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Purpose: Little is known about depression treatment for transgender and gender diverse (TGD) older adults or TGD people with disabilities. The purpose of this study was to characterize receipt of minimally recommended depression treatment and outcomes for TGD Medicare beneficiaries. Methods: Using Medicare claims data from 2009 to 2016, we identified potential TGD beneficiaries with depression (n=2223 TGD older adult beneficiaries and n=8752 TGD beneficiaries with a disability) and compared their rates of minimally recommended mental health treatment, inpatient mental health hospitalizations, psychotropic medication fills, and suicide attempt to a group of Comparison beneficiaries with depression (n=499,888 adults aged 65+ years and n=287,583 who qualified due to disability). We estimated disparities in outcomes between TGD and non-TGD beneficiaries (separately by original reason for Medicare eligibility: age 65+ years vs. a disability) using a rank-and-replace method to adjust for health needs. Results: After adjustment, rates of minimally recommended mental health treatment and psychotropic medication fills were higher among TGD versus Comparison beneficiaries, as were rates of inpatient mental health visits and suicide attempts (predicted mean of disparities estimates for older adult subgroup: 0.092, 0.096, 0.006, and 0.002, respectively, all p<0.01; and in subgroup with disability: 0.091, 0.115, 0.015, and 0.003, respectively, all p<0.001). Conclusion: Despite higher mental health treatment rates, TGD beneficiaries with depression in this study had more adverse mental health outcomes. Minimum recommended treatment definitions derived in general population samples may not capture complex mental health needs of specific marginalized populations.
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'Ramping' is a commonly used term in contemporary Australian healthcare. It is also a part of the public and political zeitgeist. However, its precise definition varies among sources. In the published literature, there are distinctions between related terms, such as 'entry overload' and 'Patient Off Stretcher Time Delay'. How ramping is defined and how it came to be defined have significance for policies and procedures relating to the described phenomenon. Through examination of the history of the term, insights are obtained into the underlying issues contributing to ramping and, accordingly, associated possible solutions.
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Research has established relationships between social determinants of health (SDOH) and mental health, with mixed findings on which ethnoracial groups are most vulnerable to deleterious outcomes. The current study examines ethnoracial differences in SDOH and their associations with acute mental health symptoms among patients hospitalized after emergency care. Using data collected in a multi-site study of 1,318 diverse adults admitted to inpatient units, we performed analyses using linear regression models. Findings show that Multiracial/Indigenous and Black adults had significantly higher discrimination and financial stress scores. However, compared with White adults, the positive association between extreme discrimination and acute mental health symptoms was diminished among Latinx (B=-2.3; p=.02) and Black individuals (B=-1.6; p=.05) as was the positive association between financial insecurity and acute mental health symptoms for Black adults (B=-2.3; p=.04). This study provides evidence of differential experiences of SDOH and mental health challenges that may warrant tailored interventions.
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Determinantes Sociais da Saúde , Humanos , Determinantes Sociais da Saúde/etnologia , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Hospitalização/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Negro ou Afro-Americano/psicologia , Transtornos Mentais/etnologia , Estresse Financeiro/etnologia , Estresse Financeiro/psicologia , Hispânico ou Latino/psicologia , Hispânico ou Latino/estatística & dados numéricos , População Branca/estatística & dados numéricos , População Branca/psicologia , Saúde Mental/etnologia , Adulto Jovem , Etnicidade/estatística & dados numéricos , Etnicidade/psicologia , Idoso , Estados Unidos/epidemiologiaRESUMO
African American caregivers providing informal kinship care are vulnerable to chronic stress. Research has indicated stress increases individuals' risk for many adverse physical and mental health outcomes, including cardiovascular disease, Alzheimer's disease and depression. Given the adverse outcomes related to stress, identifying mechanisms to help these caregivers lower and manage their stress is critical to their overall health and well-being. This pilot qualitative study aimed to explore the self-care practices of 12 African Americans providing informal kinship care using a phenomenological approach. Three themes emerged: (a) behaviours to manage stress levels, (b) support network reminding caregivers to take care of themselves and (c) prioritizing my own needs. Specifically, our findings indicate that some caregivers have high-stress levels and engage in maladaptive coping behaviours. The children they cared for reminded them to take care of themselves by attending doctors' appointments or getting their nails done. Nevertheless, some caregivers prioritized their needs by participating in positive self-care behaviours, such as listening to jazz and gospel music and exercising. Prevention and intervention programs that focus on improving caregivers' health should consider the role of self-care practices.
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Importance: Since the COVID-19 pandemic, emergency department boarding of youth with mental health concerns has increased. Objective: To summarize characteristics (including gender, age, race, ethnicity, insurance, diagnosis, and barriers to placement) of youth who boarded in emergency departments while awaiting inpatient psychiatric care and to test for racial, ethnic, and gender disparities in boarding lengths and inpatient admission rates after boarding. Secondarily, to assess whether statewide demand for inpatient psychiatric care correlated with individual outcomes. Design, Setting, and Participants: This cross-sectional analysis included administrative data collected from May 2020 to June 2022 and represented a statewide study of Massachusetts. All youth aged 5 to 17 years who boarded in Massachusetts emergency departments for 3 or more midnights while awaiting inpatient psychiatric care were included. Exposure: Boarding for 3 or more midnights while awaiting inpatient psychiatric care. Main Outcomes and Measures: Emergency department boarding length (number of midnights) and whether inpatient care was received after boarding. Statistical analyses performed included logistic and gamma regressions; assessed gender, racial, and ethnic disparities; and correlations between statewide demand for psychiatric care and boarding outcomes. Results: A total of 4942 boarding episodes were identified: 2648 (54%) for cisgender females, 1958 (40%) for cisgender males, and 336 (7%) for transgender or nonbinary youth. A total of 1337 youth (27%) were younger than 13 years. Depression was the most common diagnosis (2138 [43%]). A total of 2748 episodes (56%) resulted in inpatient admission, and 171 transgender and nonbinary youth (51%) received inpatient care compared with 1558 cisgender females (59%; adjusted difference: -9.1 percentage points; 95% CI, -14.7 to -3.6 percentage points). Transgender or nonbinary youth boarded for a mean (SD) of 10.4 (8.3) midnights compared with 8.6 (6.9) midnights for cisgender females (adjusted difference: 2.2 midnights; 95% CI, 1.2-3.2 midnights). Fewer Black youth were admitted than White youth (382 [51%] and 1231 [56%], respectively; adjusted difference: -4.3 percentage points; 95% CI, -8.4 to -0.2 percentage points). For every additional 100 youth boarding statewide on the day of assessment, the percentage of youth admitted was 19.4 percentage points lower (95% CI, -23.6% to -15.2%) and boarding times were 3.0 midnights longer (95% CI, 2.4-3.7 midnights). Conclusions and Relevance: In this cross-sectional study, almost one-half of 3 or more midnight boarding episodes did not result in admission, highlighting a need to understand the effects of boarding without admission. Gender and racial disparities were identified, suggesting the need for targeted resources to reduce boarding and promote equitable access to care.
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Importance: Poverty is associated with greater barriers to health care and worse health outcomes, but it remains unclear whether income support can improve health. Objective: To examine the effect of cash benefits on health care utilization and health. Design, Setting, and Participants: The City of Chelsea, Massachusetts, a low-income community near Boston, randomly assigned individuals by lottery to receive cash benefits. Participants' medical records were linked across multiple health systems. Outcomes were assessed during the intervention period from November 24, 2020, to August 31, 2021. Intervention: Cash benefits via debit card of up to $400 per month for 9 months. Main Outcomes and Measures: The primary outcome was emergency department visits. Secondary outcomes included specific types of emergency department visits, outpatient use overall and by specialty, COVID-19 vaccination, and biomarkers such as cholesterol levels. Results: Among 2880 individuals who applied for the lottery, mean age was 45.1 years and 77% were female. The 1746 participants randomized to receive the cash benefits had significantly fewer emergency department visits compared with the control group (217.1 vs 317.5 emergency department visits per 1000 persons; adjusted difference, -87.0 per 1000 persons [95% CI, -160.2 to -13.8]). This included reductions in emergency department visits related to behavioral health (-21.6 visits per 1000 persons [95% CI, -40.2 to -3.1]) and substance use (-12.8 visits per 1000 persons [95% CI, -25.0 to -0.6]) as well as those that resulted in a hospitalization (-27.3 visits per 1000 persons [95% CI, -53.6 to -1.1]). The cash benefit had no statistically significant effect on total outpatient visits (424.3 visits per 1000 persons [95% CI, -118.6 to 967.2]), visits to primary care (-90.4 visits per 1000 persons [95% CI, -308.1 to 127.2]), or outpatient behavioral health (83.5 visits per 1000 persons [95% CI, -182.9 to 349.9]). Outpatient visits to other subspecialties were higher in the cash benefit group compared with the control group (303.1 visits per 1000 persons [95% CI, 32.9 to 573.2]), particularly for individuals without a car. The cash benefit had no statistically significant effect on COVID-19 vaccination, blood pressure, body weight, glycated hemoglobin, or cholesterol level. Conclusions and Relevance: In this randomized study, individuals who received a cash benefit had significantly fewer emergency department visits, including those related to behavioral health and substance use, fewer admissions to the hospital from the emergency department, and increased use of outpatient subspecialty care. Study results suggest that policies that seek to alleviate poverty by providing income support may have important benefits for health and access to care.
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Objective: To describe how the intersectionality of race, ethnicity, and language with autism and intellectual and developmental disability (IDD) impacts mental health inequities in psychopharmacological management of youth. Method: This was a scoping review in which a series of searches were conducted in PubMed, Web of Science, Google Scholar, and manual review of the articles collected. Results: Although autism and/or IDD increases the risk for poor physical and mental health, social determinants of health such as race, ethnicity, and language account for approximately a third of poor outcomes. Minoritized children with autism/IDD experience significantly greater delays to diagnosis and misdiagnosis and are less likely to receive appropriate services. Access to psychological testing and psychosocial services is often limited by availability, skilled practitioners, a shortage of non-English-language providers or interpreters, and poor reimbursement. Conclusion: The intersectionality of autism and/or IDD with race, ethnicity, and language compounds the health inequities associated with either of these challenges independently.
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INTRODUCTION: Individuals with behavioral health conditions smoke at significantly higher rates and have been resistant to existing smoking cessation efforts. A clearer understanding of associations between vaping and daily cigarette consumption in this vulnerable population is warranted. METHODS: We analyzed data from the 2014-2018 National Health Interview Survey (NHIS) to examine whether vaping was associated with differences in number of cigarettes smoked per day (CPD) among adults who smoke daily and have varying levels of psychological distress. RESULTS: After adjustment for sociodemographic covariates, individuals who vaped every day smoked on average 1.48 fewer cigarettes per day than individuals who never vaped (p<0.01), while individuals who vaped some days and individuals who ever but no longer vaped smoked 0.77 and 1.48 more CPD, respectively, than individuals who never vaped. Differences between those who vaped every day and those who never vaped were even greater among those with moderate psychological distress (-2.21 CPD, p<0.01). CONCLUSIONS: Our findings suggest that use of vaping devices may be associated with lower daily cigarette use among individuals with psychological distress, potentially supporting smoking harm reduction efforts.
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BACKGROUND: Cannabis use is on the rise, but it is unclear how use is changing among individuals with serious psychological distress (SPD) compared to the general population as well as what associations this may have with mental health service use. METHODS: Retrospective cohort study using the National Survey on Drug Use and Health (NSDUH) 2009-19 public use files of 447,228 adults aged ≥ 18 years. Multivariable logistic regression and predictive margin methods were used to estimate linear time trends in any and greater-than-weekly levels of cannabis use by year and SPD status and rates of psychiatric hospitalization and outpatient mental health care. FINDINGS: Rates of any and weekly-plus cannabis use increased similarly among individuals with SPD compared to those without from 200 to 2014 but more rapidly in SPD every year from 2015 to 2019 (p < 0.001). Among individuals with SPD, no use was associated with a 4.2 % probability of psychiatric hospitalization, significantly less than less-than-weekly (5.0 %, p = 0.037) and weekly-plus cannabis use (5.1 %, p = 0.028). For outpatient mental health care, no use was associated with a 27.4 % probability (95 % CI 26.7-28.1 %) of any outpatient care, significantly less than less than weekly use (32.6 % probability, p < 0.001) and weekly-plus use (29.9 % probability, p = 0.01). CONCLUSIONS: Cannabis use is increasing more rapidly among individuals with SPD than the general population, and is associated with increased rates of psychiatric hospitalization and outpatient service use. These findings can inform policy makers looking to tailor regulations on advertising for cannabis and develop public health messaging on cannabis use by people with mental illness.
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Uso da Maconha , Serviços de Saúde Mental , Angústia Psicológica , Estados Unidos/epidemiologia , Serviços de Saúde Mental/estatística & dados numéricos , Estudos Retrospectivos , Estudos de Coortes , Humanos , Adulto , Hospitalização/estatística & dados numéricos , Uso da Maconha/epidemiologia , Uso da Maconha/psicologia , Uso da Maconha/tendências , Masculino , FemininoRESUMO
Establishing reliable access to dental services for publicly insured patients is an important part of achieving equitable oral health care. In 2023, an oral health screening requirement was added to the MassHealth Accountable Care Organization contract, which has the capacity to affect over 1.3 million members enrolled in MassHealth Accountable Care Organizations throughout the state. The goal of the oral health screening requirement is to identify MassHealth-insured patients who do not have reliable access to dental services and to provide them with resources to establish a dental home with a MassHealth-participating dentist. Primary care providers were surveyed, and results indicate a need for a care coordination mechanism to assist MassHealth-insured patients with establishing a dental home, in addition to an option to request telehealth-enabled and/or urgent dental appointments. This report describes the oral health screening program at one MassHealth Accountable Care Organization and presents some of the data collected during the first year of its implementation, in addition to discussing how this data is being used to guide equity-focused interventions with the potential for policy implications.
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Organizações de Assistência Responsáveis , Assistência Odontológica , Acessibilidade aos Serviços de Saúde , Programas de Rastreamento , Saúde Bucal , Humanos , Telemedicina , Adulto , Pessoa de Meia-Idade , Feminino , Equidade em Saúde , Masculino , Idoso , Adolescente , Adulto JovemRESUMO
Dr. Esther Duflo, Nobel Laureate in Economics, and co-founder and co-director of the Abdul Latif Jameel Poverty Action Lab (J-PAL) sat down with Dr. Benjamin Cook for a "fireside chat" at the 12th National Institute of Mental Health Global Mental Health Research Without Borders Conference. Dr. Duflo discussed J-PAL's efforts to develop and test interventions for improving mental health and how cash transfer programs can be used to improve mental health. She also discussed the importance of using randomized control trials (RCTs) in shaping global mental health initiatives. Dr. Duflo shared insights from projects addressing loneliness among older individuals in India, secondary school scholarships in Ghana, and other studies that have informed social policies. Looking forward, she discusses climate change as a threat to the reductions in poverty realized in the last 30 years and encourages the expansion of networks of research and policy collaborations to improve global health.
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Saúde Global , Saúde Mental , Humanos , Pobreza , Mudança ClimáticaRESUMO
Importance: Although people released from jail have an elevated suicide risk, the potentially large proportion of this population in all adult suicides is unknown. Objective: To estimate what percentage of adults who died by suicide within 1 year or 2 years after jail release could be reached if the jail release triggered community suicide risk screening and prevention efforts. Design, Setting, and Participants: This cohort modeling study used estimates from meta-analyses and jail census counts instead of unit record data. The cohort included all adults who were released from US jails in 2019. Data analysis and calculations were performed between June 2021 and February 2024. Main Outcomes and Measures: The outcomes were percentage of total adult suicides within years 1 and 2 after jail release and associated crude mortality rates (CMRs), standardized mortality ratios (SMRs), and relative risks (RRs) of suicide in incarcerated vs not recently incarcerated adults. Taylor expansion formulas were used to calculate the variances of CMRs, SMRs, and other ratios. Random-effects restricted maximum likelihood meta-analyses were used to estimate suicide SMRs in postrelease years 1 and 2 from 10 jurisdictions. Alternate estimate was computed using the ratio of suicides after release to suicides while incarcerated. Results: Included in the analysis were 2019 estimates for 7â¯091â¯897 adults (2.8% of US adult population; 76.7% males and 23.3% females) who were released from incarceration at least once, typically after brief pretrial stays. The RR of suicide was 8.95 (95% CI, 7.21-10.69) within 1 year after jail release and 6.98 (95% CI, 4.21-9.76) across 2 years after release. A total of 27.2% (95% CI, 18.0%-41.7%) of all adult suicide deaths occurred in formerly incarcerated individuals within 2 years of jail release, and 19.9% (95% CI, 16.2%-24.1%) of all adult suicides occurred within 1 year of release (males: 23.3% [95% CI, 20.8%-25.6%]; females: 24.0% [95% CI, 19.7%-36.8%]). The alternate method yielded slightly larger estimates. Another 0.8% of adult suicide deaths occurred during jail stays. Conclusions and Relevance: This cohort modeling study found that adults who were released from incarceration at least once make up a large, concentrated population at greatly elevated risk for death by suicide; therefore, suicide prevention efforts focused on return to the community after jail release could reach many adults within 1 to 2 years of jail release, when suicide is likely to occur. Health systems could develop infrastructure to identify these high-risk adults and provide community-based suicide screening and prevention.
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Prisioneiros , Suicídio , Humanos , Adulto , Feminino , Masculino , Suicídio/estatística & dados numéricos , Suicídio/psicologia , Prisioneiros/estatística & dados numéricos , Prisioneiros/psicologia , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Estudos de Coortes , Prisões Locais/estatística & dados numéricos , Adulto Jovem , Fatores de RiscoRESUMO
OBJECTIVE: This study aimed to examine racial-ethnic differences in engagement with and clinical outcomes of a collaborative care model (CoCM) implemented in primary care outpatient clinics in an urban academic medical center. METHODS: Adult patients (N=4,911) who screened positive for symptoms of depression, anxiety, or both on the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7 scale and who identified as non-Hispanic Black, Hispanic, or non-Hispanic White were offered participation in a CoCM implementation. The primary outcome was treatment engagement, defined as receipt of any follow-up visit, minimally adequate 4-week follow-up (at least one visit), and minimally adequate 16-week follow-up (at least three visits) after initial assessment. Secondary outcomes were response and remission of depression or anxiety. RESULTS: After adjustment of analyses for sociodemographic covariates, Black and Hispanic participants were significantly less likely than White participants to have received any or minimally adequate follow-up. Black and Hispanic participants who received any or minimally adequate 16-week follow-up were more likely than White participants to demonstrate depression symptom response and remission of anxiety symptoms. CONCLUSIONS: This CoCM implementation appears to have been effective in treating depression and anxiety among Black and Hispanic patients. However, significant disparities in receipt of follow-up care were observed. Efforts must be made to improve the retention of patients from racial-ethnic minority groups in collaborative care.
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OBJECTIVE: Many parents struggle to find mental health care for their children, and many mental health clinicians do not accept insurance payments. The authors aimed to estimate the frequency and cost of self-pay psychotherapy and psychotropic medication management visits for youths and to determine how service use varies by family income. METHODS: A descriptive cross-sectional analysis was performed among youths ages 5-17 years in the 2018-2020 Medical Expenditure Panel Survey. Specialist visits included those with psychiatrists, psychologists, social workers, and mental health counselors or family therapists. RESULTS: Approximately one in five of 13,639 outpatient mental health specialist visits were self-pay, with psychologists (23% of visits) and social workers (24% of visits) most likely to see youths on a self-pay basis. Use of self-pay care was strongly associated with higher income, but even families earning <$28,000 per year utilized some self-pay care, at a median cost of $95 per visit. Self-pay visits were associated with slightly lower clinical need than insurance-covered visits, although this measure varied by income. CONCLUSIONS: The self-pay market for child mental health care potentially exacerbates inequities in access to care by burdening low-income families with high costs. Incentivizing mental health providers to participate in insurance for larger portions of their patient panels, for example, by increasing reimbursement rates and reducing paperwork, may help improve equitable access to mental health care. To the extent that reimbursement rates drive insurance acceptance, the frequency of self-pay mental health visits suggests that mental health services are underreimbursed relative to their benefit to patients and families.
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Importance: Individuals of racial and ethnic minority groups may be less likely to use telemedicine in part due to lack of access to technology (ie, digital divide). To date, some studies have found less telemedicine use by individuals of racial and ethnic minority groups compared with White individuals, and others have found the opposite. What explains these different findings is unclear. Objective: To quantify racial and ethnic differences in the receipt of telemedicine and total visits with and without accounting for demographic and clinical characteristics and geography. Design, Setting, and Participants: This cross-sectional study included individuals who were continuously enrolled in traditional Medicare from March 2020 to February 2022 or until death. Exposure: Race and ethnicity, which was categorized as Black non-Hispanic, Hispanic, White non-Hispanic, other (defined as American Indian/Pacific Islander, Alaska Native, and Asian), and unknown/missing. Main Outcomes and Measures: Total telemedicine visits (audio-video or audio); total visits (telemedicine or in-person) per individual during the study period. Multivariable models were used that sequentially adjusted for demographic and clinical characteristics and geographic area to examine their association with differences in telemedicine and total visit utilization by documented race and ethnicity. Results: In this national sample of 14â¯305â¯819 individuals, 7.4% reported that they were Black, 5.6% Hispanic, and 4.2% other race. In unadjusted results, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 16.7 (95% CI, 16.1-17.3), 32.9 (95% CI, 32.3-33.6), and 20.9 (95% CI, 20.2-21.7) more telemedicine visits per 100 beneficiaries, respectively. After adjustment for clinical and demographic characteristics and geography, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 7.9 (95% CI, -8.5 to -7.3), 13.2 (95% CI, -13.9 to -12.6), and 9.2 (95% CI, -10.0 to -8.5) fewer telemedicine visits per 100 beneficiaries, respectively. In unadjusted and fully adjusted models, and in 2019 and the second year of the COVID-19 pandemic, Black individuals, Hispanic individuals, and individuals of other racial groups continued to have fewer total visits than White individuals. Conclusions and Relevance: The results of this cross-sectional study of US Medicare enrollees suggest that although nationally, Black individuals, Hispanic individuals, and individuals of other racial groups received more telemedicine visits during the pandemic and disproportionately lived in geographic regions with higher telemedicine use, after controlling for geographic region, Black individuals, Hispanic individuals, and individuals of other racial groups received fewer telemedicine visits than White individuals.
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Etnicidade , Pandemias , Idoso , Humanos , Estados Unidos , Estudos Transversais , Grupos Minoritários , MedicareRESUMO
Tobacco use has been established as a possible risk factor for psychosis, but the effect of electronic nicotine delivery systems (ex. nicotine vapes) has not been independently established. Using the Population Assessment of Tobacco and Health study, we found that use of electronic nicotine products was significantly associated with later first episode psychosis after controlling for substance use and other confounders, and that this relationship was only significant among the heaviest users (>20 puffs/day). Given the rapid rise in electronic nicotine products use, clinicians and public health professionals should consider potential impacts and closely monitor trends in the coming years.
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Sistemas Eletrônicos de Liberação de Nicotina , Transtornos Psicóticos , Vaping , Humanos , Nicotina/efeitos adversos , Vaping/epidemiologia , Fatores de Risco , Uso de Tabaco , Transtornos Psicóticos/epidemiologiaRESUMO
The intersection of social risk and race and ethnicity on mental health care utilization is understudied. This study examined disparities in health care treatment, adjusting for clinical need, among 25,780 Medicare Advantage beneficiaries with a diagnosis of a psychiatric disorder. We assessed contributions to disparities from racial and ethnic differences in the composition and returns of social risk variables. Black and Hispanic beneficiaries had lower rates of mental health outpatient visits than Whites. Assessing composition, Black and Hispanic beneficiaries experienced greater financial, food, and housing insecurity than White beneficiaries, factors associated with greater mental health treatment. Assessing returns, food insecurity was associated with an exacerbation of Hispanic-White disparities. Health care systems need to address the financial, food and housing insecurity of racial and ethnic minority groups with psychiatric disorder. Accounting for racial and ethnic differences in social risk adjustment-based payment reforms has significant implications for provider reimbursement and outcomes.
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Disparidades em Assistência à Saúde , Medicare Part C , Transtornos Mentais , Humanos , Estados Unidos , Feminino , Masculino , Transtornos Mentais/terapia , Transtornos Mentais/etnologia , Idoso , Medicare Part C/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Fatores de Risco , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Etnicidade/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricosRESUMO
OBJECTIVE: We examined the differences in health care spending and utilization, and financial hardship between Traditional Medicare (TM) and Medicare Advantage (MA) enrollees with mental health symptoms. DESIGN: Cross-sectional study. PARTICIPANTS: We identified Medicare beneficiaries with mental health symptoms using the Patient Health Questionnaire-2 and the Kessler-6 Psychological Distress Scale in the 2015-2021 Medical Expenditure Panel Survey. MEASUREMENTS: Outcomes included health care spending and utilization (both general and mental health services), and financial hardship. The primary independent variable was MA enrollment. RESULTS: MA enrollees with mental health symptoms were 2.3 percentage points (95% CI: -3.4, -1.2; relative difference: 16.1%) less likely to have specialty mental health visits than TM enrollees with mental health symptoms. There were no significant differences in total health care spending, but annual out-of-pocket spending was $292 (95% CI: 152-432; 18.2%) higher among MA enrollees with mental health symptoms than TM enrollees with mental health symptoms. Additionally, MA enrollees with mental health symptoms were 5.0 (95% CI: 2.9-7.2; 22.3%) and 2.5 percentage points (95% CI: 0.8-4.2; 20.9%) more likely to have difficulty paying medical bills over time and to experience high financial burden than TM enrollees with mental health symptoms. CONCLUSION: Our findings suggest that MA enrollees with mental health symptoms were more likely to experience limited access to mental health services and high financial hardship compared to TM enrollees with mental health symptoms. There is a need to develop policies aimed at improving access to mental health services while reducing financial burden for MA enrollees.
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Estresse Financeiro , Gastos em Saúde , Medicare Part C , Medicare , Humanos , Estados Unidos/epidemiologia , Masculino , Feminino , Idoso , Gastos em Saúde/estatística & dados numéricos , Estudos Transversais , Medicare/estatística & dados numéricos , Medicare/economia , Medicare Part C/economia , Medicare Part C/estatística & dados numéricos , Estresse Financeiro/epidemiologia , Serviços de Saúde Mental/estatística & dados numéricos , Serviços de Saúde Mental/economia , Idoso de 80 Anos ou mais , Transtornos Mentais/economia , Transtornos Mentais/epidemiologia , Transtornos Mentais/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricosRESUMO
BACKGROUND: Suicide rates in the United States have increased recently among Black men. To address this public health crisis, smartphone-based ecological momentary assessment (EMA) platforms are a promising way to collect dynamic, real-time data that can help improve suicide prevention efforts. Despite the promise of this methodology, little is known about its suitability in detecting experiences related to suicidal thoughts and behavior (STB) among Black men. OBJECTIVE: This study aims to clarify the acceptability and feasibility of using smartphone-based EMA through a pilot study that assesses the user experience among Black men. METHODS: We recruited Black men aged 18 years and older using the MyChart patient portal messaging (the patient-facing side of the Epic electronic medical record system) or outpatient provider referrals. Eligible participants self-identified as Black men with a previous history of STB and ownership of an Android or iOS smartphone. Eligible participants completed a 7-day smartphone-based EMA study. They received a prompt 4 times per day to complete a brief survey detailing their STB, as well as proximal risk factors, such as depression, social isolation, and feeling like a burden to others. At the conclusion of each day, participants also received a daily diary survey detailing their sleep quality and their daily experiences of everyday discrimination. Participants completed a semistructured exit interview of 60-90 minutes at the study's conclusion. RESULTS: In total, 10 participants completed 166 EMA surveys and 39 daily diary entries. A total of 4 of the 10 participants completed 75% (21/28) or more of the EMA surveys, while 9 (90%) out of 10 completed 25% (7/28) or more. The average completion rate of all surveys was 58% (20.3/35), with a minimum of 17% (6/35) and maximum of 100% (35/35). A total of 4 (40%) out of 10 participants completed daily diary entries for the full pilot study. No safety-related incidents were reported. On average, participants took 2.08 minutes to complete EMA prompts and 2.72 minutes for daily diary surveys. Our qualitative results generally affirm the acceptability and feasibility of the study procedures, but the participants noted difficulties with the technology and the redundancy of the survey questions. Emerging themes also addressed issues such as reduced EMA survey compliance and diminished mood related to deficit-framed questions related to suicide. CONCLUSIONS: Findings from this study will be used to clarify the suitability of EMA for Black men. Overall, our EMA pilot study demonstrated mixed feasibility and acceptability when delivered through smartphone-based apps to Black men. Specific recommendations are provided for managing safety within these study designs and for refinements in future intervention and implementation science research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/31241.
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Across western North America (WNA), 20th-21st century anthropogenic warming has increased the prevalence and severity of concurrent drought and heat events, also termed hot droughts. However, the lack of independent spatial reconstructions of both soil moisture and temperature limits the potential to identify these events in the past and to place them in a long-term context. We develop the Western North American Temperature Atlas (WNATA), a data-independent 0.5° gridded reconstruction of summer maximum temperatures back to the 16th century. Our evaluation of the WNATA with existing hydroclimate reconstructions reveals an increasing association between maximum temperature and drought severity in recent decades, relative to the past five centuries. The synthesis of these paleo-reconstructions indicates that the amplification of the modern WNA megadrought by increased temperatures and the frequency and spatial extent of compound hot and dry conditions in the 21st century are likely unprecedented since at least the 16th century.