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PURPOSE: To examine changes in rural and urban Veterans utilization of acute inpatient care in Veterans Health Administration (VHA) and non-VHA hospitals following access expansion from the Veterans Choice Act, which expanded eligibility for VHA-paid community hospitalization. METHODS: Using repeated cross-sectional data of VHA enrollees hospitalizations in 9 states (AZ, CA, CT, FL, LA, MA, NY, PA, and SC) between 2012 and 2017, we compared rural and urban Veterans probability of admission in VHA and non-VHA hospitals by payer over time for elective and nonelective hospitalizations using multinomial logistic regression to adjust for patient-level sociodemographic features. We also used generalized linear models to compare rural and urban Veterans travel distances to hospitals. FINDINGS: Over time, the probability of VHA-paid community hospitalization increased more for rural Veterans than urban Veterans. For elective inpatient care, rural Veterans probability of VHA-paid admission increased from 2.9% (95% CI 2.6%-3.2%) in 2012 to 6.5% (95% CI 5.8%-7.1%) in 2017. These changes were associated with a temporal trend that preceded and continued after the implementation of the Veterans Choice Act. Overall travel distances to hospitalizations were similar over time; however, the mean distance traveled decreased from 39.2 miles (95% CI 35.1-43.3) in 2012 to 32.3 miles (95% CI 30.2-34.4) in 2017 for rural Veterans receiving elective inpatient care in VHA-paid hospitals. CONCLUSIONS: Despite limited access to rural hospitals, these data demonstrate an increase in rural Veterans use of non-VHA hospitals for acute inpatient care and a small reduction in distance traveled to elective inpatient services.

BACKGROUND: While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions. METHODS: To understand barriers to ambulatory care access for patients with Medi-Cal (Californias Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal. RESULTS: Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation. CONCLUSIONS: Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.

OBJECTIVES: (1) Assess and compare the perceptions of pet owners and veterinary professionals pertaining to the extent of veterinary workforce and access to care challenges in 2023 in Colorado, and (2) Assess what programs, policies, and resources veterinary professionals and pet owners believe would be most effective at addressing access to care and workforce challenges in Colorado. SAMPLE: 736 veterinarians, veterinary technicians, or practice/owner manager (veterinary professionals) in Colorado. A total of 1,209 pet owners (919 from an online survey and 290 from in-person surveying). PROCEDURES: Distribution of an online anonymous survey to veterinary professionals in Colorado. Pet owners were surveyed both online and in-person at pet pantry or shelter events. RESULTS: Veterinary professionals reported significant workforce challenges, including having to frequently divert clients, clients forced to decline medical care or having to euthanize their pets due to cost. Veterinary professionals were especially supportive of policy efforts to enhance recruitment and retention of technicians, including through mechanisms such as clarifying their scope of practice, loan repayment programs, and enhancing career pathways. Colorado pet owners responses pertaining to the scope of access to care challenges were similar to prior national research. Pet owners reported particularly needing low-cost emergency clinics in their community as well as resources to reduce the cost of care. Pet owners were generally supportive of expanding veterinary care access through telemedicine; indicating they would feel comfortable seeing a veterinarian via telemedicine, even for the first time, and that expanded use of telemedicine would increase their ability to obtain care. CONCLUSIONS AND CLINICAL RELEVANCE: Colorado pet owners and veterinary professionals both identified numerous access to care challenges as well as indicated support for the development of several potential initiatives to address the problem. Low-cost clinics that provide sick and emergency care was the resource rated as being most helpful among pet owners. Further exploration of grants, voucher programs, expansion of telemedicine, increased utilization and title protection for CVTs, and the creation of the veterinary professional associate position are all initiatives that were noted to be worthy of further exploration.

The primary aim is to assess the implementation of an eight-session, group therapy pilot for Black and Latina transgender women in Chicago in terms of implementation outcomes regarding intervention effectiveness, acceptability, appropriateness, and feasibility. The Exploration Preparation Implementation Sustainment (EPIS) framework guided implementation processes, including community engagement as an implementation strategy, and an implementation taxonomy was used to evaluate outcomes of acceptability, appropriateness, and feasibility, in addition to intervention effectiveness regarding anxiety and community connectedness. Two rounds of the pilot were completed in 2020, during the COVID-19 pandemic, at a community-based organization serving LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning) youth on Chicago's West Side. Participants (N = 14) completed a baseline and postintervention assessment and evaluations after each of eight intervention modules. Descriptive statistics show improvement across measures of anxiety and community connectedness, and high mean scores across domains of acceptability, appropriateness, and feasibility. Pilot findings indicate intervention effectiveness, acceptability, appropriateness, and feasibility to address mental health and social support of Black and Latina transgender women. Additional resources are needed for transgender community-engaged mental health programs and research to establish core and adaptable intervention elements, scaled-up evidence for clinical effectiveness, and, most importantly, to improve mental health outcomes and the sustainability of such interventions. [ABSTRACT FROM AUTHOR]

South Asians form Canada's largest visible minority but face notable health inequities. Specifically, South Asian immigrant youth (SAIY) confront challenges like racial discrimination, stigma, and acculturative stress due to their marginalised identities. Limited research exists on the barriers they face adjusting to Canadian life. We interviewed two groups: SAIY aged 15–24 (N = 23) and unrelated parents of SAIY (N = 13). Analysing both generations helped capture young SAIY's challenges and parental insights. Our findings underscore the varied experiences of SAIY in Edmonton, Alberta, highlighting the need for better accessibility to social and healthcare services. This study offers a foundation for future research on SAIY's needs. [ABSTRACT FROM AUTHOR]

Most stroke survivors have ongoing deficits and report unmet needs. Despite evidence that rehabilitation improves stroke survivors' function, access to occupational and physical therapy is limited. Describing access to care for disadvantaged communities for different levels of stroke severity will provide proportions used to create Markov economic models to demonstrate the value of rehabilitation. The objective of this study was to explore differences in the frequency of rehabilitation evaluations via outpatient therapy and home health for Medicare Part B ischemic stroke survivors in rural and socially disadvantaged locations. We completed a retrospective, descriptive cohort analysis using the 2018 and 2019 5% Medicare Limited Data Sets (LDS) from the Centers for Medicare and Medicaid Services using STROBE guidelines for observational studies. We extracted rehabilitation Current Procedural Terminology (CPT) codes for those who received occupational or physical therapy to examine differences in therapy evaluations for rural and socially disadvantaged populations. Of the 9,076 stroke survivors in this cohort, 44.2% did not receive any home health or outpatient therapy. Of these, 64.7% had a moderate or severe stroke, indicating an unmet need for therapy. Only 2.0% of stroke survivors received outpatient occupational therapy within the first year Rural and socially disadvantaged communities accessed rehabilitation evaluations at lower rates than general stroke survivors. These findings describe the poor access to home health and outpatient rehabilitation for stroke survivors, particularly in traditionally underserved populations. These results will influence future economic evaluations of interventions aimed at improving access to care. [ABSTRACT FROM AUTHOR]

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: Behavioral and mental health conditions present significant challenges in the United States where access to care is limited. Family medicine physicians play a crucial role in addressing these challenges, often serving as frontline clinicians for behavioral and mental health conditions. Methods: This study examined the current behavioral and mental health system in a predominantly rural 10-county region in the Southeastern United States through gap analysis in addition to a survey of preparedness and barriers among family medicine physicians in the region. Results: Gap analysis results indicated that (1) stigma and lack of accessible education about behavioral and mental health, (2) fragmented resources, (3) inaccessible care, and (4) workforce shortage and burnout were primary drivers of poor outcomes in the region. Survey results indicated that physicians feel prepared to treat anxiety and depression but feel less prepared to manage bipolar disorder, schizophrenia, and substance use disorders. Respondents disagreed that there are adequate local resources and referral options for patients with behavioral and mental health conditions. Lack of timely access, distance, cost/insurance status, were all cited by respondents as barriers to appropriate care. Conclusion and Recommendations: Findings underscore the importance of supporting family medicine physicians to enhance behavioral and mental healthcare outcomes. Behavioral health integration in primary care settings is a promising strategy to improve care accessibility and clinician preparedness. Bridging gaps in health care outcomes requires collaborative efforts, enhanced training, and policy advocacy within the family medicine community to ensure comprehensive and equitable behavioral and mental healthcare delivery. [ABSTRACT FROM AUTHOR]

Background: The Dixon-Woods et al. Candidacy Framework, a valuable tool since its 2006 introduction, has been widely utilized to analyze access to various services in diverse contexts, including healthcare. This social constructionist approach examines micro, meso, and macro influences on access, offering concrete explanations for access challenges rooted in socially patterned influences. This study employed the Candidacy Framework to explore the experiences of individuals living with rheumatoid arthritis (RA) and their formal care providers. The investigation extended to assessing supports and innovations in RA diagnosis and management, particularly in primary care. Methods: This systematic review is a Critical Interpretive Synthesis (CIS) of qualitative and mixed methods literature. The CIS aimed to generate theory from identified constructs across the reviewed literature. The study found alignment between the seven dimensions of the Candidacy Framework and key themes emerging from the data. Notably absent from the framework was an eighth dimension, identified as the "embodied relational self." This dimension, central to the model, prompted the proposal of a revised framework specific to healthcare for chronic conditions. Results: The CIS revealed that the eight dimensions, including the embodied relational self, provided a comprehensive understanding of the experiences and perspectives of individuals with RA and their care providers. The proposed Candidacy 2.0 (Chronic Condition (CC)) model demonstrated how integrating approaches like Intersectionality, concordance, and recursivity enhanced the framework when the embodied self was central. Conclusions: The study concludes that while the original Candidacy Framework serves as a robust foundation, a revised version, Candidacy 2.0 (CC), is warranted for chronic conditions. The addition of the embodied relational self dimension enriches the model, accommodating the complexities of accessing healthcare for chronic conditions. Trial Registration: This study did not involve a health care intervention on human participants, and as such, trial registration is not applicable. However, our review is registered with the Open Science Framework at https://doi.org/10.17605/OSF.IO/ASX5C. [ABSTRACT FROM AUTHOR]

AbstractIntroductionMethodsResultsConclusionTransgender and gender diverse (TGD) people are disproportionately negatively impacted by gaps in several social determinants of health (SDH) domains.Using an SDH lens, this commentary leverages and reflects upon the expertise and experience of practitioners in the largest adult gender identity clinic in Canada providing services to TGD patients by facilitating access to gender-affirming healthcare.Perceived needs across SDH domains, efforts to address these needs, and recommendations for improving services and increasing access for TGD patients are shared.We argue that addressing SDH needs is a necessary and critical component of both comprehensive primary and mental healthcare for TGD individuals in particular, given the inequity many of them face across SDH domains. [ABSTRACT FROM AUTHOR]

Introduction/Objectives: Exposure to adverse social determinants of health (SDoH) in childhood is associated with poorer long-term health outcomes. Within structurally marginalized populations, there are disproportionately high rates of developmentally vulnerable children. The RICHER (Responsive, Intersectoral, Child and Community Health, Education and Research) social pediatric model was designed to increase access to care in marginalized neighborhoods. The purpose of this study was to describe the children and youth engaged with the RICHER model of service and characterize the needs of the population. Methods: A retrospective chart review was conducted on children and youth who accessed primary care services through the program between January 1, 2018 and April 30, 2021. Basic descriptive data analysis was done using Stata v15.1. Results: A total of 210 charts were reviewed. The mean age in years at initial assessment was 6.32. Patients most commonly identified their race/ethnicity as Indigenous (33%) and 15% were recent newcomers to Canada. Evidence of at least 1 adverse SDoH was noted in 41% of charts; the most common included material poverty (34%), food insecurity (11%), and child welfare involvement (20%). The median number of diagnoses per patient was 4. The most frequently documented diagnoses were neurodevelopmental disorders (50%) including developmental delay (39%), ADHD (32%), and learning disability (26%). The program referred 72% of patients to general pediatricians and/or other subspecialists; 34% were referred for tertiary neuropsychological assessments and 35% for mental health services. Conclusions: Our data suggests that this low-barrier, place-based primary care RICHER model was able to reach a medically, developmentally, and socially complex population living in disenfranchised urban neighborhoods. Half of the patients identified in our review had neurodevelopmental concerns and a third had mental health concerns, in contrast to an estimated 17% prevalence for mental health, behavioral, or developmental disorders in North American general pediatric aged populations. This highlights the impact adverse SDoH can have on child health and the importance of working with community partners to identify developmentally vulnerable children and support place-based programs in connecting with children who may be missed, overlooked, or disadvantaged through traditional models of care. [ABSTRACT FROM AUTHOR]

Patients living with multiple myeloma (MM) have a substantial disease burden and face multiple barriers to care. Building upon our previous research using mixed methods, this focus group research aimed to identify patients' priorities regarding specific social and identity-related needs, map these prioritized needs to the disease journey, and describe patient-generated ideas to improve patient support. Participants noted that patients with MM need a range of emotional, social, and financial support throughout the disease journey. They identified initial MM diagnosis and treatment adherence as two critical points in the MM journey where patients need the most support and assistance. The findings of this research suggest that overall, patients with MM need comprehensive support, ideally from a multidisciplinary team consisting of health care providers, patient advocates, social workers, and psychologists to help patients understand their disease and treatment options, make informed treatment decisions, adhere to treatment, and ultimately reduce their disease burden and improve outcomes. This research revealed that patients with MM need varying types and levels of support, with the most common needs including information on disease and treatment, connections to financial resources and support systems, assistance with navigating insurance options, and transportation and logistical support for medical appointments. [ABSTRACT FROM AUTHOR]

Background: Many studies have described barriers to gender-affirming surgery (GAS) in Canada; however, few have explored why these barriers persist. To address this knowledge gap, we sought to describe documents related to public health insurance (Medicare) for GAS to identify the types of procedures covered, variations in coverage across provinces and territories, and changes in policy over time. Methods: We conducted a descriptive cross-sectional study using an environmental scan approach. We queried 23 government websites, the Google search engine, and an online legal database between July 2022 and April 2024 to gather gray literature documents related to GAS and Medicare. Variables from relevant documents were compiled to create a present, at-glance overview of GAS Medicare coverage for all provinces and territories and a timeline of policy changes across Canada. Results: Eight provinces and three territories had documents or websites related to GAS Medicare coverage (85%). We identified 15 GAS procedures that were covered variably across Canada. Yukon (n = 14) covered the most types of GAS, while Quebec and Saskatchewan covered the least (n = 6). Mastectomy and genital surgeries were covered across Canada, but other GAS were rarely covered. Five provinces and territories provided coverage for travel-related costs. Our GAS Medicare timeline showed differential expansion of GAS coverage in Canada over the last 25 years. Conclusions : We provide previously unreported information regarding GAS Medicare coverage in Canada. We hope our findings will help patients and healthcare providers navigate a complicated public healthcare system. We also highlight barriers within GAS Medicare documents and make recommendations to alleviate those barriers. [ABSTRACT FROM AUTHOR]

Introduction: To assess differences in the diagnosis journey and access to care in a large sample of patients with axial spondyloarthritis (axSpA) from around the world, included in the International Map of Axial Spondyloarthritis (IMAS). Methods: IMAS was a cross-sectional online survey (2017–2022) of 5557 unselected patients with axSpA from 27 countries. Across five worldwide geographic regions, the patient journey until diagnosis and healthcare utilization in the last 12 months prior to survey were evaluated. Univariable and multivariable linear regression was used to analyze factors associated with higher healthcare utilization. Results: Of 5557 participants in IMAS, the diagnosis took an average of 7.4 years, requiring more than two visits to HCPs (77.7% general practitioner and 51.3% rheumatologist), and more than two diagnostic tests [67.5% performed human leukocyte antigen B27 (HLA-B27), 64.2% x-ray, and 59.1% magnetic resonance imaging (MRI) scans]. North America and Europe were the regions with the highest number of healthcare professional (HCP) visits for diagnosis, while the lowest number of visits was in the Asian region. In the previous 12 months, 94.9% (n = 5272) used at least one healthcare resource, with an average of 29 uses per year. The regions with the highest healthcare utilization were Latin America, Europe, and North America. In the multiple linear regression, factors associated with higher number of healthcare utilization were younger age (b = – 0.311), female gender (b = 7.736), higher disease activity (b = 1.461), poorer mental health (b = 0.624), greater functional limitation (b = 0.300), greater spinal stiffness (b = 1.527), and longer diagnostic delay (b = 0.104). Conclusion: The diagnosis of axSpA usually takes more than two visits to HCPs and at least 7 years. After diagnosis, axSpA is associated with frequent healthcare resource use. Younger age, female gender, higher disease activity, poorer mental health, greater functional limitation, greater spinal stiffness, and longer diagnostic delay are associated with higher healthcare utilization. Europe and North America use more HCP visits and diagnostic tests before and after diagnosis than the other regions. [ABSTRACT FROM AUTHOR]

Enhancing access to healthcare remains a formidable challenge in rural regions of low- and lower-middle-income countries. Amid evolving healthcare challenges, telerheumatology provides opportunities to bridge gaps and expand access to rheumatology care, particularly in remote areas. We describe a pilot telerheumatology program and its cost-, time-, and travel-saving potential in a remote rural setting in northern Pakistan. The telerheumatology program commenced at the Pakistan Institute of Medical Sciences Islamabad, providing services through video consultations to a basic health unit in the Gilgit-Baltistan region. Patients visiting from the Gilgit-Baltistan region willing to participate were recruited in the program. Demographics and logistical metrics were recorded in a dedicated registry. A total of 533 consultations were carried out from April 2022 to April 2023. The majority of the patients were female (318/533, 59.7%). The median age of patients was 50 ± 15.7 years. The average wait time for consultation was 20 ± 13 min. The average travel time to reach telecentre was 59 ± 53 min. The average travel cost to reach telecentre was 379 ± 780 PKR (1.85 ± 3.81 USD). The average duration of consultation was 15 ± 5 min. The most common diagnosis for consultation was knee osteoarthritis (237, 44.5%), chronic low back pain (118, 22.1%), and rheumatoid arthritis (42, 7.9%). On average, patients saved 787 ± 29 km of distance, 15 ± 1 h of traveling, and 6702 ± 535 PKR (33 ± 3 USD) that would have been required to travel to our tertiary care hospital. Telerheumatology substantially reduced travel time, distance, and cost for patients. It has the potential to deliver outpatient rheumatology consultation in an economically efficient manner, effectively breaking geographical barriers and expanding access to essential services for patients in remote areas. [ABSTRACT FROM AUTHOR]

Objective: The objective was to measure specialty provider networks in Medicare Advantage (MA) and examine associations with market factors. Data Sources and Study Setting: We relied on traditional Medicare (TM) and MA prescription drug event data from 2011 to 2017 for all Medicare beneficiaries in the United States as well as data from the Area Health Resources File. Study Design: Relying on a recently developed and validated prediction model, we calculated the provider network restrictiveness of MA contracts for nine high‐prescribing specialties. We characterized network restrictiveness through an observed‐to‐expected ratio, calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based on the prediction model. We assessed the relationship between network restrictiveness and market factors across specialties with multivariable linear regression. Data Collection/Extraction Methods: Prescription drug event data for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017. Principal Findings: Provider networks in MA varied in restrictiveness. OB‐Gynecology was the most restrictive with enrollees seeing 34.5% (95% CI: 34.3%–34.7%) as many providers as they would absent network restrictions; cardiology was the least restrictive with enrollees seeing 58.6% (95% CI: 58.4%–58.8%) as many providers as they otherwise would. Factors associated with less restrictive networks included the county‐level TM average hierarchical condition category score (0.06; 95% CI: 0.04–0.07), the county‐level number of doctors per 1000 population (0.04; 95% CI: 0.02–0.05), the natural log of local median household income (0.03; 95% CI: 0.007–0.05), and the parent company's market share in the county (0.16; 95% CI: 0.13–0.18). Rurality was a major predictor of more restrictive networks (−0.28; 95% CI: −0.32 to −0.24). Conclusions: Our findings suggest that rural beneficiaries may face disproportionately reduced access in these networks and that efforts to improve access should vary by specialty. [ABSTRACT FROM AUTHOR]

Objective To determine if patients with chronic migraine continue onabotulinumtoxinA (onabotA) long-term. Methods We performed a retrospective cohort analysis using aggregated, de-identified patient data from the Stanford Headache Center. We included patients in California who received at least one prescription for onabotA during the years of 2011–2021. The primary outcome was the number of onabotA treatments each patient received. Secondary outcomes included sex, age, race, ethnicity, body mass index (BMI), distance to the treatment facility, and zip code income quartile. Results A total of 1551 patients received a mean of 7.60 ± 7.26 treatments and a median of 5 treatments, with 16.2% of patients receiving only one treatment and 10.6% receiving at least 19. Time-to-event survival analysis suggested 26.0% of patients would complete at least 29 treatments if able. Younger age and female sex were associated with statistically significant differences between quartile groups of number of onabotA treatments (P  = .007, P  = .015). BMI, distance to treatment facility, and zip code income quartile were not statistically significantly different between quartile groups (P  > .500 for all). Prescriptions of both triptans and non-onabotA preventive medications showed a statistically significant increase with each higher quartile of number of onabotA treatments (P  < .001; P  < .001). Discussion We show long-term persistence to onabotA is high and that distance to treatment facility and income are not factors in continuation. Our work also demonstrates that as patients continue onabotA over time, there may be an increased need for adjunctive or alternative treatments. [ABSTRACT FROM AUTHOR]

Objective: Research points to disparities in disease burden and access to medical care in epilepsy. We studied the association between socioeconomic status (SES) and antiseizure medication (ASM) use in pregnancies with maternal epilepsy. Methods: We conducted a cross‐sectional study consisting of 21 130 pregnancies with maternal epilepsy identified from Nordic registers during 2006–2017. SES indicators included cohabitation status, migrant background, educational attainment, and household income. Main outcomes were the proportion and patterns of ASM use from 90 days before pregnancy to birth. We applied multiple imputation to handle SES variables with 2%–4% missingness. We estimated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) using modified Poisson regression with the highest SES category as reference. Results: Mothers with the highest education and the highest income quintile used ASMs least frequently (56% and 53%, respectively). We observed increased risks of ASM discontinuation prior to or during the first trimester for low SES. The risk estimates varied depending on the SES indicator from aRR = 1.27 for low income (95% CI: 1.03–1.57) to aRR = 1.66 for low education (95% CI: 1.30–2.13). Migrant background was associated with ASM initiation after the first trimester (aRR 2.17; 95% CI 1.88–2.52). Low education was associated with the use of valproate during pregnancy in monotherapy (aRR 1.70; 95% CI 1.29–2.24) and in polytherapy (aRR 2.65; 95% CI 1.66–4.21). Low education was also associated with a 37% to 39% increased risk of switching from one ASM to another depending on the ASM used. For the other SES indicators, aRRs of switching varied from 1.16 (foreign origin; 95% CI 1.08–1.26) to 1.26 (not married or cohabiting; 95% CI 1.17–1.36). Significance: Low SES was associated with riskier patterns of ASM use: discontinuation, late initiation, and switching during pregnancy. These findings may reflect unplanned pregnancies, disparities in access to preconception counseling, and suboptimal care. [ABSTRACT FROM AUTHOR]

Background: Patients requiring admission to the general medicine wards in a public hospital are usually assessed by a medical registrar. This study is based at a metropolitan public hospital in Melbourne where the majority of general medicine patients in the emergency department (ED) are not seen by a consultant physician until they are transferred to the ward. Aims: To assess the impact of general medicine consultant‐led ward rounds (CWRs) in the ED on patient length of stay (LOS). Methods: One‐month audit was conducted of all patients admitted to general medicine and awaiting transfer to ward from ED at a metropolitan public hospital in Melbourne. A general medicine CWR was then implemented in the ED, followed by another 1‐month audit, with the primary outcome being LOS and the secondary outcome being 30‐day readmission rate. Additionally, admitting medical registrars were invited to complete a survey before and after the implementation of CWRs to assess satisfaction rate. Results: Data from electronic medical records were analysed for 162 patients (90 preimplementation group and 72 postimplementation group). The median LOS was 6 days in the preimplementation group and 4 days in the postimplementation group (P = 0.014). There was no significant difference in 30‐day readmission rates. Surveys showed admitting medical registrars reported a reduced level of stress and fewer barriers to seeking consultant input following implementation. Conclusions: A CWR in the ED has led to decreased LOS for general medicine patients and improved satisfaction among junior medical staff. [ABSTRACT FROM AUTHOR]

Refugees experience elevated rates of mental health problems, but little is known about mental health service utilization and quality among asylum seekers and refugees in Europe. In a 12‐month follow‐up study of newly arrived refugees (N = 166, Mage = 32.38 years, 30.7% female) and a nationwide cross‐sectional study (N = 579, Mage = 33.89 years, 36.2% female) of refugees who had been living in Germany for an average of 6 years, we examined objective need for mental health treatment, perceived need, access to treatment services, and adequacy of treatment. We defined minimally adequate mental health treatment according to the WHO World Mental Health Survey as ≥8 sessions of psychotherapy (minimally adequate psychotherapy) or pharmacotherapy plus ≥4 medical visits (minimally adequate pharmacotherapy). In both studies, two in three individuals screened for mental health symptoms and additionally perceived a need for professional treatment. Of those, less than half had contact to any service provider, with only 1 in 14 receiving minimally adequate psychotherapy. Overall, no more than one in seven of refugees in need received minimally adequate treatment. Despite a comprehensive mental health‐care system, refugees' access to mental health care and the treatment provided are inadequate. Health policies are urgently needed to provide equitable mental health care for all. [ABSTRACT FROM AUTHOR]

Objectives: To examine physical therapist awareness and utilization of imaging referral privileges in the United States (US) and how it relates to direct access frequency. Methods: This study utilized survey data collected in 2020–2021 from US physical therapists. Subjects were asked about imaging referral jurisdictional authority in their state. Responses were analyzed for accuracy and compared to the level of jurisdictional authority and its impact on imaging referral. Analysis of imaging skills performance and imaging referral practices were compared to direct access frequency. Results: Only 42.0% of physical therapists practicing in states that allow imaging referral were aware of this privilege. Those practicing where imaging referral was allowed via state legislation were significantly more likely (p < 0.01) to be aware of this privilege (71.4%) compared to those granted by the state board (25.2%). Those aware of their imaging referral scope were more likely (p < 0.01) to practice imaging referral (44.5%) compared to those who were unaware (3.2%). Direct access frequency was positively associated with imaging skill performance and imaging referral practice (p < 0.01). Doctors of Physical Therapy, residency/fellowship-trained physical therapists, and board-certified physical therapists all reported practicing greater frequency of direct access (p < 0.01). Discussion/Conclusion: There is a striking lack of awareness of imaging privileges among physical therapists as influenced by the level of jurisdictional scope. These results suggest that the lack of awareness may have a dampening effect on diagnostic imaging referrals. The American Physical Therapy Association should consider engaging with state boards to raise imaging privilege awareness. [ABSTRACT FROM AUTHOR]

Background Rainbow young people (RYP; people of diverse genders, sexualities, and variations in sex characteristics) face barriers accessing primary care, often report negative experiences and the need to educate clinicians on rainbow-specific issues. This study explores general practice staff views and experiences of providing care to RYP. Methods Three focus groups were held with staff from 5 general practices in an urban area of Aotearoa New Zealand (25 participants in total). Practices were purposively selected to include some known to be more "rainbow-friendly" seeing larger numbers of RYP and some with no particular focus on RYP. All members of each practice were invited to participate, including administration and reception staff. Focus groups were audio-recorded, transcribed, and analysed in NVivo using inductive thematic analysis. Results Four main themes were identified: (i) Practice experience, (ii) Feeling awkward, (iii) Knowledge and training, and (iv) Structural barriers. Differences were apparent in health provider knowledge, comfort, and experience in providing care to RYP. Participants identified a lack of knowledge and training and wanted more resources and education. Systems limitations were common (e.g. with IT systems for recording gender) and often contributed to awkward clinical encounters. Conclusions Participants recognized shortcomings in their training, knowledge, and level of confidence providing care to RYP and expressed a desire to improve their competency. Further work is needed to identify and trial practical strategies that help improve communication skills, knowledge, and the delivery of more equitable healthcare to RYP. [ABSTRACT FROM AUTHOR]

Travel time to a patient's medical provider represents a significant component of access to care. We examined travel time to the nearest uveitis specialist for the American population and characterize its impact on access to uveitis care. Observational studies using the American Community Survey and American Census Bureau population estimates. Addresses of fellowship-trained uveitis specialists were collected from the American Uveitis Society (AUS) and the Ocular Immunology and Uveitis Foundation (OIUF) websites and geocoded using ArcGIS Pro 2.9. Service areas were defined as all locations within a 60-min drive time from each specialist's location. Demographic and population data for total population, racial groups, household poverty levels, population in dependent groups (younger than 18, older than 65), and health insurance status were overlaid. Data were aggregated for census tracts within and outside service areas and compared using chi-square analysis. Main Outcome Measures: Differences in population demographics for people within and outside service area coverage. 223 uveitis specialist addresses were geocoded into ArcGIS. Of specialist locations, 94% were found in urban areas. Of the total United States population, 63.3% were found to be within service areas. Of these, 55.9% were White and 14.7% were African American, whereas 70% of the people outside service areas were White and 10.1% were African American (p < 0.0001) (Table 1). Only 8.3% of the people within service area coverage had no health insurance compared with 9.5% outside service areas (p < 0.0001). Within coverage areas, 12.7% of the households had a total income below the federal poverty level versus 15.1% of the households outside service area coverage (p < 0.0001). Within service area coverage, 37.4% of the people were in a dependent age group compared with 40.4.% outside service area coverage (p < 0.0001). Our analysis shows a significant travel burden to the nearest uveitis specialist for a large proportion of Americans. More providers are needed in rural areas, as patients there are more likely to live under the poverty line, be uninsured, or belong to a dependent age group. [ABSTRACT FROM AUTHOR]

This study aimed to investigate access to care and financial considerations associated with the endodontic treatment of immature permanent teeth. Surveys were distributed to endodontists (n = 2,457) and pediatric dentists (n = 3,974) in the United States. Data were analyzed using X2 analysis and logistic regression. The level of significance was set to 0.05. The response rate was 13% (n = 840). Respondent specialist groups were similar by age and years since specialty residency completion, but significantly different with regard to primary practice setting (eg private practice, Federally Qualified Health Center, hospital), (P =.001). The majority (91%) of respondents reported participation with dental insurance. Pediatric dentists (69%) were significantly more likely than endodontists (17%) to participate with public-payer dental insurance (P <.001). The majority of respondents (82%) indicated that patients reported economic factors (time or money) as a barrier to accessing endodontic treatment. Pediatric dentists were significantly more likely to consider economic factors when planning for treatment (P <.001). Pediatric dentists were more likely than endodontists to have the opinion that endodontic procedures for treatment of necrotic immature permanent teeth should cost less than root canal therapy (apexification, P <.001; regenerative endodontic procedures, P =.002). Pediatric dentists (33%) reported encountering barriers when attempting to refer their patients to an endodontist. Inability to find an endodontist that participates with dental insurance was the most frequently cited barrier. Limited clinician participation with dental insurance and gaps in insurance coverage for endodontic procedures appear to contribute to access to care barriers for pediatric patients. [ABSTRACT FROM AUTHOR]

The United States grapples with over 30,000 new HIV infections annually, a challenge exacerbated by delayed diagnosis and treatment. HIV stigma hinders data collection and contributes to health disparities. High-quality data and a community-driven approach are critical to reducing these disparities. The collaborative effort of the Satcher Health Leadership Institute at Morehouse School of Medicine, and the Center for Minority Health and Health Disparities Research and Education at Xavier University of Louisiana, addresses systemic barriers perpetuating the HIV epidemic in Georgia and Louisiana. We influence policy, implement an HIV education curriculum, map resources, and display data via the Health Equity Tracker. Stigma surrounding HIV/AIDS impedes disclosure, creates data gaps, and affects care quality and access. Addressing these data gaps, influencing policy, and implementing education are crucial steps to improving outcomes for Black people living with HIV/AIDS. This framework aligns with the federal Ending the HIV Epidemic program's goals, advancing health equity for vulnerable populations. [ABSTRACT FROM AUTHOR]

Objective: Ample literature shows voice and swallowing therapy, in‐person or virtual, to be essential for Otolaryngology and Speech‐Language Pathology care. In March 2023, Medicare announced discontinuing teletherapy reimbursement in hospital‐based outpatient departments, effective May 2023. This decision was subsequently reversed; however, the uncertain interval period provided the opportunity to study the impact of eliminating teletherapy. Study Design: Prospective cohort. Setting: Tertiary laryngology center. Methods: Affected Medicare patients were contacted via mailed letter, phone, and secure patient portal and offered to change appointments to in‐person, teletherapy with cash self‐payment ($165‐282/session) or cancellation. Demographics and responses were collected. Statistical analyses conducted using Student's t test. Results: Fifty‐three patients (28 female; mean age 66.8 ± 14.2 years) were impacted. 64% (n = 34) changed to in‐person appointment, 28% (n = 15) canceled, 8% (n = 4) did not respond. No patients opted to self‐pay. 67% of patients that canceled telehealth care cited distance from in‐person care location. The mean distance for canceled versus rescheduled patients was 92.3 ± 93.0 versus 32.8 ± 57.4 miles, P =.034. Mean age, gender, and number of sessions were not different between groups. Mean time to third next available therapy appointment was 96 ± 46 versus 46 ± 12 days before and after rule change, P =.007. Upon Medicare's reversal, this trend rebounded to nearly baseline (mean 77 ± 12 days, P =.12). Conclusion: Medicare's discontinuation of reimbursement for teletherapy services caused nearly 30% of patients to cancel voice and swallowing therapy, primarily due to distance. These cancellations led to decreased access to care for Medicare patients with voice/swallowing diagnoses, which affect function, quality of life, and potentially even mortality risk. [ABSTRACT FROM AUTHOR]

Prior to the 2014 Affordable Care Act (ACA) expansion, 37% of young adults ages 19–25 in the United States were low‐income and a third lacked health insurance coverage—both the highest rates for any age group in the population. The ACA's Medicaid eligibility expansion, therefore, would have been significantly beneficial to low‐income young adults. This study evaluates the effect of the ACA Medicaid expansion on the health, health care access and utilization, and financial well‐being of low‐income young adults ages 19–25. Using 2010–2017 National Health Interview Survey data, I estimate policy effects by applying a difference‐in‐differences design leveraging the variation in state implementation of the expansion policy. I show that Medicaid expansion improved health insurance coverage, health care access, and financial well‐being for low‐income young adults in expansion states, but had no effect on their health status and health care utilization. I also find that the policy was associated with larger gains in health coverage for racial minorities relative to their Non‐Hispanic White counterparts. With the continued health policy reform debates at the state and federal levels, the empirical evidence from this study can help inform policy decisions that aim to improve health care access and utilization among disadvantaged groups. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Psoriasis significantly burdens patients' lives, but there is limited data on this in Brazil.Between May 2022 and January 2023, we conducted a cross‐sectional online survey of 563 Brazilian residents aged ≥18 years who had been diagnosed with psoriasis. Spearman's correlation (r) was used to test the correlation between self‐assessed disease severity (Simplified Psoriasis Index [saSPI] extent score; range 0 [clear/minor] to 40 [widespread/severe]) and health‐related quality of life (QoL, score of 1 means perfect health) and capability (ICECAP‐A: score of 1 means full capability) measures. Multivariable linear regression was used to identify predictors of QoL and capability. A thematic analysis examined the free‐text responses and identified common themes.The mean age of participants was 42.1 ± 12.4 years, and over half had at least one other long‐term condition. The mean QoL score was 0.59 ± 0.25, and the mean capability score was 0.71 ± 0.21. At the time of survey completion, over 80% of respondents reported some level of pain and/or discomfort, and 86% reported feeling anxious and/or depressed. The mean self‐assessed saSPI was 7.8 ± 8.6, which negatively correlated with health‐related QoL (r = −0.49, P < 0.05) and capability (r = −0.44, P < 0.05). Significant predictors of poorer QoL and reduced capability included high saSPI, number of psoriasis flares and comorbidities, female gender, Black ethnicity, and employment status (unemployed, long‐term sick). Frequently reported areas that impacted patients were social stigma/prejudice, powerlessness, lack of education and public awareness, and difficulty obtaining appropriate care/treatment.We found that the clinical manifestations, severity, and associated comorbidities of psoriasis negatively impacted health‐related QoL and capability, along with feelings of stigmatization and barriers to specialist treatment. This highlights the need for better access to care and awareness of the disease to improve the lives of people living with psoriasis in Brazil. [ABSTRACT FROM AUTHOR]

Benralizumab, a monoclonal antibody targeting IL-5 receptors, reduces exacerbations and oral corticosteroid requirements for severe, uncontrolled eosinophilic asthma. In Japan, geographic disparities in asthma outcomes suggest differential prescribing and access. This study aimed to quantify regional prescribing variations for benralizumab nationwide. Using Japan's National Database (NDB) of insurance claims (2009–2019), benralizumab standardized claim ratios (SCRs) were calculated for 47 prefectures. Correlations between SCRs and other biologics' SCRs, economic variables like average income, and physician densities were evaluated through univariate analysis and multivariate regressions. Income-related barriers to optimal prescribing were examined. Wide variation emerged in benralizumab SCRs, from 40.1 to 184.2 across prefectures. SCRs strongly correlated with omalizumab (r = 0.61, p < 0.00001) and mepolizumab (r = 0.43, p = 0.0024). Average monthly income also positively correlated with benralizumab SCRs (r = 0.45, p = 0.0016), whereas lifestyle factors were insignificant. Respiratory specialist density modestly correlated with SCRs (r = 0.29, p = 0.047). In multivariate regressions, average income remained the most robust predictor (B = 0.74, p = 0.022). Benralizumab SCRs strongly associate with income metrics more than healthcare infrastructure/population factors. Many regions show low SCRs, constituting apparent prescribing gaps. Access barriers for advanced asthma therapies remain inequitable among Japan's income strata. Addressing affordability alongside specialist allocation can achieve better prescribing quality and asthma outcomes. [ABSTRACT FROM AUTHOR]

Objective. To describe and analyze the decision to seek public health services between 2006 and 2023. Materials and methods. We used data from the 2006, 2012, 2018, and 2020-2023 National Health and Nutrition Surveys (Ensanut, by its acronym in Spanish) as well as historical data from public and private health units, adjusted by population. Results. While the increase in Seguro Popular affiliation between 2006 and 2012 was not accompanied by an increase in the decision to seek care or in the use of public services, the expansion of offices adjacent to pharmacies between 2012 and 2018 was associated with an expansion in the search (from 64 to 88% of the population with some health problem) and access to medical care. Finally, the disappearance of Seguro Popular was not associated with a reduction in the decision to seek care. Conclusions. The private sector serves approximately half of the population with a health need in Mexico. The implications on equity and the well-being of Mexican households are important. Therefore, one of the priorities of the public health system in the future is to improve its accessibility and quality to persuade the population to use public services. [ABSTRACT FROM AUTHOR]

SLE presents significant challenges for patients and health-care professionals (HCPs), both across Europe and worldwide. Improving health-care outcomes for patients with SLE requires a comprehensive understanding of patient disease pathways. In particular, the geographical distance between SLE patients and specialized care centres, combined with the scarcity of rheumatologists, exacerbates delays in diagnosis and management. Also, the initial SLE symptoms can often be non-specific, and providing guidelines for primary HCPs and other non-specialists is extremely important. Improvement in access to treatment is also important, with several recently approved therapies for SLE not being available in several European countries and many low- and middle-income countries (LMICs). Furthermore, in the LMICs in which these treatments are available, they are not always covered by the health-care system, making their access almost impossible for those of lower socio-economic status. A number of provisions are already in place within the European Union, to improve access to care for patients with rare and complex diseases, including those with SLE. In particular, European Reference Networks (ERNs), such the ERN for Autoimmune Diseases ReCONNET, are virtual networks involving HCPs across Europe with the aim of improving the care of patients with rare and complex diseases that require highly specialized treatment and a concentration of knowledge and resources. In addition, lupus patient organizations such as Lupus Europe play a crucial role in raising awareness of SLE and advocating for improved access to care. Together, we can work towards a future where all people living with lupus receive the comprehensive and timely care they deserve. [ABSTRACT FROM AUTHOR]

To explore the needs, expectations, and experiences of asylum-seeking parents and unaccompanied minors under the age of 18 years on the initial health assessment for children and adolescents and access to care upon entry in the Netherlands, We conducted five semi-structured focus group discussions with asylum-seeking parents and unaccompanied minors, from Syria, Eritrea, Afghanistan, and other Middle-East and African countries, supported by professional interpreters. To triangulate findings, semi-structured interviews with health care professionals involved in care for refugee children were conducted. Transcripts of focus group discussions were inductively and deductively coded and content analyzed; transcripts of interviews were deductively coded and content analyzed. In total, 31 asylum-seeking participants: 23 parents of 101 children (between 0 and 18 years old), 8 unaccompanied minors (between 15 and 17 years), and 6 healthcare professionals participated. Parents and minors expressed that upon entry, their needs were met for vaccinations, but not for screening or care for physical and mental health problems. Parents, minors, and health professionals emphasized the necessity of appropriate information and education about health, diseases, and the health system. Cultural change was mentioned as stressful for the parent–child interaction and parental well-being. Conclusion: The perspectives of refugee parents and unaccompanied minors revealed opportunities to improve the experience of and access to health care of refugees entering the Netherlands, especially risk-specific screening and more adequate education about health, diseases, and the Dutch health care system. What is Known: • Refugees have specific health needs due to pre-flight, flight, and resettlement conditions. Health assessment upon entry was non-obligatory in the Netherlands, except for the tuberculosis screening. Health needs were not always met, and refugees experienced barriers in access to care. What is New: • The initial health assessment met the needs concerning vaccinations but mismatched the needs regarding physical and mental health assessment. Screening for specific risk-related diseases and mental health could enable refugee parents and minors to engage better with the health system. [ABSTRACT FROM AUTHOR]

Background: Unmet healthcare need among elderly is the want for essential healthcare which is not fulfilled. Health needs of the elderly often go unrecognized. Functional limitation is one of the contributors in this unmet health need. The situation is worse in rural areas due to lack of awareness and lower socio-economic status. The study aimed to estimate the burden of unmet health needs among the elderly of Budge-Budge II block in West Bengal, to assess their morbidity pattern and to evaluate the predictors of this unmet health need. Materials and Methods: A community-based descriptive study, cross-sectional in design was conducted for a period of 3 months in selected villages of Budge-Budge II block, West Bengal. Data on unmet need were collected by face-to-face interview of 396 participants selected by simple random sampling using EASYCare standard (2010) questionnaire. Results: The most prevalent unmet health need was for preventive care (87.37%), followed by mental health and wellbeing (84.09%). Hypertension was the most common morbidity (52.02%) reported among the study population. Belonging to the age group of 60-69 years had a lower odds of experiencing unmet health needs, whereas being a homemaker or engagement in agricultural work had higher odds of facing unmet health needs among the study participants. Conclusions: The unmet health need of the elderly is a major public health problem that is influenced by age, marital status, and nature of work. [ABSTRACT FROM AUTHOR]

Research investigating the impact of barriers to care on health-related quality of life (HRQoL) among US adults with chronic inflammatory skin diseases (CISDs) is limited. In this study, we utilize multivariable-adjusted logistic regression to analyze the associations between cost barriers (e.g., delaying specialist and mental health care due to cost) and non-cost barriers (e.g., delaying care due to transportation issues and the lack of provider diversity) with HRQoL among US adults with several common CISDs in the National Institutes of Health’s All of Us Research Program (AoURP). Among the 19,208 adults with CISDs included in our analysis, the prevalence of poorer HRQoL(i.e., “fair” or “poor” HRQoL) was significantly higher among adults with CISDs who experienced cost (aOR, 2.39;95% CI, 2.10-2.73) and non-cost barriers (aOR, 2.52; 95% CI, 2.20-2.88) than those with CISDs who did not experience those barriers. Since dermatologists are often the only physician caring for patients with CISDs, this study reinforces the critical role dermatologists have in addressing social determinants of health and advocating to reduce cost and non-cost barriers for their patients with CISDs. [ABSTRACT FROM AUTHOR]

OBJECTIVE To compare results from 2 previously published surveys aimed at determining how pyometra is treated in high-quality, high-volume spay-neuter clinics (HQHVSNCs) and private practices (PPs), with a specific focus on identifying opportunities for partnership between the clinic types to improve access to care in pyometra treatment. SAMPLE Responses from 123 PPs and 87 HQHVSNCs. METHODS A previously published survey of PPs conducted from June to July 2021 and a similar previously published survey of HQHVSNCs conducted from June to July 2020 were compared regarding demographics, pyometra treatment availability, estimated outcome, alternative outcome, disruption, cost, and protocol between HQHVSNCs and PPs. A comparison was also run of the surveys' responses regarding referral of a pyometra to an HQHVSNC by a PP. RESULTS Although PPs estimated that economic euthanasia is the most likely alternative outcome for 13% of patients unable to access care at their practice, 80% would be reluctant to refer to an HQHVSNC. The 3 primary reasons indicated by PPs with a reluctance to refer were a perceived lack of prompt appointment availability (20%), lack of aftercare (18%), and lack of adequate equipment (14%). In contrast, most HQHVSNCs estimated that they generally accept referrals the same day (50%) or the next day (30%) and 95% of HQHVSNCs reported having the resources needed to treat most pyometras. CLINICAL RELEVANCE There are several opportunities for partnership between PPs and HQHVSNCs in the treatment of pyometra. The most frequent concerns expressed by PPs regarding referral to HQHVSNCs were not shared by HQHVSNCs or could be ameliorated by referral to an HQHVSNC for surgery and transfer back to the PP for aftercare. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Delay in surgery for anterior cruciate ligament (ACL) injuries increases the risk of complications including secondary injuries. Previous research has shown individuals with public insurance have greater delays in care for a variety of health conditions. Clinical Question: In pediatric patients with ACL injuries, is the time from injury to surgery longer for patients with public insurance than patients with private insurance? Summary of Key Findings: Four studies met the inclusion criteria. All studies reported a greater wait time for surgery in pediatric patients with public insurance. Clinical Bottom Line: There is moderate evidence indicating that there is a delay in ACL surgery for pediatric patients with public insurance compared to those with private insurance. Strength of Recommendation: Grade B evidence exists that there is a delay in surgery for ACL injuries in pediatric patients with public insurance compared to those with private insurance. [ABSTRACT FROM AUTHOR]

This study examines the impact of telemedicine on the variables of Ease of Scheduling, Cleanliness, Waiting Time, Professionalism, and Communication in rural healthcare settings. The main objective of the study was to examine the impact of innovation in healthcare services and hospital ambulatory accreditation on the perception of quality of care in Colombia. The probe was motivated by the necessity to analyze the unparalleled challenges vied by provincial communities. These challenges include narrow access to specialized attention and lengthy travel distances to healthcare facilities. A comprehensive literature review was conducted to explore the existing comprehension on telemedical services and their potential profits in provincial areas. The examination utilized a mixed-methods research approaches, incorporating quantitative data from patient surveys and qualitative data from interviews with healthcare providers. The main conclusion highlights the potential benefits of integrating telemedicine technologies and adhering to accreditation standards in enhancing patient experiences and satisfaction, particularly in underserved rural communities with limited access to healthcare resources. These conclusions highlight the potential of telemedical services technology as a valuable implement for refining healthcare delivery and access in provincial areas. The examination concludes by discussing the implications of these findings and suggesting recommendations for healthcare organizations and policymakers to integrate telemedicine into provincial healthcare practices effectively. [ABSTRACT FROM AUTHOR]

Sexual assault nurse examiners are crucial care providers in cases of sexual assault. However, it is not clear whether sexual assault nurse examiner availability differs throughout the 13 states that comprise the Appalachian region of the United States. Therefore, this cross-sectional analysis identified sexual assault nurse examiner availability in 13 states and determined differences in availability by both county-level Appalachian status and county-level rurality status. Data were downloaded from 2 public sexual assault nurse examiner registries for the included 13 states. Descriptive statistics of sexual assault nurse examiner certification type and availability by state were calculated. In addition, bivariate analyses of sexual assault nurse examiner availability by rurality and by Appalachian status were performed using 2-sample z-tests for equality of proportions. State-level sexual assault nurse examiner availability ranged from 0.34 to 0.86 sexual assault nurse examiners per 100,000 residents. Sexual assault nurse examiner availability in these 13 states did not differ by Appalachian status. However, rural areas had significantly lower sexual assault nurse examiner availability than urban areas in these 13 states. These data support previous literature on the need for stronger sexual assault nurse examiner programs in rural areas in the United States. Future research should take sexual assault prevalence into account to determine whether local sexual assault nurse examiner access needs, as well as appropriate support for sexual assault nurse examiners, are being met throughout Appalachian states. [ABSTRACT FROM AUTHOR]

Multiple co-existing chronic diseases impact patients' ability to manage their medical conditions. MHealth provides opportunities for continuous access to and better quality of care. This study explored access to mHealth and its Usage among people with comorbidities. Based on Social Cognitive Theory (SCT), this study also explores how environmental factors (quality of care and having a regular provider) and personal factors (self-efficacy and perception of health status) can impact behavioral factors (mHealth use for communication, health monitoring, and decision-making) of people with comorbidities. Multivariate logistic regression models use Health Information National Trends Survey data (2020–2021). The study included 9303 participants, and 3260 of them had comorbidities. The hypotheses are tested on people with comorbidities who used mHealth for health purposes. The use of mHealth to monitor health-related issues was significantly correlated with comorbidity. Having a regular provider impacts the decision to use mHealth for health monitoring, communication, and decision-making. Self-efficacy perception of patients with comorbidities impacts their use of mHealth for health monitoring and decision-making. Finally, a good perception of health status impacts the use of mHealth for health monitoring. Even though different factors impact different behaviors, the findings support the hypotheses of the social cognitive theory linking the person's behavior to their perceptions and environmental factors. These findings extend the literature supporting the validity of the social cognitive theory in healthcare applications and give insights into the importance of mHealth in supporting care for patients with comorbidities. [ABSTRACT FROM AUTHOR]

Purpose: Advantages of fluoridated water, dental insurance, and greater awareness of preventive oral healthcare allow many adults in today's aging cohort to maintain their teeth into their advanced years. The purpose of this study was to describe attitudes, expectations, knowledge, and intentions related to oral health issues from the experiences of older adults living independently in a largely rural south central state. Methods: A qualitative analysis guided by behavioral constructs of the Reasoned Action Approach was utilized to conduct semi-structured interviews of a purposeful sample of adults age 65 years and older living independently. Results: Participant data (N = 26) revealed 5 themes: difficulties accessing dental care; active coping; taking care of your mouth as part of overall health; interactions affecting oral health–related quality of life; and supporting roles. Overall, the intention to attain dental care was affected by the perceived need to prioritize many health issues over oral care. An overarching expectation to have affordable basic services available pervaded. Conclusion: The perceptions of participants reflect socioeconomic determinants that could be influenced through improved health literacy education focused on establishing a greater understanding of the oral systemic link especially as it relates to diabetes. [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]

Cancer mortality rates have declined during the last 28 years, but that process is not equitably shared. Disparities in cancer outcomes by race, ethnicity, socioeconomic status, sexual orientation and gender identity, and geographic location persist across the cancer care continuum. Consequently, community outreach and engagement (COE) efforts within National Cancer Institute‐Designated Cancer Center (NCI‐DCC) catchment areas have intensified during the last 10 years as has the emphasis on COE and catchment areas in NCI's Cancer Center Support Grant applications. This review article attempts to provide a historic perspective of COE within NCI‐DCCs. Improving COE has long been an important initiative for the NCI, but it was not until 2012 and 2016 that NCI‐DCCs were required to define their catchment areas rigorously and to provide specific descriptions of COE interventions, respectively. NCI‐DCCs had previously lacked adequate focus on the inclusion of historically marginalized patients in cancer innovation efforts. Integrating COE efforts throughout the research and operational aspects of the cancer centers, at both the patient and community levels, will expand the footprint of COE efforts within NCI‐DCCs. Achieving this change requires sustained commitment by the centers to adjust their activities and improve access and outcomes for historically marginalized communities. [ABSTRACT FROM AUTHOR]

Objective: To investigate potential differences in new patient appointment wait times for otolaryngology care based on insurance types and explore factors influencing these wait times. Study Design: A cross‐sectional audit study, using a "mystery caller" approach, analyzed with a linear mixed Poisson model to adjust for confounding factors. Setting: A total of 612 physicians across 49 states and the District of Columbia, representing 6 otolaryngology subspecialties, were included. Methods: Otolaryngology physicians were contacted by mystery callers via telephone with scripted clinical vignettes as patients with either Medicaid or Blue Cross/Blue Shield (BCBS) insurance. Callers requested next available appointment. Wait times for new patient appointments were recorded and analyzed in R using a generalized linear mixed Poisson model. Results: A total of 1183 of 1224 calls reached a representative. Medicaid patients waited 5.73% longer (P <.001) compared to BCBS patients (IRR: 1.06; confidence interval [CI]: 1.03‐1.09; P <.001), with respective mean wait times of 36.8 days (SE ± 1.6) and 32.4 days (SE ± 1.6). Longer waiting times were also associated with physicians affiliated with universities (P =.001) and certain subspecialties, such as pediatric otolaryngology (P <.001) and neurotology (P =.008). Regional differences were also observed, with specific AAO‐HNS regions showing shorter wait times. The model achieved a conditional R‐squared value of 0.947. Conclusion: This study reveals disparities in wait times for otolaryngology care based on insurance type, with extended wait times for Medicaid beneficiaries. The findings highlight a potential access to care disparity, which begets the need for strategies that ensure equitable access to otolaryngology care and further research to understand the underlying reasons for these potential disparities. [ABSTRACT FROM AUTHOR]

Objective: Families preferring to receive care in a language‐other‐than‐English have disparities in access to care. We studied the effect of implementing an ambulatory outbound scheduling team on the timeliness of scheduling referrals to pediatric otolaryngology. We hypothesized this intervention could increase access to care. Study Design: Retrospective cohort analysis. Setting: Tertiary care academic center. Methods: Data were abstracted from the hospital's enterprise database for patients referred to Otolaryngology over 3 years (October 2019‐August 2022; 7675 referrals). An outbound scheduling team was created April 2021 and tasked with calling out to schedule referrals within one business day of receipt. Referral lag was compared across patient cohorts before and after the scheduling intervention. Log‐transformed linear regression models were used to assess the impact of the scheduling intervention on referral lag for language cohorts. Results: The median preintervention referral lag was 6 days (interquartile range [IQR] 2‐18), which was reduced to 1 day postintervention (IQR 0‐5; P <.001). Preintervention language‐other‐than‐English families had a median referral lag of 8 days (IQR 2‐23), which was 1.27 times higher than for patients speaking English (P <.001). With implementation of the scheduling intervention, language‐other‐than‐English families were scheduled in a median of 1 day (IQR 0‐6), and the disparity in timeliness of scheduling was eliminated (P =.131). Postintervention, referral lag was reduced by 58% in the English and 64% in the language other than English cohorts. Conclusion: Implementation of an outbound ambulatory scheduling process reduces referral lag for all patients and eliminated a disparity in referral lag for language‐other‐than‐English families. [ABSTRACT FROM AUTHOR]

BACKGROUND: Literature evaluating the management of abnormal uterine bleeding in premenopausal patients prior to endometrial malignancy diagnosis is lacking. OBJECTIVE: To evaluate predictors and consequences of inadequate evaluation and management of abnormal uterine bleeding and time to endometrial sampling in premenopausal patients prior to endometrial malignancy diagnosis.Study Design.This was a retrospective cohort study of premenopausal individuals with endometrioid endometrial cancer or atypical hyperplasia at a single institution from 2015 to 2020.. Complete noninvasive management encompassed pelvic exam, ultrasound, and progestin treatment before or in conjunction with the endometrial sampling of diagnosis. Multivariable logistic and ordinal odds models were used to evaluate predictors and outcomes. RESULTS: 152 subjects were included, 80.3 % with cancer and 19.7 % with atypical hyperplasia. The majority of patients had anovulatory bleeding, obesityand recent health care. Only 20.4 % had complete nonvinvasive management, and only 12.5 % had complete noninvasive management or endometrial sampling within 2 months of presentation with abnormal bleeding. Class III obesity reduced the likelihood of complete assessment and increased time to sampling, while age 45 and up and parity reduced time to sampling. Most patients had partial workup but no progestin treatment and long intervals before endometrial sampling after presentation to a provider with abnormal bleeding. Incomplete workup correlated to worse cancer grade and stage. CONCLUSION: Despite high clinical risk and health care contact, most patients had insufficient gynecologic management preceding a diagnosis of endometrial malignancy. Inadequate care correlated to worse oncologic outcomes and demonstrates missed opportunities for early detection and prevention of endometrial cancer.

Introduction: Approximately 80 % of children with cancer live in resource-limited settings where prompt access to diagnosis and treatment is challenging. Data regarding delays in diagnosis and treatment and outcomes of children with cancer in Kenya are lacking. This study aims to 1) compare the reported and expected number of children with cancer; 2) explore diagnosis, treatment, and total delays; 3) determine patient characteristics that influence delays; and 4) investigate treatment outcomes. Methods: This study combined a retrospective medical records review with a case report. Data on delays and treatment outcomes of children from Bungoma County (Kenya) who were diagnosed with cancer at a large academic hospital between 2010 and 2016 were collected. Results: Between 2010 and 2016, 92 children, an average of 13 per year, were referred from Bungoma. These 13 children constitute only 9 % of the expected 140 children developing cancer in this region. The most common diagnoses were non-Hodgkin lymphoma (17 %) and acute lymphoblastic leukemia (16 %). The median total delay was 108 (7–1731) days. The median diagnosis delay was 97 days, longer than the median treatment delay (3 days; P

Abstract Background The Dixon-Woods et al. Candidacy Framework, a valuable tool since its 2006 introduction, has been widely utilized to analyze access to various services in diverse contexts, including healthcare. This social constructionist approach examines micro, meso, and macro influences on access, offering concrete explanations for access challenges rooted in socially patterned influences. This study employed the Candidacy Framework to explore the experiences of individuals living with rheumatoid arthritis (RA) and their formal care providers. The investigation extended to assessing supports and innovations in RA diagnosis and management, particularly in primary care. Methods This systematic review is a Critical Interpretive Synthesis (CIS) of qualitative and mixed methods literature. The CIS aimed to generate theory from identified constructs across the reviewed literature. The study found alignment between the seven dimensions of the Candidacy Framework and key themes emerging from the data. Notably absent from the framework was an eighth dimension, identified as the “embodied relational self.” This dimension, central to the model, prompted the proposal of a revised framework specific to healthcare for chronic conditions. Results The CIS revealed that the eight dimensions, including the embodied relational self, provided a comprehensive understanding of the experiences and perspectives of individuals with RA and their care providers. The proposed Candidacy 2.0 (Chronic Condition (CC)) model demonstrated how integrating approaches like Intersectionality, concordance, and recursivity enhanced the framework when the embodied self was central. Conclusions The study concludes that while the original Candidacy Framework serves as a robust foundation, a revised version, Candidacy 2.0 (CC), is warranted for chronic conditions. The addition of the embodied relational self dimension enriches the model, accommodating the complexities of accessing healthcare for chronic conditions. Trial Registration This study did not involve a health care intervention on human participants, and as such, trial registration is not applicable. However, our review is registered with the Open Science Framework at https://doi.org/10.17605/OSF.IO/ASX5C .

Abstract Background Many studies have described barriers to gender-affirming surgery (GAS) in Canada; however, few have explored why these barriers persist. To address this knowledge gap, we sought to describe documents related to public health insurance (Medicare) for GAS to identify the types of procedures covered, variations in coverage across provinces and territories, and changes in policy over time. Methods We conducted a descriptive cross-sectional study using an environmental scan approach. We queried 23 government websites, the Google search engine, and an online legal database between July 2022 and April 2024 to gather gray literature documents related to GAS and Medicare. Variables from relevant documents were compiled to create a present, at-glance overview of GAS Medicare coverage for all provinces and territories and a timeline of policy changes across Canada. Results Eight provinces and three territories had documents or websites related to GAS Medicare coverage (85%). We identified 15 GAS procedures that were covered variably across Canada. Yukon (n = 14) covered the most types of GAS, while Quebec and Saskatchewan covered the least (n = 6). Mastectomy and genital surgeries were covered across Canada, but other GAS were rarely covered. Five provinces and territories provided coverage for travel-related costs. Our GAS Medicare timeline showed differential expansion of GAS coverage in Canada over the last 25 years. Conclusions We provide previously unreported information regarding GAS Medicare coverage in Canada. We hope our findings will help patients and healthcare providers navigate a complicated public healthcare system. We also highlight barriers within GAS Medicare documents and make recommendations to alleviate those barriers.