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Objectives. To summarize data collection on anti–Asian American and Native Hawaiian/Pacific Islander (AANHPI) experiences during COVID-19 and measure the associations of anti-AANHPI hate incidents with mental health, health access, and public safety among AANHPI adults. Methods. We cataloged COVID-19 surveys conducted in 2020 and 2021 on anti-AANHPI experiences. We then analyzed the 2020 California Health Interview Survey (CHIS) AANHPI COVID-19 module by constructing a variable of experiencing or witnessing a hate incident and estimating its associations with serious psychological distress, forgone care, and perceived neighborhood safety. Results. Estimates of being a victim of a hate incident ranged from 6% to 30%. In the CHIS, 28% of respondents experienced or witnessed a hate incident. Experiencing or witnessing a hate incident was significantly associated with serious psychological distress (adjusted odds ratio [AOR] = 5.33), forgoing care (AOR = 2.27), and not feeling safe in one’s neighborhood (AOR = 2.70). Conclusions. Evidence from a multitude of data sources corroborates the toll of hate incidents suffered by AANHPIs. Findings regarding the negative effects of anti-AANHPI hate on mental health, health access, and public safety compel public and private investment to end victimization of AANHPI communities. (Am J Public Health. 2022;112(10):1446–1453. https://doi.org/10.2105/AJPH.2022.306977 )

As the fastest-growing racial/ethnic group in the U.S., Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) make up about 7% of the U.S. population. AANHPIs represent more than 50 ethnic groups and speak over 100 different languages, but national health data rarely collect information needed to disaggregate AANHPI into smaller groups to capture this diversity. This study reviewed AANHPI disaggregated data collection methods in large, U.S. population-based surveys, summarized disaggregated data reporting practices in the peer-reviewed literature, and conducted key informant interviews with 23 members of the National Network of Health Surveys who lead state/local and national surveys to identify challenges to data collection. We found that while large national surveys may include AANHPI subpopulation in data collection, sample sizes are often too small to permit meaningful data analysis. In our interviews, barriers cited included the lack of stakeholder interest, inadequate funding, lack of space on questionnaires, as well as methodologic challenges, such as the inability to obtain an adequate sample size and poor questionnaire design. Survey administration efforts to improve disaggregated health data are challenging, but when done, have led to a proliferation of new population-representative knowledge on the health of AANHPI subgroups. This study provides evidence of the population health value of disaggregating AANHPI data to identify the needs of vulnerable subpopulations. It also advances the field by offering key informants’ insights in overcoming implementation challenges.

In October of 2021, California enacted SB 428, the ACEs Equity Act, which mandates commercial insurance coverage of adverse childhood experiences (ACEs) screening in addition to ACEs screening already covered for the state's Medicaid enrollees. California is the first state to expand ACEs screening coverage, but it is possible other states may follow similar paths given the increasing interest in policy action to address ACEs. Increase in stress and trauma among Americans and evidence of the disproportionate impact ACEs have on historically marginalized and disadvantaged communities has increased the urgency with which policy makers, clinicians and researchers have sought to address ACEs and encourage trauma-informed care delivery to better meet the needs of patients. Family practice and other primary care providers are at the core of prevention and are arguably the largest group of stakeholders at the forefront of movements toward increasing ACEs screenings. However, debate persists among policy makers, clinicians, and researchers on whether the ACEs screening approach improves outcomes and avoids harms. In this health policy article, we describe key issues under debate with regards to ACEs screening and estimate potential change in screening utilization and expenditures due to the new ACEs legislation in California. The lessons being learned in California are applicable to other states and the US as a whole.

This cross-sectional study examines the association of avoidance of public programs among California immigrants with delayed access to health care services and prescriptions owing to concerns about how their interaction with these services may affect their immigration status.

Little data exist on the well-being of older adults from Asian American (AA) communities.Using data from the 2018 California Health Interview Survey, we examined 2 well-being metrics among AAs and AA subgroups (Korean, Filipino, Vietnamese, Chinese) 65 years and older.AA older adults reported lower life satisfaction and not having needed social and emotional support compared with all other race/ethnicities. Current life satisfaction among AA older adults was 54% compared with 80% for all other race/ethnicities; 56% of AA older adults reported usually or always receiving social/emotional compared with 80% for all other race/ethnicities. Within the AA category, life satisfaction was 40% for Korean, 48% for Chinese, 47% for Vietnamese, and 77% for Filipino older adults. Among Korean older adults, 30% reported receiving needed social/emotional support, 57% among Chinese, 59% among Filipino, and 65% among Vietnamese older adults.

BACKGROUND Real-time, rapid assessment of barriers to care experienced by patients can be used to inform relevant health care legislation. In recent years, online communities have become a source of support for patients as well as a vehicle for discussion and collaboration among patients, clinicians, advocates, and researchers. The Breast Cancer Social Media (#BCSM) community has hosted weekly Twitter chats since 2011. Topics vary each week, and chats draw a diverse group of participants. Partnering with the #BCSM community, we used Twitter to gather data on barriers to care for patients with metastatic breast cancer and potential policy solutions. Metastatic breast cancer survival rates are low and in large part conditioned by time-sensitive access to care factors that might be improved through policy changes. OBJECTIVE This study was part of an assessment of the barriers to care for metastatic breast cancer with the goal of offering policy solutions for the legislative session in California. METHODS We provided 5 questions for a chat specific to metastatic breast cancer care barriers and potential policy solutions. These were discussed during the course of a #BCSM chat on November 18, 2019. We used Symplur (Symplur LLC) analytics to generate a transcript of tweets and a profile of participants. Responses to the questions are presented in this paper. RESULTS There were 288 tweets from 42 users, generating 2.1 million impressions during the 1-hour chat. Participants included 23 patient advocates (most of whom were patients themselves), 7 doctors, 6 researchers or academics, 3 health care providers (2 nurses, 1 clinical psychologist), and 2 advocacy organizations. Participants noted communication gaps between patient and provider especially as related to the need for individualized medication dosing to minimize side effects and maximize quality of life. Timeliness of insurance company response, for example, to authorize treatments, was also a concern. Chat participants noted that palliative care is not well integrated into metastatic breast cancer care and that insurance company denials of coverage for these services were common. Regarding financial challenges, chat participants mentioned unexpected copays, changes in insurance drug formularies that made it difficult to anticipate drug costs, and limits on the number of physical therapy visits covered by insurance. Last, on the topic of disability benefits, participants expressed frustration about how to access disability benefits. When prompted for input regarding what health system and policy changes are necessary, participants suggested a number of ideas, including expanding the availability of nurse navigation for metastatic breast cancer, developing and offering a guide for the range of treatment and support resources patients with metastatic breast cancer, and improving access to clinical trials. CONCLUSIONS Rapid assessments drawing from online community insights may be a critical source of data that can be used to ensure more responsive policy action to improve patient care.

Background Real-time, rapid assessment of barriers to care experienced by patients can be used to inform relevant health care legislation. In recent years, online communities have become a source of support for patients as well as a vehicle for discussion and collaboration among patients, clinicians, advocates, and researchers. The Breast Cancer Social Media (#BCSM) community has hosted weekly Twitter chats since 2011. Topics vary each week, and chats draw a diverse group of participants. Partnering with the #BCSM community, we used Twitter to gather data on barriers to care for patients with metastatic breast cancer and potential policy solutions. Metastatic breast cancer survival rates are low and in large part conditioned by time-sensitive access to care factors that might be improved through policy changes. Objective This study was part of an assessment of the barriers to care for metastatic breast cancer with the goal of offering policy solutions for the legislative session in California. Methods We provided 5 questions for a chat specific to metastatic breast cancer care barriers and potential policy solutions. These were discussed during the course of a #BCSM chat on November 18, 2019. We used Symplur (Symplur LLC) analytics to generate a transcript of tweets and a profile of participants. Responses to the questions are presented in this paper. Results There were 288 tweets from 42 users, generating 2.1 million impressions during the 1-hour chat. Participants included 23 patient advocates (most of whom were patients themselves), 7 doctors, 6 researchers or academics, 3 health care providers (2 nurses, 1 clinical psychologist), and 2 advocacy organizations. Participants noted communication gaps between patient and provider especially as related to the need for individualized medication dosing to minimize side effects and maximize quality of life. Timeliness of insurance company response, for example, to authorize treatments, was also a concern. Chat participants noted that palliative care is not well integrated into metastatic breast cancer care and that insurance company denials of coverage for these services were common. Regarding financial challenges, chat participants mentioned unexpected copays, changes in insurance drug formularies that made it difficult to anticipate drug costs, and limits on the number of physical therapy visits covered by insurance. Last, on the topic of disability benefits, participants expressed frustration about how to access disability benefits. When prompted for input regarding what health system and policy changes are necessary, participants suggested a number of ideas, including expanding the availability of nurse navigation for metastatic breast cancer, developing and offering a guide for the range of treatment and support resources patients with metastatic breast cancer, and improving access to clinical trials. Conclusions Rapid assessments drawing from online community insights may be a critical source of data that can be used to ensure more responsive policy action to improve patient care.

To examine whether changes in food prices are associated with changes in obesity prevalence among women in developing countries, and assess effect modification by individual socioeconomic status (SES). Longitudinal study of country-level food price inflation temporally and geographically linked to anthropometric data on non-pregnant adult women (n = 295,984) in 31 low-income and middle-income countries over the 2000–2014 time period, using separate multivariable multilevel growth models of five SES indicators. Post-estimation analysis computed the relationship between food price inflation and predicted mean probabilities of being obese, by SES. Rising food price inflation was strongly associated with women’s obesity prevalence, and SES consistently modified the relationship. Regardless of indicator used, higher food price inflation was positively associated with obesity among women in top SES categories, but was flat or negative among women in low SES categories, averaging over time. The SES differences were widest across educational strata and were most pronounced when food price inflation was highest. Overall, for every 1-unit increase in food price inflation, predicted mean obesity prevalence was between 0.02 and 0.06 percentage points greater in women of high SES compared to low SES women. There is a strong link between food price inflation and obesity in adult women in developing countries which is clearly modified by individuals’ SES. Greater food price inflation was associated with greater obesity prevalence only among women in higher SES groups, who may be net food buyers most at risk of obesity in low-income and middle-income countries.

This paper explores whether health insurance coverage or improved quality at the hospital level protect better against out-of-pocket payments. Using data from a randomized policy experiment in the Philippines, we found that interventions to expand insurance coverage and improve provider quality both had an impact on out-of-pocket payments. The sample consists of 3121 child-patient patient observations across 30 hospitals either at baseline in 2003/04 or at the follow-up in 2007/08. Compared to controls, interventions that expanded insurance and provided performance-based provider payments to improve quality both resulted in a decline in out-of-pocket spending (21% decline, p-value = 0.061; and 24% decline, p-value = 0.017, respectively). With lower out-of-pocket payments for hospital care, monthly household spending on personal hygiene rose by 0.9 (p-value = 0.026) and 0.6 US$ (p-value = 0.098) under the expanded insurance and provider payment interventions, respectively, amounting to roughly a 40–60% increase relative to the controls. With the current surge for health insurance expansion in developing countries, our study suggests paying increased and possibly, equal attention to supply-side interventions will have similar impacts with operational simplicity and greater provider accountability.

Concern is growing in the United States regarding the potential for health insurance benefit designs to discriminate against persons living with HIV as research demonstrates that such practices are occurring. A recent complaint filed against health insurers in seven states alleges that some health insurance companies have been using benefit designs that discourage enrollment of people living with HIV either by not covering essential HIV medications or by requiring cost-sharing for these prohibitively expensive medications. Legislators across the country have reacted by introducing legislation to address these growing problems. This paper describes Assembly Bill 339, legislation passed in California in 2015 and going into effect on 1 January 2017, which provides protection for people living with HIV by requiring coverage for single-tablet regimens to manage HIV while placing a cap on patient cost-sharing. Given California's size and influence, and the uncertainty of the future of the Affordable Care Act, this legislation has the potential to influence the national policy debate.

Objectives. To estimate potential impacts of California Assembly Bill (AB) 1316: a requirement for universal screening and insurance coverage for child blood lead testing. Methods. In April 2017 the California Health Benefits Review Program (Oakland, CA) analyzed AB 1316 for the California legislature, including a systematic review of lead screening effectiveness, commercial insurer surveys regarding screening coverage, and actuarial utilization and cost implication assessments. Results. Universal screening requirements would increase child lead testing by 273%, raise affected populations’ premiums by 0.0043%, and detect an additional 4777 exposed children 1 year after implementation. Conclusions. The evidence for a net societal benefit of universal screening approach is limited and is not supported by prominent medical professional groups. Public Health Implications. California expanded targeted screening to identify additional children at higher risk for lead poisoning on the basis of California-specific risk factors, while mitigating the potential harms of universal screening such as an increase in false positive tests and health care costs.

Background Should health systems invest more in access to care by expanding insurance coverage or in health care services including improving the quality of care? Comparing these options experimentally would shed light on the impact and cost-effectiveness of these strategies. Methods The Quality Improvement Demonstration Study (QIDS) was a randomized policy experiment conducted across 30 districts in the Philippines. The study had a control group and two policy intervention groups intended to improve the health of young children. The demand-side intervention in QIDS was universal health insurance coverage (UHC) for children aged 5 years or younger, and a supply-side intervention, a pay-for-performance (P4P) bonus for all providers who met pre-determined quality levels. In this paper, we compare the impacts of these policies from the QIDS experiment on childhood wasting by calculating DALYs averted per US$spent. Results The direct per capita costs to implement UHC and P4P are US$4.08 and US$1.98 higher, respectively, compared to control. DALYs due to wasting were reduced by 334,862 in UHC and 1,073,185 in P4P. When adjustments are made for the efficiency of higher quality, the DALYS averted per US$ spent is similar in the two arms, 1.56 and 1.58 for UHC and P4P, respectively. Since the P4P quality improvements touches all patients seen by qualifying providers (32% in UHC versus 100% in P4P), there is a larger reduction in DALYs. With similar programmatic costs for either intervention, in this study, each US$spent under P4P yielded 1.52 DALYs averted compared to the standard program, while UHC yielded only a 0.50 DALY reduction. Conclusion P4P had a greater impact and was more cost-effective compared to UHC as measured by DALYs averted. While expanded insurance benefit ceilings affected only those who are covered, P4P incentivizes practice quality improvement regardless of whether children are insured or uninsured.

Background : Misdiagnosis may be a significant and under-recognized quality of care problem. In birthing facilities located in anurban Philippine setting, we investigated the diagnostic accuracy for three obstetric conditions: cephalopelvic disproportion (CPD), post-partum hemorrhage (PPH), and pre-eclampsia. Design : Identical simulated cases were used to measure diagnostic accuracy for every provider ( n =103). We linked misdiagnosis – identified by the simulated cases – to obstetrical complications of the patients at the participating facilities. Patient-level data on health outcomes and costs were obtained from medical records and follow-home in-person interviews. Results : The prevalence of misdiagnosis among obstetric providers was 29.8% overall, 25% for CPD, 33% for PPH, and 31% for pre-eclampsia. Linking provider decision-making to patients, we found those who misdiagnosed the simulated cases were more likely to have patients with a complication (OR 2.96; 95% CI 1.39–3.77) compared with those who did not misdiagnose. Complicated patients were significantly less likely to be referred to a hospital immediately, were more likely to be readmitted to a hospital after delivery, had significantly higher medical costs, and lost more income than non-complicated patients. Conclusion : Diagnosis is arguably the most important task a clinician performs because it determines the subsequent course of evaluation and treatment, with the direct and indirect costs of diagnostic error, placing large financial burdens on the patient. Keywords: misdiagnosis; health outcomes; health costs; Philippines; quality of care; practice variability; obstetrics (Published: 15 December 2016) To access the supplementary material for this article, please see Supplementary files under ‘Article Tools’ Citation: Glob Health Action 2016, 9 : 32672 - http://dx.doi.org/10.3402/gha.v9.32672

Background: Poor clinical outcomes are caused by multiple factors such as disease progression, patient behavior, and structural elements of care. One other important factor that affects outcome is the quality of care delivered by a provider at the bedside. Guidelines and pathways have been developed with the promise of advancing evidence-based practice. Yet, these alone have shown mixed results or fallen short in increasing adherence to quality of care. Thus, effective, novel tools are required for sustainable practice change and raising the quality of care. Methods: The study focused on benchmarking and measuring variation and improving care quality for common types of breast cancer at four sites across the United States, using a set of 12 Clinical Performance and Value ® (CPV ® ) vignettes per site. The vignettes simulated online cases that replicate a typical visit by a patient as the tool to engage breast cancer providers and to identify and assess variation in adherence to evidence-based practice guidelines and pathways. Results: Following multiple rounds of CPV measurement, benchmarking and feedback, we found that scores had increased significantly between the baseline round and the final round (P < 0.001) overall and for all domains. By round 4 of the study, the overall score increased by 14% (P < 0.001), and the diagnosis with treatment plan domain had an increase of 12% (P < 0.001) versus baseline. Conclusion: We found that serially engaging breast cancer providers with a validated clinical practice engagement and measurement tool, the CPVs, markedly increased quality scores and adherence to clinical guidelines in the simulated patients. CPVs were able to measure differences in clinical skill improvement and detect how fast improvements were made. J Clin Med Res. 2016;8(9):633-640 doi: http://dx.doi.org/10.14740/jocmr2620w

There is recognition that social protection policies such as raising the minimum wage can favourably impact health, but little evidence links minimum wage increases to child health outcomes. We used multi-year data (2003-2012) on national minimum wages linked to individual-level data from the Demographic and Health Surveys (DHS) from 23 low- and middle-income countries (LMICs) that had least two DHS surveys to establish pre- and post-observation periods. Over a pre- and post-interval ranging from 4 to 8 years, we examined minimum wage growth and four nutritional status outcomes among children under 5 years: stunting, wasting, underweight, and anthropometric failure. Using a differences-in-differences framework with country and time-fixed effects, a 10% increase in minimum wage growth over time was associated with a 0.5 percentage point decline in stunting (-0.054, 95% CI (-0.084,-0.025)), and a 0.3 percentage point decline in failure (-0.031, 95% CI (-0.057,-0.005)). We did not observe statistically significant associations between minimum wage growth and underweight or wasting. We found similar results for the poorest households working in non-agricultural and non-professional jobs, where minimum wage growth may have the most leverage. Modest increases in minimum wage over a 4- to 8-year period might be effective in reducing child undernutrition in LMICs.

Just after dawn, Vivej arrives at the hospital with her newborn under her arm to see you. She is 21 years old, two days postpartum, and exhausted after 36 hours of protracted labor. She is worried because she cannot get her firstborn, Esmile, to breastfeed. You learn that she delivered at a birthing clinic near her home and tells you that, even after her water broke, it took more than a day before the birth attendant could deliver her son. Your examination reveals a dire clinical picture: Esmile is lethargic and hypotonic, he has a poor suck reflex, his temperature is 39.8°C, his pulse is 180, and his breathing is labored. You check his white blood count, confirming leukocytosis. A spinal tap shows pleocytosis. You start him on fluids and antibiotics for neonatal sepsis with likely meningitis and quickly turn your attention to Vivej. Her situation is easier to diagnose but no less urgent: she is febrile and tachycardic, her blood pressure is 85/50. You give her fluids and start her on antibiotics. Ultimately, despite your efforts, both mother and child die.What went wrong? This chapter looks narrowly at these situations—the critical points after access and availability (including affordability) are already accomplished, when patients are in health care facilities that are staffed and equipped with appropriate technology. These are the situations in which the inputs are brought together and it is up to the provider to improve the health of the patient. Simply put, this chapter looks at the decisions and actions of the provider when seeing a patient. It is at this critical moment when we expect the doctor or nurse, or whoever is caring for the patient, to provide the best possible care by skillfully combining the available resources and technologies with the best clinical evidence and professional judgment.Esmile and Vivej received poor-quality care at the time of delivery. Several clinical steps were not taken. The prolonged rupture of membranes was not diagnosed in a timely manner. Vivej needed either to have her labor induced or, failing that, to be referred for a cesarean section. Prophylactic antibiotics should have been administered. Just as important, the provider at the birthing center needed support and professional oversight, with guidelines, supervision, or default referral systems in place to provide a path to the best care possible. The multiple failures in this case led to puerperal and neonatal sepsis. At worst, these conditions have a fatality rate greater than one in four; at best, they lead to protracted care, recovery, and clinical expense that could have been avoided. It is possible, however, to imagine providers in a different setting, with the same physical resources, giving better care and avoiding this tragic scenario.In the next section, we answer the questions raised in this scenario and in countless clinics and hospitals around the world. How much variation is there in the quality of care? How do we measure clinical practice? How and where has quality been systematically improved and practice variation reduced? What elements of care variation can be addressed by policy and what are the costs? Most important, what can be done to elevate the care given by providers in developing country settings? Our focus, therefore, is on the steps that can be taken to optimize the quality of care for patients like Esmile in pediatrics, Vivej in obstetrics, and other patients receiving care for the clinical conditions considered throughout the nine volumes of the third edition of Disease Control Priorities (DCP3).

Improving clinical performance using measurement and payment incentives, including pay for performance (or P4P), has, so far, shown modest to no benefit on patient outcomes. Our objective was to assess the impact of a P4P programme on paediatric health outcomes in the Philippines. We used data from the Quality Improvement Demonstration Study. In this study, the P4P intervention, introduced in 2004, was randomly assigned to 10 community district hospitals, which were matched to 10 control sites. At all sites, physician quality was measured using Clinical Performance Vignettes (CPVs) among randomly selected physicians every 6 months over a 36-month period. In the hospitals randomized to the P4P intervention, physicians received bonus payments if they met qualifying scores on the CPV. We measured health outcomes 4-10 weeks after hospital discharge among children 5 years of age and under who had been hospitalized for diarrhoea and pneumonia (the two most common illnesses affecting this age cohort) and had been under the care of physicians participating in the study. Health outcomes data collection was done at baseline/pre-intervention and 2 years post-intervention on the following post-discharge outcomes: (1) age-adjusted wasting, (2) C-reactive protein in blood, (3) haemoglobin level and (4) parental assessment of child's health using general self-reported health (GSRH) measure. To evaluate changes in health outcomes in the control vs intervention sites over time (baseline vs post-intervention), we used a difference-in-difference logistic regression analysis, controlling for potential confounders. We found an improvement of 7 and 9 percentage points in GSRH and wasting over time (post-intervention vs baseline) in the intervention sites relative to the control sites (P ≤ 0.001). The results from this randomized social experiment indicate that the introduction of a performance-based incentive programme, which included measurement and feedback, led to improvements in two important child health outcomes.