-
International Journal of Environmental... Apr 2021Access to healthcare for adolescents is often overlooked in the United States due to federal and state-sponsored insurance programs such as Medicaid and the Children's... (Review)
Review
Access to healthcare for adolescents is often overlooked in the United States due to federal and state-sponsored insurance programs such as Medicaid and the Children's Health Insurance Program. While these types of programs provide some relief, the issue of healthcare access goes beyond insurance coverage and includes an array of ecological factors that hinder youths from receiving services. The purpose of this scoping review was to identify social-ecological barriers to adolescents' healthcare access and utilization in the United States. We followed the PRISMA and scoping review methodological framework to conduct a comprehensive literature search in eight electronic databases for peer-reviewed articles published between 2010 and 2020. An inductive content analysis was performed to thematize the categories identified in the data extraction based on the Social-Ecological Model (SEM). Fifty studies were identified. Barriers across the five SEM levels emerged as primary themes within the literature, including intrapersonal-limited knowledge of and poor previous experiences with healthcare services, interpersonal-cultural and linguistic barriers, organizational-structural barriers in healthcare systems, community-social stigma, and policy-inadequate insurance coverage. Healthcare access for adolescents is a systems-level problem requiring a multifaceted approach that considers complex and adaptive behaviors.
Topics: Adolescent; Child; Health Facilities; Health Services; Health Services Accessibility; Humans; Insurance Coverage; Medicaid; United States
PubMed: 33919813
DOI: 10.3390/ijerph18084138 -
American Journal of Epidemiology Nov 2021We assessed the teratogenicity of tenofovir, a human immunodeficiency virus (HIV) drug similar to remdesivir that is currently being evaluated for the treatment of... (Meta-Analysis)
Meta-Analysis
We assessed the teratogenicity of tenofovir, a human immunodeficiency virus (HIV) drug similar to remdesivir that is currently being evaluated for the treatment of coronavirus disease 2019 (COVID-19). Using US Medicaid Analytic eXtract (MAX) claims data (2000-2014), we identified a population-based pregnancy cohort of women with HIV who filled at least 1 prescription for antiretroviral therapies (ART) during the first trimester. Women on tenofovir disoproxil fumarate (TDF) were compared with women receiving ART without TDF. Major malformations were identified by International Classification of Diseases, Ninth Revision, codes using validated algorithms. Relative risks and 95% confidence intervals were estimated using propensity score stratification to control for potential confounders. We incorporated the results into prior knowledge by conducting a systematic literature review and a meta-analysis. Major congenital malformations were diagnosed in 37 out of 866 (4.27%) infants exposed to TDF and 38 out of 1,020 (3.73%) infants exposed to ART other than TDF; the adjusted relative risk was 1.21 (95% confidence interval: 0.77, 1.90). Estimates for specific malformations were imprecise. The pooled relative risk from the meta-analysis with 6 prior studies was 0.88 (95% confidence interval: 0.75, 1.03). Based on evidence accumulated in patients with HIV, first-trimester TDF use does not increase the risk of major congenital malformations overall in the newborn compared with other ART.
Topics: Adult; Anti-HIV Agents; Antiviral Agents; COVID-19; Cohort Studies; Female; HIV Infections; Humans; Pandemics; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Outcome; Pregnant Women; Reverse Transcriptase Inhibitors; SARS-CoV-2; Tenofovir; COVID-19 Drug Treatment
PubMed: 33847737
DOI: 10.1093/aje/kwab109 -
Journal of General Internal Medicine Jun 2021To align patient preferences and understanding with harm-benefit perception, the Centers for Medicare & Medicaid Services (CMS) mandates that providers engage patients...
INTRODUCTION
To align patient preferences and understanding with harm-benefit perception, the Centers for Medicare & Medicaid Services (CMS) mandates that providers engage patients in a collaborative shared decision-making (SDM) visit before LDCT. Nonetheless, patients and providers often turn instead to the web for help making decisions. Several web-based lung cancer risk calculators (LCRCs) provide risk predictions and screening recommendations; however, the accuracy, consistency, and subsequent user interpretation of these predictions between LCRCs is ambiguous. We conducted a systematic review to assess this variability.
DESIGN
Through a systematic Internet search, we identified 10 publicly available LCRCs and categorized their input variables: demographic factors, cancer history, smoking status, and personal/environmental factors. To assess variance in LCRC risk prediction outputs, we developed 16 hypothetical patients along a risk continuum, illustrated by randomly assigned input variables, and individually compared them to each LCRC against the empirically validated "gold-standard" PLCO risk model in order to evaluate the accuracy of the LCRCs within identical time-windows.
RESULTS
From the inclusion criteria, 11 calculators were initially identified. The analyzed calculators also vary in output characteristics and risk depiction for hypothetical patients. There were 13 total instances across ten hypothetical patients in which the sample standard error exceeded the mean risk percentage across all general samples and set standard calculations. The largest measured difference is 16.49% for patient 8, and the smallest difference is 0.01% for patient 2. The largest measured difference is 16.49% for patient 8, and the smallest difference is 0.01% for patient 2.
CONCLUSION
Substantial variability in the depiction of lung cancer risk for hypothetical patients exists across the web-based LCRCs due to their respective inputs and risk prediction models. To foster informed decision-making in the SDM-LDCT context, the input variables, risk prediction models, risk depiction, and screening recommendations must be standardized to best practice.
Topics: Aged; Decision Making, Shared; Early Detection of Cancer; Humans; Internet; Lung Neoplasms; Medicare; United States
PubMed: 33835312
DOI: 10.1007/s11606-021-06754-0 -
BMC Health Services Research Mar 2021The aim of this study was to identify the range of ways that safety net hospitals (SNHs) have been empirically operationalized in the literature and determine the extent...
BACKGROUND
The aim of this study was to identify the range of ways that safety net hospitals (SNHs) have been empirically operationalized in the literature and determine the extent to which patterns could be identified in the use of empirical definitions of SNHs.
METHODS
We conducted a PRISMA guided systematic review of studies published between 2009 and 2018 and analyzed 22 articles that met the inclusion criteria of hospital-level analyses with a clear SNH definition.
RESULTS
Eleven unique SNH definitions were identified, and there were no obvious patterns in the use of a definition category (Medicaid caseload, DSH payment status, uncompensated care, facility characteristics, patient care mix) by the journal type where the article appeared, dataset used, or the year of publication.
CONCLUSIONS
Overall, there is broad variability in the conceptualization of, and variables used to define, SNHs. Our work advances the field toward the development of standards in measuring, operationalizing, and conceptualizing SNHs across research and policy questions.
Topics: Health Services Research; Humans; Medicaid; Safety-net Providers; United States
PubMed: 33766014
DOI: 10.1186/s12913-021-06292-9 -
Otolaryngology--head and Neck Surgery :... Dec 2021To provide a portrait of gender affirmation surgery (GAS) insurance coverage across the United States, with attention to procedures of the head and neck.
OBJECTIVE
To provide a portrait of gender affirmation surgery (GAS) insurance coverage across the United States, with attention to procedures of the head and neck.
STUDY DESIGN
Systematic review.
SETTING
Policy review of US medical insurance companies.
METHODS
State policies on transgender care for Medicaid insurance providers were collected for all 50 states. Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined. The largest medical insurance companies in the United States were identified using the National Association of Insurance Commissioners Market Share report. Policies of the top 49 primary commercial medical insurance companies were examined.
RESULTS
Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17%). Thirteen states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy. Ninety-two percent of commercial medical insurance providers had a published policy on GAS coverage. Genital reconstruction was described as a medically necessary aspect of transgender care in 100% of the commercial policies reviewed. Ninety-three percent discussed coverage of FGAS, but 51% considered these procedures cosmetic. Thyroid chondroplasty (20%) was the most commonly covered FGAS procedure. Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13% of the medical policies reviewed.
CONCLUSION
While certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers, potentially limiting patient access.
LEVEL OF EVIDENCE
Level V.
Topics: Face; Female; Health Policy; Humans; Insurance Coverage; Insurance, Health; Male; Medicaid; Sex Reassignment Surgery; State Government; Transgender Persons; United States
PubMed: 33722109
DOI: 10.1177/0194599821997734 -
European Journal of Surgical Oncology :... Aug 2021Head and neck cancers (HNC) are relatively fast-growing tumours, and delay in treatment initiation is associated with tumour progression and adverse outcome. An overview...
INTRODUCTION
Head and neck cancers (HNC) are relatively fast-growing tumours, and delay in treatment initiation is associated with tumour progression and adverse outcome. An overview of factors contributing to delay can provide critical insights on necessary adjustments to optimize care pathways. This systematic review aims to identify factors associated with delay and summarize the effect of delay on oncological outcome measures.
METHODS
A search strategy was conducted according to PRISMA guidelines to search electronic databases for studies assessing the carepathway interval (days between first visit in head and neck oncology center and treatment initiation) and/or time-to-treatment-initiation interval (days between histological diagnosis and treatment initiation) and 1) determinants of delay and/or 2) effect of delay on outcome within these timeframes. Due to heterogeneity between included studies, a meta-analysis was not possible.
RESULTS
Fifty-two studies were eligible for quantitative analysis. Non-Caucasian race, academic setting, Medicaid/no insurance and radiotherapy as primary treatment were associated with delay. Advanced tumour stage was related to increased time-to-treatment initiation in the four common sites combined (oral cavity, oropharynx, hypopharynx, larynx). Separate determinants for delay in different tumour locations were identified. In laryngeal, oral cavity cancer and the four common HNC sites combined, delay in start of treatment is associated with decreased overall survival, although no cut-off time point could be determined.
CONCLUSION
Race, facility type, type of insurance and radiotherapy as primary treatment were associated with delay and subsequent inferior survival in the four common sites combined.
Topics: Academic Medical Centers; Ethnic and Racial Minorities; Ethnicity; Head and Neck Neoplasms; Humans; Insurance, Health; Medicaid; Medically Uninsured; Neoplasm Staging; Radiotherapy; Risk Factors; Squamous Cell Carcinoma of Head and Neck; Survival Rate; Time-to-Treatment; United States
PubMed: 33715909
DOI: 10.1016/j.ejso.2021.02.029 -
Journal of Medical Internet Research Feb 2021Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the...
BACKGROUND
Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the nature of users' interactions with portals, and the contents of their generated data to meaningful cost and quality outcomes. Incentive programs in the United States have encouraged uptake of health information technology, including patient portals, by setting standards for meaningful use of such technology. However, despite widespread interest in patient portal use and adoption, studies on patient portals differ in actual metrics used to operationalize and track utilization, leading to unsystematic and incommensurable characterizations of use. No known review has systematically assessed the measurements used to investigate patient portal utilization.
OBJECTIVE
The objective of this study was to apply systematic review criteria to identify and compare methods for quantifying and reporting patient portal use.
METHODS
Original studies with quantifiable metrics of portal use published in English between 2014 and the search date of October 17, 2018, were obtained from PubMed using the Medical Subject Heading term "Patient Portals" and related keyword searches. The first search round included full text review of all results to confirm a priori data charting elements of interest and suggest additional categories inductively; this round was supplemented by the retrieval of works cited in systematic reviews (based on title screening of all citations). An additional search round included broader keywords identified during the full-text review of the first round. Second round results were screened at abstract level for inclusion and confirmed by at least two raters. Included studies were analyzed for metrics related to basic use/adoption, frequency of use, duration metrics, intensity of use, and stratification of users into "super user" or high utilizers. Additional categories related to provider (including care team/administrative) use of the portal were identified inductively. Additional analyses included metrics aligned with meaningful use stage 2 (MU-2) categories employed by the US Centers for Medicare and Medicaid Services and the association between the number of portal metrics examined and the number of citations and the journal impact factor.
RESULTS
Of 315 distinct search results, 87 met the inclusion criteria. Of the a priori metrics, plus provider use, most studies included either three (26 studies, 30%) or four (23 studies, 26%) metrics. Nine studies (10%) only reported the patient use/adoption metric and only one study (1%) reported all six metrics. Of the US-based studies (n=76), 18 (24%) were explicitly motivated by MU-2 compliance; 40 studies (53%) at least mentioned these incentives, but only 6 studies (8%) presented metrics from which compliance rates could be inferred. Finally, the number of metrics examined was not associated with either the number of citations or the publishing journal's impact factor.
CONCLUSIONS
Portal utilization measures in the research literature can fall below established standards for "meaningful" or they can substantively exceed those standards in the type and number of utilization properties measured. Understanding how patient portal use has been defined and operationalized may encourage more consistent, well-defined, and perhaps more meaningful standards for utilization, informing future portal development.
Topics: Humans; Patient Participation; Patient Portals; Utilization Review
PubMed: 33629962
DOI: 10.2196/23493 -
Journal of the American Medical... Jun 2021Although nurses comprise the largest group of health professionals and electronic health record (EHR) user base, it is unclear how EHR use has affected nurse well-being.... (Review)
Review
OBJECTIVE
Although nurses comprise the largest group of health professionals and electronic health record (EHR) user base, it is unclear how EHR use has affected nurse well-being. This systematic review assesses the multivariable (ie, organizational, nurse, and health information technology [IT]) factors associated with EHR-related nurse well-being and identifies potential improvements recommended by frontline nurses.
MATERIALS AND METHODS
We searched MEDLINE, Embase, CINAHL, PsycINFO, ProQuest, and Web of Science for literature reporting on EHR use, nurses, and well-being. A quality appraisal was conducted using a previously developed tool.
RESULTS
Of 4583 articles, 12 met inclusion criteria. Two-thirds of the studies were deemed to have a moderate or low risk of bias. Overall, the studies primarily focused on nurse- and IT-level factors, with 1 study examining organizational characteristics. That study found worse nurse well-being was associated with EHRs compared with paper charts. Studies on nurse-level factors suggest that personal digital literacy is one modifiable factor to improving well-being. Additionally, EHRs with integrated displays were associated with improved well-being. Recommendations for improving EHRs suggested IT-, organization-, and policy-level solutions to address the complex nature of EHR-related nurse well-being.
CONCLUSIONS
The overarching finding from this synthesis reveals a critical need for multifaceted interventions that better organize, manage, and display information for clinicians to facilitate decision making. Our study also suggests that nurses have valuable insight into ways to reduce EHR-related burden. Future research is needed to test multicomponent interventions that address these complex factors and use participatory approaches to engage nurses in intervention development.
Topics: Electronic Health Records; Humans
PubMed: 33367819
DOI: 10.1093/jamia/ocaa289 -
Women's Health Issues : Official... 2021We systematically reviewed the literature to understand the associations between state-level reproductive health policies and reproductive health care outcomes and...
Impact of State-Level Reproductive Health Legislation on Access to and Use of Reproductive Health Services and Reproductive Health Outcomes: A Systematic Scoping Review in the Affordable Care Act Era.
INTRODUCTION
We systematically reviewed the literature to understand the associations between state-level reproductive health policies and reproductive health care outcomes and describe policy impacts on reproductive health outcomes among women aged 18 and older. We focused on research conducted after the implementation of the Patient Protection and Affordable Care Act to understand the influence of state-level policies in the context of existing federal policy.
METHODS
Standard search terms were used to search PubMed for studies published between March 10, 2010, and August 31, 2019. Studies were included that reflected original U.S.-based research testing associations between state-level policies (i.e., laws related to family planning, maternity care, and abortion) and reproductive health outcomes related to those services (e.g., prenatal care use) among adults. Reference lists of systematic reviews were searched to improve the identification of relevant studies. Studies were excluded if they were reviews, qualitative or mixed-methods studies, or descriptive studies, or if a state was not the unit of analysis. After dual review, agreement on inclusion of studies was 100%.
RESULTS
Search results returned 1,529 articles; 56 (3.59%) met the inclusion criteria for a full review based on title and abstract review. After dual independent review, eight were selected for inclusion. Two included all 50 states and Washington, DC; one included Oregon and Washington; and the remaining studies included single states (Texas, Arizona, Ohio, and Utah). One-half of the studies (n = 4) focused solely on restrictive abortion legislation. Restricting access to family planning and abortion services (e.g., mandatory waiting periods) were associated with negative outcomes (e.g., additional interventions for medication abortion). Expanding maternity care through Medicaid reform and autonomous midwifery laws were associated with positive outcomes (e.g., prenatal care use).
CONCLUSIONS
Our review identified eight studies that were largely focused on only one key aspect of reproductive health policy. Findings suggest that state-level legislation could have considerable impact on the reproductive health care that women have access to and receive, as well as the related outcomes. Research in this area remains limited. Rigorous evaluations of the relationship between the breadth of reproductive health policies and related health outcomes are needed, as is an exploration of barriers to the conduct of this type of research.
Topics: Adolescent; Adult; Arizona; Female; Humans; Maternal Health Services; Oregon; Patient Protection and Affordable Care Act; Pregnancy; Reproductive Health; Reproductive Health Services; Texas; United States; Utah
PubMed: 33303355
DOI: 10.1016/j.whi.2020.11.005 -
Clinical Journal of the American... Dec 2020Patients with kidney failure experience depression at rates higher than the general population. Despite the Centers for Medicare and Medicaid Services' ESRD Quality...
BACKGROUND AND OBJECTIVES
Patients with kidney failure experience depression at rates higher than the general population. Despite the Centers for Medicare and Medicaid Services' ESRD Quality Incentive Program requirements for routine depression screening for patients with kidney failure, no clear guidance exists.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS
For this systematic review, we searched MEDLINE, PsycINFO, and other databases from inception to June 2020. Two investigators screened all abstracts and full text. We included studies assessing patients with kidney failure and compared a tool to a clinical interview or another validated tool (., Beck Depression Inventory II). We abstracted data related to sensitivity and specificity, positive and negative predictive value, and the area under the curve. We evaluated the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2.
RESULTS
A total of 16 studies evaluated the performance characteristics of depression assessment tools for patients with kidney failure. The Beck Depression Inventory II was by far the best studied. A wide range of thresholds were reported. Shorter tools in the public domain such as the Patient Health Questionnaire 9 and Geriatric Depression Scale 15 (adults over 60) performed well but were not well studied. Short tools such as the Beck Depression Inventory-Fast Screen may be a good option for an initial screen.
CONCLUSIONS
There is limited research evaluating the diagnostic accuracy of most screening tools for depression in patients with kidney failure, and existing studies may not be generalizable to US populations. Studies suffer from limitations related to methodology quality and/or reporting. Future research should target widely used, free tools such as the Patient Health Questionnaire 2 and the Patient Health Questionnaire 9.
CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER
Systematic Review Registration: PROSPERO CRD42020140227.
Topics: Aged; Depression; Diagnostic Screening Programs; Geriatric Assessment; Humans; Middle Aged; Patient Health Questionnaire; Predictive Value of Tests; Prognosis; Renal Insufficiency; Renal Replacement Therapy; Risk Assessment; Risk Factors
PubMed: 33203736
DOI: 10.2215/CJN.05540420