clinical characteristics., Results: The proportion of beneficiaries with two or more chronic conditions receiving CCM services increased from 1.1% in 2015 to 3.4% in 2019. The increase in CCM use was higher in the southern region, among dually eligible beneficiaries and beneficiaries with a greater burden of chronic conditions (2-5 conditions vs ≥10 conditions: 0.7% vs 2.0% in 2015; 2.1% vs 7.0% in 2019) and frailty (robust vs severely frail: 0.6% vs 3.3% in 2015; 1.9% vs 9.4% in 2019). Nearly one out of five recipients did not continue CCM service after the initial service., Conclusion: We found that CCM service is being used by a very small fraction of eligible patients. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit., (© 2024 The American Geriatrics Society.)

Objectives: Large language models (LLMs) are poised to change care delivery, but their impact on health equity is unclear. While marginalized populations have been historically excluded from early technology developments, LLMs present an opportunity to change our approach to developing, evaluating, and implementing new technologies. In this perspective, we describe the role of LLMs in supporting health equity., Materials and Methods: We apply the National Institute on Minority Health and Health Disparities (NIMHD) research framework to explore the use of LLMs for health equity., Results: We present opportunities for how LLMs can improve health equity across individual, family and organizational, community, and population health. We describe emerging concerns including biased data, limited technology diffusion, and privacy. Finally, we highlight recommendations focused on prompt engineering, retrieval augmentation, digital inclusion, transparency, and bias mitigation., Conclusion: The potential of LLMs to support health equity depends on making health equity a focus from the start., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The rapid technological advancements in cardiac implantable electronic devices such as pacemakers, implantable cardioverter defibrillators, and loop recorders, coupled with a rise in the number of patients with these devices, necessitate an updated clinical framework for periprocedural management. The introduction of leadless pacemakers, subcutaneous and extravascular defibrillators, and novel device communication protocols underscores the imperative for clinical updates. This scientific statement provides an inclusive framework for the periprocedural management of patients with these devices, encompassing the planning phase, procedure, and subsequent care coordinated with the primary device managing clinic. Expert contributions from anesthesiologists, cardiac electrophysiologists, and cardiac nurses are consolidated to appraise current evidence, offer patient and health system management strategies, and highlight key areas for future research. The statement, pertinent to a wide range of health care professionals, underscores the importance of quality care pathways for patient safety, optimal device function, and minimization of hemodynamic disturbances or arrhythmias during procedures. Our primary objective is to deliver quality care to the expanding patient cohort with cardiac implanted electronic devices, offering direction in the era of evolving technologies and laying a foundation for sustained education and practice enhancement.

Background: The association between rurality of patients' residence and hospital experience is incompletely described. The objective of the study was to compare hospital experience by rurality of patients' residence., Methods: From a US Midwest institution's 17 hospitals, we included 56,685 patients who returned a post-hospital Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. We defined rurality using rural-urban commuting area codes (metropolitan, micropolitan, small town, rural). We evaluated the association of patient characteristics with top-box score (favorable response) for 10 HCAHPS items (six composite, two individual, two global). We obtained adjusted odds ratios (aOR [95% CI]) from logistic regression models including patient characteristics. We used key driver analysis to identify associations between HCAHPS items and global rating (combined overall rating of hospital and recommend hospital)., Results: Of all items, overall rating of hospital had lower odds of favorable response for patients from metropolitan (0.88 [0.81-0.94]), micropolitan (0.86 [0.79-0.94]), and small towns (0.90 [0.82-0.98]) compared with rural areas (global test, P = .003). For five items, lower odds of favorable response was observed for select areas compared with rural; for example, recommend hospital for patients from micropolitan (0.88 [0.81-0.97]) but not metropolitan (0.97 [0.89-1.05]) or small towns (0.93 [0.85-1.02]). For four items, rurality showed no association. In metropolitan, micropolitan, and small towns, men vs. women had higher odds of favorable response to most items, whereas in rural areas, sex-based differences were largely absent. Key driver analysis identified care transition, communication about medicines and environment as drivers of global rating, independent of rurality., Conclusions: Rural patients reported similar or modestly more favorable hospital experience. Determinants of favorable experience across rurality categories may inform system-wide and targeted improvement., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Fawad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Understanding healthcare system resilience has become paramount, particularly in the wake of the COVID-19 pandemic, which imposed unprecedented burdens on healthcare services and severely impacted public health. Resilience is defined as the system's ability to absorb, recover from and adapt to disruptions; however, despite extensive studies on this subject, we still lack empirical evidence and mathematical tools to quantify its adaptability (the ability of the system to adjust to and learn from disruptions). By analyzing millions of patients' electronic medical records across US states, we find that the COVID-19 pandemic caused two successive waves of disruptions within the healthcare systems, enabling natural experiment analysis of the adaptive capacity of each system to adapt to past disruptions. We generalized the quantification framework and found that the US healthcare systems exhibit substantial adaptability (ρ = 0.58) but only a moderate level of resilience (r = 0.70). When considering system responses across racial groups, Black and Hispanic groups were more severely impacted by pandemic disruptions than white and Asian groups. Physician abundance was the key characteristic for determining healthcare system resilience. Our results offer vital guidance in designing resilient and sustainable healthcare systems to prepare for future waves of disruptions akin to COVID-19 pandemics., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Purpose: This study explored employee health behavior changes and health care utilization after workplace genetic testing (wGT). Wellness-program-associated wGT seeks to improve employee health, but the related health implications are unknown., Methods: Employees of a large US health care system offering wGT (cancer, heart disease, and pharmacogenomics [PGx]) were sent electronic surveys. Self-reported data from those who received test results were analyzed. Descriptive statistics characterized responses, whereas logistic regression analyses explored correlates of responses to wGT., Results: 53.9% (n = 418/776) of respondents (88.3% female, mean age = 44 years) reported receiving wGT results. 12.0% (n = 48/399) received results indicating increased risk (IR) of cancer, 9.5% (n = 38/398) had IR of heart disease, and 31.4% (n = 125/398) received informative PGx results. IR results for cancer and/or heart disease (n = 67) were associated with health behavior changes (adjusted odds ratio: 3.23; 95% CI 1.75, 6.13; P < .001) and health care utilization (adjusted odds ratio: 8.60; 95% CI 4.43, 17.5; P < .001). Informative PGx results (n = 125) were associated with medication changes (PGx-informative: 15.2%; PGx-uninformative: 4.8%; P = .002)., Conclusion: This study explored employee responses to wGT, contributing to the understanding of the ethical and social implications of wGT. Receiving IR results from wGT may promote health behavior changes and health care utilization in employees., Competing Interests: Conflict of Interest The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Genetic counseling and genetic testing are important tools for diagnosis, screening, and employment of effective medical management strategies for hereditary cardiovascular diseases. Despite widespread recognition of the benefits of genetic counseling and testing in cardiovascular care, little is published regarding their use in large healthcare systems. We conducted a retrospective cross-sectional study using administrative claims data in the US Military Health System to assess the state of recommended genomic counseling in clinical cardiovascular care. Logistic regression models were used to examine associations of genetic counseling among beneficiaries with hereditary cardiovascular conditions. Approximately 0.44% of beneficiaries in fiscal year 2018 had a diagnosis of a hereditary cardiovascular condition. Among the 23,364 patients with a diagnosis of hereditary cardiovascular disease, only 175 (0.75%) had documented genetic counseling and 196 (0.84%) had documented genetic testing. Genetic counseling did not differ by race, sex, service, or diagnosis. Age group, Active Duty status, rank as a proxy for socioeconomic status, and geographic location contributed significantly to the likelihood of receiving genetic counseling. These findings suggest that genetic counseling is underutilized in clinical cardiovascular care in the Military Health System and may be more broadly, despite expert consensus recommendations for its use and potential life-saving benefits. Unlike previous studies in the US civilian health sector, there did not appear to be disparities in genetic counseling by race or sex in the Military Health System. Strategies to improve care for cardiovascular disease should address the underutilization of recommended genetics evaluations for heritable diagnoses and the challenges of assessing use in large health systems studies., (© 2023 National Society of Genetic Counselors. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: The COVID-19 pandemic has necessitated rapid changes in healthcare delivery in the United States, including changes in the care of hospitalized children. The objectives of this study were to identify major changes in healthcare delivery for hospitalized children during the COVID-19 pandemic, identify lessons learned from these changes, and compare and contrast the experiences of children's and community hospitals. Methods: We purposefully sampled participants from both community and children's hospitals serving pediatric patients in the six U.S. states with the highest COVID-19 hospitalization rates at the onset of the pandemic. We recruited 2–3 participants from each hospital (mix of administrators, front-line physicians, nurses, and parents/caregivers) for semi-structured interviews. We analyzed interview data using constant comparative methods to identify major themes. Results: We interviewed 30 participants from 12 hospitals. Participants described how leaders rapidly developed new hospital policies (e.g., directing use of personal protective equipment) and how this was facilitated by reviewing internal and external data frequently and engaging all relevant stakeholders. Hospital leaders optimized communication through regular, transparent, multi-modal, and bi-directional communication. Clinicians increased use of videoconference and telehealth to facilitate physical distancing, but these technologies may have disadvantaged non-English speakers. Due to declining volumes of hospitalized children and surges of adult patients, clinicians newly provided care for hospitalized adults. This was facilitated by developing care teams supported by adult hospitalists, multidisciplinary support via videoconference, and educational resources. Participants described how the pandemic negatively impacted clinicians' mental health, and they stressed the importance of mental health resources and wellness activities/spaces. Conclusions: We identified several major changes in inpatient pediatric care delivery during the COVID-19 pandemic, including the adoption of new hospital policies, video communication, staffing models, education strategies, and staff mental health supports. We outline important lessons learned, including strategies for successfully developing new policies, effectively communicating with staff, and supporting clinicians' expanding scope of practice. Potentially important focus areas in pandemic recovery include assessing and supporting clinicians' mental health and well-being, re-evaluating trainees' skills/competencies, and adapting educational strategies as needed. These findings can help guide hospital leaders in supporting pandemic recovery and addressing future crises. [ABSTRACT FROM AUTHOR]

Purpose: Availability of mental health services is limited in the rural United States. Two promising models to reach patients with limited access to care are telehealth referral and collaborative care. The objective of this study was to assess telepsychiatrist‐ and telepsychologist‐level facilitators and barriers to satisfaction with and implementation of these 2 telehealth models in rural settings. Methods: Focus groups were held in 2019 using a semistructured interview guide. Participants were off‐site telepsychiatrists (N = 10) and telepsychologists (N = 4) for primary care clinics across 3 states (Washington, Michigan, and Arkansas) involved in a recent pragmatic comparative effectiveness trial. Qualitative analysis occurred inductively by 2 independent coders. Findings: Participants were satisfied with the models partly owing to good patient rapport and expanding access to care. Teamwork was highlighted as a facilitator in collaborative care and was often related to work with care managers. However, participants described communication with primary care providers as a challenge, especially in the telehealth referral arm. Barriers centered on variability of logistical processes (eg, symptom monitoring, scheduling, electronic medical record processes, and credentialing) among sites. Staff turnover, variable clinic investment, and inadequacy of training were possible explanations for these barriers. Conclusions: Participants described high motivation to provide team‐based, remote care for patients, though they experienced operational challenges. Centralized credentialing, scheduling, and record keeping are possible solutions. These findings are important because consulting psychiatrists and psychologists may play a leadership role in the dissemination of these models. [ABSTRACT FROM AUTHOR]