Protocol for a discrete choice experiment: understanding preferences for seeking health services for survivors of sexual violence in Uganda.

INTRODUCTION: Sexual violence is a significant public health concern with severe physical, social and psychological consequences, which can be mitigated by health service utilisation. However, in Uganda and much of sub-Saharan Africa, these services are significantly underused, with 9 out of 10 survivors not seeking care due to a range of psychological, cultural, economic and logistical factors. Thus, there is a strong need for research to improve health service utilisation for survivors of sexual violence. METHODS AND ANALYSIS: The proposed study seeks to address the underutilization of health services for female survivors of sexual violence using a discrete choice experiment (DCE). The study will be conducted in the greater Masaka region of southwestern Uganda and target adult female survivors of sexual violence. We will first undertake qualitative interviews with 56 survivors of sexual violence to identify the key attributes and levels of the DCE. In order to ensure a sufficiently powered sample, 312 women who meet inclusion criteria will be interviewed. Our primary analysis will employ a mixed (random parameters) logit model. We will also model the role of individual-specific characteristics through latent class models. ETHICS AND DISSEMINATION: The study protocol was reviewed and approved by the following ethics review boards in Uganda and the USA: the Uganda Virus Research Institute (UVRI), the Uganda National Council for Science and Technology (HS2364ES), Washington University in St Louis and the University of Michigan. Our methods conform to established guidelines for the protection of human subjects involved in research. Our dissemination plan targets a broad audience, ranging from policymakers and government agencies to healthcare providers, academic communities and survivors themselves.

Associations between intimate partner violence and women's labor market outcomes in Nigeria.

BACKGROUND: Little is known regarding economic impacts of intimate partner violence (IPV) in humanitarian settings, especially the labor market burden. Examining costs of IPV beyond the health burden may provide new information to help with resource allocation for addressing IPV, including within conflict zones. This paper measures the incidence and prevalence of different types of IPV, the potential relationship between IPV and labor market activity, and estimating the cost of these IPV-associated labor market differentials. METHODS: The association between labor market outcomes, IPV experience, and conflict exposure among women ages 15-49 in Nigeria were studied using the 2018 Nigeria Demographic and Health Survey and 2013-17 Uppsala Conflict Data Program data. Descriptive analysis was used to identify patterns of IPV and labor outcomes by region. Based on this, multivariable logistic regression models were used to estimate the association between labor market participation and lifetime IPV exposure. These models were combined with earnings data from the United Nations Human Development Report 2021/2022 and a top-down costing approach to quantify the impacts in terms of lost productivity to the Nigerian economy. RESULTS: Substantial differences in IPV exposure and labor market outcomes were found between conflict and non-conflict-affected areas. Women with past year or lifetime exposure to physical, emotional, or "any" IPV were more likely to withdraw from the labor market in the past year, although no differences were found for sexual IPV or conflict-affected regions. We estimate an average reduction of 4.14% in the likelihood of working, resulting in nearly $3.0 billion USD of lost productivity, about 1% of Nigeria's total economic output. CONCLUSIONS: Increased odds of labor market withdraw were associated with several measures of IPV. Withdrawal from the formal labor market sector has a substantial associated economic cost for all of Nigerian society. If stronger prevention measures reduce the incidence of IPV against women in Nigeria, a substantial portion of lost economic costs likely could be reclaimed. These costs underscore the economic case, alongside the moral imperative, for stronger protections against IPV for girls and women in Nigeria.

Clostridioides difficile infection across the lifespan: Estimation using life tables.

Using a life tables approach with 2011-2017 claims data, we calculated lifetime risks of Clostridioides difficile infection (CDI) beginning at age 18 years. The lifetime CDI risk rates were 32% in female patients insured by Medicaid, 10% in commercially insured male patients, and almost 40% in females with end-stage renal disease.

Associations between Medicaid enrollment and diagnosis stage and survival among pediatric cancer patients.

BACKGROUND: Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment. METHODS: SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates. RESULTS: Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively. CONCLUSIONS: Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher  distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.

Medicare Data Linkages for Conducting Patient-Centered Outcomes Research on Economic Outcomes.

BACKGROUND: Medicare patients and other stakeholders often make health care decisions that have economic consequences. Research on economic variables that patients have identified as important is referred to as patient-centered outcomes research (PCOR) and can generate evidence that informs decision-making. Medicare fee-for-service (FFS) claims are widely used for research and are a potentially valuable resource for studying some economic variables, particularly when linked to other datasets. OBJECTIVE: The aim of this study was to identify and assess the characteristics of federally funded administrative and survey data sources that can be linked to Medicare claims for conducting PCOR on some economic outcomes. RESEARCH DESIGN: A targeted internet search was conducted to identify a list of relevant data sources. A technical panel and key informant interviews were used for guidance and feedback. RESULTS: We identified 12 survey and 6 administrative sources of linked data for Medicare FFS beneficiaries. A majority provide longitudinal data and are updated annually. All linked sources provide some data on social determinants of health and health equity-related factors. Fifteen sources capture direct medical costs (beyond Medicare FFS payments); 5 capture indirect costs (eg, lost wages from absenteeism), and 7 capture direct nonmedical costs (eg, transportation). CONCLUSIONS: Linking Medicare FFS claims data to other federally funded data sources can facilitate research on some economic outcomes for PCOR. However, few sources capture direct nonmedical or indirect costs. Expanding linkages to include additional data sources, and reducing barriers to existing data sources, remain important objectives for increasing high-quality, patient-centered economic research.

Pediatric cancer patient emergency department visits and disposition by sociodemographic and economic characteristics.

BACKGROUND: Limited research has been conducted on cancer-related emergency department (ED) patterns among pediatric cancer patients, including whether there are differences in the characteristics of individuals who seek ED care for cancer complications. The objectives of this study were to determine whether rates and disposition of cancer-related ED visits and hospital admissions in childhood cancer patients differ by sociodemographic factors. METHODS: A cross-sectional analysis of ED encounters with a cancer diagnosis code among patients aged 0-19 years from the 2019 National Emergency Department Sample (NEDS) was conducted. Weighted logistic regression models were utilized to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for a primary cancer-related encounter, and hospital admission overall and by subgroup characteristics. RESULTS: Of the unweighted 6,801,711 ED encounters in children aged 0-19 years, 10,793 were classified as visits by cancer patients. ED encounters of Hispanic versus non-Hispanic White pediatric cancer patients had higher odds of having a cancer-related primary diagnosis (OR = 1.15, 95% CI: 1.04-1.27). ED encounters of non-Hispanic Black pediatric patients and those in the lowest zip code income quartile had higher odds of hospital admission (OR = 1.28, 95% CI: 1.08-1.53; OR = 1.30, 95% CI: 1.15-1.46), while rurality was associated with lower odds of hospital admission (OR = 0.69, 95% CI: 0.57-0.83). CONCLUSION: These results suggest that pediatric cancer patients from certain under-resourced communities are more likely to use the ED for cancer treatment complications, and their encounters are more likely to result in admission to the hospital.

Federal Data for Conducting Patient-centered Outcomes Research on Economic Outcomes.

BACKGROUND: Patients are increasingly interested in data on the economic burdens and impacts of health care choices; caregivers, employers, and payers are also interested in these costs. Although there have been various federal investments into patient-centered outcomes research (PCOR), an assessment of the coverage and gaps in federally funded data for PCOR economic evaluations has not been produced to date. OBJECTIVES: To classify relevant categories of PCOR economic costs, to assess current federally funded data for coverage of these categories, and to identify gaps for future research and collection. RESEARCH DESIGN: A targeted internet search was conducted to identify a list of relevant outcomes and data sources. The study team assessed data sources for coverage of economic outcomes. A technical panel and key informant interviews were used for evaluation and feedback. RESULTS: Four types of formal health care sector costs, 3 types of informal health care sector costs, and 10 types of non-health care sector costs were identified as relevant for PCOR economic evaluations. Twenty-nine federally funded data sources were identified. Most contained elements on formal costs. Data on informal costs (eg, transportation) were less common, and non-health care sector costs (eg, productivity) were the least common. Most data sources were annual, cross-sectional, nationally representative individual-level surveys. CONCLUSIONS: The existing federal data infrastructure captures many areas of the economic burden of health and health care, but gaps remain. Research from multiple data sources and potential future integrations may offset gaps in individual data sources. Linkages are promising strategies for future research on patient-centered economic outcomes.

Disparities in survival improvement for U.S. childhood and adolescent cancer between 1995 and 2019: An analysis of population-based data.

BACKGROUND: Although treatment advances have increased childhood and adolescent cancer survival, whether patient subgroups have benefited equally from these improvements is unclear. METHODS: Data on 42,865 malignant primary cancers diagnosed between 1995 and 2019 in individuals ≤ 19 years were obtained from 12 Surveillance, Epidemiology, and End Results registries. Hazard ratios (HRs) and 95 % confidence intervals (CIs) for cancer-specific mortality by age group (0-14 and 15-19 years), sex, and race/ethnicity were estimated using flexible parametric models with a restricted cubic spline function in each of the periods: 2000-2004, 2005-2009, 2010-2014 and 2015-2019, versus 1995-1999. Interactions between diagnosis period and age group (children 0-14 and adolescents 15-19 years at diagnosis), sex, and race/ethnicity were assessed using likelihood ratio tests. Five-year cancer-specific survival rates for each diagnosis period were further predicted. RESULTS: Compared with the 1995-1999 cohort, the risk of dying from all cancers combined decreased in subgroups defined by age, sex and race/ethnicity with HRs ranging from 0.50 to 0.68 for the 2015-2019 comparison. HRs were more variable by cancer subtype. There were no statistically significant interactions by age group (Pinteraction=0.05) or sex (Pinteraction=0.71). Despite non-significant differences in cancer-specific survival improvement across different races and ethnicities (Pinteraction=0.33) over the study period, minorities consistently experienced inferior survival compared with non-Hispanic Whites. CONCLUSIONS: The substantial improvements in cancer-specific survival for childhood and adolescent cancer did not differ significantly by different age, sex, and race/ethnicity groups. However, persistent gaps in survival between minorities and non-Hispanic Whites are noteworthy.

Expanding population-level interventions to help more low-income smokers quit: Study protocol for a randomized controlled trial.

BACKGROUND: Low-income Americans have higher rates of smoking and a greater burden of smoking-related disease. In the United States, smokers in every state can access evidence-based telephone counseling through free tobacco quitlines. However, quitlines target smokers who are ready to quit in the next 30 days, which can exclude many low-income smokers. A smoke-free homes intervention may help engage smokers in tobacco control services who are not yet ready to quit. Previous research in low-income populations suggests that receiving a smoke-free homes intervention is associated with higher quit rates. This study tests whether, at a population level, expanding on quitlines to include a smoke-free homes intervention for smokers not ready to quit could engage more low-income smokers and increase long-term cessation rates. METHODS: In a Hybrid Type 2 design, participants are recruited from 211 helplines in 9 states and randomly assigned to standard quitline or quitline plus smoke-free homes intervention arms. Participants in both arms are initially offered quitline services. In the quitline plus smoke-free homes condition, participants who decline the quitline are then offered a smoke-free homes intervention. Participants complete a baseline and follow-up surveys at 3 and 6 months. Those who have not yet quit at the 3-month follow-up are re-offered the interventions, which differ by study arm. The primary study outcome is self-reported 7-day point prevalence abstinence from smoking at 6-month follow-up. CONCLUSION: This real-world cessation trial involving 9 state tobacco quitlines will help inform whether offering smoke-free homes as an alternative intervention could engage more low-income smokers with evidence-based interventions and increase overall cessation rates. This study has been registered at ClinicalTrials.gov (Study Identifier: NCT04311983).

Health Insurance Coverage and Racial/Ethnic Disparities in US Childhood and Adolescent Cancer Survival.

OBJECTIVE: To evaluate potential effect modification by health insurance coverage on racial and ethnic disparities in cancer survival among US children and adolescents. STUDY DESIGN: Data from 54 558 individuals diagnosed with cancer at ≤ 19 years between 2004 and 2010 were obtained from the National Cancer Database. Cox proportional hazards regression was used for analyses. An interaction term between race/ethnicity and health insurance type was included to examine racial/ethnic disparities in survival by each insurance status category. RESULTS: Racial/ethnic minorities experienced a 14%-42% higher hazard of death compared with non-Hispanic Whites (NHWs) with magnitudes varying by health insurance type (Pinteraction < .001). Specifically, among those reported as privately insured, the hazard of death was higher for non-Hispanic Blacks (NHBs) (hazard ratio [HR] = 1.48, 95% CI: 1.36-1.62), non-Hispanic American Indian/Alaskan Natives (HR = 1.99, 95% CI: 1.36-2.90), non-Hispanic Asians or Pacific Islanders (HR = 1.30, 95% CI: 1.13-1.50), and Hispanics (HR = 1.28, 95% CI: 1.17-1.40) vs NHWs. Racial/ethnic disparities in survival among those reported as covered by Medicaid were present for NHBs (HR = 1.30, 95% CI: 1.19-1.43) but no other racial/ethnic minorities (HR ranges: 0.98∼1.00) vs NHWs. In the uninsured group, the hazard of death for NHBs (HR = 1.68, 95% CI: 1.26-2.23) and Hispanics (HR = 1.27, 95% CI: 1.01-1.61) was higher vs NHWs. CONCLUSIONS: Disparities in survival exist across insurance types, particularly for NHB childhood and adolescent cancer patients vs NHWs with private insurance. These findings provide insights for research and policy, and point to the need for more efforts on promoting health equity while improving health insurance coverage.

Is the intention to vaccinate enough? Systematic variation in the value of timely vaccinations and preferences for monetary vs non-monetary incentives among pregnant women in southern Tanzania.

Background: Globally, approximately 19.7 million children remain under-vaccinated; many more receive delayed vaccinations. Sustained progress towards global vaccination targets requires overcoming, or compensating for, incrementally greater barriers to vaccinating hard-to-reach and hard-to-vaccinate children. We prospectively assessed pregnant women's valuations of routine childhood vaccinations and preferences for alternative incentives to inform interventions aiming to increase vaccination coverage and timeliness in southern Tanzania. Methods: Between August and December 2017, 406 women in their last trimester of pregnancy were enrolled from health facilities and communities in the Mtwara region of Tanzania and asked contingent valuation questions about their willingness to vaccinate their child if they were (a) given an incentive, or (b) facing a cost for each vaccination. Interval censored regressions assessed correlates of women's willingness to pay (WTP) for timely vaccinations. Participants were asked to rank monetary and non-monetary incentive options for the timely vaccination of their children. Findings: All women expected to get their children vaccinated according to the recommended schedule, even without incentives. Nearly all women (393; 96.8 %) were willing to pay for vaccinations. The average WTP was Tanzania Shilling (Tsh) 3,066 (95 % confidence interval Tsh 2,523-3,610; 1 USD âˆ¼ Tsh 2,200) for each vaccination. Women's valuations of timely vaccinations varied significantly with vaccine-related knowledge and attitudes, economic status, and rural vs urban residence. Women tended to prefer non-monetary over monetary incentives for the timely vaccination of their children. Interpretation: Women placed a high value on timely childhood vaccinations, suggesting that unexpected system-level barriers rather than individual-level demand factors are likely to be the primary drivers of missed vaccinations. Systematic variation in the value of vaccinations across women reflects variation in perceived benefits and opportunity costs. In this setting, nonmonetary incentives and other interventions to increase demand and compensate for system-level barriers hold significant potential for improving vaccination coverage and timeliness. ClinicalTrialsgov Protocol: NCT03252288.

Excess hospital costs incurred by individuals with child abuse and neglect history in South Australia: A birth-cohort study.

Child abuse and neglect is a serious public health issue across the globe, with documented impacts on health, but the impact on hospital costs, at the population level, is unknown. We aimed to estimate the additional public hospital costs for emergency department visits and admitted patient hospitalizations, for persons with reported child protection concerns, from birth to 31 years and modelled to age 65. Using linked hospital data from 2003 to 2017 for a population birth-cohort of all individuals born in South Australia from 1986 to 2017, we estimated costs of public hospital care. Mean cost and cost differences (adjusted and unadjusted) in 2018 Australian dollars (AU$) were calculated for persons with child protection contact vs none, per person and at the population level. Persons with child protection contact had higher annualized mean hospital costs than those with no contact, with cost differentials increasing with age. Unadjusted differential cost per person was AU$338 (95% CI AU$204-AU$473) from birth to 12 years; increasing to AU$2242 (AU$2074-AU$2411) at ages 25 to 31 years, equating to an additional AU$124 (US$100) million for public hospital services from birth to 31 years, an 18% cost penalty (33% from 13 to 31 years). Modelled to age 65 years, excess costs were estimated at AU$415 (US$337, adjusted: AU$365 and US$296) million, a 27% cost impost. There is a considerable hospital cost penalty associated with persons with reported child protection concerns, especially from adolescence into adulthood, highlighting an opportunity for cost savings by preventive investment in effective early-in-life interventions.

Divergent preferences for enhanced HIV testing options among high-risk populations in northern Tanzania: a short report.

To achieve the UNAIDS target of diagnosing 95% of all persons living with HIV, enhanced HIV testing services with greater attractional value need to be developed and implemented. We conducted a discrete choice experiment (DCE) to quantify preferences for enhanced HIV testing features across two high-risk populations in the Kilimanjaro Region in northern Tanzania. We designed and fielded a survey with 12 choice tasks to systematically recruited female barworkers and male mountain porters. Key enhanced features included: testing availability on every day of the week, an oral test, integration of a general health check or an examination for sexually transmitted infections (STI) with HIV testing, and provider-assisted confidential partner notification in the event of a positive HIV test result. Across 300 barworkers and 440 porters surveyed, mixed logit analyses of 17,760 choices indicated strong preferences for everyday testing availability, health checks, and STI examinations. Most participants were averse to oral testing and confidential partner notification by providers. Substantial preference heterogeneity was observed within each risk group. Enhancing HIV testing services to include options for everyday testing, general health checks, and STI examinations may increase the appeal of HIV testing offers to high-risk populations.Trial registration: ClinicalTrials.gov identifier: NCT02714140.

Scaling-up Child and Youth Mental Health Services: Assessing Coverage of a County-Wide Prevention and Early Intervention Initiative During One Fiscal Year.

PURPOSE: In the U.S., the percentage of youth in need of evidence-based mental health practices (EBPs) who receive them (i.e., coverage rate) is low. We know little about what influences coverage rates. In 2010, the Los Angeles County Department of Mental Health (LACDMH) launched a reimbursement-driven implementation of multiple EBPs in youth mental health care. This study examines two questions: (1) What was the coverage rate of EBPs delivered three years following initial implementation? (2) What factors are associated with the coverage rates? METHODS: To assess coverage rates of publicly insured youth, we used LACDMH administrative claims data from July 1, 2013 to June 30, 2014 and estimates of the size of the targeted eligible youth population from the 2014 American Community Survey (ACS). The unit of analysis was clinic service areas (n = 254). We used Geographic Information Systems and an OLS regression to assess community and clinic characteristics related to coverage. RESULTS: The county coverage rate was estimated at 17%, much higher than national estimates. The proportion of ethnic minorities, individuals who are foreign-born, adults with a college degree within a geographic area were negatively associated with clinic service area coverage rates. Having more therapists who speak a language other than English, providing care outside of clinics, and higher proportion of households without a car were associated with higher coverage rates. CONCLUSION: Heterogeneity in municipal mental health record type and availability makes it difficult to compare the LACDMH coverage rate with other efforts. However, the LACDMH initiative has higher coverage than published national rates. Having bilingual therapists and providing services outside the clinic was associated with higher coverage. Even with higher coverage, inequities persisted.

Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections.

BACKGROUND: Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections. METHODS: We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type. RESULTS: Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections. CONCLUSIONS: Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.

Suicidal ideation and intentional self-inflicted injury in autism spectrum disorder and intellectual disability: An examination of trends in youth emergency department visits in the United States from 2006 to 2014.

LAY ABSTRACT: Youth suicide is a major problem in the United States and globally, but little is known about suicide risk in autistic youth and youth with intellectual disability specifically. Using data from the National Emergency Department Sample, which is the largest database of emergency department visits in the United States, we found that emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis were more common in autistic youth and youth with intellectual disability than in youth without these diagnoses (i.e. the comparison group). This was true when examining both suicidal ideation diagnoses and intentional self-inflicted injury diagnoses at emergency department visits. In addition, the number of emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis increased more from 2006 to 2014 in autistic youth and youth with intellectual disability compared with the comparison group. We also found both similarities and differences when examining factors, such as age, sex, and co-occurring mental health conditions, related to emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis across groups that may be helpful for understanding suicide risk. It is urgent that we improve our understanding, assessment, and treatment of suicidality and self-harm in these groups through more research and clinical efforts.